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DSM-V Controversies: Page 2 of 2

DSM-V Controversies: Page 2 of 2

Biosketches and disclosure information for the 28-member task force and 130-plus work group members are posted on the DSM-V Web site and are to be updated annually. They cover the period from 3 years before nomination to the present and indicate disclosures in areas such as consultation fees (eg, serving on scientific advisory boards); honoraria; stock or other financial options; patents; royalties from pharmaceuticals, devices, or other products; expert testimony; employment; and industry-related grant research support. Also disclosed are uncompensated leadership positions with nonprofit or advocacy organizations that are interested in psychiatric care.

Last year, the Center for Science in the Public Interest in its May 5 Integrity in Science publication noted that more than half of the 28 members of the DSM-V task force have ties to the drug industry. “They ranged from small to extensive. Leading the pack was William Carpenter Jr . . . who over the past 5 years worked as a consultant for 13 drug companies.”

The disclosure statements released to the public have been criticized in blogs and news articles as being remarkably spare, because they show only the existence of corporate connections—not dollar amounts or duration.

John Grohol, PsyD, founder and publisher of Psych Central, warned in his November 17 blog that the DSM-V process contained a “glaring loophole.” Appointees could make a million dollars a year for 10 years from a company before beginning work with DSM-V. He said, “All you need do is to cut off that relationship for a few years and then come back to it when you’re done.”

High stakes
For several months, Robert Spitzer, MD, former chair of the work group for DSM-III and DSM-III-R and professor of psychiatry at Columbia University, has condemned the confidentiality agreements required of DSM-V participants and urged the APA’s board to make the DSM-V revision process more transparent by placing detailed minutes of the task force and work group conference calls and meetings on the DSM-V Web site.

However, a recent action paper proposing that all minutes be made available on the Web was reviewed by the Reference Committee of the APA Assembly and was not supported. “The Reference Committee heard testimony from concerned parties and reviewed the current reporting system,” Burd told Psychiatric Times. “It was their conclusion that the reporting system was adequate to keep members informed of the process and to allow the DSM committees to do their work. This led to the recommendation of the Reference Committee to 'not support' the papaer. The author subsequently withdrew the paper with comments indicating that his concerns had been addressed."

Spitzer, however, remains troubled. "Full transparency of the process will only be satisfied by posting the minutes of all DSM-V conference calls and meetings, so that the process of deliberations is evident to all," he protested in a November 26 blog. "Anything less is an invitation to critics of psychiatric diagnosis to raise questions about the scientific credibility of DSM-V."

While Spitzer acknowledged that the APA's posting of work group progress reports is a step in the right direction, he felt the reports "fall far short of providing the requisite transparency" and they are "variable in terms of the amount of detail they provide regarding possible directions for change in the DSM-V."

In a November 17 opinion piece published in the Los Angeles Times, Christopher Lane, professor of English at Northwestern University and author of Shyness: How Normal Behavior Became a Sickness, described the transparency debates that are occurring over DSM-V and explained what is at state: "Not only do mental health professionals use it routinely when treating patients, but the DSM is also a bible of sorts for insurance companies deciding what disorders to cover, as well as for clinicians, courts, prisons, pharmacetuical companies, and agencies that regulate drugs," adding that many countries treat the DSM as gospel.

Psychiatric Times invited task force vice chair Regier to comment on proposed and recent changes to the information dissemination process for the DSM-V and on recent criticisms.

Building blocks

The 13 DSM-V work groups began meeting in 2007 and are building on work and recommendations from 13 conferences conducted by the APIRE and funded by an NIH grant. Those conferences focused on individual diagnostic areas, on diagnostic deficiencies in DSM, on spectra of disorders that cut across traditional boundaries, on advances in measurement-based care, and on fostering international collaboration. Conference reports are posted on the DSM-V Web site. efforts also are under way to achieve congruence between DSM and the international Classification of Diseases-11 (ICD-11).

The work groups, charged with reviewing all existing diagnostic categories in the current DSM, may propose revisions to existing disorder criteria, inclusion of new disorders, or no changes to a disorder or its criteria. They may also propose revisions to the text that accopmanies the criteria for each disorder. Since their formation, the work groups have commissioned literature reviews on several topics, and many are assessing secondary data analysis results and developing research plans for field trials.

Some proposed changes are controversial, such as Internet addiction, cannabis withdrawal, obesity, anxious depression, and childhood disitegrative disorder.

As the APA considers the inclusion of new disorders, Lane warned that the credibility of DSM is at risk, since “some critics argue that the addition of new disorders to the manual is little more than a pretext for prescribing profitable drugs.”

He advocated that some behaviors (eg, parental alienation, compulsive buying, Internet addiction), which are being discussed for possible addition to DSM, receive a full professional airing, including a vigorous debate about their validity.

Input from others
Advocacy groups, along with psychiatrists, are providing input on DSM-V. The Sensory Processing Disorder Foundation, for example, has launched an online petition urging APA to include sensory processing disorder in DSM-V.

Members of the transgender community have complained that the current diagnostic categories of gender identity disorder (GID) and transvestite fetishism reflect disparaging attitudes toward gender diversity and have called for the addition to the GID subgroup of more transgender-supportive mental health professionals. To address feedback from advocacy groups and others, the GID subgroup sent out a survey seeking input from various organizations that represent transgender adults.

The American Journal of Psychiatry has also started soliciting and publishing short editorials on DSM-V issues. Topics include Internet addiction (March), night eating syndrome (April), the medical diagnostic model (July), paraphilias (October), and suicidal behavior as a separate diagnosis on a separate axis (November).

Increasingly, task force and work group members are participating in scientific and advocacy group meetings to discuss the development process of DSM-V and to receive feedback. From March 5 to March 7, 2009, the American Psychopathological Association meeting in New York will focus on DSM-V and include many task force members as presenters. On April 3, 2009, members of the Sexual and Gender Disorders work group will make presentations at the annual meeting of the Society for Sex Therapy and Research in Arlington, Va. Eventually, more than “a thousand experts will engage in nearly a decade of intensive literature review, field trials, and discussion,” said Stotland during her presidential address. She promised the APA will “circulate drafts and make revisions,” and that all APA members as well as the public will be able to comment via the Web site.

Pages

References

1. Stotland NL,Scully JH,Kupfer DJ,Regier DA.Letters to the editor:response. Psychiatr News.2008;43:23.
2. Cosgrove L, Krimsky S,Vijayaraghavan M, Schneider L.Financial ties between DSM-IV panel members and the pharmaceutical industry.Psychother Psychosom. 2006;75:154-160
 
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