According to yesterday’s report from Deborah Brauser for Medscape Medical News (Concern Over Changes to Autism Criteria Unfounded, Says APA, January 25, 2012), the portion of the DSM-5 field trials conducted at academic centers concluded at the end of October.
The routine clinical settings field trials, scheduled to complete by December but extended in order that more participants might be recruited (DSM-5 Disorganization, Disarray, and Delays, Dr Dayle Jones, American Counseling Association, January 3, 2012), are now expected to complete in March, this year.
In November, DSM-5 Task Force Vice-chair, Darrel Regier, MD, predicted the pushing back of the final public feedback period from January–February, to “no later than May 2012” (APA Answers DSM-5 Critics, Deborah Brauser, November 9, 2011), in response to timeline slippage.
I noticed, today, that the Timeline on the DSM-5 Development site has finally been updated to reflect a “Spring” posting of draft diagnostic criteria, for a two month long stakeholder review and comment period.
No dates appear to being publicly released, at this point, for this third and final public review.
The lack of advance dates presents barriers to public and professional participation.
Patient advocacy organizations need to alert their constituencies and their professional advisers whose opinions will inform consumer group submissions. Professional organizations and bodies who submit feedback in consultation with their memberships will also need to plan the sending out of timely alerts via newsletters and membership publications.
The second release of draft proposals was posted on May 4, last year, with no prior announcement or news release by APA and left many organizations and advocates, including myself, unprepared.
It is hoped that APA will give reasonable notice before releasing this third and final draft – though how much influence professional and public feedback might have at this late stage in the DSM-5 development process is moot.
Allen Frances talked to The Coffee Klatch Parents strand on January 25, 2012
Audio
Dr Allen Frances Chair of the DSM-IV Task Force returns to discuss the confusion and concerns over the soon to be released DSMV. How will the changes impact your child? What do the changes mean for your childs accommodations? Why are so many additions and revisions causing so much controversy?
In a bitter skirmish over the definition of depression, a new report contends that a proposed change to the diagnosis would characterize grieving as a disorder and greatly increase the number of people treated for it.
The criteria for depression are being reviewed by the American Psychiatric Association, which is finishing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., the first since 1994. The manual is the standard reference for the field, shaping treatment and insurance decisions, and its revisions will affect the lives of millions of people for years to come.
In coming months, as the manual is finalized, outside experts will intensify scrutiny of its finer points, many of which are deeply contentious in the field. A controversy erupted last week over the proposed tightening of the definition of autism, possibly sharply reducing the number of people who receive the diagnosis. Psychiatrists say current efforts to revise the manual are shaping up as the most contentious ever…
…The proposed elimination of the bereavement exclusion—which like all proposals for DSM-5 is still being reviewed—is the subject of an article in the New York Times today citing researchers at Columbia who claim that removing the exclusion would medicalize normal grief.
But Jan Fawcett, M.D., chair of the work group, told Psychiatric News that people who develop the symptoms and the level of impairment associated with major depression should have access to treatment. And he wondered: Is there any difference between depression that occurs in response to grief and that which occurs in response to any other life stress? “Where do you draw the line?” he asked…
An effort that promises to broaden the definitions of mental illnesses is spurring a revolt among health-care professionals in the U.S. and the U.K…
…The October letter and the June criticism by the British Psychological Association, have a spirited exchange that resulted this month in the critics calling for an independent scientific review of the more controversial diagnosis changes.
“It really isn’t possible to identify what kind of outside group would have the expertise and range of discipline and disorders we’re covering to do that kind of outside review,” Regier said by telephone. Still, he said the panel members are interested in the criticisms of their proposals and “we’re not taking them lightly.”
Elizabeth Lopatto has written an excellent piece in today’s Bloomberg News summarizing concerns that DSM 5 will expand the boundaries of psychiatry, increase the already existing diagnostic inflation, and promote the excessive use of medications to treat life problems that don’t really require them.
