Welcome to DSM-5 Facts (The APA’s new PR site)

Welcome to DSM-5 Facts (The APA’s new PR site)

Post #175 Shortlink: http://wp.me/pKrrB-2cm

There’s just a couple of weeks left until the deadline for receipt of stakeholder comments in the third and final review of DSM-5 proposals but still no sign of the promised “full results of the field trials” from the Task Force.

In the meantime, something else from the APA, or rather its PR firm. A spanking new DSM-5 Facts site launched this week “to correct the record” and provide the public with “a complete and accurate view of this important issue.”

http://dsmfacts.org/

Welcome to DSM-5 Facts

The American Psychiatric Association believes strongly in the work that is being done to revise the Diagnostic and Statistical Manual of Mental Disorders (DSM). In preparation for the release of DSM-5, experts from psychiatry, psychology, social work, neuroscience, pediatrics and other fields have committed much of the last five years to reviewing scientific research and clinical data, analyzing the findings of extensive field trials and reviewing thousand of comments from the public.

We welcome scrutiny, not only of this process but of its results.

Regrettably, news reports and commentators alike are filling the discourse with inaccurate, biased or misinformed criticism of DSM-5. Such information undermines the important changes that are being made to the manual, and provokes unwarranted confusion and fear among the individuals and families who stand to benefit most from essential care based on the strongest available diagnostic criteria.

The APA has created this forum to ensure observers of the DSM-5 development process have the facts.

Posted below are recent news stories, articles and opinion pieces, along with our responses, to correct the record, highlight key omissions — and provide essential perspective so that the public has a complete and accurate view of this important issue….

 

On the DSM-5 Facts Issue Accuracy page you’ll find responses to recent articles and Op-Eds by Allen Frances, Paula Caplan, NYT journalist, Benedict Carey, and Cosgrove and Krimsky.

In a counterpoint to Frances’ May 12, New York Times Op-Ed piece, APA responds:

APA Responds to Allen Frances New York Times Op-Ed

…There are actually relatively few substantial changes to draft disorder criteria. Those that have been recommended are based on the scientific and clinical evidence amassed over the past 20 years and then are subject to multiple review processes within the APA.

Unfortunately there is no comment facility on this DSM-5 Fact site.

One section for which substantial changes to disorder criteria are being proposed is the Somatoform Disorders.

The Somatic Symptom Disorder Work Group proposes radical changes to this category: to rename the Somatoform Disorders section to “Somatic Symptom Disorders”; eliminate four existing DSM-IV categories: somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder; replace these discrete categories and their criteria with a single new category – “[Complex] Somatic Symptom Disorder” and apply new criteria.

“…To receive a diagnosis of complex somatic symptom disorder, patients must complain of at least one somatic symptom that is distressing and/or disruptive of their daily lives. Also, patients must have at least two [Ed: now reduced to "at least one from the B type criteria" since evaluation of the CSSD field trials] of the following emotional/cognitive/behavioral disturbances: high levels of health anxiety, disproportionate and persistent concerns about the medical seriousness of the symptom(s), and an excessive amount of time and energy devoted to the symptoms and health concerns. Finally, the symptoms and related concerns must have lasted for at least six months.

“Future research will examine the epidemiology, clinical characteristics, or treatment of complex somatic symptom disorder as there is no published research on this diagnostic category.”

“…Just as for complex somatic symptom disorder, there is no published research on the epidemiology, clinical characteristics, or treatment of simple somatic symptom disorder.”

Source: Woolfolk RL, Allen LA. Cognitive Behavioral Therapy for Somatoform Disorders. Standard and Innovative Strategies in Cognitive Behavior Therapy.

And from the SSD Work Group  Rationale/Validity Document  (as published on May 4, 2011 for the second public review of draft proposals but not revised or reissued for the third review):

“…The presence of CSSD complicates management of all disorders and must be addressed in the treatment plan.

“It is unclear how these changes would affect the base rate of disorders now recognized as somatoform disorders. One might conclude that the rate of diagnosis of CSSD would fall, particularly if some disorders previously diagnosed as somatoform were now diagnosed elsewhere (such as adjustment disorder). On the other hand, there are also considerable data to suggest that physicians actively avoid using the older 6 diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.

“The B-type criteria are crucial for a diagnosis of CSSD. These criteria in essence reflect disturbance in thoughts, feelings, and/or behaviors in conjunction with long standing distressing somatic symptoms. Whilst an exact threshold is perhaps arbitrary, considerable work suggests that the degree of functional impairment is associated with the number of such criteria. Using a threshold of 2 or more such criteria results in prevalence estimates of XXXX in the general population, XXXX in patients with known medical illnesses, and XXXX in patients who may previously have been considered to suffer from a somatoform illness. {text in development concerning impact of different thresholds for criteria B- from Francis [Creed]}…”

No data on prevalence estimates available for the second review and no data on impact of different thresholds for the B type criteria and prevalence estimates available for the third review.

I will update if a report on the field trials is released.

Commentary from Allen Frances on the launch of this new DSM-5 Fact site.

Huffington Post Blogs | Allen Frances

Public Relations Fictions Trying to Hide DSM 5 Facts

Allen Frances MD | May 31, 2012

Recently APA recruited a public relations guy from the Department of Defense to respond to my concerns that DSM 5 is way off track. He immediately went on the offensive and (in an interview for Time magazine) made the obvious PR mistake of calling me “a dangerous man.” This provided me the opportunity to pose yet again the troubling questions about DSM 5 that APA repeatedly refuses to answer. The DOD guy hasn’t surfaced since.

Instead, APA has adopted a much smoother, soft sell approach. It has hired GYMR — an expensive PR firm. GYMR actually brags in its mission statement that it can “execute strategies that include image and alliance building, public education campaigns or media relations to harness the formidable forces of Washington and produce successful results for clients.”

We now have the first fruits of GYMR’s “image building” misinformation campaign. It has launched a PR website with the claim it will provide “the facts on DSM-5 development process. Read recent news stories & opinion pieces, along with our responses, to correct the record, highlight key omissions — and provide essential perspective, so that the public has a complete and accurate view of this important issue.”

Unfortunately, the site is very short on accurate facts, very long on misleading (or just plain wrong) “image building” fiction. It is all pure PR fluff — a way to avoid answering the substantive questions that need addressing before DSM 5 is prematurely rushed to press. Let’s compare GYMR fiction versus DSM 5 fact:

GYMR Fiction: “We have extensive data from the field trials that on average there is a slight decrease in the overall rates of DSM-5 in comparison to DSM-IV disorders.”

DSM 5 Fact: This is simply wrong — APA has no such data. Except for autism, all of the DSM 5 changes will dramatically raise the rates of mental disorder and mislabel normal people as psychiatrically sick. The field trial provided no data on this crucial question because it made an unforgivable error — not including head to head prevalence comparisons between DSM IV and DSM 5. This makes it impossible to estimate how explosive will be the DSM 5 rate jumps. Moreover, false epidemics are often nurtured in the primary care settings that were untested in the DSM 5 field trials.

GYMR Fiction: The PR claim is that DSM 5 has provided a transparent process.

DSM 5 Fact: DSM 5 has been peculiarly and self-destructively secretive from its early confidentiality agreements (meant to protect intellectual property) to its current failure to make public any of the results of its ‘scientific’ reviews. Real science can never be confidential. None of this secrecy makes any sense.

GYMR Fiction: “APA takes very seriously its responsibility in developing and maintaining DSM and has devoted $25 million to the DSM-5 update process thus far.”

DSM 5 Fact: The $25 million has been a colossal waste of poorly spent money. We did DSM IV for one-fifth the price and never missed a deadline or stirred much controversy. The difference in expenditure and outcome has nothing to do with us being especially competent. It has everything to do with DSM 5 being poorly conceived and organized and spending lavishly on silly things like public relations.

GYMR Fiction: “There are several proposals in DSM-5 that aim to more accurately describe the symptoms and behaviors of disorders that typically present in children.”

DSM 5 Fact: The epidemics of excessive diagnosis in children will be muddled further by DSM 5. The threshold for ADHD is being lowered despite the tripling of rates. Temper Dyregulation (AKA DMDD) is being suggested based on just a few years of work by just one research group — despite the risk it will exacerbate the already inappropriate and dangerous use of antipsychotic drugs in kids. And DSM 5 somehow persists in not understanding how its suggestions will necessarily have a profound impact on rates of autism.

GYMR Fiction: “There are actually relatively few substantial changes to draft disorder criteria.”

DSM 5 Fact: Dead wrong — how did GYMR ever come up with this one? My guess is that the DSM 5 changes would affect the diagnosis of tens of millions of people. APA has no way of refuting this estimate since it unaccountably failed to ask the crucial prevalence question in its $3 million field trial.

GYMR Fiction: “Those that have been recommended are based on the scientific and clinical evidence amassed over the past 20 years and then are subject to multiple review processes within the APA.”

DSM 5 Fact: Most of the reviews are poorly done and none of the suggestions would stand up to the kind of impartial, independent scientific review demanded by a petition supported by 51 mental health associations. The APA internal review lacks any credibility because it is done in secret and has somehow found a way to approve DMDD and the removal of the bereavement exclusion — both of which have little or no scientific support. To be credible, APA must both make public its own scientific reviews and also contract for external and independent reviews on all the most controversial topics.

GYMR Fiction: “The APA governance attention to this is far greater than anything that ever occurred with DSM III or DSM-IV.”

DSM 5 Fact: Absurd on the face of it. If there had ever been anything resembling proper internal supervision, DSM 5 would not be in this deep mess and would not require expensive PR fig leaves to try to cover it up.

There is more, but you get the idea. DSM 5 is in a paradoxical position. Publishing profits pressure it toward premature publication, but its close to final draft is the object of almost universal opposition. On one side we have APA and its new hired gun GYMR — on the other side we have 51 professional organizations, the Lancet, the New England Journal of Medicine, the international media and outraged segments of the public. It is far too late for any superficial “image building,” however clever, to restore DSM 5 credibility. Saving DSM 5 requires radically reforming its mistakes, not covering them up with a PR smokescreen of misinformation.

The last and only hope for a safe and credible DSM 5 now resides in the new APA leadership — it is within its power to thoroughly reform DSM 5 before it is too late.

The stakes are high. A DSM 5 at war with its users will wind up losing many of them. Disillusioned members (each of whom has involuntarily sunk almost $1,000 in this lavish but misdirected DSM 5 effort) will speed up the already rapid exodus of APA members. APA will eventually lose its monopoly on psychiatric diagnosis. Psychiatry will be unfairly discredited. And, worst of all, the patients who need our help will suffer.

DSM 5 is in such public trouble now because it heedlessly missed every prior private opportunity to self-correct. The solution is not the production of more public relations pablum. Instead, DSM 5 needs to regroup, solve its problems, and avoid racing over a cliff.

American Psychiatric Association (APA) Assembly Notes and Full Treasurer’s Report

American Psychiatric Association (APA) Assembly Notes and Full Treasurer’s Report

Post #174 Shortlink: http://wp.me/pKrrB-2bX

Update @ June 1, 2012

James H. Scully, Jr., M.D., CEO and Medical Director of the American Psychiatric Association, has published a response to Allen Frances’ Huff Po blog of May 30:

DSM-5 Inaccuracies: Setting the Record Straight

Update @ May 30, 2012

1 Boring Old Man

reform, or accept your fate…

1 Boring Old Man | May, 30 2012

Huffington Post Blogs Allen Frances, MD

DSM-5 Costs $25 Million, Putting APA in a Financial Hole

Allen Frances | May 30, 2012

The American Psychiatric Association just reported a surprisingly large yearly deficit of $350,000. This was caused by reduced publishing profits, poor attendance at its annual meeting, rapidly declining membership, and wasteful spending on DSM-5. APA reserves are now below “the recommended amount for a non-profit (reserves equal to a year’s operating expenses).”

