British Psychological Society still has concerns over DSM-V.
CLICK LINK FOR ACCESS TO BPS SITE and the full DSM5 Consultation Response.
+ SIGN PETITION: http://www.gopetition.com/petitions/write-the-wrongs-in-dsm-5-n-i-c-e-must-issue-guidanc.html
The British Psychological Society has responded to the final consultation on the DSM-V diagnostic framework. You can read our full response on this website.
Dr David Murphy, Chair of the Society’s Professional Practice Board, says:
The Society applauds the American Psychiatric Association for engaging in this level of public consultation, and we welcome some of the changes from the previous iteration, such as the deferment of the decision to include the category of ‘attenuated psychosis syndrome’ and to recommend further research.
However we continue to have serious concerns about many aspects of the framework. In our response we have argued that the categorical framework of DSM-V is flawed in that it fails to take account of the evidence for the dimensional spectrum of psychiatric symptoms such as low mood, hearing voices, unusual beliefs etc in the general population.
We have also highlighted significant concerns about lowering of diagnositic thresholds and the validity ‘catch all’ diagnostic categoroies that exist within DSM-V such as ‘ADHD not elsewhere classified’, which we are concerned have poor inter rater reliability.
We are concerned that both of these aspects lead to the risk of overdiagnosis and thereby potentially unnecessary and potentially harmful treatment with medication.
About this Response :
This response was prepared for the British Psychological Society by Dr Catherine Dooley,CPsychol, AFBPsS, committee member of the Division of Clinical Psychology (DCP), Chair of
the DCP’s Professional Standards Unit, and member of the Division of Neuropsychology andthe Faculty for Psychology Specialists Working With Older People,
With contributions from:
Isabel Clarke, CPsychol, member of the DCP, Chair of the Faculty of Psychosis and Complex Mental Health (FPCMH), and member of the Transpersonal Section;
Dr David Harper,CPsychol, AFBPsS, member of the DCP and the FPCMH;
Lucy Johnstone, CPsychol, AFBPsS,past committee member of the DCP, and member of the FPCMH;
Professor Peter Kinderman,CPsychol, AFBPsS, past Chair of the DCP;
David Traxson, CPsychol, committee member and
commenting on behalf of the Division of Educational and Child Psychology;
and David Trickey, CPsychol, member of the DCP and the Faculty for Children and Young People.
We hope you find our comments useful.
The validity of the basic categories is assumed, rather than evidenced from research into distress across both psychiatric and ‘normal’ populations which might challenge the appropriateness of the paradigm. In this circular process, both the original suggestions and subsequent modifications are based more on committee decision and public responses than on patterns arising out of the identification of underlying mental phenomena.
In the absence of such signs, judgments about pathology are inevitably grounded in subjective and cultural norms. This is particularly obvious in the case of ‘Personality Disorders’, (criterion ‘D’ for ‘Personality Disorder’: “The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment”), but also applies across the spectrum of functional diagnoses.
The BPS continues to believe that, by not taking account of the evidence for the dimensional spectrum of psychiatric symptoms such as low mood, hearing voices, unusual beliefs and so on across the general population, retention of a categorical model is a methodological flaw, particularly but not exclusively for ‘functional’ rather than ‘organic’ disorders.
We also are concerned that the revised proposals have failed to take account of the growing body of evidence implicating relationship and social factors as the primary risks for mental distress across the range of psychiatric presentations, including 'psychosis'. A recent editorial in the British Journal of Psychiatry (Read and Bentall, 2012) summarised this research and called for a paradigm shift in our understanding of mental distress. We recommend a return to basic science without preconceptions.
We consider that, as it stands, the revised DSM-5 would lead to an ongoing risk of pathologising individuals while obscuring well-established social and relationship causal factors. A considerable body of evidence from service users/survivors testifies to the damaging consequences of this approach (eg Geekie et al, 2012.)
Finally, as outlined in our 2011 response (BPS, 2011), we are particularly concerned about “catch-all” categories which have a particularly weak conceptual basis, as demonstrated by the fact that one third of people diagnosed with a personality disorder fall under the heading ‘Not otherwise specified’ (Traxson, 2010). This includes all catch-all terms such as "atypical ….." and "sub-clinical, normal variation ….." which wev feel will greatly increase the risk of 'false positive diagnoses particularly for children. Personality disorder and psychoses are particularly troublesome as they are not adequately normed on the general population, where community surveys regularly report much higher prevalence and incidence than would be expected. A more scientific approach, less likely to lead to the over-diagnosing of conditions such as ADHD and bipolar disorder in children, would be to research the extent of such experiences within the wider population without making a prior assumption of pathology.
