Three professional organization responses to third and final DSM-5 stakeholder review

Posted on June 21, 2012 by meagenda

Three professional organization responses to the third and final DSM-5 stakeholder review

Post #185 Shortlink: http://wp.me/pKrrB-2hS

According to DSM-5 Task Force Vice-chair, Darrel Regier M.D., the specific diagnostic categories that received most comments during the second public review of draft proposals (May-June 2011) were the sexual and gender identity disorders, followed closely by somatic symptom disorders and anxiety disorders.

The American Psychiatric Association (APA) has yet to report how many comments the DSM-5 Task Force and its 13 Work Groups received during this third and final review period (which closed last Friday), or which categories garnered the most responses, this year.

No publication of field trial data

Following posting of the third draft on May 2, it was anticipated APA would publish full results from the DSM-5 field trials “within a month”. [Source: Deborah Brauser for Medscape Medical News: interview with Darrel Regier, May 8, 2012.]

No report emerged and stakeholders had little choice but submit feedback on this latest iteration without the benefit of scrutiny of reliability data to inform their submissions.

APA has yet to account for its failure to place its field trial results in the public domain while the feedback exercise was in progress, other than releasing some Kappa data at its May 5-9 Annual Conference.

American Psychiatric Association CEO and Medical Director, James H. Scully, Jr., M.D., blogs at Huffington Post. Last week, I asked Dr Scully why the field trial report has been withheld; whether Task Force still intends publishing field trial data and when that report might now be anticipated.

I’ve received no response from Dr Scully and APA has put out no clarification.

No publication of list of Written Submissions

These three DSM-5 public reviews of draft proposals for changes to DSM-IV categories and criteria have not been managed as formal stakeholder consultation exercises.

APA publishes no aggregations of key areas of concern identified during public comment periods nor publishes Work Group or Task Force responses to key areas of professional or lay public concern on the DSM-5 Development website – an issue I raised with the Task Force during both the first and second reviews.

Although some published submissions (ACA, British Psychological Society and the DSM-5 Reform Open Letter and Petition Committee) have received responses from the Task Force and which APA has elected to place in the public domain, submissions from the majority of professional bodies and organizations disappear into a black hole.

In the interests of transparency, APA could usefully publish lists of the names of US and international professional bodies, academic institutions, patient advocacy organizations etc. that have submitted comments, in the way that Written Submissions are listed in the annexes to reports and public inquiries.

That way, interested parties might at least approach organizations to request copies of submissions or suggest that these are placed in the public domain.

APA could not legitimately claim it would require permissions before publishing full lists of the names of professional body, academic institution and organization respondents that tendered formal responses – its legal department’s boilerplate Terms and Conditions of Use gives APA carte blanche to make use of and publish uploaded submissions in any way it sees fit.*

*See Terms and Conditions of Use, under “User Submissions”

The following have released their submissions in response to the third draft:

Submission from The American Mental Health Counselors Association (AMHCA)

The American Mental Health Counselors Association is a nationwide organization representing 6,000 clinical mental health counselors. Their submission includes concerns for the lowering of the “B type” threshold requirement for “Somatic Symptom Disorder” criteria between the second and third drafts.

[In the CSSD field trials, about 15% of the "diagnosed illness" study group (patients with cancer and coronary disease) met the criteria for coding with an additional mental health diagnosis of "SSD" when "one B type" cognition was required; about 10% met the criteria when "two B type" were required. About 26% of the "functional somatic" arm of the study group (patients with irritable bowel and "chronic widespread pain" – a term used synonymously with fibromyalgia) met the criteria for coding with an additional mental health diagnosis of "SSD" when "one B type" cognition was required; about 13% met the criteria when "two B type" were required. AMHCA recommends raising the threshold back to at least two from the three B type criteria, as the criteria for CSSD had stood for the second draft. I consider the category of "SSD" should be rejected in the absence of a substantial body of independent evidence for the reliability, validity and safety of "SSD" as a construct.]

AMHCA Submits Comments on DSM-5 06/19/12

June 18, 2012 – Alexandria, VA – The DSM-5 Task Force of the American Mental Health Counselors Association (AMHCA) has submitted comments for the third period of public comment on the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

AMHCA’s comments addressed 12 disorder categories and the Cultural Formulation Interview Guide. Per the site requirements, each was sent separately to the particular disorder site.

Download compilation of comments submitted by AMHCA DSM-5 Task Force

“Somatic Symptom Disorders

“Somatic Symptom Disorder

“A major change in this revision is the merger of Complex Somatic Symptom Disorder and Simple Somatic Symptom Disorder into one disorder, Somatic Symptom Disorder. The increased emphasis placed on cognitive distortions (along with the presence of somatic symptoms ) provides greater clarity about the nature of the disorder. However, the notion that a single B.2 criteria could be used as the sole basis for identifying these cognitive aspects seems to open the door to diagnosing individuals who have legitimate “high anxiety” about their symptoms. We recommend considering “two of three” criteria under B be required.”

The British Psychological Society writes:

The British Psychological Society still has concerns over DSM-V

…For all the reasons stated above, the BPS, having reviewed the currently proposed revisions of the new diagnostic criteria in DSM 5, continues to have major concerns. These have, if anything, been increased by the very poor reliabilities achieved in many of the recent field trials (Huffington Post, 2012), especially given the limited time available to attempt to achieve more satisfactory outcomes. Since validity depends, at the very least, on acceptable levels of reliability, the unavoidable conclusion is that many of the most frequently-used categories will be unable to fulfil their purported purposes, i.e. identification of appropriate treatments, signposting to support, providing a basis for research…

Read full submission to third draft here in PDF format.

Response to second draft here.

Christopher Lane comments:

Psychology Today | Side Effects

Arguing Over DSM-5: The British Psychological Society Has Serious Concerns About the Manual

The BPS expresses “serious reservations” about the next DSM.

Christopher Lane, Ph.D. in Side Effects | June 20, 2012

Although the American Psychiatric Association recently closed its window allowing comments on proposed changes to the DSM, the organization has yet to report on the field trials it devised for the next edition of the psychiatric manual, themselves meant to support—indeed, serve as a rationale for—the changes it is proposing in the first place.

While this unhappy outcome points to some of the organization’s chicken-and-egg problems with the manual and the disorders it is seeking to adjust or make official, those wanting to respond to the draft proposals have had to do so in the dark, unaware of the results of the field trials and thus whether the proposals draw from them any actual empirical support…

Read on

Submission from American Counseling Association (ACA)

The American Counseling Association (ACA), represents more than 50,000 counselors – one of the largest groups of DSM-5 users in the US.

ACA provides final comments on the DSM-5

ACA President Don W. Locke has sent the American Psychiatric Association a letter providing final comments for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Based on comments from ACA members and the ACA DSM Task Force, the letter acknowledges useful changes that had been made to previous drafts of the DSM-5: the development of the Cultural Formulation Outline, reversing the pathologizing of normal bereavement, and limiting the expansion of personality disorder types. ACA also calls for addressing the one-dimensional nature of the new Substance Use Disorder category and rejects the proposed dimensional assessments. Click here to view letter.

This is the third letter ACA has sent to the American Psychiatric Association providing feedback for the DSM-5. Click the links below to read the previous letters and a response from APA:

Letter from President Lynn Linde, April 16, 2010

Letter from President Don Locke, November 8, 2011

Response from APA President John Oldham, November 21, 2011

Submission by Coalition for DSM-5 Reform Committee

The Coalition for DSM-5 Reform Open Letter and Petition has garnered support from over 13,700 professionals and concerned stakeholders and the endorsement of nearly 50 organizations, since launching last October.

The DSM-5 Reform Committee continues to call for independent scientific review of draft proposals and submitted the following response during this third and final comment period:

Submission from Coalition for DSM-5 Reform (Society for Humanistic Psychology)Division 32 of the American Psychological Association)

To the DSM-5 Task Force and the American Psychiatric Association

As you know, the Open Letter Committee of the Society for Humanistic Psychology and the Coalition for DSM-5 Reform have been following the development of DSM-5 closely.

We appreciate the opportunity for public commentary on the most recent version of the DSM-5 draft proposals. We intend to submit this brief letter via the dsm5.org feedback portal and to post it for public viewing on our website at http://dsm5-reform.com/

Since its posting in October 2011, the Open Letter to the DSM-5, which was written in response to the second version of the draft proposals, has garnered support from almost 50 mental health organizations and over 13,500 individual mental health professionals and others.

Our three primary concerns in the letter were as follows: the DSM-5 proposals appear to lower diagnostic thresholds, expanding the purview of mental disorder to include normative reactions to life events; some new proposals (e.g., “Disruptive Mood Dysregulation Disorder” and “Attenuated Psychosis Syndrome”) seem to lack the empirical grounding necessary for inclusion in a scientific taxonomy; newly proposed disorders are particularly likely to be diagnosed in vulnerable populations, such as children and the elderly, for whom the over-prescription of powerful psychiatric drugs is already a growing nationwide problem; and the increased emphasis on medico-biological theories for mental disorder despite the fact that recent research strongly points to multifactorial etiologies.

