Update at July 24, 2012: Additional reporting from Straight.com, Vancouver, on the resignations of two members of the DSM-5 Personality Disorders Work Group:
In the July issue of Clinical Psychology & Psychology there is an Editorial and two Commentaries around DSM-5 proposals for Personality and Personality Disorders.
Dr Roel Verheul is CEO of de Viersprong, Netherlands Institute for Personality Disorders.
Dr. John Livesley is Professor Emeritus at the University of British Columbia.
Allen Frances, M.D. who chaired the DSM-IV Task Force blogs at DSM 5 in Distress. Drs Verheul and Livesley have written to Dr Frances setting out their concerns for what they believe to be “seriously flawed proposals” and “a truly stunning disregard for evidence.”
DSM5 in Distress The DSM’s impact on mental health practice and research.
Roel Verheul and John Livesley both felt compelled to resign from the DSM-5 Personality Disorders Work Group. Here is an email from them describing what went wrong in the preparation of this section:
“…Regrettably, the Work Group has been unable to capitalize on the opportunity and has advanced a proposal that is seriously flawed. It has also demonstrated an inability to respond to constructive feedback both from within the Work Group and from the many experts in the field who have communicated their concerns directly and indirectly. We also regret the need to resign because we were the only International members of the Work Group which is now without representation from outside the US…”
“…Early on in the DSM-5 process, we developed major concerns about the Work Group’s mode of working and its emerging recommendations that we communicated to the Work Group and Task Force… We considered the current proposal to be fundamentally flawed and decided that it would be wrong of us to appear to collude with it any longer…As we see it, there are two major problems with the proposal…”
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.
