Published DSM-5 Field Trial Results Prompt Renewed Criticism

Nov 14, 2012

Publication of the final results of the field trials for the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has prompted renewed criticism from one of its most vocal critics.

Preliminary results, which were first unveiled last May at the American Psychiatric Association’s (APA’s) 2012 Annual Meeting and were reported by Medscape Medical News at that time, were published online October 30 in 3 separate articles in the American Journal of Psychiatry.

The DSM-5 field trials, which got underway 2 years ago this month, were designed to subject proposed diagnostic criteria for the future DSM-5 to “rigorous, empirically sound evaluation across diverse clinical settings,” David J. Kupfer, MD, chair of the DSM-5 Task Force, and Helena C. Kraemer, PhD, DSM-5 Task Force member and the chief methodologist of the field trials, noted in a joint statement sent to Medscape Medical News.

“And now, as the first comprehensive analyses of that effort are published, what’s clear is just how well the field trials did their job,” they added.

But Allen Frances, MD, former head of the DSM-IV Task Force, who was has been one of the DSM-5’s greatest detractors, has a different view.

The DSM-5 field trials “asked the wrong question and then answered it with a poorly designed and sloppily conducted study. The right question was what would be the impact of DSM-5 on diagnostic inflation and the consequent risk of overtreatment with medication,” Dr. Frances, who is professor emeritus from the Department of Psychiatry at Duke University School of Medicine in Durham, North Carolina, told Medscape Medical News.

–Megan Brooks,

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Housing First: People with Mental Illness

People with severe mental illness were once housed by the hundreds of thousands in state mental hospitals. But the “deinstitutionalization” movement that began in the 1960s and gained steam in the ’70s and ’80s changed the landscape — and the challenges that mentally ill people face.

It did not, however, mean the end to institutionalization. “What we have now is trans-institutionalization,” says Andrew Sperling, legislative director for the National Alliance for the Mentally Ill. People with mental illness leave acute or chronic care facilities without adequate provisions for their housing or support, and end up sliding into homeless shelters or the criminal justice system, Sperling says.

The numbers are stark. The numbers of in-patient beds in state and county institutions for the mentally ill declined from 413,000 in 1970 to 119,000 in 1986. By the 1990s, the number fell well below 100,000.

But in 1998, 283,800 people with mental illnesses were incarcerated in American jails or prisons – four times the number in state mental hospitals, according to the Department of Justice. “These days, the largest single provider of housing for people with severe mental illness is the criminal justice system,” says Sperling.

–NPR Special Report

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Housing Resources: links to organizations that study or help the homeless, from NPR Special Report

Mental Illness and Homelessness

Those with serious mental illness are often unable to work, and so do not have money to pay for housing. Low-income and supportive housing for the mentally ill is limited and it often takes years on a waiting list to get placed in a low-income apartment. Once homeless, it’s harder to take medications and go to doctor’s appointments regularly. This often leads to self-medication with alcohol and drugs.

Many homeless people also use drugs and alcohol to cope with the stress caused by homelessness, or became homeless because they need help with their substance abuse problem. People who are homeless are often arrested and housed in jails. Crimes are often related to homelessness: stealing, disturbing the peace, vagrancy, public intoxication, drug possession, prostitution or dealing drugs (in desperation for money to live on), and assault (in self-defense, or due to their mental illness or substance abuse). It would be much cheaper for the government to provide safe housing for people with mental illness rather than paying to keep them housed in jail for crimes related to homelessness.

It’s very dangerous to be homeless. The homeless are often robbed, beaten up and raped. People with mental illness are often too sick and vulnerable to defend themselves. This is why people with mental illness are more likely to be the victim of violence than the average person.


American Psychiatric Association Approves DSM-5

This weekend the American Psychiatric Association Board of Trustees approved the final criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-5).  We are excited to have the Board’s approval and look forward to publication this spring.

That said, while the criteria have been approved, the manual is far from complete. Review of the disorder text will continue to undergo final editing and then publication by American Psychiatric Publishing. The specific criteria and text will be available in published in spring 2013.

Below is a news release that was distributed this afternoon to members of the media alerting them to this major milestone in the development of DSM-5. We look forward to continued collaboration as we near publication of DSM-5.


