The stakeholder comment period for the third and final review of draft proposals for DSM-5 categories and criteria closes on June 15. Patients, patient organizations and professional stakeholders have three weeks left in which to submit comments.
US advocate, Mary Dimmock, has prepared a “Call to action”
Call to action – DSM-5 comments needed by June 15, 2012
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is used in the U.S. to categorize mental disorders for patient diagnosis, treatment and insurance. The new version, DSM-5, includes a proposal for Somatic Symptom Disorder (SSD) that will have profound implications for ME/CFS patients. Your input is needed by June 15, 2012 to ensure that the DSM-5 authors understand your concerns…
…SSD can be applied to patients regardless of whether the symptoms are considered to be medically unexplainable or not. Severity is rated by the count and frequency of somatic symptoms. The “Justification for Criteria – Somatic Symptoms”, issued in May 2011, states that CBT, focused on “the identification and modification of dysfunctional and maladaptive beliefs”, is one of the most promising treatments.
Why this matters to ME/CFS patients
A diagnosis of SSD can be “bolted” onto any patient’s diagnosis. All that is required is for the medical practitioner to decide that the patient is excessively concerned with their somatic symptoms and their health. This is done using highly subjective and difficult to measure criteria for which very few independent reliability studies have been undertaken.
For patients with diseases that are poorly understood and misdiagnosed by the medical community, like ME/CFS, this will be disastrous. Once diagnosed inappropriately with SSD, the implications for diagnosis, treatment, disability and insurance will be profound…
A reminder that this third and final stakeholder review and comment period is scheduled to close on June 15.
On May 17, APA added the following statement to the home page of the DSM-5 Development site.
APA Position Statement on DSM-5 Draft Diagnostic Criteria
The official position of the APA on draft DSM-5 diagnostic criteria is that they are not to be used for clinical or billing purposes under any circumstances. They are published on the http://www.dsm5.org Web site to obtain feedback on these preliminary DSM-5 Task Force proposals from mental health professionals, patients, and the general public. They have not received official reviews or approval by the APA Board of Trustees and will not be available for clinical use or billing purposes until May 2013.
Two articles in this week’s online and print editions of New Scientist.
The first report, by Peter Aldhous, quotes Allen Frances, MD, who had chaired the development of the DSM-IV; APA research director and DSM-5 Task Force Vice Chair, Darrel Regier, and Dr Dayle Jones who is tracking DSM-5 for the American Counseling Association, on DSM-5 field trial kappa results and the relegation of Attenuated psychosis syndrome and Mixed anxiety/depression to the DSM-5 appendix.
This article is behind a paywall or a subscription to the print edition.
New Scientist 19 May 2012
Page 6 print edition
THIS WEEK/MENTAL HEALTH
Psychiatry’s new diagnostic bible is creating headaches for doctors and patients alike
The second article, “OPINION ‘Label jars, not people”, by James Davies, is accessible on the New Scientist website without payment or print edition subscription.
New Scientist 19 May 2012
Page 7 print edition
OPINION | James Davies
James Davies is a senior lecturer in social anthropology and psychotherapy at the University of Roehampton, London
“LABEL jars, not people” and “stop medicalising the normal symptoms of life” read placards, as hundreds of protesters – including former patients, academics and doctors – gathered to lobby the American Psychiatric Association’s (APA) annual meeting.
The demonstration aimed to highlight the harm the protesters believe psychiatry is perpetrating in the name of healing. One concern is that while psychiatric medications are more widely prescribed than almost any drugs in history, they often don’t work well and have debilitating side effects. Psychiatry also professes to respect human rights, while regularly treating people against their will. Finally, psychiatry keeps expanding its list of disorders without solid scientific justification…
…Frances proposes that a federal agency ought to assume the job of developing the DSM, although he believes a new organization would be required, one that could be housed in the US Department of Health and Human Services, the Institute of Medicine or the World Health Organization. An equivalent of the FDA is needed to “mind the store,” as he puts it.
This may raise a different set of objections, of course. To what extent, for instance, should a federal agency delve deeply into determining diagnoses and definitions? On the other hand, perhaps this would remove the concerns over self-interest and conflict that have tainted the process. What do you think?
