Letter to the DSM-5
To the DSM-5 Task Force and the American Psychiatric Association:
As you are aware, the DSM is a central component of the research,
education, and practice of most licensed psychologists in the United States.
Psychologists are not only consumers and utilizers of the manual, but we are
also producers of seminal research on DSM-defined disorder categories and their
empirical correlates. Practicing psychologists in both private and public
service utilize the DSM to conceptualize, communicate, and support their
For these reasons, we believe that the development and revision of DSM
diagnoses should include the contribution of psychologists, not only as select
individuals on a committee, but as a professional community. We have therefore
decided to offer the below response to DSM-5 development. This document was
composed in recognition of, and with sensitivity to, the longstanding and
congenial relationship between American psychologists and our psychiatrist
Though we admire various efforts of the DSM-5 Task Force, especially
efforts to update the manual according to new empirical research, we have
substantial reservations about a number of the proposed changes that are
presented on www.dsm5.org. As we will detail below, we are concerned
about the lowering of diagnostic thresholds for multiple disorder categories,
about the introduction of disorders that may lead to inappropriate medical treatment
of vulnerable populations, and about specific proposals that appear to lack
empirical grounding. In addition, we question proposed changes to the
definition(s) of mental disorder that deemphasize sociocultural variation while
placing more emphasis on biological theory. In light of the growing empirical
evidence that neurobiology does not fully account for the emergence of mental
distress, 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.
Given the changes currently taking place in the profession and science
of psychiatry, as well as the developing empirical landscape from which
psychiatric knowledge is drawn, we believe that it is important to make our
opinions known at this particular historical moment. As stated at the
conclusion of this letter, we believe that it is time for psychiatry and
psychology collaboratively to explore the possibility of developing an
alternative approach to the conceptualization of emotional distress. We believe
that the risks posed by DSM-5, as outlined below, only highlight the need for a
descriptive and empirical approach that is unencumbered by previous deductive
and theoretical models.
In more detail, our
response to DSM-5 is as follows:
Advances Made by the DSM-5 Task Force
We applaud certain efforts of the DSM-5 Task Force, most notably efforts
to resolve the widening gap between the current manual and the growing body of
scientific knowledge on psychological distress. In particular, we appreciate
the efforts of the Task Force to address limitations to the validity of the
current categorical system, including the high rates of comorbidity and Not
Otherwise Specified (NOS) diagnoses, as well as the taxonomic failure to
establish ‘zones of rarity’ between purported disorder entities (Kendell &
Jablensky, 2003). We agree with the APA/DSM-5 Task Force statement that, from a
"The DSM-III categorical diagnoses with operational criteria were a
major advance for our field, but they are now holding us back because the
system has not kept up with current thinking. Clinicians complain that the
current DSM-IV system poorly reflects the clinical realities of their patients.
Researchers are skeptical that the existing DSM categories represent a valid
basis for scientific investigations, and accumulating evidence supports this
skepticism." (Schatzberg, Scully, Kupfer, & Regier, 2009)
As researchers and clinicians, we appreciate the attempt to address
these problems. However, we have serious reservations about the proposed means
for doing so. Again, we are concerned about the potential consequences of the
new manual for patients and consumers; for psychiatrists, psychologists, and
other practitioners; and for forensics, health insurance practice, and public
policy. Our specific reservations are as follows:
Lowering of Diagnostic Thresholds
The proposal to lower diagnostic thresholds is scientifically premature
and holds numerous risks. Diagnostic sensitivity is particularly important
given the established limitations and side-effects of popular antipsychotic
medications. Increasing the number of people who qualify for a diagnosis may
lead to excessive medicalization and stigmatization of transitive, even
normative distress. As suggested by the Chair of DSM-IV Task Force Allen
Frances (2010), among others, the lowering of diagnostic thresholds poses the
epidemiological risk of triggering false-positive epidemics.
We are particularly concerned about:
· “Attenuated Psychosis
Syndrome,” which describes experiences common in the general population, and
which was developed from a “risk” concept with strikingly low predictive
validity for conversion to full psychosis.
· The proposed removal
of Major Depressive Disorder’s bereavement exclusion, which currently
prevents the pathologization of grief, a normal life process.
· The reduction in the
number of criteria necessary for the diagnosis of Attention Deficit
Disorder, a diagnosis that is already subject to epidemiological inflation.
· The reduction in
symptomatic duration and the number of necessary criteria for the diagnosis of
Generalized Anxiety Disorder.
Though we also have faith in the perspicacity of clinicians, we believe
that expertise in clinical decision-making is not ubiquitous amongst
practitioners and, more importantly, cannot prevent epidemiological trends that
arise from societal and institutional processes. We believe that the protection
of society, including the prevention of false epidemics, should be prioritized
above nomenclatural exploration.