For all the reasons stated above, the BPS, having reviewed the currently proposed revisions of the new diagnostic criteria in DSM 5, continues to have major concerns. These have, if anything, been increased by the very poor reliabilities achieved in many of the recent field trials (Huffington Post, 2012), especially given the limited time available to attempt to achieve more satisfactory outcomes. Since validity depends, at the very least, on acceptable levels of reliability, the unavoidable conclusion is that many of the most frequently-used categories will be unable to fulfil their purported purposes, i.e. identification
Additionally, given that the potentially harmful effects of psychiatric medication are well-documented, the BPS is concerned that the risks of over-diagnosis outlined earlier may result in the inappropriate use of potentially significant adverse consequences.
In fact, the differential diagnosis rates for the existing
British Psychological Society issues statement in response to DSM-5 encouraging members to sign Coalition for DSM-5 Reform petition
December 13, 2011
The Society has today (13 December 2011) released a statement expressing concerns regarding the proposed revisions of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, which is one the main internationally-used classification systems for diagnosis of people with mental health problems in clinical settings and for research trials.
The Society for Humanistic Psychology (Division 32) of the American Psychological Association (APA) has recently published an open letter to the DSM-5 taskforce raising a number of concerns about the draft revisions proposed for DSM-5 and citing a number of issues raised previously by the BPS.
In its statement today, the Society shares the concerns expressed in the open letter from the Society of Humanistic Psychology (Division 32) of the APA and encourages members of the Society to read the letter themselves and consider signing the petition.
David Murphy, Chair of the Society’s Professional Practice Board said:
“The Society recognises that a range of views exist amongst psychologists, and other mental health professionals, regarding the validity and usefulness of diagnostic frameworks in general and the Diagnostic and Statistical Manual of the American Psychiatric Association, in particular.
“However, there is a widespread consensus amongst our members that some of the changes proposed for the new framework could lead to potentially stigmatizing medical labels being inappropriately applied to normal experiences and also to the unnecessary use of potentially harmful interventions.
“We therefore urge the DSM 5 taskforce to consider seriously all the issues that have been raised and we would echo the American Psychological Association’s call for the taskforce to adhere to an open transparent process based on the best available science and in the best interest of the public”.
You can read the Society statement in full online.
Open PDF on the BPS site here: BPS Statement on DSM-5 12.12.11
Or open PDF here, on Dx Revision Watch: BPS statement on DSM-5 12-12-2011
British Psychological Society statement on the open letter to the DSM-5 Taskforce
The British Psychological Society recognizes that a range of views exist amongst psychologists, and other mental health professionals, regarding the validity and usefulness of diagnostic frameworks in mental health in general, and the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association in particular.
The Society for Humanistic Psychology (Division 32) of the American Psychological Association (APA) has recently published an open letter to the DSM-5 taskforce raising a number of concerns about the draft revisions proposed for DSM-5 which has, to date, been endorsed by 12 other APA Divisions.
A major concern raised in the letter is that the proposed revisions include lowering diagnostic thresholds across a range of disorders. It is feared that this could lead to medical explanations being applied to normal experiences, and also to the unnecessary use of potentially harmful interventions.
Particular concern is expressed about the inclusion of a new diagnostic category “Attenuated Psychosis Syndrome”. This proposes to include individuals who are experiencing hallucinations, delusions or disorganized speech “in an attenuated form with intact reality testing” but who do not meet current criteria for a psychotic disorder. The Society shares the concerns expressed in the open letter about the potentially harmful consequences of lowering diagnostic thresholds in general and the questionable validity of this proposed diagnosis in particular.
Another concern raised is about the impact of proposed revisions on vulnerable groups such as children and the elderly. The letter highlights that the proposed new diagnostic category “Mild Neurocognitive Disorder” might be diagnosed in elderly people whose memory decline simply reflects normal ageing. The Society welcomes the use of an objective psychometric criterion within this particular DSM-5 diagnosis but shares concerns expressed in the letter about potential for misdiagnosis of normal ageing. We would further highlight the importance of valid psychological interpretation of test results since the proposed psychometric threshold encompasses 1 in 8 of the normal population. There is a particular danger that cognitive functioning of people from ethnic minorities is under-represented on psychometric tests. The Society also shares concerns about the potential for children and adolescents to be misdiagnosed with Disruptive Mood Deregulation Disorder.
We also concur that there is a lack of a solid basis in clinical research literature for this disorder and are also concerned about the risk of harm from inappropriate treatment with neuroleptic medication.
The proposals for the revision of the personality disorders section in DSM-5 are described in the open letter as “perplexing”, “complex” and “idiosyncratic”. The Society has welcomed the move to a dimensional-categorical model for personality disorder. However, we have said that this has not been as visible as expected in the draft revisions.
Moreover, we share concerns expressed in the open letter about the inconsistency of the proposed changes and their limited empirical basis.