The Vice Chair of the DSM 5 Task Force tries to defend DSM 5 but with statements that have a strange Alice-in-Wonderland out-of-touch-with-reality quality…
“When it comes to revising the official diagnostic classification system, the guiding principle should be that criteria should not be changed in the absence of research demonstrating that the new approach is superior to the old in either validity or clinical utility, preferably both,” Zimmerman states. “Despite assurances that only data-driven modification would be made, with each new edition of the DSM, we have witnessed repeated instances of changes being made in the absence of sufficient data demonstrating the new criteria is superior…”
…Zimmerman comments, “The findings of the present study highlight our concerns about adopting changes in the diagnostic manual without adequate empirical evaluation beforehand. To be sure, there are problems with the classification of personality disorders, however, the identification of a problem is only the first step of a process resulting in a change to diagnostic criteria.”
He concludes, “The classification of personality disorders would not be improved if the new criteria or diagnostic material were more clinically useful but less reliable and valid.”
NOTE: This guest blog comes to you authored by Ray Blanchard, Ph.D., who is an Adjunct Professor, Department of Psychiatry, University of Toronto and an Affiliate Scientist, Centre for Addiction and Mental Health, Toronto, Ontario, Canada. He is also the Chair of the Paraphilias Subworkgroup for the DSM-5 Work Group on Sexual and Gender Identity Disorders and was the 2010 recipient of ATSA’s Significant Achievement Award.
The Proposal to Add Intense or Preferential Sexual Interest in Early Pubescent Children to the DSM-5 Diagnosis of Pedophilic Disorder
Ray Blanchard, Ph.D.
The proposal of the DSM-5 Work Group on Sexual and Gender Identity Disorders to extend the definition of Pedophilic Disorder to include preferential attraction to children in the early stages of puberty has prompted an extraordinarily vigorous and often misleading rhetorical campaign by its opponents. Although debate on this topic may be healthy, deliberate distortion and disinformation are not. I am therefore writing this piece to give an accurate account of the Work Group’s reasons for this proposal. All of the arguments in it have previously been made in conference presentations, in print documents (usually authored by members of the Paraphilias Subworkgroup of the Work Group on Sexual and Gender Identity Disorders), and in on-line sources (http://www.dsm5.org/). This piece simply puts these arguments together in one convenient and readily accessible place.
DSM-5 proposals and autism spectrum disorder (ASD)
A good deal published over the last week around DSM-5 proposals and autism spectrum disorder (ASD) which can be pulled up via Google News. Selected items:
American Psychiatric Association put out this News Release (Release No. 12.03) on January 20, 2012:
ARLINGTON, Va. (Jan. 20, 2012)—The American Psychiatric Association (APA) has proposed new diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for autism. While final decisions are still months away, the recommendations reflect the work of dozens of the nation’s top scientific and research minds and are supported by more than a decade of intensive study and analysis. The proposal by the DSM-5 Neurodevelopmental Work Group recommends a new category called autism spectrum disorder which would incorporate several previously separate diagnoses, including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified.
The proposal asserts that symptoms of these four disorders represent a continuum from mild to severe, rather than a simple yes or no diagnosis to a specific disorder. The proposed diagnostic criteria for autism spectrum disorder specify a range of severity as well as describe the individual’s overall developmental status–in social communication and other relevant cognitive and motor behaviors.
Dr. James Scully, Medical Director of the American Psychiatric Association said, “The proposed criteria will lead to more accurate diagnosis and will help physicians and therapists design better treatment interventions for children who suffer from autism spectrum disorder.”
The draft DSM-5 criteria will provide a more useful dimensional assessment to improve the sensitivity and specificity of the criteria. This change will help clinicians more accurately diagnose people with relevant symptoms and behaviors by recognizing the differences from person to person, rather than providing general labels that tend not to be consistently applied across different clinics and centers.
Proposed DSM-5 criteria are being tested in real-life clinical settings known as field trials. Field testing of the proposed criteria for autism spectrum disorder does not indicate that there will be any change in the number of patients receiving care for autism spectrum disorders in treatment centers–just more accurate diagnoses that can lead to more focused treatment.
Criteria proposed for DSM-5 are posted on the DSM-5 website and will be open for additional public comment this spring. More information on the process for developing DSM-5 is also available on the website. Final publication of DSM-5 is planned for May 2013.
DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychiatric Association (APA) will publish DSM-5 in 2013, culminating a 14-year revision process. For more information, go to www.dsm5.org .
The American Psychiatric Association is a national medical specialty society whose physician members specialize in the diagnosis, treatment, prevention, and research of mental illnesses including substance use disorders. Visit the APA at www.psych.org, www.psychiatryonline.org, and www.HealthyMinds.org.
After much study, the DSM-5 Neurodevelopemental Disorders Work Group has concluded that there is no evidence to support continued separation of autism spectrum disorder (ASD) diagnoses, Susan Swedo, M.D., the work group chair, told Psychiatric News. “That is why we’ll be recommending that DSM-5 utilize a single diagnosis—ASD.”
The move to a single diagnosis of autism spectrum disorder would eliminate Asperger’s disorder and pervasive developmental disorder-not otherwise specified as separate diagnoses. They are included in DSM-IV. The possible elimination of Asperger’s has proven controversial, as evidenced by an article in the New York Times yesterday suggesting that the proposed change would narrow the definition and exclude people in need of a diagnosis and treatment. But in fact, adults or children diagnosed with Asperger’s according to DSM-IV criteria would meet criteria for autism spectrum disorder, with “specifiers” that help clinicians identify patients who have individual differences…
Proposed changes in the definition of autism would sharply reduce the skyrocketing rate at which the disorder is diagnosed and might make it harder for many people who would no longer meet the criteria to get health, educational and social services, a new analysis suggests.
The definition is now being reassessed by an expert panel appointed by the American Psychiatric Association, which is completing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, the first major revision in 17 years. The D.S.M., as the manual is known, is the standard reference for mental disorders, driving research, treatment and insurance decisions. Most experts expect that the new manual will narrow the criteria for autism; the question is how sharply…
A debate among medical professionals over how to define autism has spilled over into the public domain, stirring anger and fear among many parents and advocates of those with the neurological disorder, even as some argue that the diagnosis has been too loosely applied.
A study reported on Thursday found that proposed revisions to the American Psychiatric Association’s definition would exclude about three-quarters of those now diagnosed with milder forms of autism called Asperger syndrome or “pervasive developmental disorder, not otherwise specified,” also known as P.D.D.-N.O.S. These are people who have difficulties with social interaction but do not share the most severe impairments of children with classic autism.
January 25, 2012 — Concerns that proposed changes to autism criteria in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) will exclude many individuals from diagnosis and treatment are unfounded, says the American Psychiatric Association (APA)…
Emily A. Kuhl, PhD, David J. Kupfer, MD, and Darrel A. Regier, MD, MPH
The forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 [1]) will mark the first time in nearly 2 decades that the field has overhauled the way mental illnesses are diagnosed and classified. Anticipation of the DSM-5 has been high, and recent discussions about changes likely to be adopted have focused largely on the manual’s increased integration of scientific and clinical evidence in support of proposed revisions [2, 3]. An equally important, though perhaps less frequently heard, voice in this dialogue concerns the potential ethical consequences of the DSM-5’s draft revisions.
The therapeutic alliance between psychiatrist and patient is unique and requires constant vigilance on ethical matters of self-harm or harm to others, confidentiality, legal aspects of diagnosis and treatment (e.g., competency), patient autonomy, involvement of third parties, dual agency and dual relationships, and patient stigma. This last issue is of particular concern; perhaps more so than in any other area of medicine, stigma has become a routine aspect of the lived experience for many people with mental illnesses.
My biggest concern regarding DSM-5 is that it will dramatically increase the rates of mental disorder by cheapening the currency of psychiatric diagnosis—arbitrarily and carelessly reducing thresholds for existing disorders and introducing new disorders with high prevalence. This would create millions of newly mislabeled “patients,” resulting in unnecessary and potentially harmful treatment, stigma, and wasteful misallocation of scarce resources…
Allen Frances, MD, who chaired the Task Force that had oversight of the development of DSM-IV, publishes the second in a series of Huffington Post blogs on his concerns for the forthcoming DSM-5.
