APA Answers DSM-5 Critics

November 9, 2011 — After initially refusing to respond to an online petition issued by several divisions within the American Psychological Association expressing "serious reservations" about the lowering of diagnostic criteria in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the American Psychiatric Association (APA) has answered its critics.

"It's always a judgment call when to respond to a given organization. It's certainly not that we weren't attentive to the concerns expressed in the petition. But this has been under fairly active review by lots of people who belong to lots of different organizations," Darrel A. Regier, MD, director of research for the APA and vice-chair of the DSM-5 Task Force, told Medscape Medical News.

We hear your concerns and are aware of those from others in the mental health field, and take them under serious consideration in our deliberations.

As reported last week by Medscape Medical News, the petition was posted online October 22 in the form of an "Open Letter" to the DSM-5 Task Force of the APA. It currently has more than 4900 signatures from mental health professionals, organizations, and students.

The main concern outlined in the petition is the new manual's "lowering of diagnostic thresholds for multiple disorder categories, the introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations, and specific proposals that appear to lack empirical grounding."

The APA's response notes an appreciation for all "who have invested such intense interest and energy" in assuring that the DSM-5 will be based on the best available clinical and research evidence.

"We hear your concerns and are aware of those from others in the mental health field, and take them under serious consideration in our deliberations."

According to Dr. Regier, the APA received 10,000 signed comments and more than 50 million hits on the association's Web site during the 2 DSM-5 public feedback periods.

He noted that the DSM-5 Task Force had previously contacted leaders of the American Psychological Association, the National Association of Social Workers, the Psychiatric Nurses Association, and the American Family Counselors Association requesting that their members participate in the DSM-5's routine clinical practice field trials.

"We've reached out to them so their members can get a good chance at looking at how the proposals are working in practice."

Addressing the Issues

The full range of disorders will be assessed in this field trial and the findings will contribute to the final decisions about the diagnoses.

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

According to David N. Elkins, PhD, president of the Society for Humanistic Psychology, the main purpose the petition was to garner attention from a task force that has "become very insular," and to urge the reconsideration of some of the proposed diagnostic categories.

"When receiving an Open Letter like that, it's important to make sure that we do address the legitimate issues," said Dr. Regier.

The online petition discusses concerns about several proposed disorders, including parental alienation syndrome (PAS). In its response, the DSM-5 committee notes that some disorders, including PAS, "were proposed by outside groups but have not been proposed for inclusion by the Task Force."

Other newly proposed diagnoses, such as disruptive mood dysregulation disorder, attenuated psychosis syndrome disorder, and generalized anxiety disorders, were part of the testing process in 11 academic field trial centers.

According to Dr. Regier, the academic center portion of the DSM-5 field trials concluded on October 31 and enrolled more than 2000 patients "in a rigorous test-retest design to assess the reliability and clinical utility of proposed criteria."

The "routine clinical practice settings" part of the field trials are now taking place and includes around 1500 randomly selected psychiatrists; another 1000 volunteer psychiatrists; and about 500 each of volunteer psychologists, social workers, psychiatric nurses, and clinical and family counselors.

"The full range of disorders will be assessed in this field trial and the findings will contribute to the final decisions about the diagnoses," notes the APA response.

Although the routine clinical settings field trials were expected to be completed by the end of December, it has been extended to around March 2012. Dr. Regier said that this will probably push back the final public feedback period to no later than May 2012.

Grey Areas

Our intent with the DSM-5 is to make it a much more fine-tuned, fine-grained system so that we have a better assessment with repeated research, like we have for blood pressure or cholesterol estimates.

As to the concern about lowering diagnostic thresholds, Dr. Regier said that the field trials, which use dimensional measurements, are important tools for figuring out clinical "grey areas."

"There are lots of clinical judgments that come with those grey areas, such as 'does this person actually need some kind of clinical care?' And there are others who are in these areas that definitely do not. So we're trying to help clinicians have the information to make these judgments empirically, rather than just by the seat of their pants."

He added that the key issue is to have as good a distinction process as possible. However, the current classification has been exclusively categorical without dimensional variations.

"Our intent with the DSM-5 is to make it a much more fine-tuned, fine-grained system so that we have a better assessment with repeated research, like we have for blood pressure or cholesterol estimates."

Instead of using the Global Assessment of Function or Axis-5 classification, as with the DSM-4, the Task Force is using the World Health Organization Disability Assessment Scale.

"By making our diagnoses more quantitative, we think we can actually replicate what is in fact a pathological level as opposed to just one extreme on a normal bell curve of a normal psychological expression," said Dr. Regier.

The petition also expresses concern that some of the new DSM-5 proposals are not based in adequate research. Surprisingly, Dr. Regier agrees.

"We are faced with an interesting situation of having what are well known deficiencies in the current diagnostic system. To some degree we need to make some judgments on options for improving it. And the mix of categorical and dimensional measures is one way that we think is scientifically an appropriate way to go with this," said Dr. Regier.

