Petition Calls for Critical Changes to Upcoming DSM-5

Group Says It Has 'Serious Reservations' About Lowering Diagnostic Thresholds

Deborah Brauser

November 04, 2011

November 4, 2011 — Divisions of the American Psychological Association have created an online petition addressing "serious reservations" about the upcoming Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Launched October 22, the petition has already garnered more than 3000 signatures from mental health professionals, students, and organizations.

Formatted as an "Open Letter" to the DSM-5 task force of the American Psychiatric Association, the document questions the new manual's "lowering of diagnostic thresholds for multiple disorder categories, about the introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations, and about specific proposals that appear to lack empirical grounding."

The American Psychological Association's Division 32 (the Society for Humanistic Psychology) sponsored the petition in alliance with divisions 27 and 49 (the Society for Community Research and Action: Division of Community Psychology and the Society for Group Psychology and Psychotherapy, respectively).

According to David N. Elkins, PhD, president of the Society for Humanistic Psychology, the petition was created to get attention from a task force that has "become very insular" and has not addressed many of the concerns raised by several organizations, including the British Psychological Society and the American Counseling Association.

Dr. David N. Elkins

"We basically put this together to urge the DSM-5 committee to reconsider some of the diagnostic categories they are proposing," Dr. Elkins, who is also a professor of psychology at Pepperdine University in Los Angeles, California, told Medscape Medical News.

Medscape Medical News approached the American Psychiatric Association, which sponsors the DSM-5, for comment, but the association declined. "The APA is not offering comment on the petition," said the association's media spokesperson, Erin Connors.

Unresponsive to Public Feedback

Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress.

When asked why the petition has been released at this late stage in the manual's revision process, Dr. Elkins said that although the task force has invited public feedback on its Web site, it has not been very responsive to the concerns received.

"With the manual scheduled to come out in 2013, it's getting to the point that if something isn't done, and done rather quickly, we're going to have a DSM-5 that has some things that we believe are dangerous to certain populations and could contribute significantly to the problems of diagnosing normal people, and kids, and the elderly with a mental disorder," he said.

"That said, we support the DSM-5 and remain hopeful that it will be modified where it needs to be."

Dr. Elkins said that when the petition was first created, the hope was it would persuade the DSM-5 task force to listen to feedback from clinicians who will be using the manual.

"We hope that they will address and make changes to really just a few areas, but very, very important areas."

Calling the DSM-5's proposal to lower diagnostic thresholds "scientifically premature," the petition states: "Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress." Areas of particular concern include:

  • questions about attenuated psychosis syndrome,

  • the proposed removal of the bereavement exclusion from major depressive disorder,

  • the reduction in criteria needed to diagnose attention deficit disorder, and

  • the reduction in necessary diagnostic criteria and symptom duration for generalized anxiety disorder.

Unintended Consequences

Sarah R. Kamens, a doctoral candidate in clinical psychology at Fordham University in New York City, and student representative to the American Psychological Association's Division 32, said that some of the responses from the DSM-5 task force have not adequately dealt with issues brought up during the public feedback sessions.

Sara R. Kamens

For example, she said that attenuated psychosis syndrome started out as psychosis risk syndrome.

"There's this idea that if you identify people early, somehow you'll be able to prevent a full-blown psychosis or full-blown schizophrenia. But research has shown that only up to 20% to 30% of identified people actually went on to develop psychosis, meaning up to 70% or 80% of these people received treatment for a disorder they never ended up developing," said Ms. Kamens.

We don't believe the DSM-5 committee intentionally wants to hurt children or the elderly. In fact, I think their rationale and efforts are coming from very good intentions. But we just disagree with them in terms of what the unintended consequences will be.

"But in response to those concerns, the DSM-5 group just changed the name, which wasn't really the point. Overall, we're looking at a risk–benefit analysis with primary prevention vs medicating people who are really closer to that threshold of normality."