We are also gravely concerned about the introduction of disorder
categories that risk misuse in particularly vulnerable populations. For
example, Mild Neurocognitive Disorder might be diagnosed in elderly with
expected cognitive decline, especially in memory functions. Additionally,
children and adolescents will be particularly susceptible to receiving a
diagnosis of Disruptive Mood Dysregulation Disorder or Attenuated Psychosis
Syndrome. Neither of these newly proposed disorders have a solid basis in the
clinical research literature, and both may result in treatment with
neuroleptics, which, as growing evidence suggests, have particularly dangerous
side-effects (see below)—as well as a history of inappropriate prescriptions to
vulnerable populations, such as children and the elderly
The DSM-5 has proposed to change the Definition of a Mental Disorder
such that DSM-IV’s Feature E: “Neither deviant behavior (e.g., political,
religious, or sexual) nor conflicts that are primarily between the individual
and society are mental disorders unless the deviance or conflict is a symptom
of a dysfunction in the individual,” will instead read “[A mental disorder
is a behavioral or psychological syndrome or pattern] [t]hat is not primarily a
result of social deviance or conflicts with society.” The latter version
fails to explicitly state that deviant behavior and primary conflicts between
the individual and society are not mental disorders. Instead, the new proposal
focuses on whether mental disorder is a “result” of deviance/social conflicts.
Taken literally, DSM-5’s version suggests that mental disorder may be the
result of these factors so long as they are not “primarily” the cause. In other
words, this change will require the clinician to draw on subjective etiological
theory to make a judgment about the cause of presenting problems. It will
further require the clinician to make a hierarchical decision about the primacy
of these causal factors, which will then (partially) determine whether mental
disorder is said to be present. Given lack of consensus as to the “primary”
causes of mental distress, this proposed change may result in the labeling of
sociopolitical deviance as mental disorder.
Revisions to Existing Disorder Groupings
Several new proposals with little empirical basis also warrant hesitation:
· As mentioned above,
Attenuated Psychosis Syndrome and Disruptive Mood Dysregulation Disorder
(DMDD) have questionable diagnostic validity, and the research on these
purported disorders is relatively recent and sparse.
· The proposed overhaul
of the Personality Disorders is perplexing. It appears to be a complex and
idiosyncratic combined categorical-dimensional system that is only loosely
based on extant scientific research. It is particularly concerning that a member
of the Personality Disorders Workgroup has publicly described the proposals as
“a disappointing and confusing mixture of innovation and preservation of the
status quo that is inconsistent, lacks coherence, is impractical, and, in
places, is incompatible with empirical facts” (Livesley, 2010), and that,
similarly, Chair of DSM-III Task Force Robert Spitzer has stated that, of all
of the problematic proposals, “Probably the most problematic is the revision of
personality disorders, where they’ve made major changes; and the changes are
not all supported by any empirical basis.”
· The Conditions
Proposed by Outside Sources that are under consideration for DSM-5 contain
several unsubstantiated and questionable disorder categories. For example, “Apathy
Syndrome,” “Internet Addiction Disorder,” and “Parental Alienation Syndrome”
have virtually no basis in the empirical literature.
New Emphasis on Medico-Physiological Theory
Advances in neuroscience, genetics, and psychophysiology have greatly
enhanced our understanding of psychological distress. The neurobiological
revolution has been incredibly useful in conceptualizing the conditions with
which we work. Yet, even after “the decade of the brain,” not one biological
marker (“biomarker”) can reliably substantiate a DSM diagnostic category. In
addition, empirical studies of etiology are often inconclusive, at best
pointing to a diathesis-stress model with multiple (and multifactorial)
determinants and correlates. Despite this fact, proposed changes to certain
DSM-5 disorder categories and to the general definition of mental disorder
subtly accentuate biological theory. In the absence of compelling evidence, we
are concerned that these reconceptualizations of mental disorder as primarily
medical phenomena may have scientific, socioeconomic, and forensic
consequences. New emphasis on biological theory can be found in the following
· The first of DSM-5’s
proposed revisions to the Definition of a Mental Disorder transforms DSM-IV’s versatile
Criterion D: “A manifestation of a behavioral, psychological, or biological
dysfunction in the individual” into a newly collapsed Criterion B: [A
behavioral or psychological syndrome] “That reflects an underlying
psychobiological dysfunction.” The new definition states that all mental
disorders represent underlying biological dysfunction. We believe that there is
insufficient empirical evidence for this claim.
· The change in
Criterion H under “Other Considerations” for the Definition of a Mental
Disorder adds a comparison between medical disorders and mental disorders with
no discussion of the differences between the two. Specifically, the qualifying
phrase “No definition adequately specifies precise boundaries for the concept
of ‘mental disorder’” was changed to “No definition perfectly specifies
precise boundaries for the concept of either ’medical disorder’ or
‘mental/psychiatric disorder’.” This effectively transforms a statement
meant to clarify the conceptual limitations of mental disorder into a statement
equating medical and mental phenomena.
