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

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

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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.

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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,, 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


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