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The American Psychiatric Association (APA) announced some revisions of the soon to be published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This followed substantial unrest in the scientific and clinical community, and wide media coverage following a briefing held at the SMC with accompanying roundup comments.
Steven Jones, Professor of Clinical Psychology, Lancaster University, said:
“”There has been no movement on the bipolar NOS category which will include
1. Major Depressive Episodes and Short (2-3 day) Hypomanic Episodes.
2. Major Depressive Episodes and Hypomanic Episodes characterized by insufficient symptoms.
3. Hypomanic Episode without Prior Major Depressive Episode.
“Together these changes will significantly increase the number of people meeting criteria for bipolar disorder and therefore likely to be prescribed long term prophylactic medication with its associated health risks. Although it is important that detection of bipolar disorder is improved, it is not clear that this will be helped by widening the criteria to the extent that even individuals with relatively limited periods of mood elevation, not necessarily associated with deterioration in functioning, are given this diagnosis.”
Peter Kinderman, Professor of Clinical Psychology and Head, Institute of Psychology, University of Liverpool , said:
“In my original comments on DSM-5, I said that the proposed changes would make a bad system worse. It is perhaps a good thing that the DSM-5 Task Force is reconsidering some of their most unfortunate mistakes, but, fundamentally, it remains a bad system.
“The very minor revisions recently announced do not constitute the wholesale revision that is called for – that would represent the only real positive reform that is needed. It would be very unfortunate if these minor changes were to be used to suggest that the Task Force has listened in any meaningful way to critics.
“The proposed reforms to DSM-4 threaten to include many individuals and many aspects of everyday psychology into the remit of psychiatry. The decision to reconsider any element of the project is welcome. But tinkering with details won’t make a bad system acceptable. Indeed, it would be unacceptable to retain DSM-4.
“Instead, we should seize the opportunity to make the substantial and intelligent revision to diagnostic approaches in mental health that scientists and service users both demand.
If these minor revisions are all that will emerge from this process, they are insufficient. If they represent the first cracks in a flawed edifice, we should be encouraged and continue to press for intelligent change.”
Sir Robin Murray, Professor of Psychiatric Research, Institute of Psychiatry, Kings College London, said:
“It is a great relief that the APA is dropping the “attenuated psychosis syndrome”. It was always a mystery why this was being proposed since all the research evidence demonstrates that the vast majority of people who meet the proposed criteria will never develop psychosis. It would have done a lot of harm by diverting doctors into thinking about imagined risk of psychosis instead of addressing the depression and anxiety that so many such people suffer; furthermore, it would have led to unnecessary fears among patients that they were about to go mad.
“Three cheers – even the APA can be persuaded by evidence to change its mind.”
Peter Jones, Professor of Psychiatry, University of Cambridge, said:
“The APA should be congratulated on stepping back from some of its proposals for DSM-5 on the basis of empirical evidence as well as opinion. I am particularly pleased to see proposals for two new conditions, Attenuated Psychosis Syndrome and Mixed Anxiety Depressive Disorder, shelved with a recommendation for further research. My own view is that there is overlap between these domains and much yet to be understood about the genesis and significance of individual symptoms and partial syndromes in the population at large.
“However, many of the changes have been made of the basis of problems in the reliability of the proposed categories and criteria when assessed in field trials. The promise of a DSM-5 underpinned by science must be built on the concept of validity of disorders and an understanding of their meaning in terms of the biology and functions of the brain and mind, together with their interactions with an individual’s environment. We are making progress in the neurosciences but are, as yet, nowhere near the realistic reformulation of mental health and its disorders on which this promise is predicated. On this basis DSM-5 is, at best, premature and a waste of time; at worst, it will cause a hiatus in the research that is necessary to meet its own ambitions by disconnecting accumulating scientific evidence from illnesses reconfigured by DSM-5 committees. That said, the trimming of the DSM-5 sails through the APA announcement is most welcome.”
Allen Frances, Emeritus Professor at Duke University and Chair of the DSM-4 Steering Committee, said:
“This is only a first small step toward desperately needed DSM 5 reform. Numerous dangerous suggestions remain and DSM 5 has badly flunked its own reliability testing. In my view, DSM 5 needs to be kept back for an additional year to allow for independent review, to clean up its obscure writing, and for retesting to ensure that adequate reliability has finally been achieved. DSM 5 as it now stands is simply not usable.”