We appreciate some of the changes made in this third version of the draft proposals, in particular the relegation of Attenuated Psychosis Syndrome and Mixed Anxiety-Depression to the Appendix for further research. We believe these disorders had insufficient empirical backing for inclusion in the manual itself. In addition, given the continuing elusiveness of biomarkers, we are relieved to find that you have proposed a modified definition of mental disorder that does not include the phrase “underlying psychobiological dysfunction.”

Despite these positive changes, we remain concerned about a number of the DSM-5 proposals, as well as the apparent setbacks in the development process.

Our continuing concerns are:

• The proposal to include new disorders with relatively little empirical support and/or research literature that is relatively recent (e.g., Disruptive Mood Dysregulation Disorder)

• The lowering of diagnostic thresholds, which may result in diagnostic expansion and various iatrogenic hazards, such as inappropriate treatment and stigmatization of normative life processes. Examples include the newly proposed Minor Neurocognitive Disorder, as well as proposed changes to Generalized Anxiety Disorder, Attention Deficit/Hyperactivity Disorder, Pedophilia, and the new behavioral addictions.

• The perplexing Personality Disorders overhaul, which is an unnecessarily complex and idiosyncratic system that is likely to have little clinical utility in everyday practice.

• The development of novel scales (e.g., severity scales) with little psychometric testing rather than utilizing established standards.

In addition, we are increasingly concerned about several aspects of the development process. These are:

• Continuing delays, particularly in the drafting and field testing of the proposals.

• The substandard results of the first set of field trials, which revealed kappas below accepted reliability standards.

• The cancelation of the second set of field trials.

• The lack of formal forensic review.

• Ad hominem responses to critics.

• The hiring of a PR firm to influence the interpretation and dissemination of information about DSM-5, which is not standard scientific practice.

We understand that there have been recent attempts to locate a “middle ground” between the DSM-5 proposals and DSM-5 criticism. We believe that, given the extremity and idiosyncrasy of some of the proposed changes to the manual, this claim of a “middle ground” is more rhetorical and polemic than empirical or measured. A true middle ground, we believe, would draw on medical ethics and scientific standards to revise the proposals in a careful way that prioritizes patient safety, especially protection against unnecessary treatment, above institutional needs.

Therefore, we would like to reiterate our call for an independent scientific review of the manual by professionals whose relationship to the DSM-5 Task Force and/or American Psychiatric Association does not constitute a conflict of interest.

As the deadline for the future manual approaches, we urge the DSM-5 Task Force and all concerned mental health professionals to examine the proposed manual with scientific and expert scrutiny.

It is not only our professional standards, but also – and most importantly – patient care that is at stake. We thank you for your time and serious consideration of our concerns, and we hope that you will continue to engage in dialogue with those calling for reform of DSM-5.

Sincerely,

The DSM-5 Open Letter Committee of the Society for Humanistic Society, Division 32 of the American Psychological Association

Round-up: Recent commentaries by Allen Frances, MD, on a DSM-5 in distress

Posted on February 22, 2012 by meagenda

Round-up: Recent commentaries by Allen Frances, MD, on a DSM-5 in distress

Post #146 Shortlink: http://wp.me/pKrrB-1X2

Allen Frances’ Blog at Huffington Post

DSM 5 Freezes Out Its Stakeholders

Allen Frances, MD | February 21, 2012

Scary news. The Chair of the DSM 5 Task Force, Dr. David Kupfer, has indicated that 90 percent of the decisions on DSM 5 have already been made.

Why so scary? DSM 5 is the new revision of the psychiatric diagnosis manual, meant to become official in May 2013. It proposes a radical redefinition of the boundary between mental disorder and normality, greatly expanding the former at the expense of the latter. Understandably, this ambitious medicalization of the human condition has generated unprecedented opposition, both from the public and from mental heath professionals. To top it off, the DSM 5 proposals are poorly written, unreliable, and likely to cause the misdiagnosis and the excessive treatment of millions of people.

Under normal circumstances the DSM 5 team would have taken the many criticisms to heart, gone back to the drawing board, and improved the quality and acceptability of their product. After all, the customer is very often right. But this DSM process has been strangely secretive, unable to self-correct, and stubbornly closed to suggestions coming from outside. As a result, current DSM 5 proposals show very little improvement over poorly done first drafts posted in February 2010.

Is there any hope of a last-minute save? I have gathered opinions from three well-informed DSM 5 watchers. They were asked to assess the current state of DSM 5 and offer suggestions about future prospects. The first comment comes from Suzy Chapman, a public advocate, whose website provides the most comprehensive documentary source on the development of DSM 5 and ICD-11. Ms Chapman writes:

DSM 5 consistently misses every one of its deadlines and then fails to update its website with a new schedule. The Timeline was finally revised a couple of weeks ago, but we are still no nearer to a firm date for the final period of invited public comment. We’ve known since November that DSM 5 is stuffed as far as its planned January-February comment period and that Dr Kupfer now reckons “no later than May” – but all the website says is “Spring.” That’s no use to those of us who need to alert patient groups and their professional advisers…

Psychology Today

DSM5 in Distress
The DSM’s impact on mental health practice and research.
by Allen Frances, M.D.

ICD-10-CM Delay Removes Excuse For Rushing DSM 5 Into Premature Publication: Time needed to avoid harmful document

Allen Frances, MD | February 22, 2012

Until yesterday, there were only two reasons to stick with the projected date of DSM 5 publication (May 2013): 1) the need to coordinate DSM 5 with ICD-10-CM coding, which was scheduled to start Oct 2013; and, 2) the need to protect APA publishing profits in order to meet budget projections.

The first reason just dropped out. Health and Human Services (HHS) Secretary Kathleen G. Sebelius has announced that the start date for ICD-10-CM has been postponed. It is not yet clear for how long, but most likely a year (see http://www.dhhs.gov/news/press/2012pres/02/20120216a.html ).

also on Psychiatric Times

Registration required for access

ICD-10-CM Delay Removes Excuse For Rushing DSM-5 Into Premature Publication

and Education Update

Psychology Today

DSM5 in Distress

DSM 5 to the Barricades on Grief

Defending The Indefensible

Allen Frances, MD | February 18, 2012

The storm of opposition to DSM 5 is now focused on its silly and unnecessary proposal to medicalize grief. DSM 5 would encourage the diagnosis of ‘Major Depressive Disorder’ almost immediately after the loss of a loved one—having just 2 weeks of sadness and loss of interest along with reduced appetite, sleep, and energy would earn the MDD label (and all too often an unnecessary and potentially harmful pill treatment). This makes no sense. To paraphrase Voltaire, normal grief is not ‘Major’, is not ‘Depressive,’ and is not ‘Disorder.’ Grief is the normal and necessary human reaction to love and loss, not some phony disease.

All this seems perfectly clear to just about everyone in the world except the small group of people working on DSM 5. The press is now filled with scores of shocked articles stimulated by two damning editorial pieces in the Lancet and a recent prominent article in the New York Times.

The role of public defender of DSM 5 has fallen on John Oldham MD, president of the American Psychiatric Association…

Psychology Today

DSM5 in Distress

Allen Frances, MD | February 17, 2012

Lancet Rejects Grief As a Mental Disorder: Will DSM 5 Finally Drop This Terrible Idea

The Lancet is probably the most prestigious medical journal in the world. When it speaks, people listen. The New York Times is probably the most prestigious newspaper in the world. Again, when it speaks, people usually listen. The Lancet and The New York Times have both spoken on the DSM-5 foolishness of turning grief into a mental disorder. Will DSM-5 finally listen?

Here are some selected quotes from today’s wonderful Lancet editorial
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60248-7/fulltext

Previous DSM editions have highlighted the need to consider, and usually exclude, bereavement before diagnosis of a major depressive disorder. In the draft version of DSM-5 , however, there is no such exclusion for bereavement, which means that feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, which continue for more than 2 weeks after the death of a loved one, could be diagnosed as depression, rather than as a normal grief reaction.”

“Medicalising grief, so that treatment is legitimized routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed…”

Psychology Today

DSM5 in Distress

DSM 5 Minor Neurocognitive Disorder: Let’s Wait For Accurate Biological Tests

Allen Frances, MD | February 16, 2012

Within the next 3-5 years, we will likely have biological tests to accurately diagnose the prodrome of Alzheimer’s disease (AD). Much remains to be done in standardizing these tests, determining their appropriate set points and patterns of results, and negotiating the difficult transition from research to general clinical practice. And, given the lack of effective treatment, there are legitimate concerns about the advisability of testing for the individual patient and the enormous societal expense with little tangible benefit. Despite these necessary caveats, there is no doubt that biological testing for prodromal AD will be an important milestone in the clinical application of neuroscience.

