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Another therapist organization turns against DSM-5


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The American Counseling Association (45,000 members) has sent its own letter of protest to the American Psychiatric Association, joining the British Psychological Society (nearly 50, 000 members) and divisions of the American Psychological Association.


The full text of the ACA open letter in PDF form is here.


Dear Dr. Oldham [president of the American Psychiatric Association]:


I am sending this letter on behalf of the American Counseling Association (ACA), the world’s largest association for professional counselors. There are 120,000 licensed professional counselors in the United States; as such, we represent the second largest group that routinely uses the DSM.


ACA appreciates the efforts of the American Psychiatric Association (APA) and the Task Force to update the manual according to new scientific evidence. However, professional counselors have voiced several concerns about the DSM-5 development process and they have reservations about many of the proposed revisions. We believe resolving these issues are critical to counselors’ continued confidence in the DSM as a tool for competent and ethical diagnosis of psychopathology. Our concerns focus on empirical evidence, dimensional and cross-cutting assessments, field trials, the definition of mental disorder, and transparency.


Empirical Evidence. While we appreciate APA’s commitment to quality research, counselors are concerned that a number of the DSM-5 proposals have little basis in empirical studies. A systematic and independent review of the research base is critical when revising diagnostic criteria. Unfortunately, guidelines for conducting evidence-based reviews (eg, Kendler et al., 2009) were not provided to work groups until approximately 18 months after revisions had begun. The rationales posted on the DSM-5 website provide either incomplete or insufficient empirical evidence to support many of the proposed revisions. Reportedly in response to this, the DSM-5 Task Force appointed a Scientific Review Committee (SRC) charged with reviewing the empirical evidence supporting the proposed revisions. While we strongly applaud this decision, we would like more information as to how the SRC will conduct their review so that those outside the process can be assured of the solidity of the empirical evidence behind the proposals.


Dimensional and Cross-Cutting Assessments. ACA members were initially supportive of the idea of using dimensional and cross-cutting assessments, but our review of the proposed assessments on the DSM-5 website causes us considerable worry. Little information regarding scale development has been provided and, according to the field trial protocols, there is no evaluation using external validators. Furthermore, more than half the disorders—including important disorders such as attention-deficit/hyperactivity disorder and conduct disorder—have no assessments posted on the website, so we cannot effectively evaluate all of the measures being proposed.


Field Trials. Evaluating diagnostic validity using “a variety of external criteria” is essential in developing or revising diagnostic criteria (Kraemer, 2007, p. S9). Yet, the DSM-5 field trial protocols focus exclusively on reliability, feasibility, and user acceptability. There is an absence of external validators (i.e., evaluation of validity using external criterion measures); thus, there is no way of determining whether any of the proposed changes improve the validity of the DSM. Furthermore, since the DSM-IV and DSM-5 criteria are not being simultaneously applied to the same clients, there is no way to assess the impact of changes on prevalence rates of the various mental disorders.


Definition of Mental Disorder. The DSM-5 Task Force has proposed a new definition of mental disorder which includes, “A behavioral or psychological syndrome or pattern that occurs in an individual that reflects an underlying psychobiological dysfunction” (APA, 2011). Using the term psychobiological implies that all mental disorders have an underlying biological component. Although advances in neuroscience have greatly enhanced our understanding of psychopathology, the current science does not fully support a biological connection for all mental disorders. We therefore request that the definition of mental disorder be amended to indicate that mental disorders may not have a biological component.


Transparency. Although the DSM-5 Task Force has described its development process as “open, transparent and free of bias” (Kupfer and Regier, 2009, p. 40), all work group members were required to sign confidentiality agreements that prohibit them from divulging information about the DSM-5 process, even after it is published. Most problematic, the reports of the DSM-5 SRC are not available for public inspection, which is a violation of one of the most basic and vital tenets of science—open access to data and/or processes for independent evaluation and critique. Without full transparency and openness, counselors may have difficulty having confidence in and trusting the DSM-5.


In conclusion, based on these issues, professional counselors have expressed uncertainty about the quality and credibility of the DSM-5. Therefore, to ensure continued trust and confidence in the


DSM-5, we ask that the APA carry out the following recommendations:


1. Make public all empirical evidence submitted to the DSM-5 Scientific Review Work Group, as well as the group’s evaluations and recommendations.


