The NAPPP mission is “to promote and advocate for the clinical practice of psychology. NAPPP welcomes licensed, doctoral level psychologists who provide healthcare related services. Retired psychologists, and students also are eligible for membership.”
Petition to Endorse ICD-10-CM for Diagnosis of Mental Disorders
The purpose of this petition is to establish a national policy for psychological practitioners to use the standards of the World Health Organization (WHO) for the diagnosis and treatment of mental disorders. The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version 10 presents worldwide standards for the diagnosis and treatment of mental and physical disorders as adopted by WHO. The advantages for psychology of using ICD-10 include ensuring that psychologists and all other doctoral healthcare providers will use the same diagnostic system. Consistent use of ICD-10 will simplify both establishment of consistent diagnosis and reimbursement for services. Workload counting of practitioners will also be better standardized for organization use.
Use of ICD-10 will also eliminate the political controversies that encumber frequent revisions to the Diagnostic and Statistical Manual (DSM). Finally, psychologists, using the ICD-10-CM to diagnose and treat mental conditions, will advance collaboration and integration of psychological and medical practices. Use of the same ICD-10 system by all health professions could also facilitate a comprehensive understanding of patients and their needs. Failure to use ICD-10-CM by psychologists would marginalize their services in the health care reform movement. All the advantages listed above will aid in implementation of the Affordable Care Act (ACA). Cooperative integration of the various health care professions is a prime goal of the Affordable Care Act (ACA). The US Department of Health and Human Services adopted a Rule April 17, 2012 that postponed compliance with ICD-10 codes until October 1, 2014.* This prime goal had originally been set for January 1, 2012. This delay will allow the Center for Medicare and Medicaid (CMS) to amend its 5010-CM coding system to comply with the ICD-10 Edition of diagnostic and procedure codes. This delay allows psychological practitioners to integrate their coding for reimbursement during the transitions of health care reform. This delay also provides psychology an opportunity to point out deficiencies in the present reimbursement system and to recommend corrective modifications to CMS as it amends its 5010-CM diagnostic and procedure coding system.
To read a comprensive statement on the rationale for the advantages to psychologists to support this petition, go HERE (http://www.nappp.org/pdf/ICD.pdf )
Petitioners strongly urge American Psychological Association Practice Organization and the APA Practice Directorate to expend all possible efforts to implement use of ICD-10 by all practicing psychologists. This action is petitioned and asked to receive priority attention because the clear advantages listed above. Expediting this request needs to be done to achieve these advantages and to circumvent unacceptable developments in the proposed edition of DSM-V**.
*Ed: This is a proposed postponement. No final rule to postpone compliance to October 1, 2014 has yet been issued by CMS.
**Ed: The forthcoming revision of the DSM will be known as “DSM-5” not “DSM-V.”
DSM; DSM-IV; DSM-IV-TR; DSM-IV-PC; DSM-V; DSM V; DSM-5; DSM 5 are registered trademarks of the American Psychiatric Association.
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 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.*
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 rejectedin the absence of a substantial body of independent evidence for the reliability, validity and safety of “SSD” as a construct.]
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.
“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.”
…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.
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…
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:
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)
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
…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…
“…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.
March 20, 2012 — Two researchers have raised concerns that the upcoming Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has been unduly influenced by the pharmaceutical industry, owing to financial conflicts of interest (FCOI) among DSM-5 panel members.
In an essay published in the March issue of PLoS Medicine, Lisa Cosgrove, PhD, from the Edmond J. Safra Center for Ethics, Harvard University, Cambridge, Massachusetts, and Sheldon Krimsky, PhD, from the Department of Public Health and Community Medicine, Tufts University, Boston, say the FCOI disclosure policy does not go far enough and has not been accompanied by a reduction in the conflicts of interest of DSM-5 panel members.
However, John M. Oldham, MD, President of the American Psychiatric Association (APA), “strongly” disagrees.
At DSM5 in Distress, Allen Frances, MD, who had chaired the task force for DSM-IV, writes:
According to this week’s Time magazine, the American Psychiatric Association has just recruited a new public relations spokesman who previously worked at the Department of Defense. This is an appropriate choice for an association that substitutes a fortress mentality and warrior bluster for substantive discussion. The article quotes him as saying: “Frances is a ‘dangerous’ man trying to undermine an earnest academic endeavor.”
