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Response to DSM-5

Chronology of Responses and Critiques to DSM-5

 

In the past five years criticism and support of the DSM-5 has come in from all directions and here are just a few of those comments:

 

2007

Kraemer, Shrout & Rubio-Stipec (2007) In a warning about the direction the DSM-5 revisions were going, these authors stated that a disorder represents something of a medical concern in a patient, an abnormality, an injury, an aberration. Generally, the word is used when the etiology or the pathological process leading to the disorder is unknown. A disease, on the other hand, generally indicates a known pathological process. Thus, a disorder may comprise two or more separate diseases, or one disease may actually be viewed as two or more separate disorders, an issue of concern because of the well-known comorbidity of psychiatric disorders. Finally, a diagnosis is a procedure used to decide whether, or not, a certain disorder or disease is present in a patient. Thus, a disorder or disease is a characteristic of the patient; a diagnosis is an opinion that the disorder or disease is present. The quality of a diagnosis depends on how well that opinion relates to the characteristic of the patient, the issue of concern in reliability and validity assessments.

2008

Kupfer, Regier & Kuhl (2008) reassured the mental health community that the creators of the DSM-5 followed a set of revision principals to guide the efforts of the DSM-V Work Groups: grounding recommendations in empirical evidence; maintaining continuity with previous editions of DSM; removing a priori limitations on the amount of changes DSM-V may incur; and maintaining DSM’s status as a living document.

 

Middleton (2008) stated that from a clinical viewpoint it is reasonable to hope that the DSM-5 would provide a scheme of diagnostic classification to determine whether or not a particular set of symptoms reflects 'mental illness’ (case definition), provides an effective way of improving public health by detecting 'hidden’ cases for treatment (case detection), and identifies indications for particular forms of treatment (guide treatment).

2009

Dalal & Sivakumar (2009) warned that a classification is as good as its theory. They pointed out that the etiology of psychiatric disorders is still not clearly known, and that  we still define them categorically by their clinical syndrome. They stated that there are doubts if they are valid discrete disease entities and if dimensional models are better to study them. They concluded that we have come a long way till ICD-10 and DSM-IV, but there are shortcomings and that with advances in genetics and neurobiology in the future, classification of psychiatric disorders should improve further. 


Maser, Norman, Zisook, Everall, Stein, Shettler & Judd (2009) pointed out that changes in criterion in DSM-5 will reduce comorbidity, allow symptom weighting, introduce noncriterion symptoms, eliminate NOS categories, and provide new directions to biological researchers. They suggested reevaluating the threshold concept and use of quality-of-life assessment with a framework for such a revision. Drawbacks to changes coming from the DSM-5 include retraining of clinicians and administrative and policy changes.
 

Moller (2009) stated that the dimensional perspective recommended to be used in the DSM-5 needs to be pursued cautiously given that using such a perspective would mean that syndromes would have to be assessed in a standardized way for each person seeking help from the psychiatric service system. Therefore this system would need to be multi-dimensional assessment covering all syndromes existing within different psychiatric disorders.

2010

Regier, Kuhl, Kupfer & McNulty (2010) reassured the public in using the following quote “In pursuit of increasing the accuracy and clinical utility of the DSM, we need people with mental illness to help us understand what they are struggling with and how best to identify it.” They went on to say that this statement rings true to them in their involvement in revising DSM-5. They pointed out that the APA’s sensitivity to the needs of patients is great, and in fact, as stated above, they are unaware of any other area of medicine that has encouraged patient and family participation to the degree that they have attempted to do with DSM-5.

 

Sinclair (2010) pointed out in the review of the progress made in the revision process that new DSM-5 disorders are considered, based on clinical need, distinct manifestations, potential harm, and potential for treatment. Though the list of revised criteria is quite extensive, particular areas of interest include psychosis and schizophrenia, post-traumatic stress disorder (PTSD), addiction, and substance abuse.

 

McLaren (2010) held that it does not matter if the language in the DSM-5 is updated. It is of no account if categories are reshuffled, broadened, blurred, or loosened; the faults are conceptual, not operational, a case of old wine in new bottles. The DSM-5 Task Force has spent some 3 million hours so far (600 people at 10 hours per week for 10 years), and the biggest jobs are still to come. It has been 3 million wasted hours, just as all those psychoanalytic textbooks and conferences, plus the therapeutic hours on the analyst’s couch, were wasted. It is the wrong model. The faults of the DSM project stem from the fact that it is not a scientific project just because the profession of psychiatry does not have a declared, articulated scientific model of mental disorder to guide its daily practice, its teaching, and its research. It has nothing on which to hang its observations.

