One Last Chance For APA To Make DSM 5 Safer: Allen Frances, M.D.

One Last Chance For APA To Make DSM 5 Safer: Allen Frances, M.D.

Post #215 Shortlink:

Psychology Today Blogs | DSM5 in Distress | Allen Frances, M.D.

One Last Chance For APA To Make DSM 5 Safer

Other wise there will likely be a buyer’s revolt.

Allen J. Frances, M.D. | December, 16 2012

Two weeks ago the Trustees of the American Psychiatric Association made the serious mistake of approving and rushing to press a DSM 5 that has many unsafe and untested suggestions.

The reaction has been unexpectedly heated: dozens of extremely negative news stories, many highly critical blogs, and a number of calls for a DSM 5 boycott in the US, England, France, Australia, Spain, and Italy…

Round up of recent DSM-5 media

The Daily Beast

The DSM’s Controversial Update

December 9, 2012

New Scientist

Magazine issue 2895.

Target faulty brain circuits to treat mental illness

Peter Aldhous | December 12, 2012

“Some critics argue that it’s time to rip up the manual and start again – with wider input. In the coming weeks, organisers of a petition to reform DSM-5 backed by 14,000 mental health professionals plan to launch an online forum to debate a new diagnostic system…”

Related material

Mislabeling Medical Illness As Mental Disorder  Allen J Frances MD, December 9, 2012

Somatic Symptom Disorder could capture millions more under mental health diagnosis 

Submission to Somatic Symptom Disorder Work Group in response to third draft proposals

Mislabeling Medical Illness As Mental Disorder: The Eleventh DSM 5 Mistake: Allen Frances, MD

Mislabeling Medical Illness As Mental Disorder: The eleventh DSM 5 mistake needs an eleventh hour correction by Allen Frances, MD

Post #214 Shortlink:

Update: Responses to Psychology Today commentary

Huffington Post
Huff Po Science

Allen Frances, Professor Emeritus, Duke University; Chair, Task Force for DSM-IV

Mislabeling Medical Illness As Mental Disorder: The Eleventh DSM-5 Mistake

Allen Frances MD | December 12, 2012

Featured Blogs

Boycott The DSM-5: Anachronistic Before Its Time

Jack Carney, DSW | December 10, 2012

When plans for the DSM-5 were first announced about ten years ago, most folks’ reaction was “Why?”. Many of us asked that same question several times as the publication date for the new tome kept on getting pushed back. Finally, the curtain enshrouding the DSM-5 Task Force and its several committees began to part and proposed revisions/additions began to appear on its website. To our dismay, we found our question answered…

Beyond Meds

DSM‘s Somatoform Disorders: millions more might be diagnosed (those with withdrawal syndrome are high risk for such misdiagnosis)

Monica Cassani | December 10, 2012

1 Boring Old Man

1 Boring Old Man | December 09, 2012

Danger! Danger!…

Today, Allen Frances, MD, who chaired the Task Force for DSM-IV, publishes his considerable concern for potential harm to all illness groups if DSM-5 Somatic Symptom Disorder (SSD) criteria go ahead in their current form.

Psychology Today blogs

DSM5 in Distress

The DSM’s impact on mental health practice and research

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

Mislabeling Medical Illness As Mental Disorder

The eleventh DSM 5 mistake needs an eleventh hour correction.

Allen J Frances MD | December 9, 2012

Allen Frances said, “…Adding to the woes of the medically ill could be one of the biggest problems caused by DSM 5. It will do this in two ways: 1) by encouraging a quick jump to the erroneous conclusion that someone’s physical symptoms are ‘all in the head’; and 2) by mislabeling as mental disorders what are really just the normal emotional reactions that people understandably have in response to a medical illness…”

Suzy Chapman said, “…the requirement of ‘medically unexplained’ symptoms is replaced by much looser and more subjective ‘excessive thoughts, behaviors and feelings’ and the clinician’s perception of “dysfunctional illness belief’ or ‘excessive preoccupation’ with the bodily symptom.

“That, and a duration of at least six months, is all that is required to tick the box for a bolt-on diagnosis of a mental health disorder – Colorectal cancer + SSD; Angina + SSD; Type 2 diabetes + SSD; IBS + SSD…”

Read full commentary here on Psychology Today

All patient groups stand to be hurt by this new DSM-5 disorder

In the DSM-5 field trials, one in six patients with serious diseases like cancer, heart disease and diabetes met the criteria for an additional diagnosis of “Somatic Symptom Disorder”.  Over 25% of the “functional somatic” field trial study group (irritable bowel and chronic widespread pain patients) were coded with ‘SSD’.

The new SSD category (which would replace four categories under the DSM-IV Somatoform Disorders) de-emphazises “medically unexplained symptoms” as the defining feature of this disorder group.

Instead, focus shifts to the subjective perceptions of the patient’s “excessive thoughts, behaviors and feelings” about the seriousness of distressing and persistent bodily symptoms, which may or may not accompany diagnosed general medical conditions, and the extent to which “illness preoccupation” is perceived to have come to “dominate” or “subsume” the patient’s life.

Families with children with chronic medical illness will also be vulnerable, as the proposals, as they stood at the third draft, allow for assigning a diagnosis of “SSD” to parents perceived as being “over-involved” in their child’s illness and symptomatology or encouraging the maintenance of “sick role behavior.”

