DSM-V Controversies

January 1, 2009

After some members and mental health writers criticized the American Psychiatric Association (APA) for “secrecy” surrounding the development of DSM-V, the Board of Trustees of the APA voted to make public regular DSM-V reports as well as summaries from work group chairs on the Web site at www.dsm5.org.

Topic Center: DSM-V

After some members and mental health writers criticized the American Psychiatric Association (APA) for “secrecy” surrounding the development of DSM-V, the Board of Trustees of the APA voted to make public regular DSM-V reports as well as summaries from work group chairs on the Web site at www.dsm5.org.

“We are aware of efforts to portray the DSM-V process as unnecessarily and counterproductively secretive,” said APA president Nada Stotland, MD, MPH, in a November 7 response to a letter to the editor.1 “On the contrary, it is more open than any previous DSM process. . . . The DSM is a diagnostic manual used in much of the world. Its development must in­clude consideration of the broadest possible range of views and the full range of available or obtainable data.”

“It’s a balancing act between transparency and giving the DSM-V groups space and time to do their work,” said Ronald Burd, MD, speaker of the APA Assembly and a psychiatrist with MeritCare Health System in Fargo, ND. “It is my understanding that prog­ress reports from the groups will be posted on an ongoing basis.”

Dr Stotland acknowledged in her presidential address published in October’s American Journal

of Psychiatry that controversy surrounding the DSM-V process has increased in the past few years.

“We are in the midst of a revolution caused by public and legislative concern about the influence of the for-profit sector on the entire field of medicine,” she said. “We have anticipated and addressed questions about conflicts of interest in the DSM process. The abolition of conflict is a myth. . . . what we can do is to be very clear what those interests are.”

Part of the debate emanates from research by Cosgrove and others2 who investigated the financial ties to the pharmaceutical industry of 170 panel members who contributed to the diagnostic criteria produced for the DSM-IV and DSM-IV-TR. Of the 170 panel members, 95 (56%) had 1 or more financial associations with companies in the pharmaceutical industry. In 6 of 18 panels, more than 80% of the panel members had financial ties to pharmaceutical companies.

For DSM-V, due out in 2012, the leadership of the APA pledged to take a stringent approach to selecting appointees for the task force, work and study groups, and advisors. The task force includes work group chairs and representatives from the APA, the NIH, and other organizations. They represent a broad spectrum of different fields of science, clinicians, and advocates. The 13 work groups and their subgroups focus on specific categories of mental disorders (eg, mood disorders and neurocognitive disorders), while 5 study groups examine crosscutting issues (eg, diagnostic spectra, assessing impairment, and psychiatric/general medical interface). More than 45 advisors work with the task force and study and work groups to assist with such issues as literature reviews and diagnostic criteria. David Kupfer, MD, of the University of Pittsburgh and Western Psychiatric Institute and Clinic, chairs the task force; and Darrel Regier, MD, MPH, director of APA’s Division of Research and executive director of the American Psychiatric Institute for Research and Education (APIRE), serves as vice chair.

Principles and disclosures
All work group and task force members have been asked to abide by a set of established principles posted on www.dsm5.org.

• Members are to serve without remuneration for their services, with the exception of the DSM-V task force chair).
• They agree to receive no more than $10,000 annually in aggregate from industry sources (excluding unrestricted research grants).
• They must not hold stock or shares worth more than $50,000 in aggregate in pharmaceutical companies/device makers/ biotechnology companies and similar health care–related commercial ventures or receive more than $10,000 annually in aggregate in dividends from such sources. (Exceptions are made for mutual fund shares and similar arrangements.)
• Members agree to abstain from par­­­­­­ticipating in any capacity in industry-sponsored symposia at an APA annual meeting during their task force and/or work group tenure after 2007.

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-VWeb 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.

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 membersand the pharmaceutical industry.Psychother Psychosom. 2006;75:154-160