…The mind, in our modern conception, is an array of circuits we can manipulate with chemicals to ease, if not cure, depression, anxiety and other disorders. Drugs like Prozac have transformed how we respond to mental illness. But while this revolution has reshaped treatments, it hasn’t done much to help us diagnose what’s wrong to begin with. Instead of ordering lab tests, psychiatrists usually have to size up people using subjective descriptions of the healthy vs. the afflicted.
…Which is why the revision of a single book is roiling the world of mental health, pitting psychiatrists against one another in bitter…
As publication of the next version of the Diagnostic and Statistical Manual of Mental Disorders, also known as DSM-5, approaches in May 2013, the so-called bible of psychiatrists is generating increasing scrutiny. The reason, of course, is that classification of various illnesses can help psychiatrists determine how to pursue treatment, which can involve prescribing medications that can ring registers for drugmakers…
Mr Silverman’s report quotes from a statement issued on March 15 by John M. Oldham, M.D., President of the American Psychiatric Association (APA), in response to the Cosgrove and Krimsky PLoS Medicine Essay, “A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists.”
Statement for John M. Oldham, M.D., President of the American Psychiatric Association:
In their article, “A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists,” which appeared in the March issue of the journal Public Library of Science, and which ABC and other news outlets quoted, Cosgrove and Krimsky question the work of DSM-5’s volunteer Task Force and Work Group members because of publicly disclosed relationships with the pharmaceutical industry. Although we appreciate that Cosgrove and Krimsky acknowledge the commitment the American Psychiatric Association (APA) has already made to reducing potential financial conflicts of interest, we strongly disagree with their analysis and presentation of APA’s publicly available disclosure documents. Specifically, the Cosgrove-Krimsky article does not take into account the level to which DSM-5 Task Force and Work Group members have minimized or divested themselves from relationships with the pharmaceutical industry.
In 2012, 72 percent of the 153 members report no relationships with the pharmaceutical industry during the previous year. The scope of the relationships reported by the other 28 percent of member varies:
• 12 percent reported grant support only, including funding or receipt of medications for clinical trial research;
• 10 percent reported consultations including advice on the development of new compounds to improve treatments; and
• 7 percent reported receiving honoraria.
Additionally, since there were no disclosure requirements for journals, symposia or the DSM-IV Task Force at the time of the 1994 release of DSM-IV, Cosgrove and Krimsky’s comparison of DSM-IV and DSM-5 Task Force and Work Group members is not valid. In assembling the DSM-5’s Task Force and Work Groups, the APA’s Board of Trustees developed an extensive process of written disclosure of potential conflicts of interest. These disclosures are required of all professionals who participate in the development of DSM-5. An independent APA committee reviews these disclosure documents, which are updated annually or whenever a member’s financial interests change. Individuals are only permitted to serve on a work group or the Task Force if they are judged to have no significant financial interests.
The Board of Trustees’ guiding principles and disclosure policies for DSM panel members require annual disclosure of any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments. In addition, all Task Force and Work Group members agreed that, starting in 2007 and continuing for the duration of their work on DSM-5, each member’s total annual income derived from industry sources would not exceed $10,000 in any calendar year. This standard is more stringent than requirements for employees at the National Institutes of Health and for members of advisory committees for the Food and Drug Administration. And since their participation in DSM-5 began, many Task Force members have gone to greater lengths by terminating many of their industry relationships.
Potential financial conflicts of interest are serious concerns that merit careful, ongoing monitoring. The APA remains committed to reducing potential bias and conflicts of interest through our stringent guidelines.
A number of stories followed the publication of the Cosgrove and Krimsky PLoS Medicine Essay. Links for selected reports in this March 14 Dx Revision Watch post:
Adriane Fugh-Berman was stunned by the question: Two graduate students who had no symptoms of mental illness wondered if she thought they should take a powerful schizophrenia drug each had been prescribed to treat insomnia.