APA has already spent an astounding $25 million on DSM-5. I can’t imagine where all that money went. As I recall it, DSM-IV cost about $5 million, and more than half of this came from outside research grants. Even if the DSM-5 product were made of gold instead of lead, $25 million would be wildly out of proportion. The rampant disorganization of DSM-5 must have caused colossal waste. One obvious example is the $3 million spent on the useless DSM-5 field trial, with its irrelevant question, poorly conceived design, and embarrassing results…

Full commentary

On May 8, in an article for Medscape Medical News, Deborah Brauser reported:

     …Members of the task force said they hope to publish the full results [of the DSM-5 field trials] “within a month.” However, the third and final public comment period for the manual opened last week and ends on June 15. Although the entire period is 6 weeks long, the public may only have 2 weeks to comment after the publication of the field trials’ findings. DSM-5 Field Trials Generate Mixed Results

With less than three weeks to go before the stakeholder and public comment period closes, there is still no sign of a report on the DSM-5 field trials.

If the Task Force does not get a report out soon, stakeholders will be obliged to submit feedback without the benefit of data from the trials to inform their comments. Once again, this third and final stakeholder review smacks of a purely tokenistic exercise.

For the two previous draft reviews, some disorders were accompanied by PDF documents expanding on new and revised disorder descriptions and work group rationales.

For the Somatic Symptom Disorders, no updated “Disorder Descriptions” or “Rationale/Validity” documents have been published that reflect substantial revisions made to proposals and criteria between the second and third drafts. The documents as published for the second review have been taken down from the DSM-5 Development site but have not been revised and reissued.

I have twice contacted APA Media and Communications for clarification of whether the Work Group intends to publish revised documents before the end of the comment period. Evidently APA Media and Communications don’t wish to provide me with a response.

 

I will update if and when a report on the field trials emerges from the Task Force.

In the meantime, here are two public domain documents that may be of interest to APA watchers:

APA Assembly Notes Spring 2012

or download here:

http://alabamapsych.org/wp-content/uploads/2012/02/apa_assembly_notes_may_2012.pdf

[Extract]

Treasurer’s Report – David Fassler, MD

The Treasurer’s report was distributed. The Association had a deficit this past year of $350,000. There were greater than expected staff savings which did not quite offset the losses of revenue.

Publishing sales were $1M less than last year, mostly due to DSM-IV sales (because of the release soon of DSM-V). The Hawaii meeting earned $2M less than the previous meeting due to lower attendance. This is part of a trend over the past five years of lower attendance and lower revenue. It was noted in the discussion that attendance for the CME, Inc. meeting has not declined as much.

Advertising revenue and revenue from membership has been fairly steady (despite losses in the number of members). Reserves for the APA are growing slowly but are somewhat less than the recommended amount for a non-profit (reserves equal to a year’s operating expenses).

For more information: The complete treasurer’s report can be accessed here

APA Treasurer’s Report May 2012  [.ppt compatible PowerPoint reader required]

or view here:

https://docs.google.com/file/d/0BzWdENl1wkVSYk5aXzRZelFYUjA/edit?pli=1

[Extract]

DSM-5 Update – David Kupfer, MD, Darrell Regier, MD, Glenn Martin MD

Glenn Martin reminded members that the Assembly’s DSM Committee has been very active and will be meeting in person and conference call as we move toward the November vote for approval. The near final draft of DSM-5 has been posted for final public comment through June 15, 2012. Two items were moved into the section for further study: Attenuated Psychosis and Mixed Anxiety and Depression. The Major Depressive Disorder criteria were modified to clarify the distinction between normal bereavement and a diagnosable disorder. Also added was a more extensive Personality Disorders discussion about the rationale for changes with the evidence for the reliability of dimensional measures and for the categorical diagnosis of Borderline Personality Disorder.

There was a discussion about the Autism Spectrum diagnosis. This new diagnosis was the reflects the difficulty separating the four diagnoses that were used in DSM-IV. There has been a lot of attention to the concern raised by families who fear the loss of services if there are changes in the diagnostic criteria.

By July a summary of the changes and talking points should be available. This will be distributed to district branches, and members of the organization so that they can provide accurate information to the public.

For more information: Go to the DSM-V web page for the latest information.

Full report here

Call to action – DSM-5 comments needed by June 15, 2012

Call to action – DSM-5 comments needed by June 15, 2012

Post #173 Shortlink: http://wp.me/pKrrB-2bO

The stakeholder comment period for the third and final review of draft proposals for DSM-5 categories and criteria closes on June 15. Patients, patient organizations and professional stakeholders have three weeks left in which to submit comments.

US advocate, Mary Dimmock, has prepared a “Call to action”

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is used in the U.S. to categorize mental disorders for patient diagnosis, treatment and insurance. The new version, DSM-5, includes a proposal for Somatic Symptom Disorder (SSD) that will have profound implications for ME/CFS patients. Your input is needed by June 15, 2012 to ensure that the DSM-5 authors understand your concerns…

…SSD can be applied to patients regardless of whether the symptoms are considered to be medically unexplainable or not. Severity is rated by the count and frequency of somatic symptoms. The “Justification for Criteria – Somatic Symptoms”, issued in May 2011, states that CBT, focused on “the identification and modification of dysfunctional and maladaptive beliefs”, is one of the most promising treatments.

Why this matters to ME/CFS patients
A diagnosis of SSD can be “bolted” onto any patient’s diagnosis. All that is required is for the medical practitioner to decide that the patient is excessively concerned with their somatic symptoms and their health. This is done using highly subjective and difficult to measure criteria for which very few independent reliability studies have been undertaken.

For patients with diseases that are poorly understood and misdiagnosed by the medical community, like ME/CFS, this will be disastrous. Once diagnosed inappropriately with SSD, the implications for diagnosis, treatment, disability and insurance will be profound…

Download Mary’s Call to action document here:

Word .docx format DSM-5 Response 2012

Word .doc format DSM-5 Response 2012 (MS 2004)

DSM-5 in New Scientist: Psychiatry’s new diagnostic bible is creating headaches for doctors and patients alike

DSM-5 in New Scientist: “Psychiatry’s new diagnostic bible is creating headaches for doctors and patients alike”

Post #171 Shortlink: http://wp.me/pKrrB-293

A reminder that this third and final stakeholder review and comment period is scheduled to close on June 15.

 

On May 17, APA added the following statement to the home page of the DSM-5 Development site.

APA Position Statement on DSM-5 Draft Diagnostic Criteria

The official position of the APA on draft DSM-5 diagnostic criteria is that they are not to be used for clinical or billing purposes under any circumstances. They are published on the www.dsm5.org Web site to obtain feedback on these preliminary DSM-5 Task Force proposals from mental health professionals, patients, and the general public. They have not received official reviews or approval by the APA Board of Trustees and will not be available for clinical use or billing purposes until May 2013.

Two articles in this week’s online and print editions of New Scientist. 

The first report, by Peter Aldhous, quotes Allen Frances, MD, who had chaired the development of the DSM-IV; APA research director and DSM-5 Task Force Vice Chair, Darrel Regier, and Dr Dayle Jones who is tracking DSM-5 for the American Counseling Association, on DSM-5 field trial kappa results and the relegation of Attenuated psychosis syndrome and Mixed anxiety/depression to the DSM-5 appendix.

This article is behind a paywall or a subscription to the print edition.

New Scientist 19 May 2012

Page 6 print edition

THIS WEEK/MENTAL HEALTH

Psychiatry’s new diagnostic bible is creating headaches for doctors and patients alike

Online title Trials highlight worrying flaws in psychiatry ‘bible’

Peter Aldhous

Diagnosis: uncertain

HOW reliable is reliable enough?

 

The second article, “OPINION ‘Label jars, not people”, by James Davies, is accessible on the New Scientist website without payment or print edition subscription.

New Scientist 19 May 2012

Page 7 print edition

OPINION | James Davies

James Davies is a senior lecturer in social anthropology and psychotherapy at the University of Roehampton, London

‘Label jars, not people’

“LABEL jars, not people” and “stop medicalising the normal symptoms of life” read placards, as hundreds of protesters – including former patients, academics and doctors – gathered to lobby the American Psychiatric Association’s (APA) annual meeting.

The demonstration aimed to highlight the harm the protesters believe psychiatry is perpetrating in the name of healing. One concern is that while psychiatric medications are more widely prescribed than almost any drugs in history, they often don’t work well and have debilitating side effects. Psychiatry also professes to respect human rights, while regularly treating people against their will. Finally, psychiatry keeps expanding its list of disorders without solid scientific justification…

Read full article

Two proposed changes dropped from DSM-5: Media round-up

Two proposed changes dropped from DSM-5: Media round-up

Post #169 Shortlink: http://wp.me/pKrrB-28a

Pharma Blog

Should A Federal Agency Oversee The DSM?

Ed Silverman | May 15, 2012

…Frances proposes that a federal agency ought to assume the job of developing the DSM, although he believes a new organization would be required, one that could be housed in the US Department of Health and Human Services, the Institute of Medicine or the World Health Organization. An equivalent of the FDA is needed to “mind the store,” as he puts it.

This may raise a different set of objections, of course. To what extent, for instance, should a federal agency delve deeply into determining diagnoses and definitions? On the other hand, perhaps this would remove the concerns over self-interest and conflict that have tainted the process. What do you think?

Should a Federal Agency Run The DSM?

Psych Central

An Epidemic of Mental Disorders?

John M. Grohol, PsyD, Founder & Editor-in-Chief | May 15, 2012

Psychiatric Times

COMMENTARY

Is There Really an “Epidemic” of Psychiatric Illness in the US?

Ronald W. Pies, MD | May 1, 2012

Epidemic: (from epidēmos, prevalent : epi-, epi- + dēmos, people) “…an epidemic refers to an excessive occurrence of a disease.”–from Friis & Sellers, Epidemiology for Public Health Practice, 4th ed, 2010

If claims in the non-professional media can be believed, there is a “raging epidemic of mental illness” in the US¹, if not world-wide—and, in one version of this narrative, psychiatric treatment itself is identified as the culprit. There are several formulations of the “epidemic narrative,” depending on which of psychiatry’s critics is writing. In the most radical version, it is psychiatric medication that is fueling the supposed burgeoning of mental illness, particularly depression and schizophrenia.² More subtle variants suggest that there is a “false epidemic” of some psychiatric disorders, driven by dramatically rising rates of “false positive” diagnoses.³…

Time Healthland

Mental Health

DSM 5 Could Mean 40% of College Students Are Alcoholics

Maia Szalavitz | May 14, 2012

Most college binge drinkers and drug users don’t develop lifelong problems. But new mental-health guidelines will label too many of them addicts and alcoholics…

Side Effects at Psychology Today

DSM-5 Is Diagnosed, with a Stinging Rebuke to the APA
The regrettable history of the DSM

Christopher Lane, Ph.D. | May 14, 2013

…Among the fiercest critics quoted is Mark Rapley, a clinical psychologist at the University of East London, who puts it this way: “The APA insists that psychiatry is a science. [But] real sciences do not decide on the existence and nature of the phenomena they are dealing with via a show of hands with a vested interest and pharmaceutical industry sponsorship.” Despite commending the DSM-5 authors for “reconsidering some of their most unfortunate mistakes,” clinical psychologist Peter Kinderman of the University of Liverpool adds that the manual remains, at bottom, a bad and faulty system. “The very minor revisions recently announced do not constitute the wholesale revision that is called for,” he is quoted as saying. “It would be very unfortunate if these minor changes were to be used to suggest that the task force has listened in any meaningful way to critics….”