 

Ben-Zeev, Young & Corrigan (2010) explored the the relationship between diagnostic labels and stigma in the context of the DSM-5. They looked at three types of negative outcomes – public stigma, self-stigma, and label avoidance. They concluded that a clinical diagnosis under the DSM-5 may exacerbate these forms of stigma through socio-cognitive processes of groupness, homogeneity, and stability.

 

Andrews, Sunderland & Kemp (2010) concluded that the diagnostic thresholds for social phobia and for obsessive–compulsive disorder are less stringent than that for the other disorders and require revision in DSM-V.

 

Wittchen (2010) in her criticism of the process pointed out that the barriers to having women’s issues addressed in the DSM-5 is the fragmentation of the field of women's mental health research, lack of emphasis on diagnostic classificatory issues beyond a few selected clinical conditions, and finally, the “current rules of game” used by the current DSM-V Task Forces in the revision process of DSM-5.

2011

The British Psychological Society (2011) put out a major critique of the DSM-5. They expressed a concern that clients and the general public are negatively affected by the “medicalization of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.” They did support the rating of the severity of different symptoms called “the dimensional classifications, which are proposed in the DSM-5. They supported that use of dimensions because it would take away the focus on specific problems and recognize the variability among symptoms in the diagnosing process. The BPS also stated that the putative diagnoses presented in DSM-5 are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgments, with little confirmatory physical 'signs' or evidence of biological causation. They stated that the criteria used in the DSM-5 are not value-free, but rather reflect current normative social expectations. The BPA pointed out that researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity. Lastly the diagnosis which they zeroed in on was “attenuated psychosis syndrome.” The stated that the concept of “attenuated psychosis system” appears very worrying; it could be seen as an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis.

 

The Society for Humanistic Psychology (2011) questioned the proposed changes to the definition(s) of mental disorder that deemphasize sociocultural variation while placing more emphasis on biological theory. They stated that in light of the growing empirical evidence that neurobiology does not fully account for the emergence of mental distress, as well as new longitudinal studies revealing long-term hazards of standard neurobiological (psychotropic) treatment, “we believe that these changes pose substantial risks to patients/clients, practitioners, and the mental health professions in general.”

  1. Attenuated Psychosis Syndrome, which describes experiences common in the general population, and which was developed from a “risk” concept with strikingly low predictive validity for conversion to full psychosis.
  2. The proposed removal of Major Depressive Disorder’s bereavement exclusion, which currently prevents the pathologization of grief, a normal life process.
  3. The reduction in the number of criteria necessary for the diagnosis of Attention Deficit Disorder, a diagnosis that is already subject to epidemiological inflation.
  4. The reduction in symptomatic duration and the number of necessary criteria for the diagnosis of Generalized Anxiety Disorder.

They went on to say: “We are also gravely concerned about the introduction of disorder categories that risk misuse in particularly vulnerable populations. For example,
1.Mild Neurocognitive Disorder might be diagnosed in elderly with expected cognitive decline, especially in memory functions. and

2. Children and adolescents will be particularly susceptible to receiving a diagnosis of Disruptive Mood Dysregulation Disorder or Attenuated Psychosis Syndrome.

The American Counseling Association  (ACA), in a letter dated Nov 8, 2011, from ACA President Dr. Don W. Locke to APA President Dr. John Oldham, Locke indicated that there are 120,000 licensed professional counselors in U.S. -- second largest group that routinely uses DSM -- and that these professionals have expressed uncertainty about quality & credibility of DSM-5.

 

ACA is concerned that many of proposed revisions will promote, inaccurate diagnoses, diagnostic inflation and the prescribing of unnecessary and potentially harmful medications.

 

A major concern for professional counselors expressed by ACA is proposed definition of mental disorders. The language suggested implies that all mental disorders have a biological component.

 

An example of mental disorders that do not necessarily have a biological basis is the severe anxiety an individual may face upon losing a job. This is an environmental issue, according to ACA, not necessarily a problem rooted in biology. The trauma faced by an earthquake victim or the grief following the death of a loved one are other examples of mental conditions that might lead an individual to seek therapy, yet would not qualify under the proposed definition emphasizing a biological basis.

 

"Although advances in neuroscience have greatly enhanced our understanding of psychopathology, the current science does not fully support a biological connection for all mental disorders," Locke stated in the letter.