2. Submit all evidence and data (from work groups and field trials) for review by an external, independent group of experts in evidenced-based decision-making and make the results of this review public.


3. Remove any DSM-5 proposed revisions deemed to lack strong empirical evidence by external, independent review, or add them to the Appendix for Criteria Sets Provided for Further Study.


4. Eliminate any dimensional or cross-cutting assessments that lack supportive reliability and validity evidence, limited feasibility and poor clinical utility.


We appreciate and value the work APA has done in developing a diagnostic classification system that is used by over half a million non-psychiatric mental health professionals in the United States. However, to produce a credible diagnostic manual, it is essential that the DSM-5 be based on research that involves rigorous, systematic, and objective procedures; an open process; and independent, objective scientific review.



Don W. Locke, PhD

ACA President



American Psychiatric Association (APA). (2011). Definition of mental disorder [sic]. Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=465.


Kendler K, Kupfer D, Narrow W, Phillips K, Fawcet J. (2009). Guidelines for making changes to DSM-V. Retrieved from http://www.dsm5.org/ProgressReports/Documents/Guidelines-for-Making-Changes-to-DSM_1.pdf.


Kraemer HC. (2007) DSM categories and dimensions in clinical and research contexts. International Journal of Methods in Psychiatric Research, 16(S1), S8-S15.


Kupfer DJ, Regier DA. (2009). Counterpoint: Toward credible conflict of interest policies in clinical psychiatry. Psychiatric Times, 26(1), 40-41.


This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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The American Psychiatric Association had a ready response to the American Counseling Association's November 21 letter. Note the patronizing reference to misinformation circulating on the Internet, as though Dr. Locke and his colleagues couldn't tell the difference:


American Psychiatric Association

1000 Wilson Boulevard

Suite 1825

Arlington, VA 22209

Telephone 703.907.7300

Fax 703.907.1085

E-mail apa@psych.org

Internet www.psych.org


November 21,2011


Don W. Locke, EdD


American Counseling Association

5999 Stevenson Avenue

Alexandria, VA 22304


Dear Dr. Locke:


Thank you for outlining the American Counseling Association's (ACA) concerns with proposed revisions for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We value the role of professional counselors in the delivery of mental health care, and we welcome the comments of mental health care providers on DSM. We share the goal of producing a DSM that is useful to all health professionals, researchers and patients so that the American Psychiatric Association (APA) can continue to play its longstanding role in advancing the understanding, diagnosis and treatment of mental disorders. A great deal of misinformation about DSM-5 has been circulating on the internet, so APA appreciates your direct inquiry and the opportunity to dispel myths generated from these sources. We address each of your concerns below.


Empirical Evidence and Independent Review. It is useful to review the most recent draft version of DSM-5 to truly understand the breadth of evidence collection and review that has taken place during its development. This process actually began in 1999 when APA and the National Institute of Mental Health (NIMH) sponsored a conference to begin creating a research agenda for the next DSM. Additional conferences sponsored by APA, NIMH, the World Health Organization (WHO) and the World Psychiatric Association took place in 2000, all of which resulted in the 2002 publication of A Research Agenda for DSM-V. Additional groups were commissioned in 2003 to further examine infant and young child, late-life and gender issues resulting in the 2007 publication of Age and Gender Considerations in Psychiatric Diagnosis: A Research Agendafor DSM-5.


APA, WHO, NIMH, and two other NIH agencies—the National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA)—held 13 conferences between 2004 and 2008, involving nearly 400 participants representing 39 countries. Over half of the participants were non-U.S. residents. The work resulted in the creation of 10 monographs and hundreds of published journal articles regarding the current state of knowledge, gaps in research, and recommendations for additional research in many fields.


After the DSM-5 Task Force was formed in 2007, and based on the work described above, APA established 13 work groups, each with 8-15 members who are leading clinicians and researchers in the field, to address various areas for review. Since then, the 160 members of the DSM-5's 13 work groups have sought to review nearly two decades of research published since the introduction of DSM-IV. Work group members selected specific diagnoses on which to focus their individual reviews of the literature in support of or against each specific topic. APA granted work group members permission to publish all of their literature reviews and nearly all have been accepted for publication in peer-reviewed scientific journals. The 2009 guidelines you referenced were developed to ensure the standardization of presentations by all work group members as they prepared draft diagnostic criteria and rationales for Task Force review. These guidelines were subsequently adopted to facilitate reviews by the Scientific Review Committee (SRC).


