Dr. Allen Frances, MD on The Diane Rehm Show, NPR

Allen Frances book 2Remember the post in which I mentioned Dr. Allen Frances, MD, Help Me with Twitter…and with DSM-5 Polemics – The Practical Psychosomaticist)? One of the administrative assistants in our Psychiatry Department notified me of the NPR interview with Dr. Frances, MD, which you can access at the link, http://thedianerehmshow.org/shows/2013-05-14/dr-allen-frances-saving-normal-insiders-revolt-against-out-control-psychiatric-diag. Dr. Frances is professor emeritus, former chair of the psychiatry and behavior science department at Duke University and was also chair of the DSM-4 Task Force. He’s been an outspoken critic of the DSM-5.

The interview was conducted by Diane Rehm, and it gave me a better feel for the different perspectives on DSM-5 and “medicalization”. Dr. David Kupfer, the chair of the DSM-5 Task Force, gave a very thoughtful description of the new edition of DSM, pointing out that it would be a “living document”, meaning that it will be revised much sooner than in the next 20 years.

I enjoyed the comments and questions from listeners as well. I thought it was a fair and open-minded discussion.

By the way, I just received my copy of Dr. Frances’ book, “Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5”. I’m sure you know the first section I read was on delirium in Chapter 10, the section on “Neurocognitive Disorders”. It was easy to read, and gave a clear and concise description of how to recognize delirium and what to do about it [1]. It’s called a “medical emergency”, which certainly is consistent with what many have been saying for years. There is a section for screening questions, and guess what it was? Essentially, it was very similar to the SQiD (the Single Question in Delirium): “Is your husband confused and acting strangely?” It’s in line with the study of Sands and colleagues [2].

Dr. Frances’ section on delirium compared well with that of the Quick Reference to the DSM-IV-TR criteria. I don’t yet have my copy of the DSM-5, but I doubt the diagnostic criteria for delirium will differ much from the DSM-IV-TR.

I felt a bit better about the whole DSM-5 polemic thing after the show. Let me know what you think.

1. Frances, A., MD (2013). Neurocognitive Disorders. Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5, The Guilford Press.

2. Sands, M., et al. (2010). “Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale.” Palliative Medicine 24(6): 561-565.
In this study we address the research question; How sensitive is a single question in delirium case finding? Of 33 ‘target’ admissions, consent was obtained from 21 patients. The single question: ‘Do you think [name of patient] has been more confused lately?’ was put to friend or family. Results of the Single Question in Delirium (SQiD) were compared to psychiatrist interview (ΨI) which was the reference standard. The Confusion Assessment Method (CAM) and two other tools were also applied. Compared with ΨI, the SQiD achieved a sensitivity and specificity of 80% (95% CI 28.3—99.49%) and 71% (41.90—91.61%) respectively. The CAM demonstrated a negative predictive value (NPV) of 80% (51.91—95.67%) and the SQiD showed a NPV of 91% (58.72—99.77%). Kappa correlation of SQiD with the ΨI was 0.431 (p = 0.023). The CAM had a kappa value of 0.37 (p = 0.050). A further important finding in our study was that the CAM had only 40% sensitivity in the hands of minimally trained clinical users. Conclusion: The SQiD demonstrates potential as a simple clinical tool worthy or further investigation.

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