How does this impact on the DSM 5 proposal to include a Minor Neurocognitive Disorder as a presumed prodrome to AD…

Psychology Today

DSM5 in Distress

PTSD, DSM 5, and Forensic Misuse: DSM 5 would lead to overdiagnosis in legal cases.

Allen Frances, MD | February 09, 2012

In preparing DSM IV, we worked hard to avoid causing confusion in forensic settings. Realizing that lawyers read documents in their own special way, we had a panel of forensic psychiatrists go over every word to reduce the risks that DSM IV could be misused in the courts. They did an excellent job, but all of us missed one seemingly small mistake– the substitution of an ‘or’ for an ‘and’ in the paraphilia section that lead to serious misunderstandings and the questionably constitutional preventive psychiatric detention of sexual offenders.

DSM 5 is about to make a very different, less crucial, but still consequential forensic mistake. The proposed A criterion for PTSD includes the following wording…

Psychology Today

DSM5 in Distress

Documentation That DSM 5 Publication Must Be Delayed because DSM 5 is so far behind schedule

Allen Frances, MD | February 07, 2012

I wrote last week that DSM 5 is so far behind schedule it can’t possibly produce a usable document in time for its planned publication date in May 2013. My blog stimulated two interesting responses that illustrate the stark contrast between DSM 5 fantasy and DSM 5 reality. Together they document just how far behind its schedule DSM 5 has fallen and illustrate why publication must be delayed if things are to be set right.

The first email came from Suzy Chapman of http://dxrevisionwatch.wordpress.com …

also on Psychiatric Times

Registration required for access

Documentation That DSM-5 Publication Must Be Delayed

Additional coverage of DSM-5 controversies

Sidney Morning Herald

About-turn on treatment of the young

Amy Corderoy | February 20, 2012

CONCERNS about the overmedication of young people and rigid models of diagnosis have led the architect of early intervention in Australian psychiatry, Patrick McGorry, to abandon the idea pre-psychosis should be listed as a new psychiatric disorder.

The former Australian of the Year had previously accepted the inclusion of pre-psychosis – a concept he and colleagues developed – in the international diagnostic manual of mental disorders, or DSM, which is being updated this year.

Professor McGorry has been part of a team researching pre- and early-psychosis, and his work in the latter helped secure a massive $222.4 million Commonwealth funding injection for Early Psychosis Prevention and Intervention Centres across Australia…

Sidney Morning Herald

Suffer the children under new rules

Kathryn Wicks | Opinion | February 20, 2012

Canberra Times

A new chapter for psychiatrists’ bible

Amy Corderoy | February 19, 2012

Madness is being redesigned. The Diagnostic and Statistical Manual of Mental Disorders (DSM) will be updated this year, meaning what counts as a psychiatric disorder will change.

Frances, one of the architects of the current manual, DSM-IV, published in 1994, knows the results of his changes to the definitions of mental illness.

“We were definitely modest, conservative and non-ambitious in our approach to DSM-IV,” he says. “Yet we had three epidemics on our watch…”

American Psychiatric Association rejects call for independent review of DSM-5 proposals

Posted on January 29, 2012 by meagenda

American Psychiatric Association rejects psychologists’ call for independent review of controversial DSM-5 proposals

Post #135 Shortlink: http://wp.me/pKrrB-1KF

On January 9, 2012, the Coalition for DSM-5 Reform, an ad hoc committee of the Society for Humanistic Psychology (Division 32 of the American Psychological Association), sent another call to the American Psychiatric Association’s Board of Trustees and DSM-5 Task Force to submit controversial proposals for DSM-5 to independent scrutiny.

American Psychiatric Association president, John Oldham, M.D., issued a response last Friday, January 27.

“…There is in fact no outside organization that has the capacity to replicate the range of expertise that DSM-5 has assembled over the past decade to review diagnostic criteria for mental disorders. In addition, the posting of the criteria on the www.dsm5.org Web site for an international review; the ongoing consultation and coordination with the WHO Mental Disorder Advisory Group for ICD-11; and the several internal reviews provided by the Scientific Review Committee, a Clinical and Public Health Committee review, and the Task Force as a whole, collectively provide the most far reaching review ever undertaken for any DSM revision…“

John Oldham M.D. President, on behalf of American Psychiatric Association

For a copy of the Coalition’s letter see Post #126: Psychologists call for independent review of DSM-5

Full response from John Oldham, M.D., on behalf of the American Psychiatric Association, here:

APA Response on 01.27.12 to Coalition for DSM-5 Reform letter of 01.09.12

Text

American Psychiatric Association

1000 Wilson Boulevard
Suite 1825
Arlington, VA 22209
Telephone 703.907.7300
Fax 703.907.1085
Email apa@psych.org
Internet www.psych.org

David N. Elkins, Ph.D.
President
Society for Humanistic Psychology
750 First Street, N.E.
Washington, DC 20002Ͳ4242

January 27, 2012

Dear President Elkins:

We appreciate the January 9, 2012, open letter from you and the members of the Division 32 Open Letter Committee to the American Psychiatric Association and developers of DSM-5 regarding the need for a more thorough external review process in revising the manual.

We echo your desire to ensure that “the proposed DSM-5 is safe and credible.” To that end, the DSM-5 Task Force and Work Groups have been purposefully assembled to include clinicians and researchers with diverse backgrounds and expertise, representing nearly 100 different academic and medical institutions from around the world. Our November 21, 2011, letter to the American Counseling Association provides a more complete listing of the steps we have taken to obtain an independent review of the DSM-5 proposals.

(This can be viewed at: http://dxrevisionwatch.files.wordpress.com/2011/11/apa_letter_to_aca_11-21-11.pdf)

[Ed: URL provided in Dr Oldham's letter returns 404, substituting file from Dx Revision Watch.]

There is in fact no outside organization that has the capacity to replicate the range of expertise that DSM-5 has assembled over the past decade to review diagnostic criteria for mental disorders. In addition, the posting of the criteria on the www.dsm5.org

Web site for an international review; the ongoing consultation and coordination with the WHO Mental Disorder Advisory Group for ICD-11; and the several internal reviews provided by the Scientific Review Committee, a Clinical and Public Health Committee review, and the Task Force as a whole, collectively provide the most far-reaching review ever undertaken for any DSM revision. However, we recognize that there will not be universal agreement with all of the final decisions made in response to these reviews. As with all scientific classifications applied to clinical practice, research will continue to refine our understanding of these disorders, and revisions to the DSM-5 as a living document will be made after publication of DSM-5 in 2013.

Since there is no “gold standard” for defining mental disorders and many other medical disorders without pathognomonic biological markers, each revision of diagnostic criteria has been seen as the best current set of diagnostic criteria that are meant to be used in clinical practice and tested for their validity. Validity criteria first published by Robins and Guze in 1970 for the Feighner criteria have formed the basic framework for testing the Research Diagnostic Criteria, DSM-III, DSM-III-R, DSM-IV, and the ICD-10. The work groups and the review groups have closely attended to these and an expanded set of validity criteria that are contained in the Guidelines for Making Changes to DSM on the http://www.dsm5.org website: (http://www.dsm5.org/ProgressReports/Documents/Guidelines-for-Making-Changes-to-DSM_1.pdf).

The work groups are accessing more than 30 years of research since the DSM-III was first published in making their recommendations. Some of the proposed changes, such as the inclusion of more dimensional components, have been recommended by members of previous Task Forces and by many participants in the National Institutes of Health-sponsored conference series leading up to the Task Force. We will also have empirical data from our field trials on how these and other proposed changes are working. Final decisions about the revisions will only be made after all of these reviews are completed.

We hope that this additional information is responsive to your members, colleagues, and individuals who use mental health services to clarify that we are undertaking an exceptionally extensive review process involving an international and multidisciplinary clinical and scientific group of experts.

As we continue to refine the proposals for DSM-5 and further progress to development of DSM-5.1 and beyond, we look forward to maintaining an open and ongoing dialogue with your organization, colleagues, and the mental health field at large.

Sincerely,

John M. Oldham, M.D.
President

Resources

Coalition for DSM-5 Reform on Dx

Open Letter and iPetition

Coalition for DSM-5 Reform on Twitter @dsm5reform

Coalition for DSM-5 Reform on Facebook

Coalition for DSM-5 Reform website

This initiative is also being covered on

The Society for Humanistic Psychology Blog

The Society for Humanistic Psychology on Twitter @HumanisticPsych

The Society for Humanistic Psychology on Facebook

Psychologists call for independent review of DSM-5

Posted on January 10, 2012 by meagenda

Psychologists call for independent review of DSM-5

Post #126 Shortlink: http://wp.me/pKrrB-1DC

The Coalition for DSM-5 Reform is calling on the American Psychiatric Association to submit its draft proposals for new categories and criteria for DSM-5 to independent scientific review.

An Open Letter and Petition sponsored by the Society for Humanistic Psychology (Division 32 of the American Psychological Association), in alliance with several other American Psychological Association Divisions, attracted nearly 7000 signatures in its first three weeks. Since launching the petition, on October 22, over 10,300 mental health and allied professionals have signed up with over 40 organizations publicly endorsing the Open Letter.