Epidemic: (from epidēmos, prevalent : epi-, epi- + dēmos, people) “…an epidemic refers to an excessive occurrence of a disease.”–from Friis & Sellers, Epidemiology for Public Health Practice, 4th ed, 2010
If claims in the non-professional media can be believed, there is a “raging epidemic of mental illness” in the US¹, if not world-wide—and, in one version of this narrative, psychiatric treatment itself is identified as the culprit. There are several formulations of the “epidemic narrative,” depending on which of psychiatry’s critics is writing. In the most radical version, it is psychiatric medication that is fueling the supposed burgeoning of mental illness, particularly depression and schizophrenia.² More subtle variants suggest that there is a “false epidemic” of some psychiatric disorders, driven by dramatically rising rates of “false positive” diagnoses.³…
Most college binge drinkers and drug users don’t develop lifelong problems. But new mental-health guidelines will label too many of them addicts and alcoholics…
…Among the fiercest critics quoted is Mark Rapley, a clinical psychologist at the University of East London, who puts it this way: “The APA insists that psychiatry is a science. [But] real sciences do not decide on the existence and nature of the phenomena they are dealing with via a show of hands with a vested interest and pharmaceutical industry sponsorship.” Despite commending the DSM-5 authors for “reconsidering some of their most unfortunate mistakes,” clinical psychologist Peter Kinderman of the University of Liverpool adds that the manual remains, at bottom, a bad and faulty system. “The very minor revisions recently announced do not constitute the wholesale revision that is called for,” he is quoted as saying. “It would be very unfortunate if these minor changes were to be used to suggest that the task force has listened in any meaningful way to critics….”
Psychiatrist and author, Allen J. Frances, believes that mental illnesses are being over-diagnosed. In his lecture, Diagnostic Inflation: Does Everyone Have a Mental Illness?, Dr. Frances outlines why he thinks the DSM-V will lead to millions of people being mislabeled with mental disorders. His lecture was part of Mental Health Matters, an initiative of TVO in association with the Centre for Addiction and Mental Health.
Produced in collaboration with the Center for Addiction and Mental Health
Allen J Frances lecture
Diagnostic inflation. Does everyone have a mental illness?
Big Ideas – May 12 and 13 at 5 pm ET
TVO’s lecture series will present special guest speaker Dr. Allen J. Frances, who will outline why he believes that mental illnesses are being over-diagnosed these days and why he thinks the fifth and latest version of the psychiatrist’s bible, Diagnostic and Statistical Manual of Mental Disorders will lead to millions of people being mislabeled with mental disorders.
The lecture will be recorded May 6 at University of Toronto’s Hart House.
BMJ 2012; 344 doi: 10.1136/bmj.e3357 (Published 11 May 2012)
Geoff Watts
The authors of the 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due to be published in May 2013, have responded to previous criticisms of their text by announcing a further series of changes.1
But far from mollifying their critics, these concessions have served to ignite a further and still more vituperative barrage of dissent.
The list of topics under reconsideration or already subject to change can be found on the DSM-5 website.2 It includes the proposed “attenuated psychosis syndrome,” which is slated for further study, and also major depressive disorder. Here the authors have added a footnote “to …
Access to the full text of this article requires a subscription or payment
“…All mental-health disciplines need representation — not just psychiatrists but also psychologists, counselors, social workers and nurses. The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts. Primary care doctors prescribe the majority of psychotropic medication, often carelessly, and need to contribute to the diagnostic system if they are to use it correctly. Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.
Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots…”
John Gever, Senior Editor, MedPage Today | May 10, 2012
…The final drafts are to be completed by August, then they must be approved by a scientific review committee and the task force leadership, and finally by the APA’s governing bodies.
Kupfer said the final version has to be completed by December, when it’s set to go to the printer. Its formal release is planned for the APA’s annual meeting next May in San Francisco.
Here’s a brief overview of the changes you can expect…
WHAT’S OUT
WHAT’S IN (or STILL IN)
WHAT DIDN’T MAKE IT
WHAT TO LOOK FORWARD TO
CHICAGO (Reuters) – Two proposed psychiatric diagnoses failed to make the last round of cuts in the laborious process of revising the Diagnostic and Statistical Manual of Mental Disorders — an exhaustive catalog of symptoms used by doctors to diagnose psychiatric illness.