Allen Frances | January 19, 2012 Professor Emeritus, Duke University
Preventive psychiatry may someday be of significant service in reducing the burden of human suffering – but only if it can be done really well. And the sad truth is that we don’t yet have the necessary tools. More people will be harmed than helped if psychiatry stretches itself prematurely to do what is currently well beyond its reach. That’s what is so scary about the unrealistic prevention ambitions of DSM-5, the new manual of mental disorders now in preparation and set to become official in 2013. DSM-5 proposes a radical redefinition of the boundaries of psychiatry, giving it the impossible role of identifying and treating mental disorders in their nascent stages before they have fully declared themselves. Tens of millions of people now deemed normal would suddenly be relabeled mentally disordered and subjected to stigma and considerable risks consequent to inappropriate treatment…
SAMHSA News Release
Date: 1/19/2012 12:05 AM
Media Contact: SAMHSA Press Office
Telephone: 240-276-2130
National report finds one-in-five Americans experienced mental illness in the past year Substance dependence and abuse rates higher among those experiencing mental illness
A new national report reveals that 45.9 million American adults aged 18 or older, or 20 percent of this age group, experienced mental illness in the past year. The rate of mental illness was more than twice as high among those aged 18 to 25 (29.9 percent) than among those aged 50 and older (14.3 percent). Adult women were also more likely than men to have experienced mental illness in the past year (23 percent versus 16.8 percent).
Mental illness among adults aged 18 or older is defined as having had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) in the past year, based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994).
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health also shows that 11.4 million adults (5 percent of the adult population) suffered from serious mental illness in the past year. Serious mental illness is defined as one that resulted in serious functional impairment, which substantially interfered with or limited one or more major life activities.
SAMHSA through its strategic initiative on substance abuse and mental illness prevention and recovery is working to assist states, territories, tribal governments, and communities to adopt evidence-based practices; deliver health education related to prevention; and establish effective policies, programs, and infrastructure to help address these problems. Throughout the nation new programs are underway to strengthen the capacity of communities to better service the needs of those suffering from mental illness.
“Mental illnesses can be managed successfully, and people do recover,” said SAMHSA Administrator Pamela S. Hyde. “Mental illness is not an isolated public health problem. Cardiovascular disease, diabetes, and obesity often co-exist with mental illness and treatment of the mental illness can reduce the effects of these disorders. The Obama Administration is working to promote the use of mental health services through health reform. People, families and communities will benefit from increased access to mental health services.”
The economic impact of mental illness in the United States is considerable—about $300 billion in 2002. According to the World Health Organization, mental illness accounts for more disability in developed countries than any other group of illnesses, including cancer and heart disease.
In terms of treatment statistics, the report indicates that about 4 in 10 people experiencing any mental illness in the past year (39.2 percent) received mental health services during that period. Among those experiencing serious mental illness the rate of treatment was notably higher (60.8 percent).
The report also noted that an estimated 8.7 million American adults had serious thoughts of suicide in the past year – among them 2.5 million made suicide plans and 1.1 million attempted suicide. Those in crisis or knowing someone they believe may be at immediate risk of attempting suicide are urged to call the National Suicide Prevention Lifeline 1-800-273-TALK (8255) or http://www.suicidepreventionlifeline.org . This suicide prevention hotline network funded by SAMHSA provides immediate free and confidential crisis round-the-clock counseling to anyone in need throughout the country, everyday of the year.
According to the report, rates for substance dependence were far higher for those who had experienced either any mental illness or serious mental illness than for the adult population which had not experienced mental illness in the past year. Adults experiencing any mental illness in the past year were more than three times as likely to have met the criteria for substance dependence or abuse in that period than those who had not experienced mental illness in the past year (20 percent versus 6.1 percent). Those who had experienced serious mental illness in the past year had even a higher rate of substance dependence or abuse (25.2 percent). “These data underscore the importance of substance abuse treatment as well,” said SAMHSA Administrator Pamela S. Hyde.
“Mental illness is a significant public health problem in itself, but also because it is associated with chronic medical diseases such as cardiovascular disease, diabetes, obesity, and cancer, as well as several risk behaviors including physical inactivity, smoking, excessive drinking, and insufficient sleep,” said Ileana Arias, Ph.D., Principal Deputy Director of CDC. “Today’s report issued by SAMHSA provides further evidence that we need to continue efforts to monitor levels of mental illness in the United States in order to effectively prevent this important public health problem and its negative impact on total health.”