The elderly, with higher rates of cancer, heart disease and age-onset diabetes, will also be vulnerable – all three diseases are cited by the SSD Work Group as candidates for an additional diagnosis of a mental health disorder + a diagnosed illness – if the patient is considered to also meet the criteria for ‘SSD’.

The DSM-5 manual texts have not yet been finalized for the publishers: it’s not too late to put pressure on the Work Group to reconsider damaging proposals that are likely to increase rates of mental health diagnosis and add to the burden of ill health in diverse patient populations.

Please click through now to Dr Frances’ blog to demonstrate to the SSD Work Group and DSM-5 Task Force the high level of concern that continues for the implications of these SSD criteria.

And please circulate the link for Dr Frances’ opposition to these criteria on forums, Facebook, Twitter, blogs and websites and all health and patient advocacy platforms. 

The most recent proposals for new category “J 00 Somatic Symptom Disorder”

IASP and the Classification of Pain in ICD-11  Prof. Dr. Winfried Rief, University of Marburg,

Slide 9

Ed: Note that the requirement for “at least two from the B type criteria” was reduced to “at least one from the B type criteria” for the third iteration of draft proposals. This lowering of the threshold is presumably in order to accommodate the merging of the previously proposed “Simple Somatic Symptom Disorder” category into the “Complex Somatic Symptom Disorder” category, a conflation now proposed to be renamed to “Somatic Symptom Disorder,” also the disorder section name. A revised “Rationale/Validity” PDF document was not issued for the third and final draft. A brief, revised “Rationale” text was published on a Tab Page for the Somatic Symptom Disorder proposal and criteria but is no longer accessible.

Proposals, criteria and rationales, as posted for the third draft in May 2012, were removed from the DSM-5 Development website on November 15, 2012 and placed behind a non public log in. Criteria as they had stood for the third draft can no longer be viewed but are set out on Slide 9 in this presentation, which note, does not include three, optional Severity Specifiers that were included with the third draft criteria.


Related material

Somatic Symptom Disorder could capture millions more under mental health diagnosis

Submission to Somatic Symptom Disorder Work Group in response to third draft proposals

American Psychiatric Association Board of Trustees approves final DSM-5 diagnostic criteria

American Psychiatric Association Board of Trustees approves final DSM-5 diagnostic criteria

Post #2012 Shortlink:

Yesterday, December 1, the American Psychiatric Association issued a news release – full text posted below or open PDF here: APA News Release 12.01.12

or download here:–newsroom/news-releases

There was also an alert published on Pyschiatric News here: APA Board of Trustees Approves DSM-5

A message from APA President Dilip Jeste, M.D., on DSM-5 was also published.

I’ll be compiling links to media coverage in the next post.

Contact: For Immediate Release:

Eve Herold, 703-907- 8640 December 1, 2012  Release No. 12-43

Erin Connors, 703-907-8562

Tamara Moore, 610-360-3405

American Psychiatric Association Board of Trustees Approves DSM-5

Diagnostic manual passes major milestone before May 2013 publication

ARLINGTON, Va. (December 1, 2012) – The American Psychiatric Association (APA) Board of Trustees has approved the final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The trustees’ action marks the end of the manual’s comprehensive revision process, which has spanned over a decade and included contributions from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other related fields from 39 countries. These final criteria will be available when DSM-5 is completed and published in spring 2013.

“The Board of Trustees approval of the criteria is a vote of confidence for DSM-5,” said Dilip Jeste, MD, president of APA. ―We developed DSM-5 by utilizing the best experts in the field and extensive reviews of the scientific literature and original research, and we have produced a manual that best represents the current science and will be useful to clinicians and the patients they serve.”

DSM-5 is the guidebook used by clinicians and researchers to diagnose and classify mental disorders. Now that the criteria have been approved, review of the criteria and text describing the disorders will continue to undergo final editing and then publication by American Psychiatric Publishing.

The manual will include approximately the same number of disorders that were included in DSM-IV. This goes against the trend from other areas of medicine that increase the number of diagnoses annually.

“We have sought to be conservative in our approach to revising DSM-5. Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry,” said David J. Kupfer, MD, chair of the DSM-5 Task Force. “I’m thrilled to have the Board of Trustees’ support for the revisions and for us to move forward toward the publication.”

Organization of DSM-5

DSM-5 will be comprised of three sections:

Section 1 will give an introduction to DSM-5 with information on how to use the updated manual;

Section 2 will outline the categorical diagnoses according to a revised chapter organization; and

Section 3 will include conditions that require further research before their consideration as formal disorders, as well as cultural formulations, glossary, the names of individuals involved in DSM-5’s development and other information.

Summary of Decisions for DSM-5

Key decisions made by the Board of Trustees include:*

• Overall Substantive Changes

o Chapter order

o Removal of multiaxial system

• Section 2 Disorders

o Autism spectrum disorder

o Binge eating disorder

o Disruptive mood dysregulation disorder

o Excoriation (skin-picking) disorder

o Hoarding disorder

o Pedophilic disorder

o Personality disorders

o Posttraumatic stress disorder

o Removal of bereavement exclusion

o Specific learning disorders

o Substance use disorder

• Section 3 Disorders

o Attenuated psychosis syndrome

o Internet use gaming disorder

o Non-suicidal self-injury

o Suicidal behavioral disorder

• Disorders Not Accepted for Sections 2 or 3

o Anxious depression

o Hypersexual disorder

o Parental alienation syndrome

o Sensory processing disorder

* More information on select decisions is available in Attachment A.