Gone from the latest revision are “attenuated psychosis syndrome,” intended to help identify individuals at risk of full-blown psychosis, and “mixed anxiety depressive disorder”, a blend of anxiety and depression symptoms. Both performed badly on field tests and in public comments gathered by the group in its march toward the May 2013 publication deadline.
Both have been tucked into Section III of the manual — the place reserved for ideas that do not yet have enough evidence to make the cut as a full-blown diagnosis.
What has survived, despite fierce public outcry, is a change in the diagnosis of autism, which eliminates the milder diagnosis of Asperger syndrome in favor of the umbrella diagnosis of autism spectrum disorder.
But that, too, could still be altered before the final manual is published, the group says. The APA opened the final comment period for its fifth diagnostic manual known as DSM-V on May 2, and it will accumulate comments through June 15.
Dr. David Kupfer, who chairs the DSM-5 Task Force, said in a statement that the changes reflect the latest research and input from the public.
Dr. Wayne Goodman, professor and chairman of the department of psychiatry at Mount Sinai Medical Center in New York, said he’s glad the task force is responding to feedback from professionals and the public.
“I think they are trying to listen,” he said.
Goodman agrees with the decisions to drop both of the two disorders in the latest revision.
With the “mixed anxiety and depressive disorder,” he said there was a risk that it would capture a number of people who did not qualify under a diagnosis of depression or anxiety alone.
“It could lead to overdiagnosis,” Goodman said.
He said the “attenuated psychosis syndrome” diagnosis would have been useful for research purposes to help identify those at risk of psychosis, but there was a concern that it might label people who were just a bit different as mentally ill.
“The predictive value is not clear yet,” he said. “I think it’s reasonable not to codify it until we have better definition of its predictive value.”
Goodman, who worked on DSM-4, the last revision of the manual published in 1994, and is working on the Obsessive Compulsive Disorder section of the current revision of DSM-5, said the strength of the process is that it can offer a reliable way for psychiatrists across the country to identify patients with the same sorts of disorders.
The weakness, he said, is that it largely lacks biological evidence — blood tests, imaging tests and the like — that can validate these diagnoses.
“DSM-5 is a refinement of our diagnostic system, but it doesn’t add to our ability to understand the underlying illness,” he said.
Dr. Emil Coccaro, chairman of the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago Medicine, said typically changes in the DSM occur because of new data.
Coccaro, who is contributing to the new section in the DSM-5 on Intermittent Explosive Disorder, said there is no question that many people aren’t convinced that some of the diagnoses need to be changed, or that there need to be new ones added.
“This also happened the last time when they did DSM-4,” he said, but that was nearly 20 years ago.
“You can keep waiting but at certain point you have to fish or cut bait and actually come out with a new edition. That is what is happening now,” he said.
Comments to the manual can be submitted at www.DSM5.org
(Reuters) – Many psychiatrists believe a new edition of a manual designed to help diagnose mental illness should be shelved for at least a year for further revisions, despite some modifications which eliminated two controversial diagnoses.
The new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) is due out this month, the first full revision since 1994 of the renowned handbook, which is used worldwide and determines how to interpret symptoms in order to diagnose mental illnesses.
But more than 13,000 health professionals from around the world have already signed an open letter petition (at dsm5-reform.com) calling for DSM 5 to be halted and re-thought.
“Fundamentally, it remains a bad system,” said Peter Kinderman, a professor of clinical psychology at Britain’s Liverpool University.
“The very minor revisions…do not constitute the wholesale revision that is called for,” he said in an emailed comment.
The American Psychiatric Association (APA), which produces the DSM, said on Wednesday it had decided to drop two proposed diagnoses, for “attenuated psychosis syndrome” and “mixed anxiety depressive disorder”.
The former, intended to help identify people at risk of full-blown psychosis, and the latter, which suggested a blend of anxiety and depression, had been criticized as too ill-defined.
With these and other new diagnoses such as “oppositional defiant disorder” and “apathy syndrome”, experts said the draft DSM 5 could define as mentally ill millions of healthy people – ranging from shy or defiant children to grieving relatives, to people with harmless fetishes.
