Publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), scheduled for May 2013, has become a controversial and much anticipated event for the mental health professions and the field of psychology. There have been five revisions of the DSM since it was first released in 1952, with the last major revision, DSM-IV, published in 1994. A 19-year period will have elapsed between the introduction of DSM-IV (1994) and the proposed release of DSM-5 (2013).
The planning process for the DSM-5 commenced over twelve years ago (in 1999) and the release of initial revisions in 2010 for this fifth edition prompted extensive public comment and debate. With this age of online technology and multimedia, the most open development and review of DSM-5 in the history of the DSM is occurring. The American Psychiatric Association, which is responsible for updating the DSM, received over 8,000 comments to the newly established DSM-5 website during the first consultation period, February-April 2010. During the second consultation period from May to July 2011, over 2,000 comments were submitted to the website regarding the proposed diagnostic criteria revisions and the newly proposed organisational structure.
This begins to give APS members an insight into the concern and controversy that has surrounded the current review of this manual. The British Psychological Society (BPS) and a Division of the American Psychological Association (APA) have both taken a strong stance on the revisions for the DSM-5 to date. Given the level of controversy, rather than simply endorse the submissions by the APA and the BPS, the APS has formed a Reference Group of members with expertise in particular aspects of mental health and in the use of taxonomies to provide an informed and relevant response to the revisions from our organisation.
Background to the development of DSM-5
Over the past two decades scientific developments have continued to rapidly progress and changes in scientific technologies, for example brain imaging techniques and methods for analysing research data, have provided new and improved tools for understanding mental illnesses. Researchers have generated a wealth of knowledge and for these reasons the National Institute of Mental Health (NIMH) and the American Psychiatric Association believed it was important to expand the scientific basis and the classification system in the revision of DSM-IV. An initial DSM-5 conference for research planning was convened in 1999 and a DSM-5 Task Force established including the 13 Chairs of each Diagnostic Work Group (made up of global experts in various areas of diagnosis). These Diagnostic Work Groups were based largely on the classification of disorders presented in DSM-IV, although many participants closely involved in the development of DSM-IV were intentionally not included in order to expand the scope of thinking. A series of research planning conferences to focus on the scientific evidence were subsequently organised, with expertise spanning the globe represented at these conferences.
More than 500 clinicians and researchers have been working together to provide a solid scientific basis for the proposed changes to DSM. Summaries of each meeting are posted on the DSM-5 website and full proceedings are available. The activities of the Diagnostic Work Groups are summarised in regular reports on the DSM-5 website (www.dsm5.org/ProgressReports/Pages/Default.aspx) and members make presentations at scientific conferences. Additionally, members and advisors of the Diagnostic Work Groups are writing and submitting scientific papers to peer-reviewed publications. The proposed draft revisions to DSM-5 are posted on the website, and anyone can provide feedback to the work groups during periods of public comment. According to the DSM-5 website, a final consultation period will be opened in the coming months. The APS will prepare a response based on the deliberations of our Reference Group; however APS members are encouraged to consider making their own individual submissions to the DSM-5 website (www.dsm5.org) particularly if they have expertise in specific diagnostic categories.
Summary of main proposed changes
The currently proposed revisions to the diagnostic criteria are one of the most substantive areas of change in the DSM-5. Four principles were established to guide the DSM-5 revision process: clinical utility; research evidence; continuity with previous editions; and no predetermined constraints on the level of change permitted between DSM-IV and DSM-5.
According to the DSM website, ensuring the manual is useful to those who diagnose and treat patients with mental illness has been the highest priority, with the aim of specifying “treatment targets” for clinicians, i.e., symptoms to be addressed in treatment and for which improvement may be possible. Proposed dimensional assessments will provide a means by which clinicians can capture symptoms and severity of mental illnesses, including a rating of the severity of the symptoms, such as “very severe,” “severe,” “moderate” or “mild”. This rating may be used to track a patient’s progress and to document all of the patient’s symptoms. Also according to the DSM-5 FAQs, reducing diagnoses currently called “Not Otherwise Specified” in DSM-IV and improving diagnostic criteria that are not precise is also occurring. A focus has also been on how to include assessment of common symptoms that are not addressed within the diagnostic criteria.