You can view the Open Letter and iPetition here

Yesterday, January 09, Division 32 Open Letter Committee sent another call to the American Psychiatric Association Board of Trustees and DSM-5 Task Force to submit controversial proposals for DSM-5 to independent scrutiny.

PSYCHOLOGISTS CALL FOR INDEPENDENT REVIEW OF DSM-5

January 9, 2012

ATTENTION:                                                                                                                                                                                    David J. Kupfer, M.D., Chair of DSM-5 Task Force
Darrel A. Regier, M.D., M.P.H., Vice Chair of DSM-5 Task Force
John M. Oldham, M.D., President of the American Psychiatric Association
Dilip V. Jeste, M.D., President-Elect of the American Psychiatric Association
Roger Peele, M.D., Secretary of the American Psychiatric Association

To the DSM-5 Task Force and the American Psychiatric Association:

We appreciate your opening a dialogue regarding the concerns that the Division 32 Open Letter Committee and others have raised about the proposed DSM-5. Your willingness to do this suggests that both the Task Force and our committee are in basic agreement that we both want the DSM-5 to be empirically grounded, credible to mental health professionals and the public, and safe to use. In keeping with this spirit of open dialogue, we are writing in regard to what we view as a critically important issue.

You will recall that the Division 32 Open Letter Committee, along with the American Counseling Association, recently asked the DSM-5 Task Force and the American Psychiatric Association to submit the controversial portions of the proposed DSM-5 for external review by an independent group of scholars and scientists who have no ties to the DSM-5 Task Force or the American Psychiatric Association.

As you know, it is common practice for scientists and scholars to submit their work to others for independent review. We believe it is time for an independent group of scientists and scholars, who have no vested interest in the outcome, to do an external, independent review of the controversial portions of the DSM-5. We consider this especially important in light of the unprecedented criticism of the proposed DSM-5 by thousands of mental health professionals, as well as mental health organizations, in the United States and Europe.

Will you submit the controversial proposals in DSM-5 to an independent group of scientists and scholars with no ties to the DSM-5 Task Force or the American Psychiatric Association for an independent, external review?

We respectfully ask that you not respond again with assurances about internal reviews and field trials because such assurances, at this point, are not sufficient. We believe an external, independent review is critical in terms of ensuring the proposed DSM-5 is safe and credible. If you are unwilling to submit the controversial proposals for external, independent review, we respectfully ask that you provide a detailed rationale for your refusal. Because the DSM is used by hundreds of thousands of mental health professionals, we are publicly posting this letter and will also post your response. We believe mental health professionals, along with concerned mental health organizations, in the United States and Europe will be very interested in this important exchange.

Sincerely,

David N. Elkins, PhD, Chair of the Division 32 Open Letter Committee   Email: David Elkins

Frank Farley, PhD, Member of Committee
Jonathan D. Raskin, PhD, Member of Committee
Brent Dean Robbins, PhD, Member of Committee
Donna Rockwell, PsyD, Member of Committee

Resources

Coalition for DSM-5 Reform on Dx Revision Watch

Open Letter and iPetition

Coalition for DSM-5 Reform on Twitter @dsm5reform

Coalition for DSM-5 Reform on Facebook

Coalition for DSM-5 Reform website

This initiative is also being covered on

The Society for Humanistic Psychology Blog

The Society for Humanistic Psychology on Twitter @HumanisticPsych

The Society for Humanistic Psychology on Facebook

When is the third stakeholder and public review of draft categories and criteria for DSM-5 scheduled?

Posted on December 28, 2011 by meagenda

When is the third stakeholder and public review of draft categories and criteria for DSM-5 scheduled?

Post #119 Shortlink: http://wp.me/pKrrB-1yz

Most likely not according to the schedule posted on the DSM-5 Development website.

The first stakeholder and public review of draft proposals for changes to DSM-IV categories and criteria ran for ten weeks, from February 10 to April 20, 2010. The APA reported receiving over 8,600 comments [1].

The second public review ran for just six weeks, from May 4 to June 15, 2011 (at which point it was extended a further month, to July 15). During this second review period, Task Force Chair, David Kupfer, MD, told Deborah Brauser for Medscape Medical News, that 2,100 individual comments had been submitted [2].

Slip slidin’ away…

According to the current DSM-5 Development Timeline, the final draft is scheduled for release in January–February 2012, although the DSM-5 Development home page states:

“In spring 2012, we will open the site for a third and final round of comments from visitors which will again be systematically reviewed by each of the work groups for consideration of additional changes.”

This article, Patient-Centered Revisions to the DSM-5, co-authored by Emily A. Kuhl, PhD, David J. Kupfer, MD, and Darrel A. Regier, MD, MPH, Virtual Mentor. December 2011, Volume 13, Number 12: 873-879.

states:

“…Given the high utility of patient and public feedback in drafting revisions thus far, a third open commenting period has been scheduled to take place in 2012, following completion of the DSM-5 field trials.”

But completion dates for field trials are slipping targets.

(See: DSM 5 in Distress: Disorganization, Disarray, and Missed Deadlines, Beware The Final Mad Rush, Allen Frances, Psychology Today, December 29, 2011).

In this November 9, 2011 report by Deborah Brauser for Medscape Medical News, DSM-5 Task Force vice-chair, Darrel Regier, MD, predicts a final public feedback period “no later than May 2012.”

APA Answers DSM-5 Critics

“…Although the routine clinical settings field trials were expected to be completed by the end of December, it has been extended to around March 2012. Dr. Regier said that this will probably push back the final public feedback period to no later than May 2012.”

So, April–May? May–June? I will update when a firm release date is published or other information received.

DSM-5 Development Timeline

References

[1] DSM-5 Development website

[2] DSM-5 Task Force Ponders Round 2 of Public Feedback: Deborah Brauser for Medscape Medical News
August 31, 2011 [Registration required to view this Medscape article.]

[3] Current DSM-5 proposals for changes to DSM-IV categories and criteria

[4] DSM-5 Development Timeline

Psychiatric Times Editor invites readership to submit views on DSM-5 for potential publication

Posted on December 20, 2011 by meagenda

Editor of Psychiatric Times invites its readership to submit views on DSM-5 for potential publication

Post #117 Shortlink: http://wp.me/pKrrB-1sx

Although the current DSM-5 Development Timeline has a third draft scheduled for release in January-February, 2012, for a two month period for public comment, this final draft is expected to be delayed until spring, pending completion of the DSM-5 field trials.

In this November 9, 2011 report by Deborah Brouser for Medcape Medical News, DSM-5 Task Force vice-chair, Darrel Regier, MD, says “no later than May 2012.”

APA Answers DSM-5 Critics

“…Although the routine clinical settings field trials were expected to be completed by the end of December, it has been extended to around March 2012. Dr. Regier said that this will probably push back the final public feedback period to no later than May 2012.”

When the third and final draft has been published, a notice and links will be posted on my sites with instructions on how to register with the DSM-5 Development site for submitting feedback to the Task Force and 13 work groups.

According to Darrel Regier, Vice-Chair of the DSM-5 Task Force, the specific diagnostic categories that received most comments in the second public review of draft proposals, in May-July, 2011, were sexual and gender identity disorders, followed closely by somatic symptom disorders and anxiety disorders.

December 16, 2011

In a brief Editorial entitled The Debate Over DSM-5: We Invite Your Views, James L. Knoll IV, MD, Editor, Psychiatric Times, clarifies Psychiatric Times’s position with regard to the journal’s intent behind posting the many blogs about DSM-5 that appear on its web site.

Dr Knoll encourages and invites readers to submit their viewpoints on DSM-5 “in the spirit of collegial and scientific investigation.”

Dr Knoll writes that manuscripts and letters sent to editor@PsychiatricTimes.com will be reviewed for possible publication either in print or on www.PsychiatricTimes.com.

Read Editorial here

(Free registration is required for access to Pyschiatric Times Editorial.)

British Psychological Society issues statement in response to DSM-5 encouraging members to sign Coalition for DSM-5 Reform petition

Posted on December 13, 2011 by meagenda

British Psychological Society issues statement in response to DSM-5 encouraging members to sign Coalition for DSM-5 Reform petition for mental health professionals

Post #116 Shortlink: http://wp.me/pKrrB-1sa

Society issues statement in response to DSM-5

The Society has today (13 December 2011) released a statement expressing concerns regarding the proposed revisions of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, which is one the main internationally-used classification systems for diagnosis of people with mental health problems in clinical settings and for research trials.

The Society for Humanistic Psychology (Division 32) of the American Psychological Association (APA) has recently published an open letter to the DSM-5 taskforce raising a number of concerns about the draft revisions proposed for DSM-5 and citing a number of issues raised previously by the BPS.

In its statement today, the Society shares the concerns expressed in the open letter from the Society of Humanistic Psychology (Division 32) of the APA and encourages members of the Society to read the letter themselves and consider signing the petition.