Finally, the open letter also draws attention to proposals to revise the basic “Definition of a Mental Disorder” and, in particular, a statement proposed by Stein et al that it “reflects an underlying psychobiological dysfunction”. The Society shares concerns about any unsubstantiated shift in emphasis towards biological factors and in particular the entirely unjustified assertion that all mental disorders represent some form of biological dysfunction. We are, however, reassured by the response from the APA task force (4 November 2011) which states that there is no intent “to diminish the importance of environmental and cultural exposure factors” and hope that this will be reflected in the final version.
In conclusion, the British Psychological Society endorses the concerns expressed in the open letter from the Society of Humanistic Psychology (Division 32) of the APA and encourage members to view the letter themselves and consider signing the petition (http://www.ipetitions.com/petition/dsm5/ ). We also urge the DSM 5 taskforce to consider seriously the issues raised therein. These have been now been endorsed by a broad range of experts in mental health, including members of the British Psychological Society and two chairs of previous DSM revision taskforces.
We are, however, encouraged that the DSM taskforce has already responded positively to the open letter and that in their letter (4 November 2011) they emphasized that the manual is “still more than a year away from publication and is continually being refined and reworked”. They commented that “Final decisions about proposed revisions will be made on the basis of field trial data as well on a full consideration of other issues such as those raised by the signatories of the petition.”
In a statement issued on 2 December 2011 the American Psychological Association (APA) called upon the DSM-5 Task Force to “adhere to an open, transparent process based on the best available science and in the best interest of the public”. The British Psychological Society would certainly echo this call.
The final draft of the DSM-5 criteria is due for publication in early 2012 followed by a third, two month, period of public feedback. The Society encourages those members who have relevant expertise to contribute to the on-going process of refinement and improvement of the DSM-5. As a Society we are, as is our counterpart the APA, committed to promoting and disseminating psychological knowledge and, as such, we are keen to ensure that the final version of DSM-5, and other internationally used diagnostic frameworks such as ICD-11, are based on the best available psychological science and will continue to monitor the DSM-5 revision process and contribute further as appropriate.
The British Psychological Society lends it support to the call for a national review of the use of medication to treat children’s behavioural issues including temporary sleep problems, mild social anxiety and shyness.
Peter Kinderman, Chair of the Division of Clinical Psychology said: “We welcome the announcement from the government pledging an extra £400 million for the provision of psychological therapies – including the promise of better support for parents and children with behavioural problems. However, we are concerned that the overall cuts to the public sector will place all of mental health care – including care for children - at risk.
“We know BPS members are involved in excellent work with Child and Mental Health Service teams, but child mental health is an area that is grossly under resourced, resulting in too few children and young people being able to get timely access to the appropriate therapy. Within the BPS we are already working closely with our psychiatry colleagues to ensure better mental health across the board. If there is evidence of inappropriate use of drugs or medication then we’re sure that our psychiatry colleagues would be equally concerned.
“Clearly, it is important to understand children’s behavioural and psychological problems fully, and to invest in proper, expert, therapeutic approaches. We would be very concerned if children were being prescribed medication as a quick fix rather than accessing the full assessments and psychological therapies which take may longer and cost more, but ultimately are likely to be better value in the long run.”
Figures released by the Department of Health show that in 2009 the number of prescriptions issued to 16-18 years olds to treat ADHD had risen by 51% in just two years.
Peter concluded: “Clearly, many children unfortunately have behavioural and emotional problems which of course demand appropriate care. Many psychologists are very concerned at the use of psychiatric and medical diagnoses in cases such as this – not only because of doubts about the validity of many of the diagnostic approaches, but also because of the possible adverse effects of the medication. Children for whom the diagnosis of ADHD is being considered should receive full multidisciplinary assessments, the option of receiving psychological and behavioural therapies, and their parents or carers should be offered parent-training and education programmes. Drugs should be considered as an option but this should be part of an overall therapy programme. In the case of problems such as temporary sleep problems, mild social anxiety and shyness, I fail to see how medicalising these problems and contemplating the use of drugs is justified. These may indeed be problems, but they are problems that clearly deserve a more psychological response”.
The call for a national review is also supported by the Society’s Division of Educational and Child Psychology.
PR: 1848 8 February 2011
For more information on these issues.
This response was prepared on behalf of the Society by Professor Peter Kinderman, CPsychol, AFBPsS, Chair of the Division of Clinical Psychology (DCP), with contributions from Susan van Scoyoc, CPsychol, CSci, AFBPsS, committee member of the DCP and member of the Division of Heath Psychology (DHP); Dr David Harper, CPsychol, AFBPsS, Professor David Pilgrim CPsychol, AFBPsS, and Professor Richard Bentall, FBPsS, all members of the DCP; Lucy Johnstone, CPsychol, AFBPsS, committee member of the DCP; Dr Amanda C de C Williams, CPsychol, member of both the DCP and the DHP, and Professor Pamela James, CPsychol, AFBPsS, committee member of the Division of Counselling Psychology.
We would like to thank