The report also has important findings regarding mental health issues among those aged 12 to 17. According to the report 1.9 million youth aged 12 to 17 (8 percent of this population) had experienced a major depressive episode in the past year. A major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had at least four of seven additional symptoms reflecting the criteria as described in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994).
In addition, the report finds that young people aged 12 to 17 who experienced a major depressive episode in the past year have more than twice the rate of past year illicit drug use (37.2 percent) as their counterparts who had not experienced a major depressive episode during that period (17.8 percent).
The 2010 National Survey on Drug Use and Health is a scientifically conducted annual survey of approximately 67,500 people throughout the country, aged 12 and older. Because of its statistical power, it is the nation’s premier source of statistical information on the scope and nature of many behavioral health issues affecting the nation.
SAMHSA is a public health agency within the Department of Health and Human Services. Its mission is to reduce the impact of substance abuse and mental illness on America’s communities.
Allen Frances, MD, chaired the DSM-IV Task Force and a former chair of the Department of Psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.
based on the The American Journal of Psychiatry article DSM-5: How Reliable Is Reliable Enough? Helena Chmura Kraemer, Ph.D.; David J. Kupfer, M.D.; Diana E. Clarke, Ph.D.; William E. Narrow, M.D., M.P.H.; Darrel A. Regier, M.D., M.P.H. January 01, 2012, Vol. 169. No. 1
Two Fallacies Invalidate the DSM-5 Field Trials APA telegraphs that DSM 5 will be unreliable.
Allen Frances, MD | January 16, 2012
The designer of the DSM-5 Field Trials has just written a telling commentary in the American Journal of Psychiatry. She makes two very basic errors that reveal the fundamental worthlessness of these field trials and their inability to provide any information that will be useful for DSM-5 decision making.
1) The commentary states: “A realistic goal is a kappa between 0.4 and 0.6, while a kappa between 0.2 and 0.4 would be acceptable.” This is simply incorrect and flies in the face of all traditional standards of what is considered ‘acceptable’ diagnostic agreement among clinicians. Clearly, the commentary is attempting to greatly lower our expectations about the levels of reliability that were achieved in the field trials – to soften us up to the likely bad news that the DSM-5 proposals are unreliable. Unable to clear the historic bar of reasonable reliability, it appears that DSM-5 is choosing to drastically lower that bar – what was previously seen as clearly unacceptable is now being accepted.
Kappa is a statistic that measures agreement among raters, corrected for chance agreement. Historically, kappas above 0.8 are considered good, above 0.6 fair, and under 0.6 poor. Before this AJP commentary, no one has ever felt comfortable endorsing kappas so low as 0.2-0.4. As a comparison, the personality section in DSM III was widely derided when its kappas were around 0.5. A kappa between 0.2-0.4 comes dangerously close to no agreement. ‘Accepting’ such low levels is a blatant fudge factor – lowering standards in this drastic way cheapens the currency of diagnosis and defeats the whole purpose of providing diagnostic criteria.
Why does this matter? Good reliability does not guarantee validity or utility – human beings often agree very well on things that are dead wrong. But poor reliability is a certain sign of very deep trouble. If mental health clinicians cannot agree on a diagnosis, it is essentially worthless. The low reliability of DSM-5 presaged in the AJP commentary confirms fears that its criteria sets are so ambiguously written and difficult to interpret that they will be a serious obstacle to clinical practice and research. We will be returning to the wild west of idiosyncratic diagnostic practice that was the bane of psychiatry before DSM III.
2) The commentary also states: “one contentious issue is whether it is important that the prevalence for diagnoses based on proposed criteria for DSM-5 match the prevalence for the corresponding DSM-IV diagnoses” …. “to require that the prevalence remain unchanged is to require that any existing difference between true and DSM-IV prevalence be reproduced in DSM-5. Any effort to improve the sensitivity of DSM-IV criteria will result in higher prevalence rates, and any effort to improve the specificity of DSM-IV criteria will result in lower prevalence rates. Thus, there are no specific expectations about the prevalence of disorders in DSM-5.”