David Murphy, Chair of the Society’s Professional Practice Board said:

“The Society recognises that a range of views exist amongst psychologists, and other mental health professionals, regarding the validity and usefulness of diagnostic frameworks in general and the Diagnostic and Statistical Manual of the American Psychiatric Association, in particular.

“However, there is a widespread consensus amongst our members that some of the changes proposed for the new framework could lead to potentially stigmatizing medical labels being inappropriately applied to normal experiences and also to the unnecessary use of potentially harmful interventions.

“We therefore urge the DSM 5 taskforce to consider seriously all the issues that have been raised and we would echo the American Psychological Association’s call for the taskforce to adhere to an open transparent process based on the best available science and in the best interest of the public”.

You can read the Society statement in full online.

Open PDF on the BPS site here: BPS Statement on DSM-5 12.12.11

Or open PDF here, on Dx Revision Watch: BPS statement on DSM-5 12-12-2011

Text version

British Psychological Society statement on the open letter to the DSM-5 Taskforce

The British Psychological Society recognizes that a range of views exist amongst psychologists, and other mental health professionals, regarding the validity and usefulness of diagnostic frameworks in mental health in general, and the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association in particular.

The Society for Humanistic Psychology (Division 32) of the American Psychological Association (APA) has recently published an open letter to the DSM-5 taskforce raising a number of concerns about the draft revisions proposed for DSM-5 which has, to date, been endorsed by 12 other APA Divisions.

A major concern raised in the letter is that the proposed revisions include lowering diagnostic thresholds across a range of disorders. It is feared that this could lead to medical explanations being applied to normal experiences, and also to the unnecessary use of potentially harmful interventions.

Particular concern is expressed about the inclusion of a new diagnostic category “Attenuated Psychosis Syndrome”. This proposes to include individuals who are experiencing hallucinations, delusions or disorganized speech “in an attenuated form with intact reality testing” but who do not meet current criteria for a psychotic disorder. The Society shares the concerns expressed in the open letter about the potentially harmful consequences of lowering diagnostic thresholds in general and the questionable validity of this proposed diagnosis in particular.

Another concern raised is about the impact of proposed revisions on vulnerable groups such as children and the elderly. The letter highlights that the proposed new diagnostic category “Mild Neurocognitive Disorder” might be diagnosed in elderly people whose memory decline simply reflects normal ageing. The Society welcomes the use of an objective psychometric criterion within this particular DSM-5 diagnosis but shares concerns expressed in the letter about potential for misdiagnosis of normal ageing. We would further highlight the importance of valid psychological interpretation of test results since the proposed psychometric threshold encompasses 1 in 8 of the normal population. There is a particular danger that cognitive functioning of people from ethnic minorities is under-represented on psychometric tests. The Society also shares concerns about the potential for children and adolescents to be misdiagnosed with Disruptive Mood Deregulation Disorder.

We also concur that there is a lack of a solid basis in clinical research literature for this disorder and are also concerned about the risk of harm from inappropriate treatment with neuroleptic medication.

The proposals for the revision of the personality disorders section in DSM-5 are described in the open letter as “perplexing”, “complex” and “idiosyncratic”. The Society has welcomed the move to a dimensional-categorical model for personality disorder. However, we have said that this has not been as visible as expected in the draft revisions.

Moreover, we share concerns expressed in the open letter about the inconsistency of the proposed changes and their limited empirical basis.

Finally, the open letter also draws attention to proposals to revise the basic “Definition of a Mental Disorder” and, in particular, a statement proposed by Stein et al that it “reflects an underlying psychobiological dysfunction”. The Society shares concerns about any unsubstantiated shift in emphasis towards biological factors and in particular the entirely unjustified assertion that all mental disorders represent some form of biological dysfunction. We are, however, reassured by the response from the APA task force (4 November 2011) which states that there is no intent “to diminish the importance of environmental and cultural exposure factors” and hope that this will be reflected in the final version.

In conclusion, the British Psychological Society endorses the concerns expressed in the open letter from the Society of Humanistic Psychology (Division 32) of the APA and encourage members to view the letter themselves and consider signing the petition (http://www.ipetitions.com/petition/dsm5/ ). We also urge the DSM 5 taskforce to consider seriously the issues raised therein. These have been now been endorsed by a broad range of experts in mental health, including members of the British Psychological Society and two chairs of previous DSM revision taskforces.

We are, however, encouraged that the DSM taskforce has already responded positively to the open letter and that in their letter (4 November 2011) they emphasized that the manual is “still more than a year away from publication and is continually being refined and reworked”. They commented that “Final decisions about proposed revisions will be made on the basis of field trial data as well on a full consideration of other issues such as those raised by the signatories of the petition.”

In a statement issued on 2 December 2011 the American Psychological Association (APA) called upon the DSM-5 Task Force to “adhere to an open, transparent process based on the best available science and in the best interest of the public”. The British Psychological Society would certainly echo this call.

The final draft of the DSM-5 criteria is due for publication in early 2012 followed by a third, two month, period of public feedback. The Society encourages those members who have relevant expertise to contribute to the on-going process of refinement and improvement of the DSM-5. As a Society we are, as is our counterpart the APA, committed to promoting and disseminating psychological knowledge and, as such, we are keen to ensure that the final version of DSM-5, and other internationally used diagnostic frameworks such as ICD-11, are based on the best available psychological science and will continue to monitor the DSM-5 revision process and contribute further as appropriate.

[Ends]

References:

1] DSM-5 Development site
2] Somatic Symptoms Disorders current proposals
3] DSM-5 Timeline
4] Coalition for DSM-5 Reform website
5] Petition for mental health professionals can be signed here
6] Dr Allen Frances MD, Chair, DSM-IV Task Force, blogs on DSM-5 on “Psychology Today”
7] Updates and developments on the Coalition for DSM-5 Reform’s petition
8] Media coverage for Coalition for DSM-5 Reform’s petition

Psychiatric Manual Revision Pushes Ahead Amid Continued Concerns (APA issues update on status of DSM-5)

Posted on November 24, 2011 by meagenda

Psychiatric Manual Revision Pushes Ahead Amid Continued Concerns (APA issues update on status of DSM-5)

Post #115 Shortlink: http://wp.me/pKrrB-1qV

Wall Street Journal Health Blog

WSJ’s blog on health and the business of health

Psychiatric Manual Revision Pushes Ahead Amid Continued Concerns

Shirley S. Wang | November 23, 2011

The American Psychiatric Association’s years-long efforts to revamp its big book of diagnoses has been fraught with controversy.

Critics have said that the committee charged with the fifth full revision of the Diagnostic and Statistical Manual for Mental Disorders, known as the DSM, is being too secretive and trying to make too many changes, among other concerns.

Read full article

On November, 23, the American Psychiatric Association posted a statement “Update on the Status of DSM-5″ (dated November 22, 2011) on its main website.

Open PDF here: APA Update on the Status of DSM-5 11.22.11

or open on the APA’s website here

Text version follows:

APA Provides Update on Status of DSM-5

The development of DSM-5, more than a decade in process, has been the object of immense public and professional interest. APA hopes that the following information about the process and substance of the emerging diagnostic manual—which will be published in 2013 and at this point is by no means a finished product—will be useful and clarifying. Certainly, everyone with an interest in DSM-5 should visit its open access Web site, www.dsm5.org/Pages/Default.aspx, which has comprehensive information about the developing manual.

The process of developing DSM-5 began in 1999, when APA and the National Institute on Mental Health (NIMH) convened a conference to begin creating a research agenda for the new diagnostic manual. In 2002, APA published A Research Agenda for DSM-5. In the ensuing years, APA worked with multiple agencies—NIMH, the World Health Organization (WHO), the World Psychiatric Association, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism—involving hundreds of participants and resulting in hundreds of publications and monographs, most of which are available on the DSM-5 Web site, regarding current state of knowledge, gaps in research, and recommendations for further research.

The DSM-5 Task Force was formed in 2007, with 13 work groups composed of world-renowned leaders in psychiatric research, diagnosis, and treatment. Since then, the 160 members of the task force and work groups have reviewed more than a decade of research on specific topics and diagnoses under consideration for the new manual. APA granted work group members permission to publish their literature reviews, and nearly all have been published in peer-reviewed journals (again, many of them available for public review on the DSM-5 Web site). In 2009 guidelines were developed to ensure the standardization of presentations by all work group members as they prepared draft diagnostic criteria and rationales for task force review.

These guidelines were subsequently adopted to facilitate reviews by the Scientific Review Committee.

Importantly, members of the work groups are not APA employees, are not under contract with APA, and are not paid by APA. They are free to leave the work group if at any time they are not satisfied that the process is unbiased or if they believe the results are lacking in scientific integrity.

Work group members come from widely diverse backgrounds and represent academic and mental health institutions throughout the world. Ninety-seven members are psychiatrists, 47 are psychologists, two are pediatric neurologists, three are statistician/epidemiologists, and there is one representative each from pediatrics, social work, pediatric nursing, speech and hearing specialties, and consumer groups. There are also more than 300 outside advisors selected for their particular expertise. Together, all of these professionals have every incentive to ensure the work, and the ultimate product, is based on science and empirical evidence.