“SIMPLY NOT USABLE”
Robin Murray, a professor of psychiatric research at the Institute of Psychiatry at Kings College London, said it was a great relief to see the changes in the draft, particularly to the attenuated psychosis diagnosis.
“It would have done a lot of harm by diverting doctors into thinking about imagined risk of psychosis (and) it would have led to unnecessary fears among patients that they were about to go mad,” he said in a statement.
But Allen Frances, emeritus professor at Duke University in the United States, said: “This is only a first small step toward desperately needed DSM 5 reform. Numerous dangerous suggestions remain.”
Frances, who chaired a committee overseeing the DSM 4, added that the DSM 5 “is simply not usable” and should be delayed for a year “to allow for independent review, to clean up its obscure writing, and for retesting”.
Diagnosis is always controversial in psychiatry, since it defines how patients will be treated based on a cluster of symptoms, many of which occur in several different types of mental illness.
Some argue that the whole approach needs to be changed to pay more attention to individual circumstances rather than slotting them into predefined categories.
“(The DSM) is wrong in principle, based as it is on redefining a whole range of understandable reactions to life circumstances as ‘illnesses’, which then become a target for toxic medications heavily promoted by the pharmaceutical industry,” said Lucy Johnstone, a consultant clinical psychologist for the Cwm Taf Health Board in Wales.
“The DSM project cannot be justified, in principle or in practice. It must be abandoned so that we can find more humane and effective ways of responding to mental distress.”
Others, however, are pushing more for the manual to be reviewed more thoroughly to allow for more accurate diagnosis and, in theory, more appropriate treatment.
One of the proposed changes that has survived in the draft DSM 5 – despite fierce public outcry – is in autism. The new edition eliminates the milder diagnosis of Asperger syndrome in favor of the umbrella diagnosis of autism spectrum disorder.
In a rare step, doctors on a panel revising psychiatry’s influential diagnostic manual have backed away from two controversial proposals that would have expanded the number of people identified as having psychotic or depressive disorders.
The doctors dropped two diagnoses that they ultimately concluded were not supported by the evidence: “attenuated psychosis syndrome,” proposed to identify people at risk of developing psychosis, and “mixed anxiety depressive disorder,” a hybrid of the two mood problems.
They also tweaked their proposed definition of depression to allay fears that the normal sadness people experience after the loss of a loved one, a job or a marriage would be mistaken for a mental disorder.
But the panel, appointed by the American Psychiatric Association to complete the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., did not retreat from another widely criticized proposal, to streamline the definition of autism. Predictions by some experts that the new definition will sharply reduce the number of people given a diagnosis are off base, panel members said, citing evidence from a newly completed study.
Both the study and the newly announced reversals are being debated this week at the psychiatric association’s annual meeting in Philadelphia, where dozens of sessions were devoted to the D.S.M., the standard reference for mental disorders, which drives research, treatment and insurance decisions.
Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and the chairman of the task force making revisions, said the changes came in response mainly to field trials — real-world studies testing whether newly proposed diagnoses are reliable from one psychiatrist to the next — and also public commentary. “Our intent for disorders that require more evidence is that they be studied further, and that people work with the criteria” and refine them, Dr. Kupfer said…
(CBS News) – A panel of doctors reviewing the much-debated Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) have recommended to drop two controversial diagnoses.
The panel announced that attenuated psychosis syndrome — which identifies people at risk of developing psychosis — and mixed anxiety depressive disorder — a diagnosis which combines both anxiety and depression — should not be included in the manual’s upcoming version, the New York Times reported.
Proposed changes to autism definition may mean new diagnoses for people with Asperger’s
However, a controversial definition for autism, which will delete diagnoses for Asperger’s syndrome and pervasive developmental disorder and combine severe cases into the broader definition of autism, will remain…
PHILADELPHIA — The head of the American Psychiatric Association committee rewriting the diagnostic criteria for autism spectrum disorders took on the panel’s critics here, accusing them of bad science.