Dr. Elkins said that overmedication of vulnerable populations remains one of their biggest concerns with the upcoming manual.

"We don't believe the DSM-5 committee intentionally wants to hurt children or the elderly. In fact, I think their rationale and their efforts are coming from very good intentions. But we just disagree with them in terms of what the unintended consequences will be."

Lack of Evidence?

In addition, the petition cites "lack of empirical grounding" for its concerns with the proposed reorganization of the personality disorders section of the manual. "It appears to be a complex and idiosyncratic combined categorical-dimensional system that is only based on extant scientific research."

Dr. Brent Dean Robbins

This is an issue that is especially critical to Brent Dean Robbins, PhD, director of the psychology program at Point Park University in Pittsburgh, Pennsylvania, and secretary of Division 32.

I'd also like to see it leaning in the direction of caution, towards not pathologizing 'normal' kids, but more clearly delineating between those who really need help from medication or from therapy and those who do not.

"Personally, I would like to see an emphasis on changes that are backed up by substantial empirical evidence, not just one single research group or one single university," said Dr. Robbins.

"I'd also like to see it leaning in the direction of caution, towards not pathologizing 'normal' kids, but more clearly delineating between those who really need help from medication or from therapy and those who do not."

The proposed categories of apathy syndrome, Internet addiction disorder, and parental alienation syndrome are also criticized for lack of research.

"[W]e question proposed changes to the definition(s) of mental disorder that deemphasize sociocultural variation while placing more emphasis on biological theory," the petition states.

DSM-4 Chair Weighs In

Allen Frances, MD, professor emeritus from the Department of Psychiatry at Duke University School of Medicine in Durham, North Carolina who also chaired the DSM-4 task force, has been a vocal critic of the DSM-5.

"The [open] letter summarizes the grave dangers of DSM-5 that for some time have seemed patently apparent to everyone except those who are actually working on DSM-5," he writes in his online blog for the Psychiatric Times.

The open letter summarizes the grave dangers of DSM-5 that, for some time, have seemed patently apparent to everyone except those who are actually working on DSM-5.

Dr. Frances adds the most compelling problems with the new manual include "reckless expansion of the diagnostic system (through the inclusion of untested new diagnoses and reduced thresholds for old ones), the lack of scientific rigor and independent review, and dimensional proposals that are too impossibly complex ever to be used by clinicians."

Dr. Elkins noted that he agrees with Dr. Frances' past suggestion that the "controversial parts" of the DSM-5 be submitted to an independent review of scholars and scientists.

"Our hope, then, is that an independent panel would give a report back suggesting what we think are much needed modifications."

Growing Frustration

Although the petition currently has 3705 signatures as of this writing, its sponsors hope for many more. In addition, they plan to resubmit it, possibly with a few updates based on suggestions from those signing the petition, during the DSM-5's final call for public feedback, which is expected to occur at the end of this year or in early 2012.

"This is a way that we, as a professional community, can get together and submit a joint response so that the task force and the public are made more aware of the issues," said Ms. Kamens.

We believe we have tapped into a growing frustration with the DSM-5 process. And the groundswell has been quite overwhelming. It's important to realize, this is not some fringe group that is anti-DSM-5 or anti-psychiatry in any way. It's a group of all kinds of professionals.

"We believe we have tapped into a growing frustration with the DSM-5 process. And the groundswell has been quite overwhelming. It's important to realize, this is not some fringe group that is anti-DSM-5 or antipsychiatry in any way. It's a group of all kinds of professionals."

When asked how their group will determine success, and if it is an "all or nothing" proposition, Dr. Elkins said that it is important to be realistic and willing to compromise.

"However, I do not feel like compromising when hundreds of thousands of kids and the elderly could be at risk. I don't know what the future holds in terms of what the movement will do in regards to the manual. But the way to head off any potential actions, such as boycotts, is for the task force to open up to the fact that thousands of us out here are very concerned."

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