The Trouble with Timelines: DSM-5 round up

The Trouble with Timelines: DSM-5 round up

Post #136 Shortlink: http://wp.me/pKrrB-1LJ

In a November 9, 2011 interview with Deborah Brauser for Medscape Medical News, Darrel Regier, MD, APA Director of Research and Task Force Vice-chair, uttered some chilling statements.

According to Dr Regier:

“Our plan is that these [judgements] will be immediately tested once the DSM is official, and then one will be able to see if revisions can be made…

“Our workgroups are struggling with this balance…for what might be the most appropriate fix. Some of these fixes are not as well studied as others and we recognize that. But we can’t move forward without some of these put into practice. So we think this is a much more testable set of scientific hypotheses…”

“And that’s what the DSM is — a set of scientific hypotheses that are intended to be tested and disproved if the evidence isn’t found to support them…”

“We’re thinking of having a DSM-5.1, DSM-5.2, etc, in much the same way is done with software updates…”

So come May 2013, does APA plan to publish an unvalidated beta as though it were the next release of Firefox, test out its pet theories then release post publication “patches” to fix the flaws?

 

First up, Allen Frances blogging, today, on Psychology Today:

Allen Frances, MD, who chaired the Task Force that had oversight of the development of DSM-IV, is a former chief of psychiatry at Duke University Medical Center and currently professor emeritus at Duke

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

APA Should Delay Publication Of DSM 5 until it can achieve adequate reliability and quality

Allen Frances, MD | January 31, 2012

“…With less than a year remaining before DSM 5 is scheduled to go to print, the signs are clear that it cannot possibly be completed on time unless we are willing to settle for a third rate product. The unmistakable red flag is the recent embarrassing admission that DSM 5 will accept diagnoses that achieve reliabilities as unbelievably low as 0.2-0.4 (barely beating the level of chance agreement two monkeys could achieve throwing darts at a diagnostic board). This dramatic departure from the much higher standards of previous DSM’s is a sure tip-off that many DSM 5 proposals must be failing to achieve adequate diagnostic agreement in the much delayed and yet to be reported field trials. Unable to meet expected standards, the DSM 5 Task Force is drastically and desperately trying to lower our expectations…”

“…The wise, safe, and responsible thing for APA to do now is to delay publication of DSM 5 until the missing second stage of rewriting and retesting can be completed. The wordings that do poorly in the first stage of field testing should be rewritten to finally attain the clarity and consistency necessary in an official manual of psychiatric diagnosis. The newly revised (and hopefully final) versions should then undergo the second stage of field testing as originally envisaged to ensure that they now work…”

“…Will APA do what is needed to protect us from a poor quality DSM 5 and instead provide us with one that is safe and scientifically sound? It seems unlikely. The DSM 5 publishing profits that are essential to APA budget projections require there be a May 2013 debut of the manual in bookstores, come hell or high water. So instead of getting DSM 5 up to minimal standards of quality, DSM 5 is trying to drop the standards to minimal – 0.2-0.4 will have to do.

“What about the DSM 5 claim that its field trials so rigorous that we should entertain only the lowest possible expectations of them? This is nonsense. The DSM 5 field trials were in fact conducted under very privileged circumstances that would guarantee much higher levels of reliability than could ever be achieved in everyday clinical practice: 1) Testing was performed in academic centers with a homogeneous corps of well trained raters interested in psychiatric diagnosis and trying their best because judgments were being observed; 2) Raters had access to the results of a computerized self report instrument, thus reducing information variance; 3) Each site specialized in a limited number of target diagnoses that were known to the raters who would therefore be on the watch for them; 4) The unrealistically high prevalences of target disorders in the sites made agreement much easier than the more needle-in-haystack situation of routine practice; 5) Academic settings attract a selected group of the more severely ill patients who are easier to diagnose reliably; and 6) The time allotted for diagnostic interviews exceeded what is typical in clinical practice…”

“…The May 2013 publication date appears to be completely unrealistic unless we are to settle for a DSM 5 so poorly done that its reliabilities will return us to the dark ages of DSM II. DSM 5 is in a very deep hole with very few remaining options.

“My recommendations: 1) Make the publication date flexible and contingent on delivery of a quality product that the field can trust; 2) Subject the current drafts and texts to extensive editing for clarity and consistency; 3) Drop the controversial suggestions that risk harmful unintended consequences or at least subject them to external scientific review; 4) Have the rewritten drafts reviewed word for word by many experts in the clinical, research, and forensic uses of DSM 5; and 5) Field test again to make sure the new versions work adequately…”

Full commentary here on DSM5 in Distress

 

On Monday, William E. Narrow, MD, in a Q & A for Pittsburgh Post Gazette:

William E. Narrow, M.D., M.P.H., is Associate Director, Division of Research, Research Director, DSM-5 Task Force for American Psychiatric Association

Q&A with Dr. William Narrow, research director for the DSM 5 Task Force

William Narrow | January 30, 2012

The Pittsburgh Post-Gazette asked the American Psychiatric Association to comment on the DSM 5:

Q: Do you think the final form of the DSM-V will differ substantially from the current draft version?

