APA Disputes Critics of DSM-V Process
A woman in her mid-30s presents complaining of sadness and loss of interest combined with irritability, confusion, and occasional impulsivity.The mother of two toddlers, she works part time, barely making ends meet. She used to live in a rural Southern community before coming, two years ago, to a large city in the Northeast. During the interview, she cries off and on, voicing hopelessness and anger at God, but denies being suicidal. She confesses to drinking “more than before”; this reminds her of experiences with an alcoholic father's angry outbursts, which were a cause of insecurity in her teenage years and a desire to run away.
How would a psychiatrist using DSM-IV diagnose the patient described above?
Does she have depression only, or depression mixed with anxiety? Is she experiencing symptoms of depersonalization or dissociation, or a thread of traumatic memories indicating PTSD? And what would the clinician make of the sociocultural factors such as the patient's process of acculturation after moving to a large city?
“With this clinical information, a psychiatrist using DSM-IV would find it difficult to be precise about a clear-cut diagnosis,” said Renato Alarçon, M.D., a member of the Personality Disorders Work Group for the DSM-V Task Force. “Due to this complicated mix, the clinician may end up with too many diagnoses, while missing important components for which DSM-IV did not allow. As a result, the clinician may focus on just one clinical area, ignore or postpone the others, or refer the patient to a social worker without appropriate or thorough information.”
The vignette suggested by Alarçon highlights a central dilemma recognizable by virtually any clinician using DSM: the patients who show up in the office do not neatly fit the diagnostic categories.
Thirty years after DSM-III, which introduced a multiaxial system using categorical diagnoses, APA is undertaking a revision of its diagnostic manual (see Time for a Change?). Unlike DSM-IV, which made some important changes but took a largely conservative approach, the work in progress that is DSM-V proposes significant revisions including the addition of “dimensional” criteria—continuous variables allowing the clinician to rate severity—and (possibly) subclinical diagnoses, such as psychosis risk syndrome to identify patients at very high risk of psychosis (see DSM-V Developers Weigh Adding Psychosis Risk).
Some voices have been raised to question this new direction, and two of the most prominent critics have been Allen Frances, M.D., chair of the DSM-IV Task Force, and Robert Spitzer, M.D., chair of the Task Force on Nomenclature and Statistics for DSM-III. Aired on the Web site of Psychiatric Times and elsewhere, as well as in a letter addressed to APA's Board of Trustees, their complaints, in summary, are these:
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The developmental process of DSM-V has been secretive, with confidentiality agreements signed by work group members acting as a gag on communication (see Secrecy Charges Rebutted).
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Sweeping changes—the inclusion dimensional categories and subclinical diagnoses such as for prodromal schizophrenia—are being contemplated that are not supported by research and for which the field is not ready.
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The entire exercise is being rushed prematurely into field trials with the unavoidable result being a fatally flawed new diagnostic manual.
In interviews with Psychiatric News, Frances and Spitzer repeated these criticisms.
“The unrealistic ambition to achieve a paradigm shift combined with a weak and closed methodology sets DSM-V up for numerous unfortunate, unintended consequences,” Frances told Psychiatric News.“ The DSM-V effort needs to quickly trim its ambitions and tighten its methodology. Every change, even carefully thought-out ones, may have unforeseen risks. Wholesale changes resulting from a closed and careless process will be dangerous for patients and embarrassing for the field.”
But APA leaders and clinician-researchers involved in the DSM-V process dispute Spitzer and Frances at every point and describe a work in progress that bears almost no resemblance to the one described by the two critics. These leaders include Alarçon as well as James H. Scully Jr., M.D., APA medical director; David Kupfer, M.D., chair of the DSM-V Task Force; William Carpenter, M.D., chair of the DSM-V Psychosis Work Group; and Darrel Regier, M.D., M.P.H., executive director of the American Psychiatric Institute for Research and Education, director of APA's Office of Research, and vice chair of the DSM-V Task Force—all of whom were interviewed separately by Psychiatric News.
Responding point by point, they said the following:
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The process has been remarkably open, with work-group deliberations being presented in multiple online and live presentations. Furthermore, the confidentiality agreements signed by work group members were not intended—and have not acted—as a gag.
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No wholesale rewrite is in the offing of the manual or of the explicit diagnostic criteria that clinicians have been familiar with since the advent of DSM-III; furthermore, dimensional categories are being added on to—not supplanting—the diagnostic criteria.
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A vigorous debate is ongoing about the inclusion of subclinical categories; for example, though there is a robust science surrounding the identification of prodromal psychosis, work-group members are exquisitely sensitive to the problem of “false positives” and of labeling of normal behavior, and no decision has yet been made about this sensitive issue (see DSM-V Developers Weigh Adding Psychosis Risk).
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The process, far from being rushed, began back in 1999 and has involved hundreds of researchers and countless work hours. Furthermore, the 2012 deadline can be changed if necessary.
Regier told Psychiatric News that he believes Spitzer and Frances are speaking for a minority and that their prediction of a“ disaster”—as expressed in a July 6 letter to the APA Board of Trustees—is without basis.
“The overwhelming feedback that we have received from the research community and our membership has been positive,” Regier said. “The 'disastrous result' in most clinicians' and researchers' minds would be for DSM to continue on the same path it has been on for 30 years, without any attempts to correct its deficiencies or prepare it for the future.”
He added, “We have already had years of scientific review through our NIH-funded conference series, secondary data analyses, and literature reviews by DSM-V work groups and study groups and their advisors. Evidence from this review has been published in the form of numerous monographs and peer-reviewed articles, and we will continue to make findings available as the groups progress. Altogether, we have had more than 500 of the world's best and brightest clinicians and researchers working together to provide a solid scientific basis for the proposed changes to DSM.
“In a perfect world, work group members would have an infinite amount of time to finish DSM-V. Unfortunately, deadlines are a necessity with which we all must contend, and in fact without them, progress would likely remain an ideal rather than a reality.”
Kupfer echoed those comments, emphasizing that the field trials of draft diagnostic criteria are designed to provide a wider review of those criteria—precisely the aim that Frances and Spitzer said is necessary—not to finalize a preordained conclusion.
“The field trials are part of an iterative process in which we will have an opportunity to test some draft criteria and possible dimensions,” Kupfer told Psychiatric News. “What we are seeking is a wider audience to comment before we make some final decisions about criteria. Many changes are likely before final criteria are formalized at the end of 2010.
“We need to test some of these criteria,” he continued.“ Some will work, and others won't. If it looks like we won't make the deadline, we will make some changes based on the science available and on clinical usefulness.”
Should clinicians expect to have to adjust to a new and unfamiliar DSM?
No, said Regier and Kupfer. “One of the three guiding principles for the development of DSM-V is that continuity with previous editions should be maintained,” Regier pointed out. “So a wholesale revision is not in the cards. Users of DSM-V will recognize the criteria-based categorical system that has been in place since DSM-III.”
Added Kupfer, “The new DSM will not make a clean break [with previous editions]. We believed we should not be encumbered by previous editions, but that we should pay a lot of attention to not having abrupt breaks with the past. No one is suggesting that categorical diagnoses are going to be replaced by dimensional diagnoses. But we are looking for enhancement of categorical diagnoses by the use of continuous measures, instead of simply a 'yes' or 'no.' We believe it can enhance the precision of our diagnoses and accommodate questions about severity.” ▪
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Published online: 21 August 2009
Published in print: August 21, 2009
Notes
Thirty years after the introduction of DSM-III, important revisions are being contemplated for DSM-V, including the addition of dimensional ratings. But clinicians will still recognize the criteria-based categorical system in place since 1980.
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