Susan Swedo, MD, of the National Institute of Mental Health, said a review released earlier this year by Yale University researchers was seriously flawed. That review triggered a wave of headlines indicating that large numbers of autism spectrum patients could lose their diagnoses and hence access to services…
Benefits of catching psychosis early are deemed to come at too high a price.
Amy Max | May 9, 2012
A controversial category of mental illness will not be included in the revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association (APA) has said. Attenuated psychosis syndrome, also known as psychosis risk syndrome, had been intended mainly for young adults who have heard whispers in their heads, viewed objects as threatening or suffered other subtly psychotic symptoms…
A reminder that the third and final DSM-5 comment period closes on June 15 and that I am collating submissions on this site.
Comments are open to professional and lay stakeholders. Please alert clinicians, researchers, allied health professionals, social workers, lawyers, educationalists, therapists, patient advocacy groups to these proposals.
Full proposals, criteria and rationales for the Somatic Symptom Disorders are set out in this post:
According to DSM-5 Task Force Chair, David Kupfer, MD, “After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.”
Somatic Symptom Disorders Work Group proposals:
Two PDF Disorder Descriptions and Rationale/Validity Propositions PDF documents had accompanied the first and second drafts. There are no revised PDFs reflecting the most recent proposals available on the DSM-5 Development website and the documents published with the second draft have been removed.
I have asked the APA’s Media and Communications Office to clarify whether the Somatic Symptom Disorder Work Group intends to publish revised Disorder Descriptions or Rationale/Validity Propositions documents during the life of the stakeholder review period or whether these documents are being dispensed with for this third draft.
Should updated documents be added to the site during the comment period I will post links.
Notes on differences between the second and third draft proposals for CSSD
As with the first and second drafts, the intention remains to rename the Somatoform Disorders section to Somatic Symptom Disorders.
The proposal continues to combine the existing DSM-IV categories:
into a single new category, Somatic Symptom Disorder.
For the second draft, the work group had suggested two separate diagnoses, Complex Somatic Symptom Disorder CSSD) and Simple Somatic Symptom Disorder (SSSD).
Following evaluation of the results of the DSM-5 field trials, the Somatic Symptom Disorders Work Group has decided that Simple Somatic Symptom Disorder is “a less severe variant of CSSD.”
The Work Group now proposes merging CSSD and SSSD into a single category called Somatic Symptom Disorder (SSD) and is suggesting dropping the word “Complex” from the category term.
The latest proposed category names for the revision of the DSM-IV’s Somatoform Disorders now look like this:
Note that the criteria for CSSD in the previous draft, released in May 2011, had read:
“B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following must be present.”
But for the third draft, this has been reduced to
“B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.”
This is presumably to accommodate Simple Somatic Symptom Disorder within what had been the criteria for CSSD.
(Last year, for the second draft, the criteria for CSSD had required two from (1), (2) and (3) and a symptom duration of greater than 6 months, whereas the criteria for SSSD had required only one from (1), (2) and (3) and a symptom duration of greater than one month.)
Note also that the option for three Severity Specifiers for J00 Somatic Symptom Disorder category: Mild, Moderate, Severe, might potentially be intended to correspond to three newly proposed categories in the ICD-11 Chapter 5: Somatoform Disorders section.
In the ICD-11 Alpha drafting platform (which is a work in progress and comes with caveats), the Somatoform Disorders categories are currently proposed to be renamed to Bodily Distress Disorders. There are three new categories listed:
These three new category suggestions have no definitions or descriptive parameters visible in the ICD-11 Alpha draft so it isn’t possible to determine at this stage what disorders these newly suggested terms might be intended to capture; nor how they would relate to the existing somatoform disorders categories that still remain listed beneath them in this section of the Alpha draft.
For comparison, this is how the corresponding section of ICD-11 categories currently displays:
Hypochondriacal disorder [ICD-10: F45.2] is currently listed in ICD-11 Chapter 5 as Illness Anxiety Disorder under 6L5 ANXIETY AND FEAR-RELATED DISORDERS > 6L5.6 Illness Anxiety Disorder.
Dissociative (Conversion disorders) [ICD-10: F44] is currently listed in ICD-11 Chapter 5 under Neurotic, stress-related and somatoform disorders > 7A5 Dissociative [conversion] disorders.