ACA's call for an "independent, third party review" of the DSM process and evidence has already been answered in the establishment of these work groups and the close coordination APA has with other national and international scientific groups. The members of the work groups are not APA employees, they are not paid by APA and are not under contract with APA. Their participation is strictly voluntary, based upon their interest in advancing the field of psychiatry and better serving patients. They are free to leave the work group if at any time they are not satisfied that the process is unbiased or believe that the results are lacking in empirical evidence. Attachment A lists the institutions from which work group members are drawn. As you can see, they represent academic and mental health institutions throughout the world. No more than two members of anyone institution are represented on anyone work group in order to achieve diversity of opinion. It should be noted that although many of these participants are affiliated with universities, the vast majority of them also engage in clinical practice.


The work group members include multiple types of mental health practitioners. Approximately one third of the work group members hold PhDs and 30 percent are international professionals. Ninety-seven members of the work groups are psychiatrists, 47 members are psychologists, 2 are pediatric neurologists, 3 are statisticians/epidemiologists and there is one representative each from pediatrics, social work, psychiatric nursing, speech and hearing specialists, and consumer groups. In addition, there are more than 300 outside advisors - each selected because of a specific and well-recognized expertise in a particular field. These individuals represent an independent group of volunteer medical and mental health professionals who are also leaders in their respective fields and who have every conceivable incentive to ensure that the work they produce is soundly based in science and supported by empirical evidence.


Every proposed change in DSM-5 is guided by a review of scientific literature, analyses of relevant data sets and full discussion by the work group members. In an unprecedented move, the APA has opened the DSM-5 development process to the public to further ensure that the widest range of opinion and information could be sought and all clinical and "real world" implications of the diagnostic criteria could be considered. The drafts that APA has put out for review by the public are posted to elicit comments from others in the field and from patients and family members who may be impacted by changes. APA has received through its website alone more than 10,000 comments-each of which has been considered and evaluated by the work groups.


Dimensional and Cross-Cutting Assessments. These assessments were introduced in order to diagnose psychiatric disorders in a more detailed way and to recognize the frequent co-morbidities in persons who suffer from mental illness. Level 1 crosscutting assessments are based on the model of the brief two-question screener for depression, adopted by the U.S. Task Force for Preventive Services, to assess the presence of significant symptoms in 12 different psychological domains-a total of 23 questions that permit a rapid review of mental systems. If positive symptoms are present, level 2 cross-cutting measures are modeled on the NIH-developed Patient Reported Outcome Measurement Information System (PROMIS) that has been extensively tested. Where PROMIS measures were not available, we used the most widely tested comparable measures to cover other domains such as the NIDA developed ASSIST scale. Severity measures for individual diagnoses include well-documented and publicly available measures such as the PHQ-9 for Major Depression, PHQ-8 for somatic symptoms, the Swanson SNAP scale for Attention, the Stringaris scale from NIMH for irritability, the Altman scale for bipolar disorder, and others that were developed specifically by the DSM-5 work group experts that are built on past instruments and are being tested in the field trials.


All of these scales are being subjected in field trials to test-retest reliability assessments, patient evaluations of their utility, and clinician assessments of their feasibility and utility in identifying symptomatic areas such as substance abuse or suicidal risk, which might otherwise be overlooked. External validators will include correlates with diagnoses as well as other measures of impairment and disability. Regarding the cross-cutting disability measure, the WHO Disability Assessment Scale (WHO-DAS) is one of the most widely tested disability measures in the world-developed by NIH and WHO with over a decade of testing.


Field Trials/Validity of Diagnoses. With regard to the critique of our field trials, we were pleased to see that you referenced Dr. Helena Kraemer, who serves on the DSM-5 Task Force. Dr. Kraemer helped design the field trials and authored the referenced paper as part of the DSM-5 conference series on the integration of dimensional and categorical diagnosis. As Dr. Kraemer notes in the referenced paper, a field trial is not the forum in which validity can be fully assessed, and as in every field of medicine, diagnostic criteria reflect the best scientific understanding at the time, but they continue to develop and evolve as more scientific research comes to light.