Moreover, APA has welcomed the public’s input by making all of the drafts of the evolving document available on the DSM-5 Web site. The drafts that APA has put out for review by the public are posted to elicit comments from others in the field and from patients and family members who may be impacted by changes. APA has received through the Web site alone more than 10,000 comments—each of which has been considered and evaluated by the work groups.

The task force is working on including “dimensional and cross-cutting assessments” in order to diagnose psychiatric disorders in a more detailed and nuanced way and to recognize the frequent comorbidities that exist with many mental illnesses. The measurement instruments used in these assessments are modeled on proven instruments, such as the NIH-developed Patient Reported Outcome Measurement Information System (PROMIS), the PHQ-9 for Major Depression, PHQ-8 for somatic symptoms, the Swanson SNAP scale for attention, the Stringaris scale from NIMH for irritability, and the Altman scale for bipolar disorder. All of these scales are being subjected in field trials to extensive tests of reliability and clinical utility.

The definition of mental disorder used in DSM-IV is undergoing a thorough review by the DSM-5 Task Force. Throughout the review process, APA has assimilated input from around the world and across disciplines and is reformulating its recommendations for the definition of a mental disorder. The task force continues to work toward a definition of mental disorder that is evidence-based and acceptable to the mental health community at large, and APA welcomes comments on the revised definition when it is posted in the third round of revisions expected to come out in the spring.

Throughout this process, APA has been committed to transparency. DSM-5 Task Force and work group members have presented and participated in open discussions at hundreds of psychiatric and other major medical meetings around the world and have received permission whenever requested to publish on the proposed changes in DSM-5 without regard to their point of view. (A list of those meetings and publications is available for review on the DSM-5 Web site.)

APA has asked those involved in the DSM-5 process to sign a member acceptance form that has been the subject of some misunderstanding. The confidentiality portion of the member acceptance form is not intended to promote secrecy, but rather to facilitate the verbal process of deliberation. Most, if not all, scientific institutions—including the National Institutes of Health, the Institute of Medicine, WHO, and all scientific journal preparations and reviews—share results of research and explanations for their conclusions, but do not fully open the deliberative process itself for comment. This is crucial in order to ensure the free-exchange of ideas during deliberation.

The Scientific Review Committee was appointed by the Board of Trustees of APA and charged with the ultimate approval of the final DSM-5 recommendations. As part of that charge, the committee will evaluate the strength of the evidence in support of proposed revisions. This separate peer-review process will provide important guidance to the Board. The committee’s contributions will be reflected in the final criteria of DSM-5. Another committee, the Clinical and Public Health Committee, has recently been appointed by the Board to consider clinical utility and public health issues that are not being reviewed by the Scientific Review Committee.

In addition, APA has worked with WHO on an ongoing basis to develop harmonization between disorders included in both DSM-5 and ICD-11. Public comment has twice been solicited on proposed diagnostic criteria, and a third public comment period is planned for 2012.

APA believes the extensive process of development for DSM-5 will result in a scientifically and clinically useful new edition of the diagnostic manual, and the Task Force is indebted to the hundreds of experts who are contributing to its content.

November 22, 2011

Related information:

1] DSM-5 Development website

2] American Counseling Association releases letter: Calls for external review of DSM-5

3] Coalition for DSM-5 Reform Tab page on Dx Revision Watch site

4] Coalition for DSM-5 Reform website

5] Open Letter and iPetition

American Psychiatric Association responds to letter from American Counseling Association

Posted on November 22, 2011 by meagenda

American Psychiatric Association responds to American Counseling Association’s letter, calling for external review of DSM-5

Post #114 Shortlink: http://wp.me/pKrrB-1qt

On November 17, the American Counseling Association, which represents 20% of all mental health professionals, published a letter to the American Psychiatric Association, calling for external review of DSM-5. For a PDF and text copies of the ACA’s letter see this Dx Revision Watch post:

American Counseling Association releases letter: Calls for external review of DSM-5

Today, the American Psychiatric Association (APA) has issued a 7 page response to the ACA’s concerns.

It should be noted that the APA does not publish the names of the 300 external advisors to the DSM-5 Development process.

Open American Psychiatric Association’s response to ACA in PDF below, followed by text version

or on the APA’s DSM-5 Development site here

APA letter to ACA 11.21.11

American Psychiatric Association
1000 Wilson Boulevard Suite 1825
Arlington, VA 22209
Telephone 703.907.7300 Fax 703.907.1085
Email apa@psych.org Internet www.psych.org

November 21, 2011

Don W. Locke, Ed.D.
President
American Counseling Association 5999 Stevenson Avenue
Alexandria, VA 22304

Dear Dr. Locke:

Thank you for outlining the American Counseling Association’s (ACA) concerns with proposed revisions for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We value the role of professional counselors in the delivery of mental health care, and we welcome the comments of mental health care providers on DSM. We share the goal of producing a DSM that is useful to all health professionals, researchers and patients so that the American Psychiatric Association (APA) can continue to play its longstanding role in advancing the understanding, diagnosis and treatment of mental disorders.

A great deal of misinformation about DSM-5 has been circulating on the internet, so APA appreciates your direct inquiry and the opportunity to dispel myths generated from these sources. We address each of your concerns below.

Empirical Evidence and Independent Review. It is useful to review the most recent draft version of DSM-5 to truly understand the breadth of evidence collection and review that has taken place during its development. This process actually began in 1999 when APA and the National Institute of Mental Health (NIMH) sponsored a conference to begin creating a research agenda for the next DSM. Additional conferences sponsored by APA, NIMH, the World Health Organization (WHO) and the World Psychiatric Association took place in 2000, all of which resulted in the 2002 publication of A Research Agenda for DSM-V. Additional groups were commissioned in 2003 to further examine infant and young child, late-life and gender issues resulting in the 2007 publication of Age and Gender Considerations in Psychiatric Diagnosis: A Research Agenda for DSM-5.

APA, WHO, NIMH, and two other NIH agencies—the National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) —held 13 conferences between 2004 and 2008, involving nearly 400 participants representing 39 countries. Over half of the participants were non-U.S. residents. The work resulted in the creation of 10 monographs and hundreds of published journal articles regarding the current state of knowledge, gaps in research, and recommendations for additional research in many fields.

After the DSM-5 Task Force was formed in 2007, and based on the work described above, APA established 13 work groups, each with 8-15 members who are leading clinicians and researchers in the field, to address various areas for review. Since then, the 160 members of the DSM-5′s 13 work groups have sought to review nearly two decades of research published since the introduction of DSM-IV. Work group members selected specific diagnoses on which to focus their individual reviews of the literature in support of or against each specific topic. APA granted work group members permission to publish all of their literature reviews and nearly all have been accepted for publication in peer-reviewed scientific journals. The 2009 guidelines you referenced were developed to ensure the standardization of presentations by all work group members as they prepared draft diagnostic criteria and rationales for Task Force review. These guidelines were subsequently adopted to facilitate reviews by the Scientific Review Committee (SRC).

ACA’s call for an “independent, third party review” of the DSM process and evidence has already been answered in the establishment of these work groups and the close coordination APA has with other national and international scientific groups. The members of the work groups are not APA employees, they are not paid by APA and are not under contract with APA. Their participation is strictly voluntary, based upon their interest in advancing the field of psychiatry and better serving patients. They are free to leave the work group if at any time they are not satisfied that the process is unbiased or believe that the results are lacking in empirical evidence. Attachment A lists the institutions from which work group members are drawn. As you can see, they represent academic and mental health institutions throughout the world. No more than two members of any one institution are represented on any one work group in order to achieve diversity of opinion. It should be noted that although many of these participants are affiliated with universities, the vast majority of them also engage in clinical practice.

The work group members include multiple types of mental health practitioners. Approximately one third of the work group members hold PhDs and 30 percent are international professionals. Ninety-seven members of the work groups are psychiatrists, 47 members are psychologists, 2 are pediatric neurologists, 3 are statisticians/epidemiologists and there is one representative each from pediatrics, social work, psychiatric nursing, speech and hearing specialists, and consumer groups. In addition, there are more than 300 outside advisors — each selected because of a specific and well-recognized expertise in a particular field. These individuals represent an independent group of volunteer medical and mental health professionals who are also leaders in their respective fields and who have every conceivable incentive to ensure that the work they produce is soundly based in science and supported by empirical evidence.

Every proposed change in DSM-5 is guided by a review of scientific literature, analyses of relevant data sets and full discussion by the work group members. In an unprecedented move, the APA has opened the DSM-5 development process to the public to further ensure that the widest range of opinion and information could be sought and all clinical and “real world” implications of the diagnostic criteria could be considered. The drafts that APA has put out for review by the public are posted to elicit comments from others in the field and from patients and family members who may be impacted by changes. APA has received through its website alone more than 10,000 comments—each of which has been considered and evaluated by the work groups.