David J. Kupfer, MD

Chair, DSM-5 Task Force


Dilip Jeste, MD

President, American Psychiatric Association


Diagnostic manual passes major milestone before May 2013 publication

ARLINGTON, Va. (December  1, 2012) – The American Psychiatric Association (APA) Board of Trustees has approved the final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The trustees’ action marks the end of the manual’s comprehensive revision process, which has spanned over a decade and included contributions from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other related fields from 39 countries. These final criteria will be available when DSM-5 is completed and published in spring 2013.

“The Board of Trustees approval of the criteria is a vote of confidence for DSM-5,” said Dilip Jeste, MD, president of APA. “We developed DSM-5 by utilizing the best experts in the field and extensive reviews of the scientific literature and original research, and we have produced a manual that best represents the current science and will be useful to clinicians and the patients they serve.”

DSM-5 is the guidebook used by clinicians and researchers to diagnose and classify mental disorders. Now that the criteria have been approved, review of the criteria and text describing the disorders will continue to undergo final editing and then publication by American Psychiatric Publishing.

The manual will include approximately the same number of disorders that were included inDSM-IV. This goes against the trend from other areas of medicine that increase the number of diagnoses annually.

“We have sought to be conservative in our approach to revising DSM-5. Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry,” said David J. Kupfer, MD, chair of the DSM-5 Task Force. “I’m thrilled to have the Board of Trustees’ support for the revisions and for us to move forward toward the publication.”

Organization of DSM-5

DSM-5 will be comprised of three sections:

  • Section 1 will give an introduction to DSM-5 with information on how to use the updated manual;
  • Section 2 will outline the categorical diagnoses according to a revised chapter organization; and
  • Section 3 will include conditions that require further research before their consideration as formal disorders, as well as cultural formulations, glossary, the names of individuals involved in DSM-5’s development and other information.

Summary of Decisions for DSM-5

Key decisions made by the Board of Trustees include:*

  • Overall Substantive Changes
    • Chapter order
    • Removal of multiaxial system
  • Section 2 Disorders
    • Autism spectrum disorder
    • Binge eating disorder
    • Disruptive mood dysregulation disorder
    • Excoriation (skin-picking) disorder
    • Hoarding disorder
    • Pedophilic disorder
    • Personality disorders
    • Posttraumatic stress disorder
    • Removal of bereavement exclusion
    • Specific learning disorders
    • Substance use disorder
  • Section 3 Disorders
    • Attenuated psychosis syndrome
    • Internet use gaming disorder
    • Non-suicidal self-injury
    • Suicidal behavioral disorder
  • Disorders Not Accepted for Sections 2 or 3
    • Anxious depression
    • Hypersexual disorder
    • Parental alienation syndrome
    • Sensory processing disorder

* More information on select decisions is available in Attachment A.

Collaborative Process for Development of DSM-5

Beginning in 1999, during the initial phase of this DSM revision, the APA engaged almost 400 international research investigators in 13 conferences supported by the National Institutes of Health. To invite comments from the wider research, clinical and consumer communities, the APA launched a DSM-5 Prelude website in 2004 to garner questions, comments, and research findings during the development process.

Starting in 2007 and 2008, the DSM-5 Task Force and Work Groups, made up of more than 160 world-renowned clinicians and researchers, were tasked with building on the previous seven years of scientific reviews, conducting additional focused reviews, and garnering input from a breadth of advisors as the basis for proposing draft criteria. In addition to the Work Groups in diagnostic categories, study groups were assigned to review gender, age and cross-cultural issues. The Work Groups have led the effort to review the scientific advances and research-based information that have formed the basis of the content for DSM-5.

The first draft of proposed changes was posted publicly on the website in February 2010 and the site also posted two subsequent drafts. With each draft, the site acceptedfeedback on proposed changes, receiving more than 13,000 comments on draft diagnostic criteria from mental health clinicians and researchers, the overall medical community, and patients, families, and advocates. Following each comment period, the DSM-5 Task Force and Work Groups reviewed and considered each response and made revisions where warranted.