Collaborative Process for Development of DSM-5

Beginning in 1999, during the initial phase of this DSM revision, the APA engaged almost 400 international research investigators in 13 conferences supported by the National Institutes of Health. To invite comments from the wider research, clinical and consumer communities, the APA launched a DSM-5 Prelude website in 2004 to garner questions, comments, and research findings during the development process.

Starting in 2007 and 2008, the DSM-5 Task Force and Work Groups, made up of more than 160 world-renowned clinicians and researchers, were tasked with building on the previous seven years of scientific reviews, conducting additional focused reviews, and garnering input from a breadth of advisors as the basis for proposing draft criteria. In addition to the Work Groups in diagnostic categories, study groups were assigned to review gender, age and cross-cultural issues. The Work Groups have led the effort to review the scientific advances and research-based information that have formed the basis of the content for DSM-5.

The first draft of proposed changes was posted publicly on the website in February 2010 and the site also posted two subsequent drafts. With each draft, the site accepted feedback on proposed changes, receiving more than 13,000 comments on draft diagnostic criteria from mental health clinicians and researchers, the overall medical community, and patients, families, and advocates. Following each comment period, the DSM-5 Task Force and Work Groups reviewed and considered each response and made revisions where warranted.

The Work Groups’ proposals were evaluated by the Task Force and two panels convened specifically to evaluate the proposals—a Scientific Review Committee and a Clinical and Public Health Committee. The Scientific Review Committee looked at the supporting data for proposed changes. The Clinical and Public Health Committee was charged with assessing the potential impact of changes to clinical practice and public health. Additionally, there was a forensic review by members of the Council on Psychiatry and Law.

All of the reviews were coordinated in meetings of the Summit Group, which includes the DSM-5 Task Force co-chairs, and review committee co-chairs, consultants, and members of the Executive Committee of the Board of Trustees. The criteria were then put before the APA Assembly for review and approval. The Board of Trustees’ review was the final step in this multilevel, comprehensive process.

“At every step of development, we have worked to make the process as open and inclusive as possible. The level of transparency we have strived for is not seen in any other area of medicine,” said James H. Scully, MD, medical director and chief executive officer of APA.


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 .

Attachment A: Select Decisions Made by APA Board of Trustees

Overall Changes

 • Chapter order: DSM-5’s 20 chapters will be restructured based on disorders’ apparent relatedness to one another, as reflected by similarities in disorders’ underlying vulnerabilities and symptom characteristics. The changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11) and are expected to facilitate improved communication and common use of diagnoses across disorders within chapters.

 • Removal of multiaxial system: DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).

Section 2 Disorders

1. Autism spectrum disorder: The criteria will incorporate several diagnoses from DSM-IV including autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified), into the diagnosis of autism spectrum disorder for DSM-5 to help more accurately and consistently diagnose children with autism.

2. Binge eating disorder will be moved from DSM-IV’s Appendix B: Criteria Sets and Axes Provided for Further Study to DSM-5 Section 2. The change is intended to better represent the symptoms and behaviors of people with this condition.

3. Disruptive mood dysregulation disorder will be included in DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The diagnosis is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children.

4. Excoriation (skin-picking) disorder is new to DSM-5 and will be included in the Obsessive-Compulsive and Related Disorders chapter.

5. Hoarding disorder is new to DSM-5. Its addition to DSM is supported by extensive scientific research on this disorder. This disorder will help characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value. The behavior usually has harmful effects—emotional, physical, social, financial and even legal—for a hoarder and family members.

6. Pedophilic disorder criteria will remain unchanged from DSM-IV, but the disorder name will be revised from pedophilia to pedophilic disorder.

7. Personality disorders: DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study how this could be used to diagnose personality disorders in clinical practice.

8. Posttraumatic stress disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. PTSD will also be more developmentally sensitive for children and adolescents.

9. Removal of bereavement exclusion: the exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.

10. Specific learning disorder broadens the DSM-IV criteria to represent distinct disorders which interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, or mathematics.

11. Substance use disorder will combine the DSM-IV categories of substance abuse and substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms.

PDF: Message from APA President on DSM-5

A Message From APA President Dilip Jeste, M.D., on DSM-5

December 1, 2012

I am pleased to announce that DSM-5 has just been approved by APA’s Board of Trustees. Getting to the finish line has taken a decade of arduous work and tens of thousands of pro-bono hours from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other related fields from 39 countries. We look forward to the book’s publication next May.

The goal of the DSM-5 process has been to develop a scientifically based manual of psychiatric diagnosis that is useful for clinicians and our patients. APA’s interest in developing DSM dates back to the organization’s inception in 1844, when one of its original missions was to gather statistics on the prevalence of mental illness. In 1917, the Association officially adopted the first system for uniform statistical reporting called the Statistical Manual for the Use of Hospitals for Mental Diseases, which was adopted successfully by mental hospitals throughout the country. It was expanded into the first Diagnostic and Statistical Manual (DSM) in 1952 and first revised (DSM-II) in 1968. Like the rest of the field in that era, these first two versions were substantially influenced by psychoanalytic theories.