David Elkins, Professor Emeritus of Psychology, Pepperdine University, Los Angeles, and Chair of the Division 32 Task Force for DSM-5 Reform, said:
“The Division 32 Open Letter Committee is pleased that the DSM-5 Task Force has finally “heard” the worldwide criticisms of the DSM-5 as currently proposed. However, as the saying goes, “two swallows do not a summer make.”
“There are many problematic proposals in the DSM-5 that need to be changed. So, at this point, my committee has a “wait and see” attitude. We certainly hope the changes made are precursors of a complete overhaul of the DSM-5 that will make it safe to use.
“Regardless, however, my committee is already planning an international summit in the summer of 2013 with representatives from all major mental health associations to discuss alternative ways of conceptualising psychological distress.
“The American Psychiatric Association, with only 38,000 members, holds a monopoly on the DSM and the conceptualisation of emotional distress. We believe it’s time to have a more egalitarian approach that is not dominated by one, relatively small profession.”
Dr Warren Mansell, Reader in Psychology, University of Manchester, said:
“The changes in DSM-5 are to be welcomed, but the enterprise of diagnosing psychological disorders must undergo a paradigm shift to catch up with evidence from contemporary neuroscience and cognitive behavioural therapies – that there are common mechanisms of causing psychological distress and promoting recovery. Scientific movements begin with classification and then move forward through exploring the real mechanisms underlying these categories. Galileo needed Newtonian physics. Mendeleev needed a theory of subatomic particles. Linnaeus needed a theory of evolution. Psychiatry needs a theory of well-being.”
Mark Rapley, Professor of Clinical Psychology, University of East London, said:
“The APA suggests that: “members of the DSM-5 Task Force and Work Groups reviewed feedback submitted to this [web]site and, where appropriate, revised their proposed diagnostic criteria and made other changes….Proposed diagnostic criteria found on this site are the result of the DSM-5 Work Groups’ ongoing deliberations, based on findings from scientific field studies, patient and clinician perspectives, and views from the general public.”
“The APA insists that psychiatry is a science, that it is a bona fide branch of medicine. Indeed much is made of “findings from scientific field studies”.
“As such why, I wonder, does the Royal College of Physicians not seek website comments from the public on the diagnosis of breast cancer in the light of recently reported research into a possible new typology? Why does not the Royal Society of Chemistry seek a “user perspective” consensus on whether carbon should, really, be categorised as an element? When, oh, when will the Geological Society finally solicit “views from the general public” on the appropriateness of diagnosing granite as an igneous rock? I imagine such things will never happen. Why? Because real sciences do not decide on the existence and nature of the phenomena they are dealing with via a show of hands with a vested interest and pharmaceutical industry sponsorship. Until such time as the APA can conduct itself in a manner in keeping with widely accepted standards of scientific conduct, sadly all of its “diagnostic” pronouncements are of as much worth as those of the celebrated passenger on the top of the Clapham omnibus, and quite possibly of significantly less.”
Dr David Harper, Reader in Clinical Psychology, University of East London, said:
“While it is welcome that the American Psychiatric Association has responded to some of the criticisms of DSM5, they have ignored many of the most fundamental criticisms about the reliability and validity of psychiatric diagnostic categories. Even with the changes proposed, many experiences seen as part of human experience are still medicalised. Many diagnostic categories will still suffer from problems of reliability (where psychiatrists disagree on the correct diagnosis). Problems of co-morbidity (where people are given simultaneous multiple diagnoses) will still remain, as will the fact that many categories are so broad that people with entirely different symptoms can be given the same diagnosis. It is time for a much more significant overhaul of the ways in which we understand mental health distress.”
Dr Lucy Johnstone, Consultant Clinical Psychologist, Cwm Taf Health Board, Mid Glamorgan, South Wales, said:
“While I welcome some response to the outcry about DSM-5’s more outrageous proposals, I would not want these concessions to create a false sense of security. DSM-5 remains fundamentally flawed, despite some minor modifications. It is wrong in principle, based as it is on re-defining a whole range of understandable reactions to life circumstances as ‘illnesses’, which then become a target for toxic medications heavily promoted by the pharmaceutical industry. Despite what you may have read, there is no evidence at all that mental distress is caused by biological factors such as ‘biochemical imbalances’.
“However, there is very substantial evidence that even the most severe forms of mental distress can be seen as a response to loss, trauma and deprivation. Adding to people’s despair by telling them that they are mentally ill as well, is not only scientifically unjustified – it is actively damaging. The DSM committee’s latest response is simply moving the goalposts. The DSM project cannot be justified, in principle or in practice. It must be abandoned so that we can find more humane and effective ways of responding to mental distress.”
The fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will be published in May 2013 by the American Psychiatric Association.