There had been discussions by the SSD and Dissociative Disorders work groups for potentially locating Conversion Disorder under the DSM-5 Dissociative Disorders section, for congruency with its location within ICD-10.
For the third draft, it appears that the groups with oversight of the revision of conversion disorder have decided that this categoryshould be renamed to Conversion Disorder (Functional Neurological Symptom Disorder) and classified as a Somatic Symptom Disorder.
In a future post, for ease of comparison, I will post a table comparing DSM-5 third draft proposals with current listings for ICD-11.
…Members of the task force said they hope to publish the full results “within a month.” However, the third and final public comment period for the manual opened last week and ends on June 15. Although the entire period is 6 weeks long, the public may only have 2 weeks to comment after the publication of the field trials’ findings.
…“No previous field trial had such a sophisticated design. And it has resulted in more statistically significant data for specific disorders,” said Dr. Regier.
The current DSM-5 field trials, as well as field trials for past manuals, use Kappa score as a statistical measure of criteria reliability. A Kappa score of 1.0 was considered perfect, a score of greater than .8 was considered almost perfect, a score of .6 to .8 was considered good to very good, a score of .4 to .6 was considered moderate, a score of .2 to .4 was considered fair and could be accepted, and a score of less than .2 was considered poor.
At adult sites, schizophrenia was shown to have a pooled Kappa score of .46. However, that is down from the .76 and .81 Kappa scores found in the DSM-IV and DSM-III, respectively, and it is less than the .79 score found in the International Classification of Diseases, Tenth Revision (ICD-10).
“It’s important to realize in some ways that the Kappa in the current field trial was from a totally different design…,” said Dr. Regier
Included in Ms Brauser’s report are data for “Complex somatic disorder”:
The field trials for the new proposed category Complex Somatic Symptom Disorder (CSSD) were held at Mayo. According to one of several tables within Ms Brauser’s report, the following data have been released for “Complex somatic disorder” [sic]:
CSSD is a new category for DSM-5 which redefines and replaces some, but not all of the existing DSM-IVSomatoform Disorders categories under a new rubric with a new definition and criteria.
Following evaluation of the field trials, this new category, Complex Somatic Symptom Disorder is now proposed to drop the “Complex” descriptor, be named Somatic Symptom Disorder and absorb Simple Somatic Symptom Disorder (SSSD) – a separate diagnosis that had been introduced for the second draft, with criteria requiring fewer symptoms than for a diagnosis of CSSD and shorter chronicity.
In order to accommodate SSSD, criteria and Severity Specifiers for CSSD have been modified since the second draft. (More on this in the next post.)
Since CSSS (or SSD, as is now proposed) did not exist as a category in DSM-IV, or in ICD-10 or DSM-III, it’s unclear and unexplained by the table what data for which existing somatoform disorders have been used for Kappa comparison for this new category with data for ICD-10 and DSM-III, and how meaningful comparison between them would be.
You can find out more about how the field trials were conducted on the DSM-5 Development site.
Delay in publication of field trial results and no key documents in support of proposals
Stakeholders may not get to scrutinise a report on the field trials until as late as a couple of weeks before the public comment period closes.
There are no Disorder Descriptions and Rationale/Validity Propositions PDF documents that expand on category descriptions and rationales (at least not for the Somatic Symptom Disorders) and reflect revisions to proposals between the release of the second and third draft.
Yesterday, I contacted APA’s Communications and Media Office to enquire whether the Somatic Symptom Disorders work group intends to publish either a Disorder Descriptions or Rationale/Validity Propositions document, or both, to accompany this latest draft during the life of the stakeholder review period or whether these key documents are being dispensed with for the third draft.
I’ll update if and when APA Media and Communications provides clarification.
“…Darrel Regier, MD, the APA’s research director, explained that the trials were intended primarily to establish reliability – that different clinicians using the diagnostic criteria set forth in the proposed revisions would reach the same diagnosis for a given patient. The key reliability measure used in the academic center trials was the so-called intraclass kappa statistic, based on concordance of the “test-retest” results for each patient. It’s calculated from a complicated formula, but the essence is that a kappa value of 0.6 to 0.8 is considered excellent, 0.4 to 0.6 is good, and 0.2 to o.4 “may be acceptable.” Scores below 0.2 are flatly unacceptable.