With advances in clinical and scientific knowledge, changes in diagnostic systems are inevitable. The World Health Organization’s International Classification of Diseases (ICD)—the standard diagnostic tool for epidemiology, health management, and clinical care used around the world, which covers all medical diagnoses—has been through 10 editions since the late 1800s and is now preparing its 11th edition, due in 2015. Likewise, DSM has undergone changes to take into account progress in our understanding of mental illnesses. DSM-III, published in 1980 under the leadership of Dr. Robert Spitzer, and DSM-IV, published in 1994 under the leadership of Dr. Allen Frances, represented the state of science of psychiatry at those times and significantly advanced the field.

In the two decades since the publication of DSM-IV, we have witnessed a wealth of new studies on epidemiology, neurobiology, psychopathology, and treatment of various mental illnesses. So, it was time for APA to consider making necessary modifications in the diagnostic categories and criteria based on new scientific evidence. But there were, of course, challenges inherent in revising an established diagnostic system.

The primary criterion for any diagnostic revisions should be strictly scientific evidence. However, there are sometimes differences of opinion among scientific experts. At present, most psychiatric disorders lack validated diagnostic biomarkers, and although considerable advances are being made in the arena of neurobiology, psychiatric diagnoses are still mostly based on clinician assessment.

Also, there are unintended consequences of psychiatric diagnosis. Some arise from the unfortunate social stigma and discrimination in getting jobs or even obtaining health insurance (notwithstanding the mental health parity law) associated with a psychiatric illness. There is also the double-edged sword of underdiagnosis and overdiagnosis. Narrowing diagnostic criteria may be blamed for excluding some patients from insurance coverage and needed services, while expanded efforts to diagnose (and treat) patients in the early stages of illness to prevent its chronicity are sometimes criticized for increasing its prevalence and potentially expanding the market for the pharmaceutical industry. (It should be noted, however, that DSM is not a treatment manual and that diagnosis does not equate to a need for pharmacotherapy.)

APA has carefully sought to balance the benefits of the latest scientific evidence with the risks of changing diagnostic categories and criteria. We realize that, given conflicting views among different stakeholders, there will be inevitable disagreements about some of the proposals—whether they involve retaining the traditional DSM-IV criteria or modifying them.

The process of developing DSM-5 began in earnest in 2006, when APA appointed Dr. David Kupfer as chair and Dr. Darrel Regier as vice chair of the task force to oversee the development of DSM-5. The task force included the chairs of 13 diagnostic work groups, who scrutinized the research and literature base, analyzed the findings of field trials, reviewed public comments, and wrote the content for specific disorder categories within DSM-5. To ensure transparency and reduce industry-related conflicts of interest, APA instituted a strict policy that all task force and work group members had to make open disclosures and restrict their income from industry. In fact, the vast majority of the task force and work group members had no financial relationship with industry.

To obtain independent reviews of the work groups’ diagnostic proposals, the APA Board of Trustees appointed several review committees. These included the Scientific Review Committee (co-chaired by Drs. Ken Kendler and Robert Freeman), Clinical and Public Health Committee (co-chaired by Drs. Jack McIntyre and Joel Yager), and APA Assembly Committee (chaired by Dr. Glenn Martin). Additionally, there was a forensic review by members of the Council on Psychiatry and Law. Drs. Paul Appelbaum and Michael First were consultants on forensic issues and criteria/public comments, respectively. Reviews by all these groups were coordinated in meetings of the Summit Group, which included the task force and review committee co-chairs and consultants along with members of the Executive Committee of the Board of Trustees.

There has been much more public interest and media scrutiny of DSM-5 than any previous revisions. This reflects greater public awareness and media interest in mental illness, as well as widespread use of the Internet and social media. To facilitate this transparent process, APA created a Web site ( ) where preliminary draft revisions were available for the public to examine, critique, and comment on. More than 13,000 Web site comments and 12,000 additional comments from e-mails, letters, and other forms of communication were received. Members of the DSM-5 work groups reviewed the feedback submitted to the Web site and, where appropriate, made modifications in their proposed diagnostic criteria.

We believe that DSM-5 reflects our best scientific understanding of psychiatric disorders and will optimally serve clinical and public health needs. Our hope is that the DSM-5 will lead to more accurate diagnoses, better access to mental health services, and improved patient outcomes.

DSM-5 Round up: November #1

DSM-5 Round up: November #1

Post #207 Shortlink:

Huffington Post Blog

David J. Kupfer, MD | Chair, DSM-5 Task Force | November 7, 2012

Field Trial Results Guide DSM Recommendations

Written with Helena C. Kraemer, Ph.D.

Two years ago this month, APA announced the start of field trials that would subject proposed diagnostic criteria for the future DSM-5 to rigorous, empirically sound evaluation across diverse clinical settings. And now, as the first comprehensive analyses of that effort are published, what’s clear is just how well the field trials did their job…

Full commentary

1 Boring Old Man


1 Boring Old Man | November 9, 2012

Side Effects

From quirky to serious, trends in psychology and psychiatry

by Christopher Lane, Ph.D.