The New American

Critics Blast Big Psychiatry for Invented and Redefined Mental Illnesses

Alex Newman | May 13, 2012

Allen J Frances lecture

Published on 11 May 2012 by tvochannel

Psychiatrist and author, Allen J. Frances, believes that mental illnesses are being over-diagnosed. In his lecture, Diagnostic Inflation: Does Everyone Have a Mental Illness?, Dr. Frances outlines why he thinks the DSM-V will lead to millions of people being mislabeled with mental disorders. His lecture was part of Mental Health Matters, an initiative of TVO in association with the Centre for Addiction and Mental Health.

Podcast http://bit.ly/KhLuhd

57:36 mins | 19 MB

As part of Mental Health Matters Week, Big Ideas presents a lecture by Allen J Frances, MD, who had chaired the DSM-IV Task Force.

Website http://a2zn.com/?p=3507

News wire

May 6, 2012 University of Toronto

Produced in collaboration with the Center for Addiction and Mental Health

Allen J Frances lecture

Diagnostic inflation. Does everyone have a mental illness?

Big Ideas – May 12 and 13 at 5 pm ET

TVO’s lecture series will present special guest speaker Dr. Allen J. Frances, who will outline why he believes that mental illnesses are being over-diagnosed these days and why he thinks the fifth and latest version of the psychiatrist’s bible, Diagnostic and Statistical Manual of Mental Disorders will lead to millions of people being mislabeled with mental disorders.

The lecture will be recorded May 6 at University of Toronto’s Hart House.

1 Boring Old Man

the dreams of our fathers I…

1 Boring Old Man |  May 12, 2012

University Diaries

“Diagnostic Exuberance”…

Margaret Soltan | May 13, 2012

BMJ News

More psychiatrists attack plans for DSM-5

BMJ 2012; 344 doi: 10.1136/bmj.e3357 (Published 11 May 2012)

Geoff Watts

The authors of the 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due to be published in May 2013, have responded to previous criticisms of their text by announcing a further series of changes.1

But far from mollifying their critics, these concessions have served to ignite a further and still more vituperative barrage of dissent.

The list of topics under reconsideration or already subject to change can be found on the DSM-5 website.2 It includes the proposed “attenuated psychosis syndrome,” which is slated for further study, and also major depressive disorder. Here the authors have added a footnote “to …

Access to the full text of this article requires a subscription or payment

Scientific American Blogs

Why Are There No Biological Tests in Psychiatry?

By Ingrid Wickelgren | May 11, 2012 | 2

Part 5 of a 5-part series Allen Frances

New York Times

Op-Ed Contributor

Diagnosing the D.S.M.

Allen Frances | May 11, 2012

“…All mental-health disciplines need representation — not just psychiatrists but also psychologists, counselors, social workers and nurses. The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts. Primary care doctors prescribe the majority of psychotropic medication, often carelessly, and need to contribute to the diagnostic system if they are to use it correctly. Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.

Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots…”

MedPage Today

DSM-5: What’s In, What’s Out

John Gever, Senior Editor, MedPage Today |  May 10, 2012

   …The final drafts are to be completed by August, then they must be approved by a scientific review committee and the task force leadership, and finally by the APA’s governing bodies.

Kupfer said the final version has to be completed by December, when it’s set to go to the printer. Its formal release is planned for the APA’s annual meeting next May in San Francisco.

Here’s a brief overview of the changes you can expect…

WHAT’S OUT
WHAT’S IN (or STILL IN)
WHAT DIDN’T MAKE IT
WHAT TO LOOK FORWARD TO

Reuters 1

Two proposed changes dropped from psychiatric guide

Julie Steenhuysen | Reuters CHICAGO | May 9, 2012

CHICAGO (Reuters) – Two proposed psychiatric diagnoses failed to make the last round of cuts in the laborious process of revising the Diagnostic and Statistical Manual of Mental Disorders — an exhaustive catalog of symptoms used by doctors to diagnose psychiatric illness.

Gone from the latest revision are “attenuated psychosis syndrome,” intended to help identify individuals at risk of full-blown psychosis, and “mixed anxiety depressive disorder”, a blend of anxiety and depression symptoms. Both performed badly on field tests and in public comments gathered by the group in its march toward the May 2013 publication deadline.

Both have been tucked into Section III of the manual — the place reserved for ideas that do not yet have enough evidence to make the cut as a full-blown diagnosis.

What has survived, despite fierce public outcry, is a change in the diagnosis of autism, which eliminates the milder diagnosis of Asperger syndrome in favor of the umbrella diagnosis of autism spectrum disorder.

But that, too, could still be altered before the final manual is published, the group says. The APA opened the final comment period for its fifth diagnostic manual known as DSM-V on May 2, and it will accumulate comments through June 15.

Dr. David Kupfer, who chairs the DSM-5 Task Force, said in a statement that the changes reflect the latest research and input from the public.

Dr. Wayne Goodman, professor and chairman of the department of psychiatry at Mount Sinai Medical Center in New York, said he’s glad the task force is responding to feedback from professionals and the public.

“I think they are trying to listen,” he said.

Goodman agrees with the decisions to drop both of the two disorders in the latest revision.

With the “mixed anxiety and depressive disorder,” he said there was a risk that it would capture a number of people who did not qualify under a diagnosis of depression or anxiety alone.

“It could lead to overdiagnosis,” Goodman said.

He said the “attenuated psychosis syndrome” diagnosis would have been useful for research purposes to help identify those at risk of psychosis, but there was a concern that it might label people who were just a bit different as mentally ill.

“The predictive value is not clear yet,” he said. “I think it’s reasonable not to codify it until we have better definition of its predictive value.”

Goodman, who worked on DSM-4, the last revision of the manual published in 1994, and is working on the Obsessive Compulsive Disorder section of the current revision of DSM-5, said the strength of the process is that it can offer a reliable way for psychiatrists across the country to identify patients with the same sorts of disorders.

The weakness, he said, is that it largely lacks biological evidence — blood tests, imaging tests and the like — that can validate these diagnoses.

“DSM-5 is a refinement of our diagnostic system, but it doesn’t add to our ability to understand the underlying illness,” he said.

Dr. Emil Coccaro, chairman of the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago Medicine, said typically changes in the DSM occur because of new data.

Coccaro, who is contributing to the new section in the DSM-5 on Intermittent Explosive Disorder, said there is no question that many people aren’t convinced that some of the diagnoses need to be changed, or that there need to be new ones added.

“This also happened the last time when they did DSM-4,” he said, but that was nearly 20 years ago.

“You can keep waiting but at certain point you have to fish or cut bait and actually come out with a new edition. That is what is happening now,” he said.

Comments to the manual can be submitted at www.DSM5.org

(Reporting By Julie Steenhuysen)

Reuters 2

Experts unconvinced by changes to psychiatric guide

Kate Kelland | Reuters LONDON | May 10, 2012

(Reuters) – Many psychiatrists believe a new edition of a manual designed to help diagnose mental illness should be shelved for at least a year for further revisions, despite some modifications which eliminated two controversial diagnoses.

The new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) is due out this month, the first full revision since 1994 of the renowned handbook, which is used worldwide and determines how to interpret symptoms in order to diagnose mental illnesses.

But more than 13,000 health professionals from around the world have already signed an open letter petition (at dsm5-reform.com) calling for DSM 5 to be halted and re-thought.

“Fundamentally, it remains a bad system,” said Peter Kinderman, a professor of clinical psychology at Britain’s Liverpool University.

“The very minor revisions…do not constitute the wholesale revision that is called for,” he said in an emailed comment.

The American Psychiatric Association (APA), which produces the DSM, said on Wednesday it had decided to drop two proposed diagnoses, for “attenuated psychosis syndrome” and “mixed anxiety depressive disorder”.

The former, intended to help identify people at risk of full-blown psychosis, and the latter, which suggested a blend of anxiety and depression, had been criticized as too ill-defined.

With these and other new diagnoses such as “oppositional defiant disorder” and “apathy syndrome”, experts said the draft DSM 5 could define as mentally ill millions of healthy people – ranging from shy or defiant children to grieving relatives, to people with harmless fetishes.

“SIMPLY NOT USABLE”

Robin Murray, a professor of psychiatric research at the Institute of Psychiatry at Kings College London, said it was a great relief to see the changes in the draft, particularly to the attenuated psychosis diagnosis.

“It would have done a lot of harm by diverting doctors into thinking about imagined risk of psychosis (and) it would have led to unnecessary fears among patients that they were about to go mad,” he said in a statement.

But Allen Frances, emeritus professor at Duke University in the United States, said: “This is only a first small step toward desperately needed DSM 5 reform. Numerous dangerous suggestions remain.”

Frances, who chaired a committee overseeing the DSM 4, added that the DSM 5 “is simply not usable” and should be delayed for a year “to allow for independent review, to clean up its obscure writing, and for retesting”.

Diagnosis is always controversial in psychiatry, since it defines how patients will be treated based on a cluster of symptoms, many of which occur in several different types of mental illness.

Some argue that the whole approach needs to be changed to pay more attention to individual circumstances rather than slotting them into predefined categories.

“(The DSM) is wrong in principle, based as it is on redefining a whole range of understandable reactions to life circumstances as ‘illnesses’, which then become a target for toxic medications heavily promoted by the pharmaceutical industry,” said Lucy Johnstone, a consultant clinical psychologist for the Cwm Taf Health Board in Wales.

“The DSM project cannot be justified, in principle or in practice. It must be abandoned so that we can find more humane and effective ways of responding to mental distress.”

Others, however, are pushing more for the manual to be reviewed more thoroughly to allow for more accurate diagnosis and, in theory, more appropriate treatment.

One of the proposed changes that has survived in the draft DSM 5 – despite fierce public outcry – is in autism. The new edition eliminates the milder diagnosis of Asperger syndrome in favor of the umbrella diagnosis of autism spectrum disorder.

(Editing by Myra MacDonald)

New York Times

Psychiatry Manual Drafters Back Down on Diagnoses

Benedict Carey | May 8, 2012

In a rare step, doctors on a panel revising psychiatry’s influential diagnostic manual have backed away from two controversial proposals that would have expanded the number of people identified as having psychotic or depressive disorders.

The doctors dropped two diagnoses that they ultimately concluded were not supported by the evidence: “attenuated psychosis syndrome,” proposed to identify people at risk of developing psychosis, and “mixed anxiety depressive disorder,” a hybrid of the two mood problems.

They also tweaked their proposed definition of depression to allay fears that the normal sadness people experience after the loss of a loved one, a job or a marriage would be mistaken for a mental disorder.

But the panel, appointed by the American Psychiatric Association to complete the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., did not retreat from another widely criticized proposal, to streamline the definition of autism. Predictions by some experts that the new definition will sharply reduce the number of people given a diagnosis are off base, panel members said, citing evidence from a newly completed study.

Both the study and the newly announced reversals are being debated this week at the psychiatric association’s annual meeting in Philadelphia, where dozens of sessions were devoted to the D.S.M., the standard reference for mental disorders, which drives research, treatment and insurance decisions.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and the chairman of the task force making revisions, said the changes came in response mainly to field trials — real-world studies testing whether newly proposed diagnoses are reliable from one psychiatrist to the next — and also public commentary. “Our intent for disorders that require more evidence is that they be studied further, and that people work with the criteria” and refine them, Dr. Kupfer said…

CBS News

Panel suggests DSM-5 psychiatry manual drops two disorders, keeps new autism definition

Michelle Castillo | May 10, 2012

(CBS News) – A panel of doctors reviewing the much-debated Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) have recommended to drop two controversial diagnoses.

The panel announced that attenuated psychosis syndrome — which identifies people at risk of developing psychosis — and mixed anxiety depressive disorder — a diagnosis which combines both anxiety and depression — should not be included in the manual’s upcoming version, the New York Times reported.

Proposed changes to autism definition may mean new diagnoses for people with Asperger’s

However, a controversial definition for autism, which will delete diagnoses for Asperger’s syndrome and pervasive developmental disorder and combine severe cases into the broader definition of autism, will remain…

MedPage Today

Autism Criteria Critics Blasted by DSM-5 Leader

John Gever, Senior Editor | May 08, 2012

PHILADELPHIA — The head of the American Psychiatric Association committee rewriting the diagnostic criteria for autism spectrum disorders took on the panel’s critics here, accusing them of bad science.

