First published in 1952, the “Diagnostic and Statistical Manual of Mental Disorders” is used throughout the U.S. and in many places around the world, in the diagnosis of mental illness and, as such, each revision is carefully debated and dissected.
DSM-5, scheduled to be completed by May 2013, has prompted feedback and criticism.
Several American Psychological Association divisions have added their voices to the discussion. In an open letter/petition posted online in October, the Society for Humanistic Psychology (Division 32) and five other APA divisions raised concerns about both the process and revisions themselves.
“The main concerns we have [with the revisions],” says Brent Dean Robbins, Ph.D., chair of the psychology department at Point Park University in Pittsburgh and secretary for Division 32, “are the lowering of diagnostic thresholds of existing disorders and the addition of new diagnoses with very little empirical support behind them.”
In many cases, Robbins adds, the new version appears to favor a biomedical basis of disease, which could encourage the use of pharmaceutical treatment and possibly increase the stigma of issues that might be temporary or even expected in normal human development.
“In light of the growing empirical evidence that neurobiology does not fully account for the emergence of mental distress,” the open letter states, “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.”
Specific concerns include a proposal to remove or shorten the bereavement exclusion from the diagnosis of major depressive disorder, which could lead to an over-diagnosis of depression among people who are experiencing normal processes when faced with the death of a loved one.
While the organizations involved gave the DSM-5 task force credit for attempting to correct issues with the out-dated revisions, they claim that there is not enough discussion and transparency with the process and that makes it difficult for them to fully back the proposed changes.
“When you have transparency then you enhance the trust of those who are going to use your product,” says Robbins.
The Division 32 letter was posted online on Oct. 22 and within six weeks, more than 7,500 people had signed it, as well as 33 other mental health organizations.
Allen Frances, M.D., a chief architect of the DSM-IV, has also backed the petition and written about the concerns in Psychiatry Today, stating, “The 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 it.
In November, the DSM-5 task force responded to the letter, stating that members plan to take into account the numerous comments and suggestions made online and in letters such as theirs.
In part, the letter reads: “Final decisions about proposed revisions will be made on the basis of field trial data as well as on a full consideration of other issues such as those raised by the signatories to this petition, the 10,000 individuals who responded to the Feb. 2010 and April 2011 postings of draft criteria on DSM5.org, other internal reviews by a Scientific Review Committee, the DSM-5 Task Force and the APA Board of Trustees.”
The field trials do not satisfy the complaints made by the writers of the petition, however.
“The problem,” says Robbins, “is that they look at how accurate clinicians are in applying the criteria in practice but they do not look at whether the criteria in themselves are valid.”
The response to their letter did not address a request for an outside review by an organization that would not stand to benefit from any revision to the DSM, says Robbins.
The number of people signing on to the petition points to the serious reservations among mental health professionals regarding the validity of DSM-5 and, at the most extreme, to a possible boycott of the final product.
“That’s not what we want to do,” says Robbins. “That is something we are not trying to move towards. We would hope that the task force is going to see this as a reasonable request. We would feel more confident using their manual in clinical practice if they address these concerns.”
By Catherine Robertson Souter