Dimensional and Cross-Cutting Assessments. These assessments were introduced in order to diagnose psychiatric disorders in a more detailed way and to recognize the frequent co-morbidities in persons who suffer from mental illness. Level 1 crosscutting assessments are based on the model of the brief two-question screener for depression, adopted by the U.S. Task Force for Preventive Services, to assess the presence of significant symptoms in 12 different psychological domains—a total of 23 questions that permit a rapid review of mental systems. If positive symptoms are present, level 2 cross-cutting measures are modeled on the NIH-developed Patient Reported Outcome Measurement Information System (PROMIS) that has been extensively tested. Where PROMIS measures were not available, we used the most widely tested comparable measures to cover other domains such as the NIDA developed ASSIST scale.

Severity measures for individual diagnoses include well-documented and publicly available measures such as the PHQ-9 for Major Depression, PHQ-8 for somatic symptoms, the Swanson SNAP scale for Attention, the Stringaris scale from NIMH for irritability, the Altman scale for bipolar disorder, and others that were developed specifically by the DSM-5 work group experts that are built on past instruments and are being tested in the field trials.

All of these scales are being subjected in field trials to test-retest reliability assessments, patient evaluations of their utility, and clinician assessments of their feasibility and utility in identifying symptomatic areas such as substance abuse or suicidal risk, which might otherwise be overlooked. External validators will include correlates with diagnoses as well as other measures of impairment and disability. Regarding the cross-cutting disability measure, the WHO Disability Assessment Scale (WHO-DAS) is one of the most widely tested disability measures in the world—developed by NIH and WHO with over a decade of testing.

Field Trials/Validity of Diagnoses. With regard to the critique of our field trials, we were pleased to see that you referenced Dr. Helena Kraemer, who serves on the DSM-5 Task Force. Dr. Kraemer helped design the field trials and authored the referenced paper as part of the DSM-5 conference series on the integration of dimensional and categorical diagnosis. As Dr. Kraemer notes in the referenced paper, a field trial is not the forum in which validity can be fully assessed, and as in every field of medicine, diagnostic criteria reflect the best scientific understanding at the time, but they continue to develop and evolve as more scientific research comes to light.

Definition of Mental Disorder. The definition of mental disorder that is used in DSM-IV is undergoing a thorough review by the DSM-5 Task Force. There have been two revised definitions proposed: one, as you mention, by Stein et al. published in Psychological Medicine, the other proposed by the DSM-5′s Study Group on Impairment and Disability Assessment. Neither definition has been accepted by the Task Force at this time. There is no intent on the part of the Task Force to overstate the psychobiological advances in mental disorders; all other paradigms are being considered as well. Through the review process, APA assimilated input from around the world and across disciplines and is reformulating its recommendations for the definition of a mental disorder. Many other proposals have been revised after consideration of public comments as well. We continue to work towards a definition of mental disorder that is evidence-based and acceptable to the mental health community at large. We will look forward to your comments on the revised definition when it is posted in the third round of revisions expected to come out in the spring—when we plan to open another public comment period on our website.

Transparency. The APA asked those involved in the DSM-5 process to sign a member acceptance form. The form contains a confidentiality provision that has been the subject of much misunderstanding and which APA has addressed in detail in the past. This form is not intended to restrict the free discussion of ideas on the issues involved in revising DSM and developing new diagnostic criteria. In fact, DSM-5 Task Force and work group members have presented and participated in open discussions at hundreds of psychiatric and other major medical meetings around the world. Work group members have requested and received permission whenever requested to publish on the proposed changes in DSM-5 without regard to their point of view. (A list of those meetings and publications is available for review on the DSM-5 website.)

Indeed, we encourage members to have open discussions with knowledgeable colleagues just as APA has encouraged comments from those interested in mental health on its website. It is only through broad and diverse opinions that we can, as scientists and clinicians, come to a consensus on how to interpret the data that are available. Further, by widely discussing these issues, APA hopes to stimulate funding for further research into areas that are not sufficiently developed to date to be included in the main body of DSM. Thus, our publication and review process has been beneficial in defining various mental disorders and also in defining and developing interest in additional areas in the field of mental health that require further study.

The confidentiality portion of the member acceptance form is not intended to promote secrecy. Instead, APA sought confidentiality to facilitate the verbal process of deliberation. Most, if not all scientific institutions of which APA is aware, including NIH, the Institute of Medicine, WHO, and all scientific journal preparations and reviews share results of research and explanations for their conclusions, but do not fully open the deliberative process itself for comment. This is crucial in order to ensure the free-exchange of ideas. While the work groups are following this established model in our own deliberations, we also made an important decision to make our proposed revisions to the diagnostic criteria, while still in draft form, available for public review both nationally and internationally.

The Scientific Review Committee. The SRC was appointed by the Board of Trustees of APA which is charged with the ultimate approval of the final DSM-5 recommendations. The SRC’s charge is to evaluate the strength of the evidence in support of proposed revisions, based on a specific template of validators. This separate peer-review process will provide important guidance to the Board. While the ongoing feedback from the SRC to work groups on specific disorders will not be made available during the DSM-5 development process (as is the case for the deliberations of NIH study sections), summaries of the committee’s final decisions will be incorporated into DSM-5 “source books.” The SRC’s contributions will be reflected in the final criteria of DSM-5. Another committee, the Clinical and Public Health (CPH) Committee, has recently been appointed by the Board to consider clinical utility and public health issues that are not being reviewed by the SRC.

In addition, the APA has worked with the World Health Organization on an ongoing basis to develop harmonization between disorders included in both DSM-5 and ICD-II . Public comment has twice been solicited on proposed diagnostic criteria, and a third public comment period is planned for 2012. Work group members review each comment submitted through the DSM-5 website and consider revisions to criteria based on this input from other health professionals, consumer advocates, patients and families, and other members of the public.

The APA believes that the extensive process of development for DSM-5 will result in a scientifically and clinically useful new edition of the diagnostic manual, and we are indebted to the hundreds of experts who have contributed to its content. We are grateful, as well, for the valuable input from concerned individuals and organizations, and we appreciate the opportunity to respond to the concerns of the American Counseling Association.

Sincerely,
John Oldham, MD President
Attachment

Attachment A: DSM-5 Task Force and Work Group Member Affiliations

2 APA
1 Boston College
1 Brown University 1 Cardiff University
1 Case Western Reserve University
1 The Chinese University of Hong Kong
9 Columbia University
1 Dartmouth Medical School
3 Duke University
1 Emory University
1 Federal University of Rio Grande do Sul
1 Florida State University
1 Free University Medical Center, Amsterdam
1 Hamburg University 9 Harvard University
1 Heinrich Heine University
3 Johns Hopkins University
1 Karolinska Institute
4 King’s College London
1 Maastricht University
2 Mayo Clinic College of Medicine
1 McGill University 1 MDDA-RI
1 The Menninger Clinic
1 Mt Sinai School of Medicine
1 George Washington University/Howard University
1 NICHD
5 NIMH
1 NIAAA
1 NIDA
1 New York Medical College
2 New York University
1 Oregon Health Sciences University
1 Robert Wood Johnson Medical School
1 Rutgers University
4 Stanford University
1 Texas A&M University
1 Tulane University
1 Uniformed Services University
1 Universidad Autonoma Metropolitana-Xochimilco
1 University College London
1 University Hospital of Freiburg
1 University Medical Center Groningen
1 University of Alabama, Birmingham
1 University of Bordeaux 1 University of Dresden
1 University of Amsterdam
2 University of Arizona/Sunbelt Collaborative
1 University of Arkansas for Medical Sciences
2 University of British Columbia
4 University of California, Los Angeles
1 University of California, Berkeley
1 University of California, Davis
5 University of California, San Diego
1 University of Cape Town
1 University of Cincinnati
2 University of Colorado
1 University of Connecticut
1 University of Florida
2 University of Illinois at Chicago
3 University of Iowa
1 University of Laval
1 University of Manchester 1 University of Maryland
1 University of Michigan 1 University of Minnesota
1 University of Naples
2 University of New Mexico 1 University of New Orleans
3 University of New South Wales
1 University of North Carolina
2 University of North Dakota
1 University of Notre Dame
1 University of Oxford
3 University of Pennsylvania
5 University of Pittsburgh
2 University of Puerto Rico
2 University of Rochester 1 University of San Diego 1 University of South Carolina
1 University of Southampton
3 University of Toronto
2 University of Washington 1 Vanderbilt University
1 Viersprong Institute
1 Virginia Commonwealth University
4 Washington University
1 Weill Cornell Medical College
1 Wesleyan University
2 Yale School of Medicine

[Letter ends]

Related information:

1] DSM-5 Development website

2] American Counseling Association releases letter: Calls for external review of DSM-5

3] Coalition for DSM-5 Reform Tab page on Dx Revision Watch site

4] Coalition for DSM-5 Reform website

5] Open Letter and iPetition

American Counseling Association releases letter: Calls for external review of DSM-5

Posted on November 18, 2011 by meagenda

American Counseling Association releases letter: Calls for external review of DSM-5

Post #113 Shortlink: http://wp.me/pKrrB-1pF

The Coalition for DSM-5 Reform Petition can be viewed here iPetition

ACA In The News

Press Release 11.17.11

ACA Expresses DSM-5 Concerns to the American Psychiatric Association

Yesterday, November 17, the American Counseling Association (ACA) released a letter from ACA President Don W. Locke to the to the American Psychiatric Association on behalf of professional counselors expressing current concerns about the DSM-5 revision process. The letter focuses on the need for better empirical evidence, the lack of information about proposed dimensional and cross cutting assessments, problems with the ongoing field trials, concerns about the biological emphasis of the revised definition of mental disorders, and the need for greater transparency.