This is also a fudge. For completely unexplained and puzzling reasons, the DSM-5 field trials failed to measure the impact of its proposals on rates of disorder. These quotes in the commentary are an attempt to justify this fatal flaw in design. The contention is that we have no way of knowing what true rates of a given diagnosis should be – so why bother to measure what will be the likely impact on rates of the DSM-5 proposals. If rates double under DSM-5, the assumption will be that it is picking up previous false negatives with no need to worry about the risks of creating an army of new false positives.
This is irresponsible for two reasons. First off, we are already suffering from serious diagnostic inflation. Rates of psychiatric disorder are already sky high (25% in the general population in any year; 50% lifetime) and we recently have experienced three runaway false epidemics of childhood disorders in the past 15 years. Second, drug company marketing has been so abusive as to warrant enormous fines and so successful as to result in widespread misuse of medication for very questionable indications. Recent CDC data suggest that the severely ill remain very undertreated, but that the mildly ill or not ill at all have become massively overtreated, especially by primary care physicians.
The DSM-5 proposals will uniformly increase rates, sometimes dramatically. Not to have measured by how much is unfathomable and irresponsible. The new diagnoses suggested for DSM-5 will (mis)label people at the very populous boundary with normality. Mixed anxiety depression and binge eating disorder will likely have astounding high rates between 5-10% – that’s tens of millions people now considered ‘normal’ suddenly converted into mentally ill by arbitrary DSM-5 fiat. Psychosis risk and disruptive mood disorder will be extremely common in the young; minor neurocognitive among the elderly. Legions of the recently bereaved will be misdiagnosed as clinically depressed; rates of generalized anxiety and addiction will mushroom; and ADD which has already almost tripled will find even more room at the top. The field trial developers seem either unaware or insensitive to the unacceptable risks involved in creating large numbers of false positive, pseudo-patients.
Indeed, quite contrary to the blithe assertions put forward in the commentary, we should have rigorous expectations about prevalence changes triggered by any DSM revision. Rates should not be wildly different for the same disorder UNLESS there is clear evidence of a serious false negative problem and firm protections against creating a massive false positive problem. And new disorders with high prevalences should not be included without substantial scientific evidence and convincing proof of accuracy, reliability, and safety. We have known since they were first posted that none of the DSM-5 proposals comes remotely close to meeting a minimal standard for accuracy and safety. And now, the AJP commentary seems to be softening us up for the bad news that their reliability is also lousy.
The workers on DSM-5 ignore the often dire implications of drastically raising the prevalence of an existing disorder or adding an untested new disorder with high prevalence – i.e., the misguided and potentially harmful treatment, the unnecessary stigma, and rising health care costs that also cause a misallocation of very scarce resources. Just two examples. Do we really want even more antipsychotic medications prescribed for children, the elderly, and returning war veterans when these are already being used so loosely and inappropriately? Isn’t the current legal and illegal overuse of stimulant medications already a big enough problem without introducing a drastically lowered set of criteria for diagnosing ADD? Sad to say, DSM-5 has failed to do an adequate risk/benefit analysis on any of its suggestions. Every one of its changes is designed to chase elusive false negatives; none protects the interests of mislabeled false positives.
Given our country’s current binge of loose diagnostic and medication practice (particularly by the primary care physicians who do most of the prescribing), DSM-5 should not be in the business of casually raising rates and offering inviting new targets for aggressive drug marketing. Instead, DSM-5 should be working in the opposite direction – taking steps to increase the precision and specificity of its diagnostic criteria. And the texts describing each disorder should contain a new section warning about the risks of overdiagnosis and ways of avoiding it. It is impossible to say what is the “right” prevalence of any disorder, but it is careless and reckless to so dramatically increase the prevalences of mental disorders without evidence of need or proof of safety.
The DSM-5 field trials have cost APA at least $3 million (perhaps a whole lot more). They started off on the wrong foot by asking the wrong question – focusing only on reliability and completely ignoring prevalence. The deadlines for starting the trials and for delivering results have been repeatedly postponed because of poor planning, an excessively cumbersome design, and disorganized implementation. The results will be arriving at the very last minute when decisions should have already be made. And now we get a broad hint that the reliabilities, when they are finally reported, will be disastrously low.