“It’s a total outrage,” said Fugh-Berman, a physician who is an associate professor of pharmacology at Georgetown University. “These kids needed some basic sleep [advice], like reducing their intake of caffeine and alcohol, not a highly sedating drug.”
Those Georgetown students exemplify a trend that alarms medical experts, policymakers and patient advocates: the skyrocketing increase in the off-label use of an expensive class of drugs called atypical antipsychotics. Until the past decade these 11 drugs, most approved in the 1990s, had been reserved for the approximately 3 percent of Americans with the most disabling mental illnesses, chiefly schizophrenia and bipolar disorder; more recently a few have been approved to treat severe depression.
But these days atypical antipsychotics — the most popular are Seroquel, Zyprexa and Abilify — are being prescribed by psychiatrists and primary-care doctors to treat a panoply of conditions for which they have not been approved, including anxiety, attention-deficit disorder, sleep difficulties, behavioral problems in toddlers and dementia. These new drugs account for more than 90 percent of the market and have eclipsed an older generation of antipsychotics. Two recent reports have found that youths in foster care, some less than a year old, are taking more psychotropic drugs than other children, including those with the severest forms of mental illness…
…In a conversation with MedPage Today, APA President John Oldham, MD, and DSM-5 task force chairman David Kupfer, MD, defended their handling of the revision and argued that many of the criticisms were off-base.
For starters, Kupfer said, the proposed revisions were still open to change or abandonment. The DSM-5 will assume its near-final form in June or July, he said – meaning that the APA’s annual meeting in May would provide another forum to debate the changes.
“[The proposals] are still open to revision,” he said. “The door is still very much open…”
[Ed: A third and final stakeholder review and comment period is anticipated in “May at the latest.” Benedict Carey reported for New York Times, January 19, “The revisions are about 90 percent complete and will be final by December, according to Dr. David J. Kupfer…chairman of the task force making the revisions.”]
Magazine issue 2853 (Subscription or paywall for access)
Print edition: Page 31 February 25, 2012
One minute with…Nick Craddock
There’s no sense in simply revising the psychiatrist’s diagnostic bible: it will need to be totally replaced to fit the emerging science…
Nick Craddock is professor of psychiatry at the Institute of Psychological Medicine and Clinical Neurosciences at Cardiff University School of Medicine, and is the director of the Welsh National Centre for Mental Health
Full version(Subscription required for online access)
By Anjana Ahuja Anjana Ahuja is a freelance science journalist
In 1973, the American psychologist David Rosenhan sent eight healthy people, and also himself, to visit mental institutions and claim they were hearing voices. All were certified mad; some were incarcerated for a month. Rosenhan’s paper, “On Being Sane in Insane Places,” created a media sensation and a crisis in psychiatry. Doctors, it seemed, unlike suspicious fellow patients, could not tell a lucid stooge from a lunatic.
The ensuing controversy led to the tightening of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM), the “psychiatrists’ bible” that lists mental disorders and their symptoms. The DSM, first published in 1952, is produced by the American Psychiatric Association (APA), which, every decade or two, assembles a hundred or so mental health professionals to review disorders in the light of new science or shifting cultural norms…
Full version(Subscription required for online access)
Donna Rockwell, Psy.D. was once a CNN reporter covering Capitol Hill. She is now a psychologist and a member of the petition committee calling for an independent scientific review of DSM 5. With her journalist’s instinct for the crux of any story, Dr. Rockwell has focused on increasing public scrutiny of DSM 5. She hopes to stimulate government intervention to ensure that DSM 5 meets its public trust. Dr Rockwell sent this email on Feb. 17:
You recently described the press as the one last hope to ensure that DSM 5 will be safe and sound. While I certainly agree that the press can do a great deal, there is an additional last hope you didn’t mention, one that could be even more powerful. Don’t discount the role of government intervention as a way of influencing the American Psychiatric Association.
I am currently networking on Capitol Hill and also with the Department of Defense and with the Veterans Administration. My goal is to increase awareness of the risks of DSM 5 and to recruit government assistance in forcing APA to abandon dangerous suggestions.