A newly proposed organisational structure is the other most noticeable change in the draft DSM-5. The chapters are arranged by general categories such as neurodevelopmental and emotional, rather than based on underlying vulnerabilities as in the DSM-IV. The restructured organisation has been designed to better reflect scientific advances in the understanding of psychiatric disorders, as well as to make diagnosis easier and more clinician-friendly. All of the chapters are proposed to be organised according to the developmental lifespan, i.e., those diagnosed in infancy and early childhood, and progressing through diagnostic areas more commonly diagnosed in adulthood.
Areas of controversy in the DSM-5 revision
As discussed above, a large number of submissions have been received by the DSM-5 Task Force as part of the first two consultation processes. Submissions have come from organisations and individuals representing a range of professional groups including psychology, psychiatry and counselling. The key areas of controversy identified in the submissions include:
- The proposed revision to the definition of mental disorder
- An increased emphasis on biological theory as a basis for mental health diagnosis
- The lowering of diagnostic thresholds
- The increased use of ‘other’ and ‘not otherwise specified’ categories
- The introduction of new disorders without a clear
- scientific basis.
Concerns identified by the American Psychological Association
In response to the proposed diagnostic criteria revisions and the newly proposed organisational structure, Division 32 of the APA, the Society for Humanistic Psychology, posted an ‘open letter’ on a petition website in October 2011. Members were encouraged to read the letter, and if they agreed, to sign the petition. Within a week 2,000 psychologists and other professionals had signed the letter. The letter, proposed as a scholarly critique of some of the more problematic areas of the DSM-5, indicated two main concerns. Firstly, that the DSM-5, as proposed, lowers the diagnostic threshold for several major disorder categories, which may result in normal variations in human disorders being labelled as a ‘pathology’ (for example, in dpression). The second concern was that young children, adolescents and the elderly may become over treated with psychiatric drugs as a result of lower thresholds and the introduction of questionable diagnostic categories. The letter also described a lack of scientific grounding for specific proposals and its emphasis on biological theory. Four other Divisions of the APA have joined Division 32 in signing the letter and other large psychological organisations have also called for changes to the future manual. Two previous Chairs of DSM Task Forces (DSM-III, DSM-IV) have also voiced concerns.
The national APA has not adopted an official position on the proposed revisions; rather it has called for the DSM-5 Task Force to adhere to an ‘open and transparent’ process. The APA has called on its members to continue to add their perspectives and feedback to enhance the validity and clinical usefulness of the DSM-5.
Concerns identified by the British Psychological Society
By comparison the BPS has taken a more extreme philosophical view, expressing concerns about the ‘medical’ model approach to mental health problems. Its submission to the DSM-5 development consultation states a belief that most mental distress is caused by psychosocial factors, including the environment the person finds themselves in and relational aspects of the environment. The submission argues that mental health is better viewed as being on a spectrum of ‘normal’ experience. The BPS is urging alternatives to the diagnostic framework to be considered, for example using specific problems (e.g., feelings of anxiety) as the ‘unit of measurement’. They are also concerned about the increased use of medication in treatment of certain disorders such as autism spectrum disorders and learning disorders. The BPS submission indicates concerns regarding the scientific validity of diagnoses and the problems with labelling. In particular it expresses concern about some of the new and controversial categories, for example ‘attenuated psychosis system’ which could ‘label’ eccentric people, and ‘disruptive mood deregulation disorder’ in which ‘severe and recurrent temper outbursts in response to common stressors’ are the basis for a diagnosis.
APS Reference Group on the DSM-5 revision
The APS Reference Group will formulate a position paper for review by the APS Board, which will then be submitted during the final consultation period for the DSM-5 revision. The outcomes of the Reference Group’s deliberations will be presented in a later edition of InPsych.
The World Health Organisation is also undergoing revision of the International Classification of Diseases (ICD-10) to create the 11th revision. The APS will also consider providing a submission to this process.