· We are puzzled by the
proposals to “De-emphasize medically unexplained symptoms” in Somatic Symptom
Disorders (SSDs) and to reclassify Factitious Disorder as an SSD. The SSD
Workgroup explains: “…because of the implicit mind-body dualism and the
unreliability of assessments of ‘medically unexplained symptoms,’ these
symptoms are no longer emphasized as core features of many of these
disorders.” We do not agree that hypothesizing a medical explanation for
these symptoms will resolve the philosophical problem of Cartesian dualism
inherent in the concept of “mental illness.” Further, merging the
medico-physical with the psychological eradicates the conceptual and historical
basis for somatoform phenomena, which are by definition somatic symptoms that
are not traceable to known medical conditions. Though such a redefinition may
appear to lend these symptoms a solid medico-physiological foundation, we
believe that the lack of empirical evidence for this foundation may lead to
practitioner confusion, as might the stated comparison between these disorders
and research on cancer, cardiovascular, and respiratory diseases.
· The proposed
reclassification of Attention Deficit/Hyperactivity Disorder (ADHD) from
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence to the
new grouping “Neurodevelopmental Disorders” seems to suggests that that ADHD
has a definitive neurological basis. This change, in combination with the
proposal to lower the diagnostic threshold for this category as described
above, poses high risk of exacerbating the extant over-medicalization and
over-diagnosis of this disorder category.
· A recent publication
by the Task Force, The Conceptual Evolution of DSM-5 (Regier, Narrow, Kuhl,
& Kupfer, 2011), states that the primary goal of DSM-5 is “to produce
diagnostic criteria and disorder categories that keep pace with advances in
neuroscience.” We believe that the primary goal of DSM-5 should be to keep
pace with advances in all types of empirical knowledge (e.g., psychological,
social, cultural, etc.).
Taken together, these proposed changes seem to depart from DSM’s 30-year
“atheoretical” stance in favor of a pathophysiological model. This move appears
to overlook growing disenchantment with strict neurobiological theories of
mental disorder (e.g., “chemical imbalance” theories such as the dopamine
theory of schizophrenia and the serotonin theory of depression), as well as the
general failure of the neo-Kraepelinian model for validating psychiatric
illness. Or in the words of the Task Force:
“…epidemiological, neurobiological, cross-cultural, and basic behavioral
research conducted since DSM-IV has suggested that demonstrating construct
validity for many of these strict diagnostic categories (as envisioned
most notably by Robins and Guze) will remain an elusive goal” (Kendler, Kupfer,
Narrow, Phillips, & Fawcett, 2009, p. 1).
We thus believe that a move towards biological theory directly
contradicts evidence that psychopathology, unlike medical pathology, cannot be
reduced to pathognomonic physiological signs or even multiple biomarkers.
Further, growing evidence suggests that though psychotropic medications do not
necessarily correct putative chemical imbalances, they do pose substantial
iatrogenic hazards. For example, the increasingly popular neuroleptic
(antipsychotic) medications, though helpful for many people in the short term,
pose the long-term risks of obesity, diabetes, movement disorders, cognitive
decline, worsening of psychotic symptoms, reduction in brain volume, and
shortened lifespan (Ho, Andreasen, Ziebell, Pierson, & Magnotta, 2011;
Whitaker, 2002, 2010). Indeed, though neurobiology may not fully explain the
etiology of DSM-defined disorders, mounting longitudinal evidence suggests that
the brain is dramatically altered over the course of psychiatric treatment.
In sum, we have serious reservations about the proposed content of the
future DSM-5, as we believe that the new proposals pose the risk of
exacerbating longstanding problems with the current system. Many of our
reservations, including some of the problems described above, have already been
articulated in the formal response to DSM-5 issued by the British Psychological
Society (BPS, 2011) and in the email communication of the American Counseling
Association (ACA) to Allen Frances (Frances, 2011b).
In light of the above-listed reservations concerning DSM-5’s proposed
changes, we hereby voice agreement with BPS that:
• “…clients and the general public are
negatively affected by the continued and continuous medicalization of their
natural and normal responses to their experiences; responses which undoubtedly
have distressing consequences which demand helping responses, but which do not
reflect illnesses so much as normal individual variation.”
• “The putative diagnoses
presented in DSM-V are clearly based largely on social norms, with 'symptoms'
that all rely on subjective judgments, with little confirmatory physical
'signs' or evidence of biological causation. The criteria are not
value-free, but rather reflect current normative social expectations.”
• “… [taxonomic]
systems such as this are based on identifying problems as located within
individuals. This misses the relational context of problems and the undeniable
social causation of many such problems.”
• There is a need for “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 the fact that strongly evidenced
causal factors include “psychosocial factors such as poverty, unemployment and
• An ideal empirical system for classification would not be based on
past theory but rather would “ begin from the bottom up – starting with
specific experiences, problems or ‘symptoms’ or ‘complaints’.”
The present DSM-5 development period may provide a unique opportunity to
address these dilemmas, especially given the Task Force’s willingness to
reconceptualize the general architecture of psychiatric taxonomy. However, we
believe that the proposals presented on www.dsm5.org are more likely to
exacerbate rather than mitigate these longstanding problems. We share BPS’s hopes
for a more inductive, descriptive approach in the future, and we join BPS in
offering participation and guidance in the revision process.
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