An Interview with Thomas Widiger

Transcription

1 Annual Reviews Conversations Presents An Interview with Thomas Widiger Annual Reviews Audio First published online on March 27, 2012 Annual Reviews Audio interviews are online at Copyright 2012 by Annual Reviews. All rights reserved Host: Anna Rascouët-Paz Anna Rascouët-Paz: Hello, and welcome to Annual Reviews Audio, part of the Conversation Series from Annual Reviews, where insightful research begins. I am your host, Anna Rascouët-Paz. In each episode of our show, we speak to top scientists in fields ranging from astrophysics to sociology. Today, we are talking to Thomas Widiger, professor of psychology at the University of Kentucky and a member of the Editorial Committee of the Annual Review of Clinical Psychology. Professor Widiger was the research coordinator for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, also known as DSM-IV. He was also a cochair of the National Institute of Mental Health and the Research Planning Conference for DSM-5 Personality Disorders. Professor Widiger, welcome to our show. Thomas Widiger: Thanks a lot. Really glad to be here and participate in this. Anna Rascouët-Paz: The reason I m calling you today is that you wrote a paper with Allen Frances, who was the chair of the DSM-IV 1

2 task force, in which you both tried to draw lessons from your experience so as to warn those involved in DSM-5 about the potential pitfalls. Thomas Widiger: Yes. Anna Rascouët-Paz: Research coordinator for DSM-IV what exactly does this entail? Thomas Widiger: Well, that job was primarily working with Allen Frances as the chair, as you said, and Harold Pincus, the vice chair. We developed the methods by which DSM-IV was going to be developed. One of the mandates given to us was to have a much more strongly empirically based nomenclature. We set up a procedure for that, a three-stage procedure, involving literature reviews, data analyses and field trials, and, in all cases, emphasizing that authors were not to try to provide the best results, or make the best case for what they re proposing, but to cover all the alternative proposals and major concerns regarding these proposals. I just monitored that, and then all of that came out in the four-volume DSM-IV Sourcebook as a result. Anna Rascouët-Paz: Tell us a bit more about the process and the guidelines. You say in the paper that you adopted a more conservative approach than in earlier editions. How did this translate, practically? Thomas Widiger: It s always been unclear exactly what should be the basis for adding a new diagnosis, for example, or revising a diagnostic criterion set. It certainly was the case in DSM-III and -III-R that it was pretty liberal. Bob Spitzer, in one place, stated what the threshold was, and it was that if a group of clinicians said they see a certain condition, and they could come up with a reliable criteria set, then it would be included in a diagnostic manual. This, however, led to a lot of very controversial proposals, four of which were actually eventually vetoed by the Board of Trustees of the APA [American Psychological Association]: paraphilic rapism, premenstrual dysphoric disorder, sadistic personality disorder, and selfdefeating [personality disorder]. There was a mandate for DSM-IV to have a much more careful and conscientious effort to address possible social consequences, costs of including a new diagnosis, and whether or not the proposal actually had empirical support. It really was a useful process because there was an apparent tendency in DSM-IV that the people who were appointed to the task force and work groups always had a strong invested interest in their ideas and their proposals, and they wanted to get them through. Unless you monitor them closely, there s a tendency to try to downplay opposing research and downplay concerns. Anna Rascouët-Paz: This is what you call in the paper reining in the creativity of the experts, right? Thomas Widiger: That s correct. Anna Rascouët-Paz: Can you give us a few examples of how DSM-IV changed clinical psychiatry and psychology? Specifically, we re talking about the problem of overdiagnosis. You were really careful, probably more careful than in earlier editions, and yet you came upon a few problems that you hadn t necessarily anticipated. Thomas Widiger: It s very difficult to anticipate how a revision to criteria will actually play out 2 Widiger