 

ACA had appointed a task force to work on DSM-5 revision in 2010 this task force called for an independent scientific review to ensure that counselors can have faith that the DSM-5 will be a safe & scientifically sound guide to psychiatric diagnosis. Locke in his letter pointed out that this ACA Task force on the DSM-5 took the position that: "in general, counselors are against pathologizing or 'medicalizing' clients with diagnoses as we prefer to view clients from a strength-based approach and avoid the stigma that is often associated with mental health diagnoses."

 

In a reply dated Nov. 21, 2011 APA addressed ACA's concerns & expressed their strong desire to ensure that the DSM-5 is a tool that is useful to the counseling profession and all mental health providers. The letter also stated that the definition of mental disorder is still a work in progress and, in fact, a revised definition will be posted in the spring and will be open to another round of public comment.

2012

 

In her ACA Blog (2012), K. Dayle Jones who has been posting a Blog on the DSM-5 since June 2011, stated that: APA has repeatedly bragged about the “unprecedented” open comment periods whereby clinicians can post comments about the DSM-5 proposals online during specified time periods. Ironically, the first comment period in January/February 2010 was initiated only after outside pressure insisted that all proposed revisions be reviewed and vetted by the field before field trials could begin. And, interestingly, very few substantive changes have been made in response to public comments since the first drafts were posted-despite the fact that so many DSM-5 proposals have been so heavily criticized. The final public comment period was originally scheduled for September/October 2011, but has been twice postponed because everything is so far behind–first to January/February 2012 and recently to May 2012. Given this late date, new public feedback will almost certainly have no impact whatever on DSM-5 and appears to be no more than a public relations gimmick.

References

American Counseling Association (2011). Letter to American Psychiatric Association, November 8, 2011 retrieved at: http://www.counseling.org/Resources/pdfs/ACA_DSM-5_letter_11-11.pdf

 

American Counseling Association (2011-2012). ACA weblog on DSM-5, retrieved at: http://my.counseling.org/?s=DSM-5

 

Andrews, G., Sunderland, M. & Kemp, A. (2010). Consistency of diagnostic thresholds in DSM-V. The Royal Australian and New Zealand Journal of Psychiatry,44:309-313.

 

Ben-Zeev, D., Young, M.A., & Corrigan, P.W. (2010). DSM-V and the stigma of mental illness. Journal of Mental Health, 19(4):318-327.

 

The British Psychological Society. (2011). Response to the American Psychiatric Association DSM-5 Development. British Psychological Society, June 2011:1-26.

 

Dalal, P.K. & Sivakumar, T. (2009). Moving towards ICD-11 and DSM-V: Concepts and evolution of psychiatric classification. Indian Journal of Psychiatry, 51(4):310-319.

 

Kraemer, H.C., Shrout, P.E. & Rubio-Stipec, M.(2007). Developing the diagnostic and statistical manual V: what will “statistical” mean in DSM-V? Social Psychiatry & Psychiatric Epidemiology,42:259-267.

 

Kupfer, D.J., Regier, D.A. & Kuhl, E.A. (2008). On the Road to DSM-V and ICD-11. European Archives of Psychiatry & Clinical Neuroscience, 258(Suppl 5):2-6.

 

Maser, J.D., Norman, S.B., Zisook, S., Everall, I.P., Stein, M.P., Shettler, P.J. & Judd, L.L. (2009). Psychiatric nosology is ready for a paradigm shift in DSM-V. Clinical Psychology: Science and Practice, 16(1): 24-40.

 

McLaren, N. (2010). The DSM-V Project: Bad science produces bad psychiatry. Ethical Human Psychology and Psychiatry, 12(3): 189-199

 

Middleton, H. (2008). Whither DSM and ICD, Chapter V? Mental Health Review Journal, 13(4):4-15.

 

Moller, H.J. (2009). Development of DSM-V and ICD-II: Tendencies and potential new classifications in psychiatry at the current state of knowledge. Psychiatry and Clinical Neurosciences, 63:595-612.

 

Regier, D.A., Kuhl, E.A., Kupfer, D.J. & McNulty, J.P. (2010). Patient involvement in the development of DSM-V. Psychiatry, 73(4):308-310.

 

Sinclair, H.Q. (2010). DSM-V Updated Guidelines. MD Conference Express, 4-6. Downloaded from www.mdconferencexpress.com 

 

Society for Humanistic Psychology (2011). Open Letter to DSM-5. Retrieved from http://www.ipetitions.com/petition/dsm5/  
 

Wittchen, H.U. (2010). Women-specific mental disorders in DSM-V: are we failing again? Archives of Women’s Mental Health, 13:51-55.