Susan Swedo, MD, of the National Institute of Mental Health, said a review released earlier this year by Yale University researchers was seriously flawed. That review triggered a wave of headlines indicating that large numbers of autism spectrum patients could lose their diagnoses and hence access to services…

Nature

Psychosis risk syndrome excluded from DSM-5

Benefits of catching psychosis early are deemed to come at too high a price.

Amy Max | May 9, 2012

A controversial category of mental illness will not be included in the revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association (APA) has said. Attenuated psychosis syndrome, also known as psychosis risk syndrome, had been intended mainly for young adults who have heard whispers in their heads, viewed objects as threatening or suffered other subtly psychotic symptoms…

Scientific American Blogs

Trouble at the Heart of Psychiatry’s Revised Rule Book

Ingrid Wickelgren | May 9, 2012

Part 3 in a series

Huffington Post | Allen Frances Blog

Psychiatric Mislabeling Is Bad for Your Mental Health

Allen Frances, MD | May 9, 2012

Make Yourself Heard! says DSM-5′s Kupfer – but are they listening?

Make Yourself Heard! says DSM-5′s Kupfer – but are they listening?

Post #166: Shortlink: http://wp.me/pKrrB-26L

Four further commentaries from 1 boring old man on DSM-5 field trial results and Kappa values:

major depressive disorder κ=0.30?…

May 6, 2012

a fork in the road…

May 7, 2012

Village Consumed by Deadly Storm…

May 8, 2012

box scores and kappa…

May 8, 2012

MedPage Today

Most DSM-5 Revisions Pass Field Trials

John Gever, Senior Editor | May 07, 2012

“…Darrel Regier, MD, the APA’s research director, explained that the trials were intended primarily to establish reliability – that different clinicians using the diagnostic criteria set forth in the proposed revisions would reach the same diagnosis for a given patient. The key reliability measure used in the academic center trials was the so-called intraclass kappa statistic, based on concordance of the “test-retest” results for each patient. It’s calculated from a complicated formula, but the essence is that a kappa value of 0.6 to 0.8 is considered excellent, 0.4 to 0.6 is good, and 0.2 to o.4 “may be acceptable.” Scores below 0.2 are flatly unacceptable.

Kappa values for the dozens of new and revised diagnoses tested ranged from near zero to 0.78. For most common disorders, kappa values from tests conducted in the academic centers were in the “good” range:

Bipolar disorder type I: 0.54
Schizophrenia: 0.46
Schizoaffective disorder: 0.50
Mild traumatic brain injury: 0.46
Borderline personality disorder: 0.58

In the “excellent” range were autism spectrum disorder [0.69], PTSD [0.67], ADHD [0.61], and the top prizewinner, major neurocognitive disorder [better known as dementia], at 0.78. But some fared less well. Criteria for generalized anxiety disorder, for example, came in with a kappa of 0.20. Major depressive disorder in children had a kappa value of 0.29. A major surprise was the 0.32 kappa value for major depressive disorder. The criteria were virtually unchanged from the version in DSM-IV, the current version, which also underwent field trials before they were published in 1994. The kappa value in those trials was 0.59.

But a comparison is not valid, Regier told MedPage Today…”

Read full report

DSM5 in Distress
The DSM’s impact on mental health practice and research.

Newsflash From APA Meeting: DSM 5 Has Flunked its Reliability Tests
Needs To Be Kept Back For Another Year

Allen J. Frances, M.D. | May 6, 2012

“…The results of the DSM 5 field trials are a disgrace to the field. For context, in previous DSM’s, a diagnosis had to have a kappa reliability of about 0.6 or above to be considered acceptable. A reliability of .2-4 has always been considered completely unacceptable, not much above chance agreement…”

Reconstructed from data published by A Frances, DSM 5 in Distress, Psychology Today, 05.06.12

“…No predetermined publication date justifies business as usual in the face of these terrible Field Trial results (which are even more striking since they were obtained in academic settings with trained and skilled interviewers, highly selected patients, and no time pressure. The results in real world settings would be much lower). Reliability this low for so many diagnoses gravely undermines the credibility of DSM 5 as a basis for administrative coding, treatment selection, and clinical research…”

Read full commentary

Scientific American

Field Tests for Revised Psychiatric Guide Reveal Reliability Problems for Two Major Diagnoses

Ferris Jabr | May 6, 2012

“…The kappa for generalized anxiety disorder was about 0.2 and the kappa for major depressive disorder was about 0.3.

“…These numbers are way too low according to the APA’s own scales—and they are much lower than kappas for the disorders in previous versions of the DSM. Regier and other members of the APA emphasized that field trial methodology for the latest edition is far more rigorous than in the past and that kappas for many diagnoses in earlier editions of the DSM were likely inflated. But that doesn’t change the fact that the APA has a problem on its hands: its own data suggests that some of the updated definitions are so flawed that only a minority of psychiatrists reach the same conclusions when using them on the same patient. And the APA has limited time to do something about it…”

“…Until the APA officially publishes the results of the field trials, nobody outside the association can complete a proper analysis. What I have seen so far has convinced me that the association should anticipate even stronger criticism than it has already weathered. In fairness, the APA has made changes to the drafts of the DSM-5 based on earlier critiques. But the drafts are only open to comment for another six weeks. And so far no one outside the APA has had access to the field trial data, which I have no doubt many researchers will seize and scour. I only hope that the flaws they uncover will make the APA look again—and look closer…”

Read full report

Psychiatric News | May 04, 2012
Volume 47 Number 9 page 1a-28
American Psychiatric Association
Professional News

DSM Field Trials Providing Ample Critical Data

David J. Kupfer, M.D.

This article is part a series of commentaries by the chair of the DSM-5 Task Force, which is overseeing the manual’s development. The series will continue until the release of DSM-5 in May 2013.

As of this month, the 12-month countdown to the release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) officially begins. While the developers of DSM-5 will continue to face several deadlines over the coming year, the progress that has been made since APA’s 2011 annual meeting has been nothing short of remarkable.

One of the most notable and talked-about recent activities of the DSM revision concerns the implementation and conclusion of the DSM-5 Field Trials, which were designed to study proposed changes to the manual…

Read on

From the same article and note that

“After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.”

Make Yourself Heard!

The DSM-5 Web site (www.dsm5.org) is open to a third and final round of feedback. For six weeks, patients and their loved ones, members of the profession, and the general public can submit questions and comments via the Web site. All will be read by members of the appropriate DSM-5 work groups.

A summary of changes made to the draft diagnostic criteria since the last comment period (May-July 2011) will help guide readers to important areas for review, but visitors are encouraged to comment on any aspect of DSM-5. After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.

Psychiatrists can use this important opportunity to express their opinions about proposed changes and how they may impact patient care. Since www.dsm5.org was first launched in February 2010, the work groups have discussed— and in many cases, implemented draft changes in response to—the feedback received from the site. This final comment period presents a historic opportunity for APA members to take part in the DSM-5 revision process and help impact the way in which psychiatric disorders are diagnosed and classified in the future.

David J. Kupfer, M.D., is chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic.

Commentary on Dr Kupfer’s report from 1 boring old man

self-evident…

I boring old man | May 6,  2012

Further commentary from 1 boring old man on DSM-5 controversy

not a good time…

1 boring old man | May 5, 2012

DSM-5 Somatic Symptoms Work Group submissions 2012: Last chance to tell SSD Work Group why it needs to ditch flawed, unsafe and unscientific proposals

DSM-5 Somatic Symptoms Work Group submissions 2012: Last chance to tell SSD Work Group why it needs to ditch unsafe and scientifically flawed proposals

Post #165 Shortlink: http://wp.me/pKrrB-26q

Under the guise of “eliminating stigma” and eradicating “terminology [that] enforces a dualism between psychiatric and medical conditions” the American Psychiatric Association appears hell bent on colonising the entire medical field by licensing the application of a mental health diagnosis to all medical diseases and disorders.

 

Last chance to tell the SSD Work Group why it needs to ditch its unsafe and scientifically flawed proposals

The third DSM-5 Development public review of proposals for revisions to DSM-IV categories and criteria runs through May 2 – June 15. This will be the last opportunity for stakeholders to submit feedback.

Register on the DSM-5 Development site to submit comment or use your previous user name and log in details if you submitted during the earlier reviews. For information on registration see this post from 2011.

One again, I’m collating copies of submissions to the Somatic Symptom Disorders Work Group on a dedicated page from international patient organizations, medical, allied health and other professional stakeholders, patients, advocates and professional bodies.

Any consumer groups, medical professionals, allied health professionals, social workers, lawyers etc with concerns for the Somatic Symptom Disorders proposals are welcome to forward copies of submissions for publication here.

If you are looking for submissions for the first and second public reviews, you need these pages:

Submissions to first public review (February 10 – April 20, 2010): http://wp.me/PKrrB-AQ

Submissions to second public review (May 4 – July 15, 2011): http://wp.me/PKrrB-19a

This year’s submissions are being collated here as they come to my attention:

DSM-5 SSD Work Group submissions 2012 

Shortlink for submissions page is: http://wp.me/PKrrB-1Ol

Today I am publishing UK patient and advocate, Peter Kemp’s submission to the SSD Work Group:

Submission from Peter Kemp, UK advocate

How people with M.E. and CFS (and other illnesses) could be misdiagnosed as Somatic Symptom Disorder using DSM-5

Misdiagnosis is a common occurrence by all accounts. Therefore medical definitions or criteria should not only assist diagnosis – they should positively aim to prevent or reduce misdiagnosis.

Somatic Symptom Disorder (SSD) as proposed for DSM-5 allows too many possibilities for misdiagnosis. Misdiagnosis that could have disastrous consequences. This is so readily foreseeable that this must be addressed.

Once a physician diagnoses SSD, they have effectively judged the patient incompetent to interpret their own symptoms. If the patient has an unrecognised disease that progresses, or develops a new disease and reports the new symptoms to the doctor, what will the doctor do? The patient is untrustworthy. The doctor is busy and has ‘real’ patients to treat.

It is inevitable that even patients that are correctly diagnosed with SSD will sooner or later present with actual physical disease. The diagnosis of SSD could predictably obstruct investigation and treatment of their disease. This obstruction could be directly attributed to the use of an SSD diagnosis.

SSD should not be included in DSM-5 unless specific guidance to prevent misdiagnosis are included and these have been proven effective.

Imagine a doctor with a patient presenting in the early stages of MS. MS can be difficult to diagnose. When Professor Poser reviewed 366 MS diagnoses made by board certified neurologists, he found that only 65% had been correctly diagnosed (http://www.cfids.org/archives/2000rr/2000-rr4-article03.asp ).

It can take years before the signs, symptoms and tests are clear enough to make a diagnosis (http://ms.about.com/popular.htm ). The symptoms of ‘pre-diagnosis’ MS can be very distressing and the lack of a laboratory test or firm diagnosis may add to a patient’s worries. The patient may try all sorts of strategies to try and find out about, and improve what is happening to them. They may appear to pester their GP, they may appear neurotic and irrational.

Now imagine that in accordance with DSM-5, a doctor gives them a diagnosis of the proposed SSD. The patient has an official diagnosis in their medical records that amounts to ‘hypochondriac’. What effect will that have on the patient’s chances of getting the necessary investigations as the disease progresses? How is it going to help them to cope with their distressing physical symptoms now they have been explained as psychosomatic? The time it will take for them to get a true diagnosis may be further prolonged, and the years spent waiting could be made even more harrowing because of inaccurate psychological labelling.

Therefore sensible doctors will avoid diagnosing SSD. Foolish doctors risk spending their time at professional disciplinary hearings and in court; and this still might not adequately reflect the amount of suffering their diagnosis of SSD could cause.