3 in practice, or how it will impact society and the practice of psychiatry and clinical psychology. Whenever you have something in a DSM, it provides a tremendous sense of credibility in the view of the public and the profession their assumption that Okay, it must be a well-validated condition to have been included. Then we tinker with diagnostic criteria. The wording may have such an effect that the problems may change substantially. We always, in the field trials, compared the 15 criteria sets to the proposals. But the DSM-IV field trials were very limited. There were only 10 of them, and they re confined to only about a similar number of diagnoses. A lot of the ideas that were approved probably weren t field tested as well as they should have been, which resulted in some rather dramatic increases in certain diagnoses. Anna Rascouët-Paz: How does this translate for DSM-5? How do you see this coming for the next edition that s coming out next year? Do you feel that the field trials are happening that there s enough vetting happening for the inclusion of new disorders? Thomas Widiger: Well, it s an interesting process. One thing that is different for DSM-5 than for DSM-IV is the Internet process. That really wasn t as strong of a factor in DSM-IV. In one regard, the vetting of the proposals is more open in DSM-5 than in DSM-IV because they posted them on the Internet, and a lot of people could respond to them. A lot more people were aware of them. DSM-IV it was the old postal mail--delivery system, where there were small minipaperback versions that were freely made available, but you d have to ask for them, so the communication was much slower. On the other hand, we had a much more conservative process for the development of proposals and for the empirical documentation. In DSM-5, for example, they were going to start the field trials without the proposals ever even being posted. They were eventually posted, but they were planning on getting the field trials started before the posting actually was going to occur if that was the original intention to actually post them. Once you start the field trials with the proposals, the train has now left the station, and it s very hard at that point to make any strong major impact on it. I think the process in DSM-5, in some regards even though it is on the Internet and that makes it more open even the existence of that may have been actually prompted by the outside critical reviewers, by the letter by Allen Frances and Bob Spitzer to the Board of Trustees to actually delay the field trials until it was posted. The field trial, itself, is far more limited than was the case in DSM-IV. In DSM-IV all the proposals had to be compared to DSM-III-R criteria sets, and alternative proposals had to be tested, and they had to include validators to determine whether or not the revisions were likely to increase or decrease validity. None of that is being required in DSM-5. The DSM-5 field trials are confined largely to feasibility and interrater reliability, and they re not collecting data on the DSM-IV criteria sets, so you don t really know whether or not a proposal will radically change prevalence whether it improves the validity of the diagnosis or perhaps decreases it. It s a far more limited field trial, more like what was done for DSM-III. Anna Rascouët-Paz: Examining another problem that people have raised concern about: It appears that about 70% of the professionals involved with the making of DSM-5 have ties to the pharmaceutical industry. Is this a concern for you? Thomas Widiger: It s not a concern for me for DSM-5, not at least by what I m aware of. It s my An Interview with Thomas Widiger 3

4 understanding and I don t know this for a fact, but this is my understanding that they initially appointed a number of persons and that a number of them did have some degree of financial connection to a pharmaceutical industry. It s obvious that the pharmaceutical industry would be highly invested in increasing the number of diagnoses and lowering thresholds. But they then implemented a rule that you couldn t get beyond a certain amount of financial connection with a pharmaceutical industry, so these persons had to resign. I don t think there is a strong financial connection with respect to group members decisions in any pharmaceutical industry. Anna Rascouët-Paz: Turning to your focus: You focus on personality disorders, and you wrote a paper for us a couple of years ago where you advocated a new, dimensional system of diagnosis. Would you be able to explain this system to us, and explain to us how it s different from the way that it s done now? Thomas Widiger: Let me also emphasize that Allen Frances and I probably have a different view on this, but both of those views are acknowledged in the paper. I ve long advocated for shifting from the categorical model of diagnosis to a dimensional model that recognizes that personality disorders are maladaptive variants of general personality traits. I work from the perspective of the five-factor model, which is certainly the predominant dimensional model of general personality structure developed in psychology, whereas DSM-IV works from a more traditional clinical perspective where there exist these categorically distinct syndromes that represent some sort of qualitative disease or illness. I would say DSM-5 is clearly shifting toward this five-factor dimensional assessment. The proposal for DSM-5 is to include a five-factor model, five broad domains, that are closely aligned with the five-factor model of general psychology; the disorders themselves would be diagnosed largely by those traits within that model, although the work group also will have some theoretically based, self--other impairments that they feel are impairments that are qualitatively distinct from personality traits. I would disagree with that particular aspect of it. But outside of that, it s a pretty close shift to what I d been proposing in the prior Annual Reviews paper. Allen Frances would say he feels that it s just too radical of a shift to actually make that change for DSM-5. Anna Rascouët-Paz: This is a concern that s also been raised. It s a question of looking at personalities in terms of spectra. You have adaptive traits, and you have maladaptive traits that, essentially, everybody has to a lesser or greater extent. The worry that comes up is that if you re going to use a spectrum system, the threshold for diagnosis is going to be lower, and normality is going to become the exception. How do you respond to that? Thomas Widiger: One doesn t know what will happen unless one does the research. That s where Allen and I would agree. I m not sure they re even collecting any data on this themselves. It s my understanding they re not comparing their current diagnostic system, using these traits, to the DSM-IV criteria sets. They re not going to be able to tell us to what extent this way of diagnosing personality disorders will radically shift the problem rates for each disorder. They don t know what the cutoff points will be. They have seven traits, let s say, for borderline [personality disorder], and they don t know how many you have to have to get the diagnosis. What they re saying on the Web site right now is, You have to have all seven, but it s my understanding that they re just saying that because they have no basis to say anything else. They 4 Widiger