"However, a lot of this has not been tested as well as we would like. The current problem is that because the DSM has so dominated research practices for the last 30 years, nobody would even think or get funding to test different diagnostic criteria until they're really adopted by the DSM."

Living Document

Our intent is to have an ongoing review process just like we do for our practice guidelines...[but] it's also important to get it as accurate as we possibly can at this point in time. So we're eager to have this kind of open review.

He said that this practice actually started with the introduction of the DSM-3 in 1980, when a limited database formed the organizational principles for several diagnoses that had almost no empirical justification.

"We need to make some judgements now to go forward that will change some of those conventions. Our plan is that these will be immediately tested once the DSM is official, and then one will be able to see if revisions can be made."

"Our workgroups are struggling with this balance…for what might be the most appropriate fix. Some of these fixes are not as well studied as others and we recognize that. But we can't move forward without some of these put into practice. So we think this is a much more testable set of scientific hypotheses," said Dr. Regier.

"And that's what the DSM is — a set of scientific hypotheses that are intended to be tested and disproved if the evidence isn't found to support them."

When asked if many concerns have been brought up because of worries that the DSM-5 will become the "clinical bible" for a generation of clinicians, Dr. Regier said the hope is that "it won't be set in stone for a number of years, like the last version has been."

Because of the increasing rate of research developing for mental disorders, he explained that the Task Force hopes to make the manual a "living document" that can be revised regularly. As reported in a story published earlier this year by Medscape Medical News, this is part of the reason why the manual will be offered in both print and digital formats.

"We're thinking of having a DSM-5.1, DSM-5.2, etc, in much the same way is done with software updates," said Dr. Regier.

"Our intent is to have an ongoing review process just like we do for our practice guidelines, or like the American Medical Association has for procedure codes. However, it's also important to get it as accurate as we possibly can at this point in time. So we're eager to have this kind of open review."

Dr. Regier noted that changes to criteria, and rationales for the changes, are posted on the APA's constantly updated DSM-5 Web site.

Response to the Response

We remain deeply concerned about the issues we raised and find that your response did not adequately address them.

In a posted response to the APA's response letter, the petition authors write that they are grateful that the Task Force opened a public dialogue.

"However, we remain deeply concerned about the issues we raised and find that your response did not adequately address them," they write. Their letter ends with a call for an external review of the DSM-5 proposals by "scientists and scholars who are not appointed by or affiliated with the American Psychiatric Association."

"Now that we have written back to them, we hope that this dialogue continues and is helpful for them, for us, and for all mental health professions," Dr. Elkins told Medscape Medical News.

He noted, though, that lowering the diagnostic thresholds remain a concern that is still not being properly addressed by the Task Force.

"With a diagnostic category that would be relatively easy to give to children or the elderly, it's entirely possible that a physician may create false epidemics by pathologizing thousands of people who are really just going through the continuum of normal variations of human experience. This could lead to giving them a stigmatizing diagnosis that will follow them the rest of their lives."

Dr. Elkins said that although the rationale about diagnostic grey areas is well intentioned, he disagrees with it.

"Instead of liberalizing diagnoses, I think we should be more conservative in the interest of our potential patients. There's nothing preventing mental health professionals from assisting someone who does not qualify for a mental disorder. They may have difficulty getting reimbursed by insurance, but that's a different issue altogether."

He added that he hopes that future DSM processes will include "on an even basis" other mental health clinicians and organizations. "Because the American Psychiatric Association is so small, in comparison to all the rest of the mental health professions, I think they really need to be more egalitarian in the process of producing the manual."

Dr. Elkins said the central message of the response letter is their request for the submittal of the DSM-5 for independent review.

"Even patients have a right to a second opinion. So that's the emphasis of what we're trying to bring to this conversation at this point."

Transparency Important

Our primary interest is that the revisions process be open and transparent; that it's based on the best available science; and that it's based on the best interest of the public.

Melba Vasquez, PhD, president of the American Psychological Association, told Medscape Medical News that although the overall organization "is not taking a stand," they have encouraged both members and groups within to provide feedback about the DSM-5.

"Even though we haven't taken a critical position, we're monitoring the process, we've shared information with our members, and we've encouraged them to add their voices and their expertise. And we are pleased that members are working through their divisions to do so."

Dr. Vasquez emphasized that although the American Psychiatric Association's response letter was addressed to both her and Dr. Elkins, the petition did not come from the overall American Psychological Association.

"However, we are supporting the divisions. Our primary interest is that the revisions process be open and transparent; that it's based on the best available science; and that it's based on the best interest of the public," she said.

"So we do applaud the role that Division 32 has played in giving feedback and we appreciate the American Psychiatric Association's willingness to engage in a dialogue. And we encourage them to continue to be open, to listen, and to give serious consideration to input from the psychology community."

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Cite this: APA Answers DSM-5 Critics - Medscape - Nov 09, 2011.