The rationale for SSD also states: “The proposed classification for Somatic Symptom Disorders deemphasizes the central role of medically unexplained symptoms. Instead, it defines disorders on the basis of positive symptoms (distressing somatic symptoms + excessive thoughts, feelings, and behaviors in response to these symptoms).”

I believe it safe to say that ‘positive symptoms’ does not mean ‘good symptoms’ or ‘symptoms with the right attitude’. I imagine it means definite, definable, testable and maybe even measurable. But when terms like ‘distressing’ and ‘excessive’ are used to measure symptoms, the definition is not a definition. It is not even a convincing concept.

The idea is right, to base the definition on signs and symptoms that are actually present, as long as these sufficiently differentiate the condition from other conditions and do not lead to too many misdiagnoses. Unfortunately, they would predictably fail to achieve this because the definition proposed is significantly subjective.

The ‘DSM-5 Proposed Revision’ could certainly misdiagnose M.E. This would be a serious matter as M.E. is classified by the WHO ICD as a neurological illness. A doctor whose diagnosis of SSD was contradicted by a doctor that diagnosed M.E could find themselves in an awkward legal situation. The implications to the proper care of a patient, due to misdiagnosing a serious neurological illness as a neurotic illness hardly bear thinking about. Hindering necessary investigations and treatment might only be a small part of the problems this might create.

The latest proposal states:

“Somatic Symptom Disorder

Criteria A, B, and C must all be fulfilled to make the diagnosis:”

“A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.”

The Myalgic Encephalomyelitis: International Consensus Criteria – states:
(http://www.meassociation.org.uk/?p=7173)

“A patient will meet the criteria for post-exertional neuroimmune exhaustion (A), at least one symptom from three neurological impairment categories (B), at least one symptom from three immune/gastro-intestinal/genitourinary impairment categories (C), and at least one symptom from energy metabolism/transport impairments (D).”

The Canadian Expert Consensus Panel Clinical Case Definition for ME/CFS states:
(http://www.cfids-cab.org/MESA/ccpccd.pdf)

“A patient with ME/CFS will meet the criteria for fatigue, post-exertional malaise and/or fatigue, sleep dysfunction, and pain; have two or more neurological/cognitive manifestations and one or more symptoms from two of the categories of autonomic, neuroendocrine and immune manifestations; and adhere to item 7.”

Therefore every patient with M.E. or CFS or ME/CFS will present with ample distressing and disruptive symptoms to satisfy DSM-5 Somatic Symptom Disorder Part A.

“B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.

(1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
(2) Persistently high level of anxiety about health or symptoms
(3) Excessive time and energy devoted to these symptoms or health concerns”

The NICE Guidelines for CFS/ME state:
(http://www.nice.org.uk/nicemedia/live/11824/36191/36191.pdf )

“People with mild CFS/ME are mobile, can care for themselves and can do light domestic tasks with difficulty. Most are still working or in education, but to do this they have probably stopped all leisure and social pursuits. They often take days off, or use the weekend to cope with the rest of the week.”

Therefore even the mildest form of CFS sees persons who have often greatly reduced or stopped socializing, hobbies, sports etc.; and spend much of the time formerly devoted to these pursuits in resting and recuperating their energy to continue working.

When this level of disruptive illness goes on for more than 6 months, people will naturally and rationally become worried. They will be fearful of what is happening and what is going to happen. They will be anxious about their responsibilities, their job, their family and friend connections – everything. They may quite naturally seek help from their GP. They may be given antidepressants, sleeping medications, pain killers, etc. All these combined with a chronic illness necessitate frequent visits to their GP. They may try alternative therapies (possibly after having found what their GP offered did not help them). They may alter their diet, take nutritional supplements, go for acupuncture, homeopathy or other type of therapy.

And here is the rub; if one does not believe they are actually physically ill, their ‘thoughts, feelings and behaviours’ will certainly appear ‘excessive’. This could apply not just to CFS, but many other high impact and distressing illnesses.

The ‘Rationale’ for SSD states: “Undifferentiated Somatoform Disorder has such a low threshold that it is applicable to a very large proportion of patients attending primary care. The same low threshold issue occurs with Somatoform Disorder NOS.”

The proposed definition does not address this problem. It might actually make it worse. If doctors believe that SSD has a valid definition they may start actually using it – then God help us.

If a person with just ‘mild’ CFS is justified in being worried, justified in resting so they can keep working, justified in searching for something that will improve their health – then anyone with the illnesses mentioned could meet the criteria to satisfy DSM-5 Somatic Symptom Disorder Part B.

The only proviso is that to some extent this could depend on interpretation of the subjective aspects of part B (there may be more detailed explanations elsewhere – this essay is based on what is included here). What is ‘excessive’, ‘persistantly’, ‘disproportionate’, ‘seriousness’?*

The same ‘Rationale’ for SSD remarks on: “The lack of positive psychological features in the definition”. Unfortunately the proposed criteria attempt to define “positive psychological features” based entirely upon a physician’s subjectivity. That is not, in any sense, a definition.

This is why I believe the circular-reasoning trap constructed with SSD makes it risible. They construct a concept for SSD. They construct criteria for the concept. Chicken-egg or egg-chicken, take your pick.

The problem with this approach is that it does not IDENTIFY the psychological condition they are trying to define. SSD cannot exist only by differentiating features, this is true. Yet differentiating is an essential step. SSD must discern from other anxiety or depressive disorders. It must be discern from normal or rational anxiety, whether that anxiety is acute, chronic or fluctuating. It must discern from anxiety or depressive disorders due to neurological illness or injury. It must discern from physical illness that has not yet been diagnosed, or from physical illness for which diagnosis is complex or often delayed. It must discern from new or emerging diseases. If SSD cannot discern from these, then misdiagnosis could be a common and predictable result.

The criteria should define the disorder but they don’t. They attempt to define the criteria. The disorder should inform the criteria, but it doesn’t. The disorder is lost in a confusion of subjective terms, ‘excessive’, ‘persistantly’, ‘disproportionate’, ‘seriousness’.

The only way it can work is if someone (and here’s another trap); someone who believes that SSD exists and is defined by the DSM, decides what ‘excessive’ and ‘disproportionate’ etc., mean. Then all they have to do, is reach exactly the same conclusion that every other physician using the DSM would reach in the same position. Bingo. A diagnosis that does not mean anything other than what the ‘diagnoser’ decides that it means. And they better hope they got it right, otherwise a good lawyer will wipe the floor with them.

“C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 months).”

This is either synchronicity, or they got this direct from the NICE Guidelines for ‘CFS/ME’. The NICE Guidelines ‘Making a diagnosis’ state:

“The range of presenting symptoms is wide, and fatigue and pain may not always be the prominent disabling features at initial presentation.”

“Symptoms tend to vary in intensity and type over a period of weeks or months (and evolve into what is more clearly CFS/ME with time)”

Mild CFS will satisfy DSM-5 Somatic Symptom Disorder Part C. Therefore every person with M.E. or CFS could get a diagnosis of SSD unless they can convince any psychiatrist they encounter that they are not ‘excessive’, ‘persistent’, ‘disproportionate’, or that they don’t believe they are seriously ill.

A serious anomaly might arise with SSD in both M.E. and CFS. These illnesses can start with only fatigue or just a few symptoms. Extreme fatigue and pain might be all that a patient reports. However, if the illness continues over years, some symptoms may improve whilst new ones appear. Problems such as sensory impairments, bladder and bowel problems, immune dysfunction, and a host of neurological symptoms (to name but a few) can develop.

Will the M.E. or CFS patient then be vulnerable to having their previous diagnosis ‘cancelled-out’ by a new diagnosis of SSD, because they developed too many symptoms and are worried about them?

The SSD development group have repeated previous flaws they identified as creating the need for new definitions. They have not defined anything. Yet there may be some positive outcome from their efforts. I imagine that some medical insurance company executives must be rubbing their hands together in glee, but medical negligence lawyers should be turning cartwheels.

Peter Kemp

*Editor: Accompanying the first and second release of draft proposals for the Somatic Symptom Disorders categories, two quite lengthy PDF documents that expanded on the disorder descriptions and validity/rationales were published in conjunction with the webpage Proposed Revision, Rationale and Severity texts.

For this third draft, no PDFs have been published that reflect the Work Group’s revisons since release of the second draft, last May, or set out its rationales in detail. No draft DSM-5 textual content, more comprehensive disorder descriptions or field trial evaluations are available for public scrutiny other than brief, revised Rationale texts:

Criteria for Proposed Revision J00 Somatic Symptom Disorder

Rationale text for category J00 Somatic Symptom Disorder:

Rationale

The proposed classification for Somatic Symptom Disorders deemphasizes the central role of medically unexplained symptoms. Instead, it defines disorders on the basis of positive symptoms (distressing somatic symptoms + excessive thoughts, feelings, and behaviors in response to these symptoms).
The group considers that the current DSM-IV somatoform diagnoses (Somatization Disorder, Somatoform Disorder NOS, Undifferentiated Somatoform Disorder, Hypochondriasis and the Pain Disorders) are so flawed that complete restructuring of these diagnoses is required. Change is needed as:

- The DSM-IV somatoform diagnoses are used rarely in clinical practice in most countries; the terms cause confusion among doctors and are resented by many patients.

- The criteria for DSM-IV somatization disorder are too restrictive. Undifferentiated Somatoform Disorder has such a low threshold that it is applicable to a very large proportion of patients attending primary care. The same low threshold issue occurs with Somatoform Disorder NOS.

- These diagnoses are based on “medically unexplained symptoms,” but this term is unreliable, especially in the presence of medical illness. Doctors disagree on the use of the term and patient recall of such symptoms is variable, so reliability of these diagnoses is low.

- The lack of positive psychological features in the definition of these disorders means they fail to satisfy one of the criteria for a mental disorder.

The new diagnoses of Somatic Symptom Disorder (SSD) is proposed to overcome these problems with relevant DSM-IV diagnoses.

The previous posting proposed diagnoses of Complex Somatic Symptom Disorder (CSSD) and Simple Somatic Symptom Disorder (SSSD). In this revision, we have merged the two disordes [sic], recognizing that SSSD is a less severe variant of CSSD. The work group is considering dropping the adjective “complex” from the name of the resulting disorder and is desirous of feedback.   Accessed May 4, 2012

Related material:

1] DSM-5 proposals for Somatoform Disorders revised on April 27, 2012

2] DSM-5 Development site

3] Somatic Symptom Disorders proposals

APA Press Release: DSM-5 Draft Criteria Open for Public Comment

APA Press Release: DSM-5 Draft Criteria Open for Public Comment

Post #164 Shortlink: http://wp.me/pKrrB-20I

Commentaries and media, followed by APA Press Release No. 24

(Not specific to DSM-5 third draft: Ethics complaints filed against APA.)

Psychology Today

Science Isn’t Golden
Matters of the mind and heart

Patients Harmed by Diagnosis Find Their Voices
Victims of psychiatric labeling file ethics complaints.

Paula J. Caplan, Ph.D. | April 28, 2012

The American Psychiatric Association’s 2012 Annual Meeting

This coverage is not sanctioned by, nor a part of, the American Psychiatric Association.

From Medscape Medical News > Conference News
DSM-5 Field Trial Results a Hot Topic at APA 2012 Meeting

Deborah Brauser | May 3, 2012

May 3, 2012 — Telepsychiatry, neuromodulation, the role of genetics, and updates for the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are just some of the hot items on the agenda of this year’s American Psychiatric Association’s 2012 Annual Meeting in Philadelphia…

(Not specific to DSM-5 third draft: Letter, AJP re DSM-5 field trial reliability and kappas.)