The DSM-5 Field Trials’ Decidedly Mixed Results

Far from being a ringing endorsement, the field trials set off fresh alarm bells

Christopher Lane, Ph.D. | November 11, 2012

“What’s the chance that a second, equally expert diagnosis will agree with the first, making a particular diagnosis reliable?” asks David Kupfer, chair of the DSM-5 task force, of the decidedly mixed results of the DSM-5 field trials. First off, are you sure you really want to know?…

Full commentary

also here on Psychiatric Times (registration required):

You Can’t Turn a Sow’s Ear Into a Silk Purse

By Allen Frances, MD | November 11, 2012

In his recent Huffington Post piece titled Field Trial Results Guide DSM Recommendations,1 DSM-5 Task Force Chair Dr David Kupfer says, “What’s clear is just how well the field trials did their job.” This surprisingly optimistic claim has inspired these telling rejoinders from Mickey Nardo, MD, and Barney Carroll, MD, 2 of the best informed critics of DSM-5.

Dr Nardo first: “The absence of biological tests in psychiatry is unique in medicine and sentences the classification of mental disorders to endless controversy. In the 1970s, Dr Robert Spitzer proposed we use inter-rater reliability as a stand in for objective tests. His statistician colleagues developed a simple measure (called ‘kappa’) to indicate the level of diagnostic agreement corrected for chance. In 1974, Spitzer reported on 5 studies that clearly exposed the unreliability of DSM-II, the official diagnostic system at the time.

“To correct this problem and obtain the diagnostic agreement necessary for research studies, Spitzer then set about constructing sets of diagnostic criteria meant to tap overt signs and symptoms, rather than the more inferential mechanisms that informed DSM-II. He also developed structured clinical interviews that provided a uniform method of assessment. These approaches worked well to improve the poor kappas obtained using the free form approach of DSM-II.

“In 1980, Spitzer took the next big step of introducing the criterion based method of diagnosis into DSM-III. What had originated as a research tool now informed all clinical practice. It was an important milestone for psychiatry when DSM-III field testing showed that the system achieved good kappas. The new manual was an instant success throughout the mental health professions and brought a measure of objectivity to a field previously dominated by warring subjective opinions. Later, in 1994, DSM-IV was also able to demonstrate good kappas in its much more extensive field testing.

“The DSM-5 Task Force originally planned two sets of field trials, the second of which was meant to provide quality control to correct whatever weaknesses would be exposed in the first. But along the way, the field testing got far behind its schedule and the quality control step was quietly cancelled. No explanation was ever offered, but it seemed likely that DSM-5 was being rushed to press so that APA could reap publishing profits.

“Dr David Kupfer now wants us to believe that the recently published results of the DSM-5 field testing somehow serve to justify the inclusion in DSM 5 of extremely controversial and much feared changes. This is a terribly misleading claim. Independent of all the other criticisms of DSM-5 (and there are plenty), the poor results of the field trials must have been a major disappointment to the Task Force. Dr Kupfer is now making a desperate attempt to salvage the failed project by putting an unrealistically positive spin on its results.

“Our forty-year experience in reliability testing for DSM-II, the RDC, DSM-III, and DSM-IV makes clear what are acceptable and what are unacceptable kappa levels. There is no way of avoiding or cloaking the stark and troubling fact that the DSM-5 field trials produced remarkably low kappas—harking back to the bad old days of DSM-II.

[see ].

“Equally disturbing, three of the eight diagnoses tested at multiple centers had widely divergent kappa values at the different sites—hardly a vote for their reliability. Even worse, two major diagnostic categories [Major Depressive Disorder and Generalized Anxiety Disorder] performed terribly, in a range that is clearly unacceptable by anybody’s standard.

[see ].

“Dr Kupfer has been forced to drastically lower our expectations in an effort to somehow justify the remarkably poor and scattered DSM-5 kappa results. There is, in fact, only one possible explanation for the results—the DSM-5 field trials were poorly designed and incompetently administered. Scientific integrity requires owning up to the defects of the study, rather than asking us to deviate from historical standards of what is considered acceptable reliability. It is not cricket to lower the target kappas after the study results fail to meet reasonable expectations.

“Diagnostic agreement is the bedrock of our system—a non-negotiable bottom line. The simple truth is that by historical standards, the DSM-5 field trials did not pass muster. Dr Kupfer can’t expect to turn this sow’s ear into a silk purse.”

Dr Carroll adds this: “The purpose of DSM-5 is to have criteria that can be used reliably across the country and around the world. The puzzling variability of results across the sites in the DSM-5 field trials is a major problem. Let’s take just one of many examples—for Bipolar I Disorder, the Mayo Clinic came in with a very good kappa value of 0.73 whereas the San Antonio site came in with a really lousy kappa of 0.27. You can’t just gloss over this gaping discrepancy by reporting a mean value. The inconsistencies across sites have nothing to do with the criteria tested—they are instead prima facie evidence of unacceptably poor execution of the study protocol. The inconsistent results prove that something clearly wasn’t right in how the study was done.

“The appropriate response is to go back to the drawing board by completing the originally planned quality control second stage of testing—rather than barreling ahead to premature publication and pretending that everything is just fine when it is not. The DSM-5 leaders have lowered the goal posts and are claiming a bogus sophistication for their field trials design as an excuse for its sloppy implementation. But a low kappa is a low kappa no matter how you try to disguise it. Dr Kupfer is putting lipstick on the pig.

