Protesting proposed changes to the DSM

When President David N. Elkins, PhD, and two colleagues within APA's Div. 32 (Society for Humanistic Psychology) heard about the proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM), they were alarmed. But what could three people do?

Plenty, as it turns out.

Although their original aim was simply to educate the division's members, Elkins, Secretary Brent Dean Robbins, PhD, and student representative Sara R. Kamens soon decided to share their concerns in an open letter to the American Psychiatric Association. Thinking it would pack more punch with a few more signatures, they posted it online last October.

The response astounded them. "Within two days, we had more than 1,500 signatures," says Elkins. So far, more than 10,000 individuals and 40 mental health organizations have signed on, and media outlets as diverse as Nature, USA Today and Forbes have covered the controversy. APA, which has no official position on the controversy, urges its members to get involved in the debate (see APA's statement in the January Monitor, page 10).

The open letter outlines three major concerns with the proposed draft of the DSM-5, set for publication in 2013:

• Lowering of diagnostic thresholds. The draft proposal expands the potential pool of people with some disorders, such as attention-deficit hyperactivity disorder. "There's already a great deal of concern that children are being misdiagnosed," says Elkins. "With a lowered diagnostic threshold, we fear that thousands more kids will be misdiagnosed and treated with Ritalin or other drugs."
• Introduction of new disorders. The proposal also introduces several new disorders that protesters fear may increase risks for certain vulnerable populations, such as children and older adults. Take mild neurocognitive disorder, for example. "Older people, especially those in nursing homes, are already victims of over-zealous prescribing of psychiatric drugs," says Elkins. "We believe mild cognitive disorder is a net that is going to catch hundreds of thousands of baby boomers who are now on their way to retirement and experiencing expected, normal declines in cognitive function."
• Lack of empirical grounding for some proposals. Protesters also question the scientific validity of some of the proposed changes. The introduction of a new disorder called attenuated psychosis syndrome, for example, would allow adolescents with unusual behaviors or thought processes to be treated with psychiatric drugs in hopes of warding off schizophrenia. However, says Elkins, research shows that most adolescents with such signs don't go on to develop schizophrenia and those who do aren't helped by taking psychiatric drugs earlier in life.

The protesters also reject proposed changes in the definition of "mental disorder," arguing that it de-emphasizes sociocultural factors and over-emphasizes biological theory.

"We hear your concerns and are aware of those from others in the mental health field, and take them under serious consideration in our deliberations," the DSM-5 Task Force responded. Final decisions about proposed changes will draw on field trial data and comments from thousands of individuals who responded to calls for comment. "This level of both internal and external review and field trial exposure has never before been undertaken by any previous DSM or ICD [International Classification of Diseases] revision proposals," the task force noted.

The response didn't satisfy Elkins and his group, who note that the British Psychological Society, American Counseling Association and even DSM–IV Chair Allen Frances, MD, have also raised concerns. In another open letter, the Div. 32 group calls for an independent review of the controversial proposals by experts unaffiliated with the American Psychiatric Association.

In December, the American Psychological Association Board of Directors called upon the DSM Task Force to ensure that the revision process is based on the best available science, improves treatment outcomes and considers the potential impact of new classifications on vulnerable populations. Psychology professor Frank Farley, PhD, of Temple University, an APA past president, would like to go even further. He'd like to scrap what he calls "a failed manifesto of mental illness" and start over.

Citing the proliferation in the number of disorders with each edition of the DSM, Farley says, "The DSM has really become a diagnostic growth industry."

—R.A. Clay