Kappa values for the dozens of new and revised diagnoses tested ranged from near zero to 0.78. For most common disorders, kappa values from tests conducted in the academic centers were in the “good” range:
In the “excellent” range were autism spectrum disorder [0.69], PTSD [0.67], ADHD [0.61], and the top prizewinner, major neurocognitive disorder [better known as dementia], at 0.78. But some fared less well. Criteria for generalized anxiety disorder, for example, came in with a kappa of 0.20. Major depressive disorder in children had a kappa value of 0.29. A major surprise was the 0.32 kappa value for major depressive disorder. The criteria were virtually unchanged from the version in DSM-IV, the current version, which also underwent field trials before they were published in 1994. The kappa value in those trials was 0.59.
But a comparison is not valid, Regier told MedPage Today…”
“…The results of the DSM 5 field trials are a disgrace to the field. For context, in previous DSM’s, a diagnosis had to have a kappa reliability of about 0.6 or above to be considered acceptable. A reliability of .2-4 has always been considered completely unacceptable, not much above chance agreement…”
Reconstructed from data published by A Frances, DSM 5 in Distress, Psychology Today, 05.06.12
“…No predetermined publication date justifies business as usual in the face of these terrible Field Trial results (which are even more striking since they were obtained in academic settings with trained and skilled interviewers, highly selected patients, and no time pressure. The results in real world settings would be much lower). Reliability this low for so many diagnoses gravely undermines the credibility of DSM 5 as a basis for administrative coding, treatment selection, and clinical research…”
“…The kappa for generalized anxiety disorder was about 0.2 and the kappa for major depressive disorder was about 0.3.
“…These numbers are way too low according to the APA’s own scales—and they are much lower than kappas for the disorders in previous versions of the DSM. Regier and other members of the APA emphasized that field trial methodology for the latest edition is far more rigorous than in the past and that kappas for many diagnoses in earlier editions of the DSM were likely inflated. But that doesn’t change the fact that the APA has a problem on its hands: its own data suggests that some of the updated definitions are so flawed that only a minority of psychiatrists reach the same conclusions when using them on the same patient. And the APA has limited time to do something about it…”
“…Until the APA officially publishes the results of the field trials, nobody outside the association can complete a proper analysis. What I have seen so far has convinced me that the association should anticipate even stronger criticism than it has already weathered. In fairness, the APA has made changes to the drafts of the DSM-5 based on earlier critiques. But the drafts are only open to comment for another six weeks. And so far no one outside the APA has had access to the field trial data, which I have no doubt many researchers will seize and scour. I only hope that the flaws they uncover will make the APA look again—and look closer…”
This article is part a series of commentaries by the chair of the DSM-5 Task Force, which is overseeing the manual’s development. The series will continue until the release of DSM-5 in May 2013.
As of this month, the 12-month countdown to the release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) officially begins. While the developers of DSM-5 will continue to face several deadlines over the coming year, the progress that has been made since APA’s 2011 annual meeting has been nothing short of remarkable.
One of the most notable and talked-about recent activities of the DSM revision concerns the implementation and conclusion of the DSM-5 Field Trials, which were designed to study proposed changes to the manual…
“After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.”
Make Yourself Heard!
The DSM-5 Web site (www.dsm5.org) is open to a third and final round of feedback. For six weeks, patients and their loved ones, members of the profession, and the general public can submit questions and comments via the Web site. All will be read by members of the appropriate DSM-5 work groups.
A summary of changes made to the draft diagnostic criteria since the last comment period (May-July 2011) will help guide readers to important areas for review, but visitors are encouraged to comment on any aspect of DSM-5. After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.
Psychiatrists can use this important opportunity to express their opinions about proposed changes and how they may impact patient care. Since http://www.dsm5.org was first launched in February 2010, the work groups have discussed— and in many cases, implemented draft changes in response to—the feedback received from the site. This final comment period presents a historic opportunity for APA members to take part in the DSM-5 revision process and help impact the way in which psychiatric disorders are diagnosed and classified in the future.
David J. Kupfer, M.D., is chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic.
dx revision watch 