American Journal of Psychiatry

Letters to the Editor | May 01, 2012
Standards for DSM-5 Reliability

Am J Psychiatry 2012;169:537-537. 10.1176/appi.ajp.2012.12010083

Robert L. Spitzer, M.D.; Janet B.W. Williams, Ph.D.; Jean Endicott, Ph.D.
Princeton, N.J.
New York City

DSM5 in Distress
The DSM’s impact on mental health practice and research.

DSM 5 Rejects ‘Hebephilia’ Except for the Fine Print

Alan Frances MD | May 3, 2012

Scientific American blogs

APA Announces New Changes to Drafts of the DSM-5, Psychiatry’s New “Bible”

Ferris Jabr | May 3, 2012

Observations

Opinion, arguments & analyses from the editors of Scientific American

“…This year, the APA is holding its annual meeting from May 5 to 9 in Philadelphia, where much of the discussion will focus on the drafts of the DSM-5 and the results of “Field Trials”—dry runs of the new diagnostic criteria in clinical settings. I am attending the conference to learn more and, next week, my colleague Ingrid Wickelgren at Scientific American MIND and I will bring you a series of blogs about the DSM-5 authored by ourselves and some well-known researchers and psychiatrists. For the duration of next week, we will also publish my feature article about DSM-5 in its entirety on our website. After next week, you can still read the feature in the May/June issue of MIND. Stay tuned!”

About the Author: Ferris Jabr is an associate editor focusing on neuroscience and psychology.

1 boring old man

1 boring old man | May 3, 2012

the future of an illusion IV½…

and

the future of an illusion IV

1 boring old man | May 2, 2012

Psychology Today | DSM 5 in Distress

Wonderful News: DSM 5 Finally Begins Its Belated and Necessary Retreat
Perhaps this will be the beginning of real reform.

Alan Frances MD | May 2, 2012

MindFreedom International Newswire

Protesters, Rejecting Mental Illness Labels, Vow to “Occupy” the American Psychiatric Association Convention

MindFreedom International
Last modified: 2012-05-01T16:46:46Z
Published: Tuesday, May. 1, 2012 – 9:46 am

PHILADELPHIA, May 1, 2012 — /PRNewswire-USNewswire/ — On Saturday, May 5, 2012, as thousands of psychiatrists congregate for the American Psychiatric Association (APA) Annual Meeting, individuals with psychiatric labels and others will converge in a global campaign to oppose the APA’s proposed new edition of its “bible,” the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), scheduled for publication in 2013. Occupy the APA will include distinguished speakers from 10 a.m. to noon at Friends Center (1515 Cherry Street, Philadelphia), and a march at approximately 12:15 p.m. to the Pennsylvania Convention Center (12th and Arch Streets), where the group will protest from approximately 1 p.m. while the APA meets inside…

http://www.psychiatry.org/advocacy–newsroom/newsroom/dsm-5-draft-criteria-open-for-public-comment

Wed May 02, 2012

Contact: For Immediate Release                                  
Eve Herold, 703-907- 8640 Release No. 24
press@psych.org
Erin Connors, 703-907-8562
econnors@psych.org

DSM-5 Draft Criteria Open for Public Comment
Mental health diagnostic manual available for final online comment period

ARLINGTON, Va. (May 2, 2012) – For a third and final time, the American Psychiatric Association (APA) invites public comment on the proposed criteria for the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). DSM is the handbook used by health care professionals as an authoritative guide to the diagnosis of mental disorders.

The public comment period will last six weeks, beginning May 2 and continuing until June 15. All responses submitted via the DSM-5 website will be considered by the DSM-5 Work Groups, which are charged with assessing the latest scientific evidence and recommending the disorder definitions and criteria to be included in the manual. Nearly 10,800 comments from health care professionals, mental health advocates, families and consumers were submitted in the first two public comment periods in 2010 and 2011.

“The comments we have received over the past two years have helped sharpen our focus, not only on the strongest research and clinical evidence to support DSM-5 criteria but on the real-world implications of these changes,” said APA President John M. Oldham, M.D. “We appreciate the public’s interest and continued participation in the DSM-5 development process.”

In preparation for this final comment period, members of the DSM-5 Task Force and Work Groups have updated their proposals for diagnostic criteria. The revised criteria reflect recently published research, results from DSM-5 field testing of the criteria and public comments received since 2010.

Key changes posted for this round of public review include:

• Revised proposals to place Attenuated Psychosis Syndrome and Mixed Anxiety Depressive Disorder in Section III of the manual, covering conditions that require further research before their consideration as formal disorders

•  Added language to Major Depressive Disorder criteria to help differentiate between normal bereavement associated with a significant loss and a diagnosis of a mental disorder

• Added rationale for changes to Personality Disorders, with field trial data now supporting the reliability of dimensional measures and the categorical diagnosis of Borderline Personality Disorder

• Modified diagnostic criteria for Pedophilic Disorder to make the category more consistent with the World Health Organization’s International Classification of Diseases

• Condensed diagnoses within Communication Disorders to only include Language Disorders and Speech Disorders

• A proposal for a new diagnosis of Suicidal Behavioral Disorder

• Modified diagnostic criteria for numerous disorders, including some in the Neurocognitive Disorders and Anxiety Disorders chapters

• A proposed Cultural Formulation Interview, which includes specific questions to help clinicians more effectively assess cultural aspects of psychiatric diagnosis

• A detailed list of changes made to draft proposals since July 2011 can be found on www.DSM5.org .

Revisions to DSM reflect scientific advances in the field and new knowledge gained since the last manual was published in 1994. Since 1999, more than 500 mental health and medical researchers and clinicians from the United States and abroad have been involved in the planning, review and deliberations for DSM-5. Field trials in both large academic medical centers and routine clinical practices have tested select criteria.

Feedback to the proposed diagnostic criteria can be submitted through www.DSM5.org , which will be available until the comment period ends June 15. After that, the site will remain viewable but will be closed to comments as the Work Groups and Task Force complete revisions and submit criteria for evaluation by the Scientific Review Committee and the Clinical and Public Health Committee. The Task Force will then make final recommendations to the APA Board of Trustees. The final version of DSM-5 is expected to go before the Board of Trustees in December 2012.

“As with every stage in this thorough development process, DSM-5 is benefiting from a depth of research, expertise and diverse opinion that will ultimately strengthen the final document,” noted David J. Kupfer, M.D., chair of the DSM-5 Task Force.

Publication of DSM-5 is expected in May 2013.

The American Psychiatric Association is a national medical specialty society whose physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org  and www.HealthyMinds.org .

APA releases third draft of DSM-5 for final stakeholder review and comment

American Psychiatric Association (APA) releases third draft of DSM-5 for final stakeholder review and comment

Post #163 Shortlink: http://wp.me/pKrrB-20I

 

The American Psychiatric Association, publishers of the Diagnostic and Statistical Manual of Mental Disorder (DSM), has today released its third draft of proposed revisions to DSM-IV diagnostic categories and criteria.

The next edition of the DSM, which will be known as DSM-5, is due for publication in May 2013.

This third and final stakeholder review and comment period runs for six weeks until June 15, 2012

Revised proposals can be found on the DSM-5 Development website here:

http://www.dsm5.org/ProposedRevision/Pages/Default.aspx

Submitting comment

As with the two previous feedback exercises, comments from professionals, professional bodies, consumer groups and individuals are being accepted via a registration process on the DSM-5 Development website, for which a valid email address is required for validation purposes. Comments are uploaded via a WYSIWYG/html editor.

(If you had registered to submit comment for either of the earlier feedback exercises your log in details may still work.)

These review and feedback exercises are open to all stakeholders in DSM-5  – medical professionals, clinicians, researchers, psychiatrists, psychologists, allied mental health and health professionals, counselors, social workers, OTs, lawyers, teachers, patients and their families, caregivers, advocates and patient organizations.

These public reviews are not run as formal consultation exercises and the DSM-5 Task Force does not publish comments received nor lists of the names of professional bodies, organizations, institutions and individuals who have submitted feedback.

This page on the DSM-5 Development site says:

“…At this time, we are accepting comment submissions on this Web site until June 15, 2012. Comments about specific diagnoses can be made on the pages below, while you may leave feedback about non-diagnostic specific issues in DSM-5 in the Overall Comments section. The work group members will review all feedback and make decisions about further revisions based in part on the comments provided as well as on results from field trial testing, which is currently underway. Once the next edition of changes have been implemented, we will post the revised criteria on this site to allow commentary once again…”

However, the Home Page announcement states,

“…This commenting period marks the third and final time DSM-5 draft criteria will be available for your feedback. Following this period the site will remain viewable with the draft proposals until DSM-5’s publication…”

The second public review exercise ran from May 4 to June 15, 2011 but was extended a further month until July 15. If the closure date for receipt of submissions for this third review is extended I will update this site.

 

THIRD and FINAL stakeholder review published

http://www.dsm5.org/Pages/Default.aspx

Final Updates to DSM5.org

For the next 6 weeks we are pleased to once again offer the opportunity to submit comments on the draft fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This commenting period marks the third and final time DSM-5 draft criteria will be available for your feedback. Following this period the site will remain viewable with the draft proposals until DSM-5’s publication.

Following the previous commenting period (May-July 2011), members of the DSM-5 Task Force and Work Groups reviewed feedback submitted to this site and, where appropriate, revised their proposed diagnostic criteria and made other changes. With the completion of the DSM-5 Field Trials, Work Group members have spent the past several months examining data and findings from these important studies. Therefore, the proposed diagnostic criteria found on this site are the result of the DSM-5 Work Groups’ ongoing deliberations, based on findings from scientific field studies, patient and clinician perspectives, and views from the general public. We want to stress that revisions will continue to be made, as necessary, over the next several months.

What’s New?

What specifically has changed on this site over the past year? Visitors may notice differences in the ways in which some proposed disorders are classified. Below are some of the changes.

Based on concerns about the reliability of the proposed Attenuated Psychosis Syndrome and Mixed Anxiety Depressive Disorder in the field trials, these two conditions are being recommended for further study in Section III, an area of DSM-5 for conditions that require further research before consideration as formal disorders.

We also added a footnote to the Major Depressive Disorder criteria to clarify the difference between normal bereavement associated with a significant loss and a diagnosis of a mental disorder. Many commentators noted the previous criteria erroneously implied that bereavement could be assumed to only last 2 months and we wanted to correct that misunderstanding and provide more information on how bereavement and other loss reactions differ from Major Depressive Disorder. The extensive public comment also highlighted the need to clarify that use of a checklist of the diagnostic criteria by people without clinical training is insufficient to make a clinical diagnosis.

Among the other significant changes in this posting is a more extensive Personality Disorders rationale for change with the reliability of dimensional measures and the categorical diagnosis of Borderline Personality Disorder now supported by Field Trial data. However, additional data analysis in this area is ongoing.

Diagnostic criteria for Pedophilic Disorder have been modified. The adjusted boundaries of this disorder are based more on biological developmental indicators of early puberty in victims to avoid implications that the disorder involves post-pubertal adolescent victims and to make the criteria consistent with the International Classification of Diseases.

Communication Disorders now include two diagnoses – Language Disorders and Speech Disorders – each with appropriate subtypes to cover all seven of the disorders previously proposed for categorization here.

Similarly, based on clinical feedback and the field trial documentation that Simple Somatic Symptom Disorder was a milder form of Complex Somatic Symptom Disorder, the two have now been combined as a single disorder: Somatic Symptom Disorder.

The diagnosis of Suicidal Behavioral Disorder is a newly proposed disorder that is intended to complement the previous proposal for Non-Suicidal Self Injury Disorder. The latter disorder was tested in the Field Trials with highly variable levels of reliability—final decisions about its placement in Section III for further study have not been made. Another disorder suggested for placement in Section III includes Persistent Complex Bereavement Disorder which has had conflicting disorder criteria proposed from previous studies of this condition. The Work Group has suggested a new criteria set that builds on previous research prior to full endorsement of this condition.