“Many people experience a glazing of the eyes when the term kappa appears, but it’s really a simple idea. The kappa value tells us how far we have moved from completely random agreement (a kappa of 0) to completely perfect agreement (a kappa of 1.0). The low end of kappas that DSM-5 wants us to find acceptable are barely better than blind raters throwing random darts. If there is this much slop in the system when tested at academic centers, imagine how bad things will become in the real world of busy and less specialized clinical practice.

“Something isn’t right . . . and when something isn’t right in a matter as serious as psychiatric diagnosis the professional duty is to fix it. Having shirked this responsibility, APA deserves to fail in the business enterprise that it has made of DSM-5. If ever there was a clear conflict of interest, this is it.”

Thanks are due to Drs Nardo and Carroll. There can be no doubt that the DSM-5 Field Trials were a colossal waste of money, time, and effort. First off, they didn’t ask the most obvious and important question—What are the risks that DSM-5 will create millions of misidentified new ‘patients’ who would then be subjected to unnecessary treatment? Second, the results on the question it did ask (about diagnostic reliability) are so all over the map that they are completely uninterpretable. And to top it off, DSM-5 cancelled the quality control stage that might have cleaned up the mess.

It is almost certain that DSM-5 will be a dangerous contributor to our already existing problems of diagnostic inflation and inappropriate prescription of psychotropic drugs. The DSM-5 leadership is trying to put a brave face on its badly failed first stage of field testing and has offered no excuse or explanation for canceling its second and most crucial quality control stage. This field testing fiasco erases whatever was left of the credibility of DSM-5 and APA.


1. Kupfer DJ. Field trial results guide DSM recommendations. Huffington Post. November 7, 2012. . Accessed November 13, 2012.

Nature News Blog

DSM field trials inflame debate over psychiatric testing

05 Nov 2012 | 15:00 GMT | Posted by Heidi Ledford | Category: Health and medicine

As the latest revision of a key psychiatric tome nears completion, field trials of its diagnoses have prompted key changes to controversial diagnoses and sparked questions as to how such trials should be conducted…

Read on

Aging Well – News & Insight for Professionals in Geriatric Medicine

Dementia and DSM-5:

Changes, Cost, and Confusion

James Siberski, MS, CMC

Aging Well, Vol. 5 No. 6 P. 12

DSM-5 changes will require providers to learn the differences between major and minor neurocognitive disorders and to explain the differences and their significance to patients and their families.

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association and used for diagnosis by mental health professionals in the United States, describes symptoms for all mental disorders. Its primary components are the diagnostic classifications, diagnostic criteria sets, and descriptive texts. DSM-I was initially approved in 1951 and published the following year. Since then it has been revised several times and resulted in DSM-II in 1968, DSM-III in 1980, DSM-III-R in 1987, DSM-IV in 1994, and the current version, DSM-IV-TR, in 2000. Historically, it has been both praised and criticized…

Full article

Health Care Renewal


Bernard Carroll, MD | November 03, 2012

…What lies ahead? Stakeholders are going to vote with their feet. DSM-5 is likely to be a footnote in the history of psychiatric classification. The APA will become even less relevant than it is today, much like the American Medical Association, which now commands the loyalty of maybe 30% of U.S. physicians….

Full commentary

APA finally posts DSM-5 Field Trials online and DSM-5 Round up

APA finally posts DSM-5 Field Trials online and DSM-5 Round up

Post #206 Shortlink:

Three papers discussing the results of the DSM-5 field trials were posted online yesterday by the American Journal of Psychiatry. The papers describe the methods and results of the 23 diagnoses assessed during the field trials.

APA failed to publish field trial results during the life of the third and final public review and comment period.

Access to the abstracts is free but you will need subscriber or institution access for the full PDFs or cough up $$ for the papers. ($35 per paper for 24 hours’ access. Why have these reports not been published on the DSM-5 Development website? Many classes of stakeholder will be disenfranchised.)

The article states that criteria were tested in October 2010 through February 2012 by 279 clinicians at 11 U.S. and Canadian academic centers. A second set of data from small group practices and private practices is expected to be reported early next year (that is, after the finalized draft has gone to the publishers).

Proposed criteria are still under review and won’t be finalized until approved by APA Board of Trustees.

DSM-5 draft proposals for criteria and categories as issued for the third and final stakeholder review can be read here on the DSM-5 Development website.

Note that the draft is now frozen and criteria sets and manual texts subject to embargo until publication of the DSM-5 manual. Any revisions made by the Task Force and Work Groups since the third iteration was released in May, this year, won’t be reflected on the DSM-5 Development website.

Published yesterday in the American Journal of Psychiatry and at Psychiatry Online:

Tuesday, October 30, 2012

Full text of article:

DSM-5 Field Trials Posted Online by AJP

Article 1 | October 30, 2012


DSM-5 Field Trials in the United States and Canada, Part I: Study Design, Sampling Strategy, Implementation, and Analytic Approaches

Diana E. Clarke, Ph.D., M.Sc.; William E. Narrow, M.D., M.P.H.; Darrel A. Regier, M.D., M.P.H.; S. Janet Kuramoto, Ph.D., M.H.S.; David J. Kupfer, M.D.; Emily A. Kuhl, Ph.D.; Lisa Greiner, M.S.S.A.; Helena C. Kraemer, Ph.D.