Definition of Mental Disorder. The definition of mental disorder that is used in DSM-IV is undergoing a thorough review by the DSM-5 Task Force. There have been two revised definitions proposed: one, as you mention, by Stein et al. published in Psychological Medicine, the other proposed by the DSM-5's Study Group on Impairment and Disability Assessment. Neither definition has been accepted by the Task Force at this time. There is no intent on the part of the Task Force to overstate the psychobiological advances in mental disorders; all other paradigms are being considered as well. Through the review process, APA assimilated input from around the world and across disciplines and is reformulating its recommendations for the definition of a mental disorder. Many other proposals have been revised after consideration of public comments as well. We continue to work towards a definition of mental disorder that is evidence-based and acceptable to the mental health community at large. We will look forward to your comments on the revised definition when it is posted in the third round of revisions expected to come out in the spring-when we plan to open another public comment period on our website.


Transparency. The APA asked those involved in the DSM-5 process to sign a member acceptance form. The form contains a confidentiality provision that has been the subject of much misunderstanding and which APA has addressed in detail in the past. This form is not intended to restrict the free discussion of ideas on the issues involved in revising DSM and developing new diagnostic criteria. In fact, DSM-5 Task Force and work group members have presented and participated in open discussions at hundreds of psychiatric and other major medical meetings around the world. Work group members have requested and received permission whenever requested to publish on the proposed changes in DSM-5 without regard to their point of view. (A list of those meetings and publications is available for review on the DSM-5 website.)


Indeed, we encourage members to have open discussions with knowledgeable colleagues just as APA has encouraged comments from those interested in mental health on its website. It is only through broad and diverse opinions that we can, as scientists and clinicians, come to a consensus on how to interpret the data that are available. Further, by widely discussing these issues, APA hopes to stimulate funding for further research into areas that are not sufficiently developed to date to be included in the main body of DSM. Thus, our publication and review process has been beneficial in defining various mental disorders and also in defining and developing interest in additional areas in the field of mental health that require further study.


The confidentiality portion of the member acceptance form is not intended to promote secrecy. Instead, APA sought confidentiality to facilitate the verbal process of deliberation. Most, if not all scientific institutions of which APA is aware, including NIH, the Institute of Medicine, WHO, and all scientific journal preparations and reviews share results of research and explanations for their conclusions, but do not fully open the deliberative process itself for comment. This is crucial in order to ensure the free-exchange of ideas. While the work groups are following this established model in our own deliberations, we also made an important decision to make our proposed revisions to the diagnostic criteria, while still in draft form, available for public review both nationally and internationally.


The Scientific Review Committee. The SRC was appointed by the Board of Trustees of APA which is charged with the ultimate approval of the final DSM-5 recommendations. The SRC's charge is to evaluate the strength of the evidence in support of proposed revisions, based on a specific template of validators. This separate peer-review process will provide important guidance to the Board. While the ongoing feedback from the SRC to work groups on specific disorders will not be made available during the DSM-5 development process (as is the case for the deliberations of NIH study sections), summaries of the committee's final decisions will be incorporated into DSM-5 "source books." The SRC's contributions will be reflected in the final criteria of DSM-5. Another committee, the Clinical and Public Health (CPH) Committee, has recently been appointed by the Board to consider clinical utility and public health issues that are not being reviewed by the SRC.


In addition, the APA has worked with the World Health Organization on an ongoing basis to develop harmonization between disorders included in both DSM-5 and ICD-11. Public comment has twice been solicited on proposed diagnostic criteria, and a third public comment period is planned for 2012. Work group members review each comment submitted through the DSM-5 website and consider revisions to criteria based on this input from other health professionals, consumer advocates, patients and families, and other members of the public.


The APA believes that the extensive process of development for DSM-5 will result in a scientifically and clinically useful new edition of the diagnostic manual, and we are indebted to the hundreds of experts who have contributed to its content. We are grateful, as well, for the valuable input from concerned individuals and organizations, and we appreciate the opportunity to respond to the concerns of the American Counseling Association.




John Oldham, MD




This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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