Readers will also notice changes in specific criteria for some of the disorders, including those in the Neurocognitive Disorders and the Anxiety Disorders chapters. Finally, we have also now included a proposed Cultural Formulation Interview for DSM-5, which also includes some specific questions for visitors to consider in thinking about how the manual can help clinicians more effectively assess cultural aspects of psychiatric diagnosis.

A detailed listing of changes to draft proposals that have been made since July 2011 can be found on the Recent Updates page. We also encourage readers to visit each diagnostic section, which includes a brief introductory statement about changes within that section, as well as a listing of the proposed disorders for that particular section.

Next Steps

It is important to note that the proposed changes listed here do not represent the final changes for DSM-5. The proposals listed here reflect the most up-to-date drafts, final versions of which will be put forth for review and approval by the Board of Trustees of the American Psychiatric Association (APA) later this year. However, these proposed changes will undergo further revisions between now and the end of 2012, in part generated from your input, and also because results from the DSM-5 Field Trials continue to be analyzed, discussed, and integrated into proposals, along with an extensive review process that is taking place for these proposals. This review process includes: a Scientific Review Committee which will review the scientific validating evidence for revisions; an extensive peer review process where hundreds of expert reviewers will consider the clinical and public health risks and benefits of making changes from DSM-IV; and a review by an Assembly DSM-5 committee. Revisions will continually be made based on feedback from these various groups. This represents an unprecedented level of internal and external review for the DSM including the public review via the three postings on the DSM5.org.

Finally, there will be an overall review by the DSM-5 Task Force that integrates these assessments and sends final recommendations along with all supporting data to the APA’s Board of Trustees for a final review. The Board of Trustees will consider the recommendations of the Task Force along with those from the Scientific Review Committee as well as other review committees mentioned above and the public comments. The final manual approved by the Board will be submitted to the American Psychiatric Publishing for publication by December 31, 2012. The 166th APA Annual Meeting in San Francisco, May 18-22, 2013, will mark the official release of DSM-5.

(Ed: See DSM-5 Development site for links)

Neurodevelopmental Disorders
Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma and Stressor Related Disorders
Dissociative Disorders
Somatic Symptom Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control, and Conduct Disorders
Substance Use and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilias
Other Disorders

http://www.dsm5.org/ProposedRevision/Pages/Default.aspx

Proposed Draft Revisions to DSM Disorders and Criteria

The draft disorders and disorder criteria proposed by the DSM-5 Work Groups for new and existing mental disorders can be found on these pages. You will notice that the diagnostic chapters listed below are no longer organized according to DSM-IV. Instead, we have restructured the diagnostic chapters in DSM-5 to better reflect advances in our scientific understanding of psychiatric disorders, as well as to make diagnosis easier and more feasible for clinicians. You can read more about the proposed chapter structure by clicking here.

Use the links below to read about proposed changes to the disorders that interest you. Although the disorders listed below are listed according to their proposed placement in DSM-5, you may click here if you are interested in seeing which work groups are addressing which disorders. Please note that the proposed criteria listed here are not final. These are initial drafts of the recommendations that have been made to date by the DSM-5 Work Groups.

You will also notice for each disorder a section pertaining to the assessment of disorder severity. The severity criteria being proposed differs somewhat across disorders, largely because the work groups are in different stages in their deliberation processes. Therefore, you will notice some variability in the range of options presented across disorders, as well as differences in the severity scales being proposed. However, by DSM-5’s completion, we look forward to presenting a standardized method for assessing severity for all diagnoses, with an emphasis on simplicity and clinical utility. Finally, in addition to pages on each of the DSM-IV diagnostic categories, please be sure to review the sections on proposed revisions to the definition of a mental disorder, a listing of Conditions Proposed by Outside Sources that are still under consideration, and Other Clinical Conditions that may be the Focus of Clinical Attention. Please be sure to review these sections in addition to the diagnostic categories.

At this time, we are accepting comment submissions on this Web site until June 15, 2012. Comments about specific diagnoses can be made on the pages below, while you may leave feedback about non-diagnostic specific issues in DSM-5 in the Overall Comments section. The work group members will review all feedback and make decisions about further revisions based in part on the comments provided as well as on results from field trial testing, which is currently underway. Once the next edition of changes have been implemented, we will post the revised criteria on this site to allow commentary once again.*

*Please note that all input we receive will be reviewed, though we can not guarantee that your suggestions will be incorporated into any revisions.

*Ed: Update @ May 3, 2012

I am advised that APA has clarified that the paragraph above contained erroneous text; the webpage has since been amended to read:

“…At this time, we are accepting comment submissions on this Web site until June 15, 2012. Comments about specific diagnoses can be made on the pages below, while you may leave feedback about non-diagnostic specific issues in DSM-5 in the Overall Comments section. The work group members will review all feedback and make decisions about further revisions based in part on the comments provided as well as on results from field trial testing, which is currently underway.”

*Please note that all input we receive will be reviewed, though we can not guarantee that your suggestions will be incorporated into any revisions.

 

(Ed: One focus of this site has been the monitoring of proposals for the Somatic Symptom Disorders. The categories and criteria proposals for Somatic Symptom Disorders, as published today, do not appear to have changed since April 27, other than an edit to the introduction reflecting the proposal to merge CSSD with SSSD and name “Somatic Symptom Disorder”. See Post #162: DSM-5 proposals for Somatoform Disorders revised on April 27, 2012 )

http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx 

Somatic Symptom Disorders

Please find below a list of disorders that are currently proposed for the diagnostic category, Somatic Symptom Disorders. This category contains diagnoses that were listed in DSM-IV under the chapter of Somatoform Disorders. The Somatic Symptom Disorders Work Group has been responsible for addressing these disorders. Among the work group’s recommendations is the proposal to rename this category Somatic Symptom Disorders. Because the current terminology for somatoform disorders is confusing and because somatoform disorders, psychological factors affecting medical condition, and factitious disorders all involve presentation of physical symptoms and/or concern about medical illness, the work group suggests renaming this group of disorders Somatic Symptom Disorders. In addition, 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. Since Somatization Disorder, Hypochondriasis, Undifferentiated Somatoform Disorder, and Pain Disorder share certain common features, namely somatic symptoms and cognitive distortions, the work group is proposing that these disorders be grouped under a common rubric called Somatic Symptom Disorder. The work group had previously suggested separate diagnoses of Complex Somatic Symptom Disorder and Simple Somatic Symptom Disorder, but they are now proposing that these be combined into a singular diagnosis of Somatic Symptom Disorder. The work group has also proposed that Factitious Disorder be moved from its previous location under Other Disorders to this chapter. Lastly, the work group is proposing that Conversion Disorder now be named Conversion Disorder (Functional Neurological Symptom Disorder) . We appreciate your review and comment on these disorders.

J 00 Somatic Symptom Disorder |
J 01 Illness Anxiety Disorder |
J 02 Conversion Disorder (Functional Neurological Symptom Disorder) |
J 03 Psychological Factors Affecting Medical Condition |
J 04 Factitious Disorder |
J 05 Somatic Symptom Disorder Not Elsewhere Classified |

DSM-5 proposals for Somatoform Disorders revised on April 27, 2012

DSM-5 proposals for Somatoform Disorders revised on April 27, 2012

Post #162 Shortlink: http://wp.me/pKrrB-24D

Update @ May 02, 2012: Since publication of this post, APA has posted its third draft (see Post #163)

Although the American Psychiatric Association (APA) has still to announce the dates for its third review of proposals for revisions to DSM-IV categories and criteria, I discovered, today, that proposals for the revision of the Somatoform Disorders were updated yesterday, April 27.

The APA’s third and final stakeholder review exercise is expected to launch by “end of May at the latest.” This is the only information we currently have and the Timeline remains unspecific – other than “Spring” and “for two months.”

Revisions to other DSM-IV categories may also have been published prior to the launch of the third public review and I would advise readers to check the DSM-5 Development site for potential changes to other categories.

 

Somatic Symptom Disorders

Earlier proposals for two new categories, “Complex Somatic Symptom Disorder” (CSSD) and “Simple Somatic Symptom Disorder” (SSSD); “Functional Neurological Disorder (Conversion Disorder)” and proposed revisions to selected other categories, as they had stood at the time of the second public review (May 4 – July 15, 2011), are archived on Dx Revision Watch site here, for comparison:

http://dxrevisionwatch.wordpress.com/dsm-5-proposals/dsm-5-proposals-sub-page-1/dsm-5-drafts-2/

and in this Dx Revision Watch post from May 10, 2011: http://wp.me/pKrrB-13z

 

From the DSM-5 Development website

Revisions as of April 27, 2012 (J 04 Factitious Disorder was updated on March 22, 2012)

http://www.dsm5.org/proposedrevision/Pages/SomaticSymptomDisorders.aspx

Somatic Symptom Disorders

Please find below a list of disorders that are currently proposed for the diagnostic category, Somatic Symptom Disorders. This category contains diagnoses that were listed in DSM-IV under the chapter of Somatoform Disorders. The Somatic Symptom Disorders Work Group has been responsible for addressing these disorders. Among the work group’s recommendations is the proposal to rename this category Somatic Symptom Disorders. Because the current terminology for somatoform disorders is confusing and because somatoform disorders, psychological factors affecting medical condition, and factitious disorders all involve presentation of physical symptoms and/or concern about medical illness, the work group suggests renaming this group of disorders Somatic Symptom Disorders. In addition, 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. Since Somatization Disorder, Hypochondriasis, Undifferentiated Somatoform Disorder, and Pain Disorder share certain common features, namely somatic symptoms and cognitive distortions, the work group is proposing that these disorders be grouped under a common rubric called Complex Somatic Symptom Disorder.*

[*Ed: The Work Group now proposes to merge the previously proposed category, "Simple Somatic Symptom Disorder" with "Complex Somatic Symptom Disorder" and is also considering dropping "Complex" from the name of the resulting disorder and instead, calling it "Somatic Symptom Disorder." Update @ May 02, 2012: The text above has been revised by the Somatic Symptom Disorder Work Group since publication of this post. See Post #163 for revised text.]

[Ed: Note: There have been two key PDF documents associated with the proposals for the "Somatic Symptom Disorders" – the "Disorders Description" and "Rationale/Validity" documents. These have been removed from the webpages, presumably pending updating to reflect changes to proposals for this section of DSM-5. If and when these two documents are republished, I will update this page. These updated proposal texts, below, are littered with typos.]

Instead of the categories as they had stood since May 2011:

Somatic Symptom Disorders

J 00 Complex Somatic Symptom Disorder
J 01 Simple Somatic Symptom Disorder
J 02 Illness Anxiety Disorder
J 03 Functional Neurological Disorder (Conversion Disorder)
J 04 Psychological Factors Affecting Medical Condition
J 05 Other Specified Somatic Symptom Disorder
J 06 Unspecified Somatic Symptom Disorder Pseudocyesis

the proposed categories now read (and note, are now renumbered):

Somatic Symptom Disorders

J 00 Somatic Symptom Disorder
J 01 Illness Anxiety Disorder
J 02 Conversion Disorder (Functional Neurological Symptom Disorder)
J 03 Psychological Factors Affecting Medical Condition
J 04 Factitious Disorder
J 05 Somatic Symptom Disorder Not Elsewhere Classified

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=368

[Ed: Proposal, Rationale and Severity texts have been revised since the May 2011 iteration.]

J 00 Somatic Symptom Disorder

Updated April-27-2012

Proposed Revision

Somatic Symptom Disorder

Criteria A, B, and C must all be fulfilled to make the diagnosis:

A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.

B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.

(1) Disproportionae and persistent thoughts about the seriousness of one’s symptoms.

(2) Persistently high level of anxiety about health or symptoms

(3) Excessive time and energy devoted to these symptoms or health concerns

C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 months).