5 won t require all the seven because that would be far too restrictive. But how many would it be three, four, or five? I don t know how they re going to make that decision. I would be sympathetic with the concern that this could have a major dramatic change in the prevalence of personality disorder diagnoses. I would wish that they would be collecting the data to justify whatever threshold they use to have some sort of clinical meaningfulness. Anna Rascouët-Paz: Right. It seems that it would be something difficult to implement for clinicians, people who are practicing psychology and psychiatry with patients directly on a daily basis. That would require some training, right? Thomas Widiger: Well, they won t be as familiar with the trait approach to diagnosis as they are with the diagnostic criteria sets. But I m not as worried about that as some might be because I don t see the trait approaches being that tremendously difficult. The traits are rather obvious in terms of what they are. If you have specific criteria for each trait, then I don t think clinicians will have that much difficulty with it. I do agree that it ll look like quite a different system for them. Again, it would be useful to have some piloting of that. The field trial is doing that. They re having clinicians apply these traits in a number of I think four sites, and they ll have some information about how feasible or how acceptable this approach is to those clinicians. Anna Rascouët-Paz: In terms of new diagnoses or new disorders that will be added to DSM- 5 at least, it s rumored that they will be added to DSM-5, like bereavement, Internet addiction what do you make of these? Thomas Widiger: I think there is a real quality in DSM-5 of having quite a large number of new proposals, much more broadening as to what constitutes a mental disorder. They re getting a lot of negative publicity over this, again in part because of the explosive Internet communication. I also feel that a lot of the criticism probably is deserved. I m concerned that they re not doing a good enough job of anticipating problems and misapplications. For example I mean, they do have an outstanding paper by Ken Kendler and others, including, I think, the chair and vice chair of the task force, which sets forth the empirical support they should have for a new change, and a further statement that each proposal must acknowledge and address possible consequences of a new proposal. But if you actually look at the products that are coming out, the work groups vary tremendous in how well they follow the Kendler outline. If you look at the Web site and anybody can go there themselves, and I certainly encourage people to reach their own judgments they could go to the Web site and look at the review for hypersexual disorder, a brand-new diagnosis involving your life revolving around sex. It would include things like an addiction to porn, or going to strip clubs an excessive amount. The review for that, I think, is outstanding. But if you look at some of the other reviews, there s next to nothing the review for change in the [unintelligible] to substance dependence to behavioral addiction, and you fold then pathological gambling into that. Once you ve done that, you can fold in lots of other things, like Internet addiction and shopping addiction. The review for that doesn t address any of those concerns. It s just two sentences, which say that there s a lot of similarities between substance dependence and pathological gambling. Then you have some number 15, 20 of citations, and that s it. No discussion at all about the potential consequences. The bereavement isn t really a new diagnosis. It s the idea of removing bereavement exclusion criteria. Currently, you don t diagnose somebody with major depression who s depressed because An Interview with Thomas Widiger 5

6 they lost a significant loved one. That s been a tradition in the long history of psychiatry. The proposal to remove it really comes from the compelling logic that what s the difference between the loss of a loved one versus the loss of a job, versus the loss of physical health. All those things are depressing, but if we would diagnose major depressive disorder in response to those losses, why make an exception for the loss of a loved one? I agree with that logic. That s really very compelling logic. But it s quite a fundamental change to suggest to people that if you lost all your children, or you lost your husband or your wife, and it s been now three weeks, and you re still depressed about it, then you re mentally ill. You re mentally ill for being so depressed about having lost somebody. I don t think they appreciate that that could lead to a tremendous amount of overpathologizing what many people think is an appropriate reaction to such a loss. Anna Rascouët-Paz: Right. When you talk to clinicians, how do you describe the DSM? What do you tell them this is? What do you tell them this is not? How should people understand the DSM? Thomas Widiger: Many people can confuse the DSM with something like a periodic table of elements that it s something that out there in nature, and it exists. The DSM is a set of constructs. It s more a set of perceptions and hypotheses. It represents the beliefs of the field regarding what would constitute a mental disorder. In no case has there ever been any laboratory study laboratory instrument I should have said that could document that this thing exists independently of our opinions. That makes it fundamentally very different. I think it s very credible. I think those opinions are largely correct. I think it s correct to think that schizophrenia is a mental disorder, that psychopathy is a mental disorder. But it is an opinion, so I wouldn t want someone to reify what the DSM is, and realize that it could be wrong in some cases. It s open to question and debate. Anna Rascouët-Paz: Thank you very much for your time today. It s been a pleasure talking to you, Professor Widiger. Thomas Widiger: I enjoyed it myself. I m glad you called me. Anna Rascouët-Paz: Thank you very much. You ve been listening to Annual Reviews Audio. For 80 years, Annual Reviews has guided scientists to the essential research literature in the biomedical, life, physical, and social sciences. Learn more at I m Anna Rascouët-Paz. Thanks for listening. [End of audio] Duration: 20 minutes 6 Widiger