Am J Psychiatry 2012;:. 10.1176/appi.ajp.2012.12070998

PDF for those with subscriber access:

Article 2 | October 30, 2012


DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses

Darrel A. Regier, M.D., M.P.H.; William E. Narrow, M.D., M.P.H.; Diana E. Clarke, Ph.D., M.Sc.; Helena C. Kraemer, Ph.D.; S. Janet Kuramoto, Ph.D., M.H.S.; Emily A. Kuhl, Ph.D.; David J. Kupfer, M.D.

Am J Psychiatry 2012;:. 10.1176/appi.ajp.2012.12070999

PDF for those with subscriber access:

Article 3 | October 30, 2012


DSM-5 Field Trials in the United States and Canada, Part III: Development and Reliability Testing of a Cross-Cutting Symptom Assessment for DSM-5

William E. Narrow, M.D., M.P.H.; Diana E. Clarke, Ph.D., M.Sc.; S. Janet Kuramoto, Ph.D., M.H.S.; Helena C. Kraemer, Ph.D.; David J. Kupfer, M.D.; Lisa Greiner, M.S.S.A.; Darrel A. Regier, M.D., M.P.H.

Am J Psychiatry 2012;:. 10.1176/appi.ajp.2012.12071000

PDF for those with subscriber access:


DSM5 in Distress
The DSM’s impact on mental health practice and research.

by Allen Frances, M.D.

DSM 5 Field Trials Discredits APA

You can’t turn a sow’s ear into a silk purse.

…According to the authors, 14 of the 23 disorders had “very good” or “good” reliability; 6 had questionable, but ‘acceptable’ levels; and just three had “unacceptable” rates. Sounds okay until you look at the actual data and discover that the cheerful words used by the DSM 5 leaders simply don’t fit their extremely disappointing results. The paper is a classic example of Orwellian ‘newspeak’…

Allen Frances, M.D. | August 30, 2012

Read full article here

Also on Huffington Post


1 Boring Old Man


1 Boring Old Man | October 30, 2012

Well, they finally published the results of the DSM-5 Field Trials. Here are the links to the abstracts and the main table of kappa values to look over…


DSM-5 Round up

Public Lecture St Mary’s College of Maryland

DSM-V: Social, Political, and Ethical Implications

November 2

3:00 PM – 5:00 PM

Cole Cinema, Campus Center

This presentation will describe the DSM-V, scheduled for publication in May 2013, and the controversy surrounding its development. Dr. Ancis will provide an overview of the newly proposed classification system and diagnoses.

It is imperative that those involved in using the DSM-V, or potentially impacted by the DSM, be duly informed. Questions associated with the DSM-V revision process; the empirical bases of proposed changes; social, legal, and political implications; and ethical and cultural considerations will be addressed.

Dr. Ancis will describe her involvement in a number of initiatives related to DSM-V proposals, including those of the Association of Women in Psychology and Counselors for Social Justice. She will also review concerns of major mental health organizations worldwide, such as the American Psychological Association, the American Counseling Association, and the British Psychological Society, and related divisions.

Dr. Ancis is currently a Professor of Counseling and Psychological Services at Georgia State University. She earned her Bachelors, Masters, and Ph.D from the University at Albany, State University of New York. Her major areas of interest are multicultural competency training, diversity attitudes, race and gender issues, education and career development, and legal system experiences.

Event Contact Info

Janet Kosarych-Coy


Phone: 2408954283

Website: Click to Visit

Location: Cole Cinema, Campus Center

18952 E. Fisher Rd

St. Mary’s City, MD 20686


Psychology Today

Side Effects

From quirky to serious, trends in psychology and psychiatry

The Tranquilizer Trap The scandal over benzodiazepines gets different emphasis in the UK and U.S.

Published on October 3, 2012 by Christopher Lane, Ph.D. in Side Effects

Anti-DSM Sentiment Rises in France Why French psychiatrists and psychoanalysts are opposed to the diagnostic manual  (French Stop DSM-5 Campaign)

Published on September 28, 2012 by Christopher Lane, Ph.D. in Side Effects

New York Times

Report Sees Less Impact in New Autism Definition

By BENEDICT CAREY | Published: October 2, 2012

Proposed changes to the official diagnosis of autism will not reduce the proportion of children found to have it as steeply as many have feared, scientists reported on Tuesday, in an analysis that contradicts several previous studies…


Medscape Medical News > Psychiatry

Controversial New Diagnosis in DSM-5 May Be Faulty

Pam Harrison | October 17, 2012

Attenuated psychosis syndrome (APS), a new and controversial diagnosis for potential inclusion in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is questionable, new research suggests…

DSM-5 and Employment Law

In September, Douglas Hass (Franczet Radelet) published an article Could the American Psychiatric Association Cause You Headaches? The Dangerous Interaction between the DSM-5 and Employment Law:


Since its first publication in 1952, the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) has long served not only as the primary reference for mental health disorders for medical practitioners, but also as a primary authority for the legal community…

Full text in PDF format: Hass

Research Article

Research Article

The Effect of Draft DSM-V Criteria on Posttraumatic Stress Disorder Prevalence

Patrick S. Calhoun Ph.D.1,2,3,*,
Jeffrey S. Hertzberg B.A.3,
Angela C. Kirby M.S.3,
Michelle F. Dennis B.A.2,
Lauren P. Hair M.S.3,
Eric A. Dedert Ph.D.1,2,3,
Jean C. Beckham Ph.D.1,2,3
Article first published online: 26 OCT 2012

DOI: 10.1002/da.22012

© 2012 Wiley Periodicals, Inc.

