To the DSM–5 Task Force and the American Psychiatric Association.
As you know, the Open Letter Committee of the Society for Humanistic Psychology and the Coalition for DSM–5 Reform have been following the development of DSM–5 closely. We appreciate the opportunity for public commentary on the most recent version of the DSM–5 draft proposals. We intend to submit this brief letter via the dsm5.org feedback portal and to post it for public viewing on our website at http://dsm5-reform.com/.
Since its posting in October 2011, the Open Letter to the DSM–5 (http://www.ipetitions.com/petition/dsm5/), which was written in response to the second version of the draft proposals, has garnered support from over 50 mental health organizations and over 13,000 individual mental health professionals and others. Our three primary concerns in the letter were as follows: the DSM–5 proposals appear to lower diagnostic thresholds, expanding the purview of mental disorder to include normative reactions to life events; some new proposals (e.g., “Disruptive Mood Dysregulation Disorder” and “Attenuated Psychosis Syndrome”) seem to lack the empirical grounding necessary for inclusion in a scientific taxonomy; newly proposed disorders are particularly likely to be diagnosed in vulnerable populations, such as children and the elderly, for whom the over-prescription of powerful psychiatric drugs is already a growing nationwide problem; and the increased emphasis on medico-biological theories for mental disorder despite the fact that recent research strongly points to multifactorial etiologies.
We appreciate some of the changes made in this third version of the draft proposals, in particular the relegation of Attenuated Psychosis Syndrome and Mixed Anxiety-Depression to the Appendix for further research. We believe these disorders had insufficient empirical backing for inclusion in the manual itself. In addition, given the continuing elusiveness of biomarkers, we are relieved to find that you have proposed a modified definition of mental disorder that does not include the phrase “underlying psychobiological dysfunction.”
Despite these positive changes, we remain concerned about a number of the DSM–5 proposals, as well as the apparent setbacks in the development process. Our continuing concerns are:
- The proposal to include new disorders with relatively little empirical support and/or research literature that is relatively recent (e.g., Disruptive Mood Dysregulation Disorder)
- The lowering of diagnostic thresholds, which may result in diagnostic expansion and various iatrogenic hazards, such as inappropriate treatment and stigmatization of normative life processes. Examples include the newly proposed Minor Neurocognitive Disorder, as well as proposed changes to Generalized Anxiety Disorder, Attention Deficit/Hyperactivity Disorder, Pedophilia, and the new behavioral addictions.
- The perplexing Personality Disorders overhaul, which is an unnecessarily complex and idiosyncratic system that is likely to have little clinical utility in everyday practice.
- The development of novel scales (e.g., severity scales) with little psychometric testing rather than utilizing established standards.
In addition, we are increasingly concerned about several aspects of the development process. These are:
- Continuing delays, particularly in the drafting and field testing of the proposals.
- The substandard results of the first set of field trials, which revealed kappas below accepted reliability standards.
- The cancelation of the second set of field trials. The lack of formal forensic review.
- Ad hominem responses to critics.
- The hiring of a PR firm to influence the interpretation and dissemination of information about DSM–5, which is not standard scientific practice.
We understand that there have been recent attempts to locate a “middle ground” between the DSM–5 proposals and DSM–5 criticism. We believe that, given the extremity and idiosyncrasy of some of the proposed changes to the manual, this claim of a “middle ground” is more rhetorical and polemic than empirical or measured. A true middle ground, we believe, would draw on medical ethics and scientific standards to revise the proposals in a careful way that prioritizes patient safety, especially protection against unnecessary treatment, above institutional needs.
Therefore, we would like to reiterate our call for an independent scientific review of the manual by professionals whose relationship to the DSM–5 Task Force and/or American Psychiatric Association does not constitute a conflict of interest.
As the deadline for the future manual approaches, we urge the DSM–5 Task Force and all concerned mental health professionals to examine the proposed manual with scientific and expert scrutiny. It is not only our professional standards, but also –and most importantly– patient care that is at stake. We thank you for your time and serious consideration of our concerns, and we hope that you will continue to engage in dialogue with those calling for reform of DSM–5.
The DSM–5 Open Letter Committee of the Society for Humanistic Society, Division 32 of the American Psychological Association