DSM-5 CRITICISMS AND NEW REVISIONS COURTESY OF WIKIPEDIA

http://en.wikipedia.org/wiki/DSM-5

First draft diagnostic criteria for DSM-5

The first draft diagnostic criteria for DSM-5 has now been released. Revisions include the following:^[10]

1. The recommendation of new categories for learning disorders and a single diagnostic category, "autism spectrum disorders" that will incorporate the current diagnoses of autistic disorders, Asperger's Syndrome, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). Work group members have also recommended that the diagnostic term "mental retardation" be changed to "intellectual disability," bringing the DSM criteria into alignment with terminology used by other disciplines.
2. Eliminating the current categories substance abuse and dependence, replacing them with the new category "addiction and related disorders." This will include substance use disorders, with each drug identified in its own category. Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.
3. Creating a new category of "behavioral addictions," in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual's appendix instead, with a goal of encouraging additional study.
4. New suicide scales for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of enhancing interventions across a broad range of mental disorders; the scales include research-based criteria such as impulsive behavior and heavy drinking in teens.
5. Consideration of a new "risk syndromes" category, with information to help clinicians identify earlier stages of some serious mental disorders, such as neurocognitive disorder (dementia) and psychosis.
6. A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. The new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.
7. New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa, as well as recommended changes in the definitions of some eating disorders now described as beginning in infancy and childhood to emphasize that they may also develop in older individuals.

Criticism

Robert Spitzer, the head of the DSM-III task force, has publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: "When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you're going to have people complaining all over the place that they didn't have the opportunity to challenge anything."^[38] Allen Frances, chair of the DSM-IV Task Force, expressed a similar concern.^[39]

Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the Association has not gone far enough in its efforts to be transparent and to protect against industry influence.^[40] In a recent Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties---an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties---shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed." ^[41]

David Kupfer, MD, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, Vice Chair of the task force, whose industry ties are disclosed with those of the task force,^[42] countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders." They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM." The developments to this new version can be viewed on the APA website.^[43] Perhaps as an effort towards this transparency, public input is requested for the first time in the history of the manual. During periods of public comment, members of the general public could sign up at the DSM-V website^[44] and provide feedback on the various proposed changes.^[45]

In June 2009 Allen Frances issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, (…) ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process.".^[46] His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.^[47]

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, has led to an internet petition to remove them.^[48] According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career."^[49] According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse."^[50] Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views."^[50] Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"^[49]

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Approximately 13,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other American Psychological Association divisions have endorsed the petition.^[51] In a recent article about the debate in the San Francisco Chronicle, Robbins notes that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.^[52] In 2012, a footnote was added to the draft text which explains the distinction between grief and depression.^[36]

Borderline personality disorder controversy

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of borderline personality disorder in DSM-5.^[53] The paper How Advocacy is Bringing BPD into the Light^[54] reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma...". There is also discussion about changing Borderline Personality Disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).

More radical criticisms

Some authors believe that the problem is not simply of a few criteria to be deleted or modified. For example, a Kuhnian reformulation of the diagnostic debate suggested that apparently trivial problems of the DSM, like the extremely high rates of comorbidity, might fruitfully be analysed as Kuhnian anomalies leading the DSM system to a scientific crisis.^[55] As a consequence, a radical rethinking of the concept of mental disorder was proposed, acknowledging for its constructive nature.^[56] Based on similar views, several revolutionary approaches were proposed, ranging from dimensional diagnosis to various forms of etiopathogenetic diagnosis.^[57])

British Psychological Society response

The British Psychological Society in the United Kingdom stated in its June 2011 response that it had "more concerns than plaudits".^[58] It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflect[ing] current normative social expectations", noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.

It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".

The Society suggested as its primary specific recommendation, a change from using "diagnostic frameworks" to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality:

[We recommend] a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or 'symptoms' or 'complaints'...... We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc)? These would be more helpful too in terms of epidemiology.

While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of 'schizophrenia' or 'personality disorder' may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person's real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person's problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives.

—British Psychological Society, June 2011 response