To view the ACA letter sent to American Psychiatric Association President John Oldham, open here in PDF format:

ACA letter to DSM-5 Task Force November 2011

Full text below, with brief commentary from Dr Allen Frances, MD, who had chaired the DSM-IV Task Force.

DSM-5 Blog

Counselor’s Turn Against DSM-5: Can APA Ignore 120,000 Users?

Allen Frances, MD | 17 November 2011

The users’ revolt against DSM-5 marches on and just became a much, much bigger parade. There are 120,000 counselors in the US — more than 20% of all mental health professionals — and DSM-5 is integral to their daily work. The American Counseling Association DSM-5 Task Force, skillfully led by Dr Dayle Jones, has made a meticulous study of DSM-5 and is alarmed by many of its suggestions.

The following open letter from the ACA president to the president of the American Psychiatric Association, quoted in full, was just posted. It nicely summarizes what is wrong with DSM-5 and recommends essential corrective actions. How long can DSM-5 afford to battle with its users?

***

Dear Dr. Oldham:

I am sending this letter on behalf of the American Counseling Association (ACA), the world’s largest association for professional counselors. There are 120,000 licensed professional counselors in the United States; as such, we represent the second largest group that routinely uses the DSM.

ACA appreciates the efforts of the American Psychiatric Association (APA) and the Task Force to update the manual according to new scientific evidence. However, professional counselors have voiced several concerns about the DSM-5 development process and they have reservations about many of the proposed revisions. We believe resolving these issues are critical to counselors’ continued confidence in the DSM as a tool for competent and ethical diagnosis of psychopathology. Our concerns focus on empirical evidence, dimensional and cross-cutting assessments, field trials, the definition of mental disorder, and transparency.

Empirical Evidence. While we appreciate APA’s commitment to quality research, counselors are concerned that a number of the DSM-5 proposals have little basis in empirical studies. A systematic and independent review of the research base is critical when revising diagnostic criteria. Unfortunately, guidelines for conducting evidence-based reviews (eg, Kendler et al., 2009) were not provided to work groups until approximately 18 months after revisions had begun. The rationales posted on the DSM-5 website provide either incomplete or insufficient empirical evidence to support many of the proposed revisions. Reportedly in response to this, the DSM-5 Task Force appointed a Scientific Review Committee (SRC) charged with reviewing the empirical evidence supporting the proposed revisions. While we strongly applaud this decision, we would like more information as to how the SRC will conduct their review so that those outside the process can be assured of the solidity of the empirical evidence behind the proposals.

Dimensional and Cross-Cutting Assessments. ACA members were initially supportive of the idea of using dimensional and cross-cutting assessments, but our review of the proposed assessments on the DSM-5 website causes us considerable worry. Little information regarding scale development has been provided and, according to the field trial protocols, there is no evaluation using external validators. Furthermore, more than half the disorders—including important disorders such as attention-deficit/hyperactivity disorder and conduct disorder—have no assessments posted on the website, so we cannot effectively evaluate all of the measures being proposed.

Field Trials. Evaluating diagnostic validity using “a variety of external criteria” is essential in developing or revising diagnostic criteria (Kraemer, 2007, p. S9). Yet, the DSM-5 field trial protocols focus exclusively on reliability, feasibility, and user acceptability. There is an absence of external validators (i.e., evaluation of validity using external criterion measures); thus, there is no way of determining whether any of the proposed changes improve the validity of the DSM. Furthermore, since the DSM-IV and DSM-5 criteria are not being simultaneously applied to the same clients, there is no way to assess the impact of changes on prevalence rates of the various mental disorders.

Definition of Mental Disorder. The DSM-5 Task Force has proposed a new definition of mental disorder which includes, “A behavioral or psychological syndrome or pattern that occurs in an individual that reflects an underlying psychobiological dysfunction” (APA, 2011). Using the term psychobiological implies that all mental disorders have an underlying biological component. Although advances in neuroscience have greatly enhanced our understanding of psychopathology, the current science does not fully support a biological connection for all mental disorders. We therefore request that the definition of mental disorder be amended to indicate that mental disorders may not have a biological component.

Transparency. Although the DSM-5 Task Force has described its development process as “open, transparent and free of bias” (Kupfer and Regier, 2009, p. 40), all work group members were required to sign confidentiality agreements that prohibit them from divulging information about the DSM-5 process, even after it is published. Most problematic, the reports of the DSM-5 SRC are not available for public inspection, which is a violation of one of the most basic and vital tenets of science—open access to data and/or processes for independent evaluation and critique. Without full transparency and openness, counselors may have difficulty having confidence in and trusting the DSM-5.

In conclusion, based on these issues, professional counselors have expressed uncertainty about the quality and credibility of the DSM-5. Therefore, to ensure continued trust and confidence in the

DSM-5, we ask that the APA carry out the following recommendations:

1. Make public all empirical evidence submitted to the DSM-5 Scientific Review Work Group, as well as the group’s evaluations and recommendations.

2. Submit all evidence and data (from work groups and field trials) for review by an external, independent group of experts in evidenced-based decision-making and make the results of this review public.

3. Remove any DSM-5 proposed revisions deemed to lack strong empirical evidence by external, independent review, or add them to the Appendix for Criteria Sets Provided for Further Study.

4. Eliminate any dimensional or cross-cutting assessments that lack supportive reliability and validity evidence, limited feasibility and poor clinical utility.

We appreciate and value the work APA has done in developing a diagnostic classification system that is used by over half a million non-psychiatric mental health professionals in the United States. However, to produce a credible diagnostic manual, it is essential that the DSM-5 be based on research that involves rigorous, systematic, and objective procedures; an open process; and independent, objective scientific review.

Sincerely,
Don W. Locke, PhD
ACA President

References [as they appear in Dr Locke's open letter, located at http://www.counseling.org/Resources/pdfs/ACA_DSM-5_letter_11-11.pdf ]

American Psychiatric Association (APA). (2011). Definition of mental disorder. Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=465

Kendler K, Kupfer D, Narrow W, Phillips K, Fawcet J. (2009). Guidelines for making changes to DSM-V. Retrieved from http://www.dsm5.org/ProgressReports/Documents/Guidelines-for-Making-Changes-to-DSM_1.pdf

Kraemer HC. (2007) DSM categories and dimensions in clinical and research contexts. International Journal of Methods in Psychiatric Research, 16(S1), S8-S15

Kupfer DJ, Regier DA. (2009). Counterpoint: Toward credible conflict of interest policies in clinical psychiatry. Psychiatric Times, 26(1), 40-41.

——————

The letter to John M. Oldham, MD, APA President, has been CCd to

Dilip V. Jeste, MD, President-Elect
Roger Peele, MD, Secretary
David Fassler, MD, Treasurer
Carol Ann Bernstein, MD, APA Past President
Alan F. Schatzberg, MD, APA Past President
Nada L. Stotland, MD, MPH APA Past President
Joyce A. Spurgeon, MD, APA ECP Trustee-at-large
Frederick J. Stoddard Jr, MD, APA Area 1 Trustee
James E. Nininger, MD, APA Area 2 Trustee
Brian Crowley, MD, APA Area 3 Trustee
John J. Wernert III, MD, APA Area 4 Trustee
James A. Greene, MD, APA Area 5 Trustee
Marc David Graff, MD, APA Area 6 Trustee
William M. Womack, MD, APA Area 7 Trustee
Ann Marie T. Sullivan, MD, APA Speaker
R. Scott Benson, MD, APA Speaker-Elect
Sarah B. Johnson, MD, APA Member-in-training Trustee
Alik S. Widge, MD, PhD, APA Member-in-training Trustee-Elect
Brian Hurley, MD, APA/Public Psychiatry Fellow
Kimberly Gordon, MD, APA/SAMHSA Fellow
Sarah Faad, MD, American Psychiatric Leadership Fellow
James H. Scully Jr, MD, Medical Director & CEO

dx revision watch

Monitoring the development of DSM-5, ICD-11, ICD-10-CM

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American Psychiatric Association responds to letter from American Counseling Association

American Counseling Association releases letter: Calls for external review of DSM-5

The Coalition for DSM-5 Reform Petition can be viewed here iPetition

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