What should be done now as DSM-5 enters its depressing endgame? There really is no rational choice except to drop the many unsupportable DSM-5 proposals and to dramatically improve the imprecise writing that plagues most of the DSM-5 criteria sets.
DSM-5: How Reliable Is Reliable Enough? DSM 5 is willing to except poor quality.
Allen Frances, MD | January 18, 2012
This is the title of a disturbing commentary written by the leaders of the DSM 5 Task Force and published in this month’s American Journal of Psychiatry. The contents suggest that we must lower our expectations and be satisfied with levels of unreliability in DSM 5 that historically have been clearly unacceptable. Two approaches are possible when the DSM 5 field trials reveal low reliability for a given suggestion: 1) admit that the suggestion was a bad idea or that it is written so ambiguously as to be unusable in clinical practice, research, and forensics; Or, 2) declare by arbitrary fiat that the low reliability is indeed now to be relabeled ‘acceptable’.
In the past, ‘acceptable’ meant kappas of 0.6 or above. When the personality disorders in DSM III came in at 0.54, they were roundly derided and given only a reluctant bye. For DSM 5, ‘acceptable’ reliability has been reduced to a startling 0.2-0.4. This barely exceeds the level of agreement you might expect to get by pure chance.
Previously in its development, DSM 5 has placed great store in its field trials. This quote is from the Chair of the DSM 5 Task Force: “There’s a myth that all the decisions have been made, when in fact, all the decisions haven’t been made. Just because things have been proposed doesn’t necessarily mean they’ll end up in the DSM-5. If they don’t achieve a level of reliability, clinician acceptability, and utility, it’s unlikely they’ll go forward.”
And this quote is from a 2010 interview given to a science writer by the head of the DSM 5 Oversight Committee: “It’s going to be based on the work of the field trials – based on the assessment and analysis of them. I don’t think anyone is going to say we’ve got to go forward if we get crappy results.”
The DSM 5 tune has now changed dramatically. The commentary written for AJP by the leadership of DSM 5 Task Force appears to be suggesting that they will, in fact, “go forward,” and with sub par reliabilities of 0.2-0.4. Now consider that the original field trial plan was to have a second phase to permit fixing those diagnostic criteria that were found to have unacceptable reliability in the first phase. These would go back to the workgroups who could then rewrite the offending criteria and retest the new version in the second phase of the field trial. But poor planning and administrative foul-ups kept pushing back the field trials so that they are now at least 18 months late in completion. As time was running out, DSM 5 leadership quietly dropped the second phase of the field trials, removing any reference to it from the timeline posted on the DSM-5 website. Their Plan B substitute for adequate field testing appears in AJP- To wit: a drastic lowering of the bar for what is ‘acceptable’ reliability.
Can ‘accepting’ unacceptably poor agreement uphold the integrity of psychiatric diagnosis? Poor reliability degrades our ability to communicate with one another clinically, and prohibits meaningful research. ‘Accepting’ as reliable kappas of 0.2-0.4 is to go backwards more than thirty years to the days of DSM II. Before DSM III, Bob Spitzer and Mel Sabshin saw the need to develop a criterion based system that could achieve reasonable diagnostic agreement. This is the very minimum condition necessary for current clinical work and future progress in psychiatry.
The American Journal of Psychiatry | January 01, 2012
Helena Chmura Kraemer, Ph.D.; David J. Kupfer, M.D.; Diana E. Clarke, Ph.D.; William E. Narrow, M.D., M.P.H.; Darrel A. Regier, M.D., M.P.H. January 01, 2012, Vol. 169. No. 1
Commentary from Allen Frances, MD, Psychiatric Times, January 09, 2012:
(Free registration required to view Psychiatric Times.)
“The designer of the DSM-5 Field Trials has just written a telling commentary in the American Journal of Psychiatry (AJP). She makes what I consider to be 2 basic errors that reveal the fundamental worthlessness of these Field Trials and their inability to provide any information that will be useful for DSM-5 decision making…”
dx revision watch 