A: There is currently no draft version of DSM-5. The information on the DSM-5 Web site consists of proposed DSM-5 diagnostic criteria and assessment instruments, along with rationales for all changes that have been proposed. The first draft version of the DSM-5, which also includes explanatory text for each disorder and introductory chapters, is currently being developed. We anticipate that many of the proposed changes will be officially adopted. Most notable among these is the proposed change in chapter organization to better reflected a developmental, lifespan approach as well as purported neuroscientific and genetic linkages between diagnostic categories (e.g., placement of the psychosis chapter alongside the bipolar disorders chapter, then followed by the mood disorders chapter). We also anticipate that the proposed inclusion of dimensional assessments will be accepted for DSM-5, although these too were field tested and results are currently being examined. Proposed changes that are considered minimal (e.g., minor changes in wording or criteria) that did not require field testing and, at this point, appear to be sufficiently supported by findings from the literature have a high likelihood of being adopted.

Read the rest of Dr Narrow’s responses here

 

From January 6, John M. Oldham, M.D., President, American Psychiatric Association comments on the APA’s December Board of Trustees meeting, in Psychiatric News:

Psychiatric News | January 06, 2012
Volume 47 Number 1 page 4-6
© American Psychiatric Association

From the President

Your Board’s Agenda Focuses on the Future

John M. Oldham, M.D.

At the  foot of Dr Oldham’s Board meeting commentary you will find a link for a collection of PDF files of meeting materials available to download as a “Board packet”. (This bundle of PDFs may take a while to load.)

See file 11 Item 11.A – DSM Task Force Report.pdf   Retrieved: 01.31.12

Item: 11.A
Board of Trustees
December 2011

DSM-5 TASK FORCE AND WORK GROUP UPDATE

APA Division of Research Report to the APA Board of Trustees
Submitted by: David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.

———–

This report contains:

An overview of DSM-5 text development activities;
Current progress and timeline for the DSM field trials;
Scientific Oversight Committee’s (SOC) current progress and timeline for DSM field trials;
Scientific Oversight Committee’s progress in reviewing proposed DSM-5 disorders;
Overview of a Clinical and Public Health (CPH) review process that is to take place in conjunction with the Scientific Oversight Committee’s review;
Plans for the remainder of 2011 and for 2012.

Under Plans for 2012 it reports:

That the primary focus for 2012 will be on completion of initial draft text for all proposed DSM-5 disorders and data analysis of information gathered from the Large Academic Site and the Routine Clinical Practice (RCP) Field Trials.

That all of the text will receive editorial review throughout December and January.

That a penultimate draft of DSM-5 will be presented to the DSM-5 Task Force for their recommendations by February 1, though portions, it says, will be provided beginning in December, as these become available.

That the SOC and CPH will continue to conduct reviews through Spring of 2012.

That DSM criteria and text will continue to undergo changes based on reviews and recommendations of these various parties as well on comments received from a third public posting of the DSM-5 criteria on the DSM5.org web site, slated for May, 2012.

That the final draft of DSM-5 will be submitted to the APA Assembly and to the Board of Trustees in Fall of 2012 and submitted to APPI press for publication by December 31.

This report provides further confirmation that in December, it was anticipated that the third and final public review of proposals for changes to DSM-IV categories and criteria would be held in May, this year. (Note that the DSM-5 Development website Timeline was updated a few days ago but gives, only vaguely, “Spring”, as the date for a two month public review and comment period).

 

On January 29, Gary Greenberg, author of Inside the Battle to Define Mental Illness, Wired, December 2010, for NYT Op-Ed:

Op-Ed Contributor

Not Diseases, but Categories of Suffering

Gary Greenberg | January 29, 2012

“…On the other hand, given that the current edition of the D.S.M. has earned the association — which holds and tightly guards its naming rights to our pain — more than $100 million, we might want to temper our sympathy. It may not be dancing at the ball, but once every mental health worker, psychology student and forensic lawyer in the country buys the new book, it will be laughing all the way to the bank…”

The Autism Society and Autistic Self Advocacy Network have put out a joint statement on DSM-5:

“The Autism Society and Autistic Self Advocacy Network encourage other organizations and groups to join with us in forming a national coalition aimed at working on issues related to definition of the autism spectrum within the DSM-5.”

The joint statement by the Autistic Self Advocacy Network and the Autism Society of America on the DSM-5 can be read here

 

Benjamin Nugent, Op-Ed piece, NYT:

New York Times

Op-Ed Contributor

I Had Asperger Syndrome. Briefly.

Benjamin Nugent | January 31, 2012

FOR a brief, heady period in the history of autism spectrum diagnosis, in the late ’90s, I had Asperger syndrome…”

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