Specifiers

Predominant Pain (previously pain disorder). This category is reserved for individuals presenting predominantly with pain complaints who also asatisfy criteria B and C of this diagnosis. Some patients with pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=368#

Rationale

The proposed classification for Somatic Symptom Disorders deemphasizes the central role of medically unexplained symptoms. Instead, it defines disorders on the basis of positive symptoms (distressing somatic symptoms + excessive thoughts, feelings, and behaviors in response to these symptoms).

The group considers that the current DSM-IV somatoform diagnoses (Somatization Disorder, Somatoform Disorder NOS, Undifferentiated Somatoform Disorder, Hypochondriasis and the Pain Disorders) are so flawed that complete restructuring of these diagnoses is required. Change is needed as:

- The DSM-IV somatoform diagnoses are used rarely in clinical practice in most countries; the terms cause confusion among doctors and are resented by many patients.

- The criteria for DSM-IV somatization disorder are too restrictive. Undifferentiated Somatoform Disorder has such a low threshold that it is applicable to a very large proportion of patients attending primary care. The same low threshold issue occurs with Somatoform Disorder NOS.

- These diagnoses are based on “medically unexplained symptoms,” but this term is unreliable, especially in the presence of medical illness. Doctors disagree on the use of the term and patient recall of such symptoms is variable, so reliability of these diagnoses is low.

- The lack of positive psychological features in the definition of these disorders means they fail to satisfy one of the criteria for a mental disorder.

The new diagnoses of Somatic Symptom Disorder (SSD) is proposed to overcome these problems with relevant DSM-IV diagnoses.

The previous posting proposed diagnoses of Complex Somatic Symptom Disorder (CSSD) and Simple Somatic Symptom Disorder (SSSD). In this revision, we have merged the two disordes, recognizing that SSSD is a less severe variant of CSSD. The work group is considering dropping the adjective “complex” from the name of the resulting disorder and is desirous of feedback.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=368#

Severity

Severity Specifiers (mild, moderate, severe)*

[Ed: Cf with ICD-11 Alpha drafting platform proposals for three (as yet undefined) degrees of Mild, Moderate and Severe "Bodily Distress Disorder." See Post #145: “Bodily Distress Disorders” to replace “Somatoform Disorders” for ICD-11? February 20, 2012]

Somatic Symptom Disorder is a disorder characterized by persistency, symptom burden, and excessive or maladaptive response to somatic symptoms. There is a considerable range of severity. Typically, the disorder is more severe when multiple somatic syptoms are present. In addition to fulfilling criteria A and C, the following metrics may be used to rate severity:

Mild: only 1 of the B criteria fulfilled
Moderate: 2 or more B criteria fulfilled
Severe: 2 or more B criteria fulfilled plus multiple somatic symptoms

PHQ Somatic Symptom Short Form (PHQ-SSS)*

*Ed: Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine 2002;64:258-266.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/11914441
PDF: http://www.psychosomaticmedicine.org/content/64/2/258.full.pdf+html

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=10

[Ed: Proposal, Rationale and Severity texts have been revised since the May 2011 iteration.]

J 01 Illness Anxiety Disorder

Updated April-27-2012

Proposed Revision

Illness Anxiety Disorder

A. Somatic symptoms are not present or, if present, are only mild in intensity.

B. Preoccupation with having or acquiring a serious illness. If another medical condition or high risk for developing a medical condition (e.g. strong family history) is present, the preoccupation is clearly excessive or disproportionate.

C. High level of anxiety about health and a low threshold for becoming alarmed about their health.

D. The individual performs excessive health-related behaviors (e.g., repeatedly checking one’s body for signs of illness), or exhibits maladaptive avoidance (e.g., avoiding doctors’ appointments and hospitals).

E. Although the specific preoccupation may not be continuously present, the state of being preoccupied is chronic (at least 6 months).

F. The illness-related preoccupation is not better accounted for by another psychiatric disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, or obsessive-compulsive disorder.

Subtypes

Care-seeking subtype: care-seeking individuals have elevated rates of medical utilization.

Care-avoidant subtype: avoidant individuals rarely seek medical care because seeing a physician and undergoing laboratory tests and diagnostic procedures heighten their anxiety to intolerable levels.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=10#

Rationale

Studies suggest that patients with hypochondriasis fall into two distinct subgroups. In one subgroup (75% of hypochondriasis patients), somatic symptoms predominate and form the patient’s primary concern. The other subgroup (25% of hypochondriacs) is composed of patients with minimal somatic symptoms but who are highly anxious about and suspicious of the presence of an undiagnosed, serious medical illness.

In our proposal for DSM 5, the former subgroup of patients would be subsumed under the new diagnosis of Somatic Symptom Disorder (SSD), while the latter subgroup would now be subsumed under the proposed Illness Anxiety Disorder (IAD). IAD is closely related to other somatic symptom disorders, anxiety disorders, and depressive disorders, but it is included here because of its close relationship to the other somatic symptom disorders in clinical presentation, phenomenology, and in cognitive, affective and behavioral characteristics.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=10#

Severity

Recommendations for severity criteria for this disorder are forthcoming. We encourage you to check our website regularly for updates.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=8

J 02 Conversion Disorder (Functional Neurological Symptom Disorder)

[Ed: Previous proposal was for renaming "Conversion Disorder" to "Functional Neurological Disorder (Conversion Disorder)" and to possibly relocate under "Dissociative Disorders" in line with ICD-10. Proposal, Rationale and Severity texts have been revised since the May 2011 iteration.]

Updated April-27-2012

Proposed Revision

Conversion Disorder (Functional Neurological Symptom Disorder)

A. One or more symptoms or deficits are present that affect voluntary motor or sensory function, with or without apparent impairment of consciousness.

B. Clinical findings provide evidence of internal inconsistency or incompatibility with recognized neurological or medical disease.

C. The symptom or deficit is not better explained by another recognized medical or DSM disorder.

D. The symptom or deficit is associated with clinically significant distress or imapairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=8#

Rationale

Name Change: The additional parenthetical “functional neurological symptom disorder” has been introduced as it is more frequently used by neurologists who see the majority of these patients. It is also a term that is more acceptable to patients.

Removal of previous criterion B. “Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors” We propose that this criterion be eliminated and discussion of etiologic factors placed in accompanying text. This DSM IV criterion reduces the utility and reliability of the diagnosis in practice because:

(a) It confounds clinical description with a proposed but unproven etiology.

(b) The research evidence indicates that observed psychological factors are often non-specific; that is, they occur in patients with other conditions, often with a similar frequency; this non-specificity makes a judgment of their relevance in an individual case of ‘conversion’ subjective and potentially unreliable.

(c) In a substantial proportion of apparent cases of conversion – as defined by neurological symptoms not explained by disease – psychological factors cannot be convincingly or reliably demonstrated.

Removal of previous criterion C. “The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering)”. This criterion reduces the utility and reliability of the diagnosis because:

(a) It is difficult, and probably clinically impossible, to prove reliably that a patient is not feigning.

(b) While the clinician needs to be aware of the possibility of feigning, and to make an appropriate diagnosis if it is found, there is no evidence that feigning is more common in patients with possible conversion disorder than with other mental disorders. Highlighting it for conversion alone is unnecessarily stigmatizing and may be detrimental to the physician-patient relationship.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=8#

Severity

- Minor and brief impairment (i.e., non-incapacitating symptom such as aphonia lasting less than 2 days)

- Minor impairment and persistent/recurrent (i.e., from 3 days to 3 months)

- Moderate impairment and brief duration

- Severe and persistent/recurrent (e.g., more than 3 months bedbound with contractures and/or muscle wasting)

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=387

J 03 Psychological Factors Affecting Medical Condition

Updated April-27-2012

Proposed Revision

Psychological Factors Affecting Medical Condition

To meet criteria for Psychological Factors Affecting Medical Condition, both criteria A and B are necessary.

A general medical condition is present.

B Psychological or behavioral factors adversely affect the general medical condition in one of the following ways:

1 the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition

2 the factors interfere with the treatment of the general medical condition (e.g., poor adherence)

3 the factors constitute additional well-established health risks for the individual

4 the factors influence the underlying pathophysiology to precipitate or exacerbate symptoms or to necessitate medical attention.

[Ed: Rationale and Severity texts have been revised since May 2011 iteration.]

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=387#

Rationale

The work group recommends retaining the diagnosis of Psychological Factors Affecting a Medical Condition (PFAMC) with only minor wording changes in the criteria.

In DSM-IV, PFAMC had 6 subtypes; since there is no evidence the subtypes have been used, we have recommended eliminating them. Finally, we have advocated moving PFAMC from its obscure place in the back of prior DSM editions into the Somatic Symptom Disorders chapter.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=387#

Severity

1 = increases medical risk (e.g. inconsistent adherence with anti-hypertension treatment)

2 = aggravates underlying medical condition (e.g. anxiety aggravating asthma)

3 = results in medical hospitalization or emergency room visit

4 = results in severe life-threatening risk (e.g. ignoring heart attack symptoms)

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=386

J 04 Factitious Disorder

[Ed: Proposal, Rationale and Severity texts have been revised since the May 2011 iteration.]

Updated March-22-2012

Proposed Revision

Proposed Subtypes:

Factitious Disorder Imposed on Self

To meet criteria for Factitious Disorder Imposed on Self, all four criteria must be met.

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified perception.

B. Presenting oneself to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The abnormal illness behavior is not better accounted for by another mental disorder such as delusional disorder or other psychotic disorder.

Factitious Disorder Imposed on Another (previously, Factitious Disorder By Proxy)

To meet criteria for Factitious Disorder Imposed on Another, all four criteria must be met. Note that the perpetrator, not the victim, receives this diagnosis.

A. Falsification of physical or psychological signs or symptoms or of induction of injury or disease in another, associated with identified deception.

B. Presenting another (victim) to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The abnormal illness behavior is not better accounted for by another mental disorder such as delusional disorder or other psychoitc disorder.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=386#

Rationale

The Somatic Symptom Disorders workgroup requests that Factitious Disorders be grouped within the Somatic Symptom chapter of DSM V. Such a grouping is more logical than the status quo where factitious disorders appear in their own chapter. Our proposed grouping supports clinical utility and facilitates future research.

Utility: This grouping would help physicians with the differential diagnosis of patients who present with persistent problems related to illness perception, frequently including unexpected and/or unexplained psychological and/or physical symptoms. In making a differential diagnosis, it is conceptually and pragmatically useful to group disorders that show diagnostic overlap with one another in the same section. This grouping will be particularly advantageous in terms of comparing and contrasting Factitious Disorder with Conversion Disorder and, to a lesser extent, with Complex Somatic Symptom Disorder.

Research: The grouping of Factitious Disorders with the other Somatic Symptom Disorders would facilitate research progress on the broad spectrum of symptom reporting phenomena, including the feigning of symptoms. In the status quo, Factitious Disorder is listed in a separate chapter, where it is not routinely considered.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=386#

Severity

There are few widely employed measures of severity in factitious disorder or conversion disorder.

For factitious disorder, one might grade severity levels as “1” when symptoms alone are reported (“bright red blood in stool”), as “2” when a lab test was modified (e.g. introducing blood into a urine sample), as “3” when patients make themselves sick or as “4” when patients’ actions lead to life threatening illness.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=541

J 05 Somatic Symptom Disorder Not Elsewhere Classified

Proposed Revision

Updated April-27-2012

Somatic Symptom Disorder Not Elsewhere Classified

Pseudocyesis A false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=541#

Rationale

Pseudocyesis is a rare disorder with characteristic somatic features. Because of its prominent somatic presentation, pseudocyesis is included in the NEC section of Somatic Symptom Disorder.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=541#

Severity

The work group has not yet finalized their severity for this disorder. Please continue to check this Web site for updates, as this will be forthcoming.

I will continue to monitor the DSM-5 Development site for any further changes and for the announcement of the third and final stakeholder review.