I tell government officials that DSM 5 will have a big impact on many important public health and public policy decisions that will directly affect their constituents. My short list includes: 1) raising the percentage of our citizens who are considered to be mentally ill — they are surprised to learn that it is already an astounding 50% lifetime; 2) increasing the cost of drug treatments and their harmful side effects; 3) pulling scarce mental health resources away from those who are really ill and most need them; 4) distorting benefit determinations for insurance, disability, compensation, and school services; and 5) creating great confusion in the courts.
The people I speak to all quickly understand the public health and public policy significance of DSM 5 and that government has a big stake in making it safe.
I am especially reaching out to the HELP (Health, Education, Labor & Pensions) committee chaired by Sen. Tom Harkin (D-IA), which oversees mental health issues and to Sen. Charles Grassley (R-IA), who has been very successful in holding doctors accountable. People in government are particularly concerned when I tell them that DSM 5 will have its worst impact on the most vulnerable populations — children, teenagers, and the elderly; veterans; and the severely mentally ill. I think the sentiment is growing that government intervention will be necessary to protect the public interest from the guild interests of the American Psychiatric Association and the economic interests of the drug companies.
I use concrete examples to get my points across. Most alarming, that DSM 5 will increase the already shameful overuse of antipsychotic drugs in kids and thus contribute to the dangerous epidemic of childhood obesity. DSM 5 will also greatly expand the diagnosis and medication treatment of ADD and indirectly facilitate the booming illegal market in prescription stimulants. DSM 5 will turn normal grief into depression. And DSM 5 will scare people into thinking they are on the road to dementia when all they have is the normal forgetfulness of aging. The Hill staffers I talk to all seem understand the risks of DSM 5 and I hope they will soon hold hearings. There is also considerable interest in the risks of DSM 5 at the VA and at DOD, where polypharmacy has been such a big problem.
The general public can help by calling or emailing congressional representatives to request protection from DSM 5. People should demand that DSM 5 be subjected to an outside, unbiased scientific review before accepting the controversial proposals that are getting so much negative press attention. I hope a legislative option can be forged in this battle to protect the nation’s mental health from the excesses of DSM 5.
I do wonder how loudly must the public and the professional mental health community shout, “Stop!”, before reason prevails. We need a government agency or elected official to take the lead in protecting the American people from the impending crisis of medicalised normality and excessive prescription drug use. The government must apply the brakes on DSM-5 before pharmacological over-kill impacts harmfully on even more people.”
As I read this, I find it both sad and silly that DSM 5 has allowed things to degenerate to the point where government intervention may indeed be necessary. DSM 5 has stubbornly ignored the general consensus that many of its suggestions simply make no sense and may cause grave damage both to public health and public policy. The DSM 5 hot potato suggestions should have been dropped long ago. They certainly must be rejected now.
Adding a new diagnoses in psychiatry can be far more dangerous than approving one of the new “me-too” drugs that so often come to market. It is paradoxical and nonsensical for us to carefully vet new drugs through a fairly rigorous FDA procedure but at the same time allow new diagnoses to be introduced through a badly flawed decision-making process completely controlled by just one professional organization that has lost its credibility. The new diagnoses suggested by DSM 5 will lead to widespread misdiagnosis and inappropriate drug use — causing far more damage than could possible be wrought by any new “me-too” drug.
To date, APA has failed to provide appropriate governance. DSM 5 has proven unable to govern itself, is not governed by APA, is not responsive to the heated opposition of mental health professionals and the public, and is insensitive to being shamed repeatedly by the world press. Government intervention may turn out to be the only hope to prevent massive misdiagnosis and all its harmful, unintended consequences.
Over 12,000 individuals and organizations have now signed the Coalition for DSM-5 Reform petition
Mental health professionals and mental health organizations can sign the petition here:
Please note the Coalition for DSM-5 Reform petition is intended for endorsement by mental health organizations and professional bodies and for signing by mental health professionalsnot intended for signing by patients.
Dx Revision Watch has no connection with the Coalition for DSM-5 Reform, its Open Letter initiative or associated petition. All enquiries relating to the Coalition for DSM-5 Reform should be addressed directly to Dr David Elkins, Ph.D., Chair, Coalition for DSM-5 Reform committee.
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