The Work Groups’ proposals were evaluated by the Task Force and two panels convened specifically to evaluate the proposals—a Scientific Review Committee and a Clinical and Public Health Committee.  The Scientific Review Committee looked at the supporting data for proposed changes. The Clinical and Public Health Committee was charged with assessing the potential impact of changes to clinical practice and public health. Additionally, there was a forensic review by members of the Council on Psychiatry and Law.

All of the reviews were coordinated in meetings of the Summit Group, which includes the DSM-5 Task Force co-chairs, and review committee co-chairs, consultants, and members of the Executive Committee of the Board of Trustees. The criteria were then put before the APA Assembly for review and approval. The Board of Trustees’ review was the final step in this multilevel, comprehensive process.

“At every step of development, we have worked to make the process as open and inclusive as possible. The level of transparency we have strived for is not seen in any other area of medicine,” said James H. Scully, MD, medical director and chief executive officer of APA.


Attachment A: Select Decisions Made by APA Board of Trustees

Overall Changes

  • Chapter order: DSM-5’s 20 chapters will be restructured based on disorders’ apparent relatedness to one another, as reflected by similarities in disorders’ underlying vulnerabilities and symptom characteristics. The changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11) and are expected to facilitate improved communication and common use of diagnoses across disorders within chapters.
  • Removal of multiaxial system: DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).

Section 2 Disorders

1.     Autism spectrum disorder: The criteria will incorporate several diagnoses from DSM-IVincluding autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified), into the diagnosis of autism spectrum disorder for DSM-5 to help more accurately and consistently diagnose children with autism.

2.     Binge eating disorder will be moved from DSM-IV’s Appendix B: Criteria Sets and Axes Provided for Further Study to DSM-5 Section 2. The change is intended to better represent the symptoms and behaviors of people with this condition.

3.     Disruptive mood dysregulation disorder will be included in DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The diagnosis is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children.

4.     Excoriation (skin-picking) disorder is new to DSM-5 and will be included in the Obsessive-Compulsive and Related Disorders chapter.

5.     Hoarding disorder is new to DSM-5. Its addition to DSM is supported by extensive scientific research on this disorder. This disorder will help characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value. The behavior usually has harmful effects—emotional, physical, social, financial and even legal—for a hoarder and family members.

6.     Pedophilic disorder criteria will remain unchanged from DSM-IV, but the disorder name will be revised from pedophilia to pedophilic disorder.

7.     Personality disorders: DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study how this could be used to diagnose personality disorders in clinical practice.

8.     Posttraumatic stress disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. PTSD will also be more developmentally sensitive for children and adolescents.

9.     Removal of bereavement exclusion: the exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.

10.  Specific learning disorder broadens the DSM-IV criteria to represent distinct disorders which interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, or mathematics.

11.  Substance use disorder will combine the DSM-IV categories of substance abuse and substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms.


If You’re Homeless or Need Help

The National Coalition for the Homeless has advice and resources on their website for those who are currently homeless or will soon be homeless. Individuals with schizophrenia and other serious mental illnesses are more likely to become homeless. 1/3 of homeless people are mentally ill.

If you or anyone you know is homeless or soon-to-be homeless, please don’t give up. Fight for your survival by finding the resources to get housing, medical help, and safety. It’s easy to get overwhelmed and hopeless, but if you stay mentally strong, you can overcome the obstacles and get the help you need.


Homelessness Can Cause PTSD

Homelessness as a traumatic experience can lead to PTSD in a number of ways. First, the actual event of becoming homeless can lead to trauma through the loss of (a) stable shelter; and (b) family connections and accustomed social roles and routines. Second, the ongoing condition of homelessness and its attendant stressors, such as the uncertainty of where to find food and safe shelter, can erode a person’s coping mechanisms. Third, homelessness might serve as a breaking point for those who have pre-existing behavioral health conditions or a history of traumatization.
According to one study, “a literature review found consistent and well-documented evidence of high levels of multiple forms of traumatic stress within individuals and families who are homeless.” The presence of stress is to be expected in these populations. That it rises to the level of trauma might come as a surprise, but “researchers have documented that the rates of traumatic stress are extremely high, and may even be normative, among those experiencing homelessness.” This reality is about “more than the absence of physical shelter, it is a stress-filled, dehumanizing, dangerous circumstance.”
–National Alliance to End Homelessness