Journal of Psychosomatic Research

November 2012 Issue, Journal of Psychosomatic Research

Issue: Vol 73 | No. 5 | November 2012 | Pages 325-400

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder – Comparison with DSM-IV somatoform disorders and additional criteria for consideration

Katharina Voigt
Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Klinik Hamburg-Eilbek, Hamburg, Germany

Corresponding author at: Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany. Tel.: +49 40 7410 54408; fax: +49 40 7410 54975.

Eileen Wollburg
Schön Klinik Bad Bramstedt, Bad Bramstedt, Germany

Nina Weinmann
Schön Klinik Bad Bramstedt, Bad Bramstedt, Germany

Annabel Herzog
Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Klinik Hamburg-Eilbek, Hamburg, Germany

Björn Meyer
GAIA AG, Hamburg, Germany

Gernot Langs
Schön Klinik Bad Bramstedt, Bad Bramstedt, Germany

Bernd Löwe
Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Klinik Hamburg-Eilbek, Hamburg, Germany

Received 3 July 2012; received in revised form 29 August 2012; accepted 30 August 2012; published online 24 September 2012.


Major changes to the diagnostic category of somatoform disorders are being proposed for DSM-5. The effect of e.g. the inclusion of psychological criteria (criterion B) on prevalence, predictive validity, and clinical utility of “Somatic Symptom Disorder” (SSD) remains unclear. A prospective study was conducted to compare current and new diagnostic approaches.

In a sample of N=456 psychosomatic inpatients (61% female, mean age=44.8±10.4years) diagnosed with somatoform, depressive and anxiety disorders, we investigated the current DSM-5 proposal (SSD) plus potential psychological criteria, somatic symptom severity, and health-related quality of life at admission and discharge.

N=259 patients were diagnosed with DSM-IV somatoform disorder (56.8%). With a threshold of 6 on the Whiteley Index to assess psychological criteria, the diagnosis of SSD was similarly frequent (51.8%, N=230). However, SSD was a more frequent diagnosis when we employed the recommended threshold of one subcriterion of criterion B. Patients diagnosed with only SSD but not with DSM-IV somatoform disorder showed greater psychological impairment. Both diagnoses similarly predicted physical functioning at discharge. Bodily weakness and somatic and psychological attributions at admission were among significant predictors of physical functioning at discharge. Reduction of health anxiety, bodily weakness, and body scanning significantly predicted an improvement of physical functioning.

Psychological symptoms enhance predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder compared to DSM-IV somatoform disorders. The SSD diagnosis identifies more psychologically impaired patients than its DSM-IV precursor. The currently suggested diagnostic threshold for criterion B might increase the disorder’s prevalence.

Keywords: Somatoform disorder, Diagnosis, Diagnostic and Statistical Manual of Mental Disorders, Classification of diseases, Validation studies as topic

Ed: Note: Between publication of the second iteration of the DSM-5 draft proposals for public review and publication of the third set of draft proposals, the SSD “B type criteria” were reduced from the requirement to meet at least two from the “B type” criteria to at least one [1].


Somatic Symptom Disorder Criteria

Two resign from DSM-5 Personality Disorders Work Group over “seriously flawed” proposals

Two resign from DSM-5 Personality Disorders Work Group over “seriously flawed” proposals

Post #191 Shortlink:

Update at July 24, 2012: Additional reporting from, Vancouver, on the resignations of two members of the DSM-5 Personality Disorders Work Group:

UBC prof emeritus John Livesley and Dutch expert quit DSM-V committee defining personality disorders

Charlie Smith | July 23, 2012

Update at July 16, 2012:

In the July issue of Clinical Psychology & Psychology there is an Editorial and two Commentaries around DSM-5 proposals for Personality and Personality Disorders.

Clinical Psychology & Psychotherapy


No abstract is available for this article.

Personality Disorder Proposal for DSM-5: A Heroic and Innovative but Nevertheless Fundamentally Flawed Attempt to Improve DSM-IV

Roel Verheul

Article first published online: 12 JUL 2012 | DOI: 10.1002/cpp.1809


No abstract is available for this article.

DSM-5 Personality Disorders: Stop Before it is Too Late

Paul Emmelkamp and Mick Power

Article first published online: 3 JUL 2012 | DOI: 10.1002/cpp.1807


No abstract is available for this article.

Disorder in the Proposed DSM-5 Classification of Personality Disorders

W. John Livesley

Article first published online: 3 JUL 2012 | DOI: 10.1002/cpp.1808

Roel Verheul, Ph.D. and W. John Livesley, M.D., Ph.D. resigned as members of the DSM-5 Personality and Personality Disorders Work Group in April.

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.

by Allen Frances, M.D.

Two Who Resigned From DSM-5 Explain Why
They spell out the defects in the personality section

Allen Frances, M.D. | July 11, 2012

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…”

Read full article here

Proposals for the DSM-5 Personality Disorders as issued for the third and final stakeholder review can be read here on the DSM-5 Development site.

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