DSM-5 Is Progressing to the Finish Line
By Gary Gintner, PhD, LPC, Chair
AMHCA DSM-5 Task Force
The past year has been marked by a number of significant developments in the American Psychiatric Association’s (APA) DSM-5, including significant organizational changes and field trial testing of the criteria. While a little more than a year remains until the final version is scheduled to be released in May 2013, AMHCA’s DSM-5 Task Force continues to work to ensure that the perspective of mental health counselors is represented in the final version.
AMHCA’s DSM-5 Task Force was established two years ago, in February 2010, after APA posted its first draft of the DSM-5 on its DSM website and invited comments and feedback from the public, professionals, and other stakeholders.
The first action AMHCA’s task force took was to post a news release on AMHCA’s website urging members to make their voices heard by taking advantage of the public comment period. The task force itself systematically reviewed the draft and submitted more than 30 detailed reviews to APA. Along with the reviews, the task force sent a letter to the chair of APA’s DSM-5 Task Force, David J. Kupfer, MD, expressing appreciation for the opportunity for input and noting several concerns that AMHCA believed APA needed to address in the DSM-5 draft.
New Organization Prompts Task Force Concern on Lack of Empirical Support for Some Disorders and Scales
APA posted the next noteworthy revision of the DSM-5 in May 2011. Perhaps the most significant change was a major reorganization of the DSM chapters and the disorders within each. This reorganization was intended to reflect current scientific findings about how symptoms and disorders tend to relate to one another and cluster into what has been referred to as “meta-structures.”
Hopefully, this framework will prove to be valid and address problems such as the high rates of comorbidity and frequent use of the “Not Otherwise Specified” (NOS) category. An integral aspect of this reorganization is the dismantling of the existing chapter on “Disorders First Evident in Infancy, Childhood and Adolescence,” and the redistribution of many of these disorders into other chapters with kindred disorders. The primary aim was to infuse a stronger developmental, lifespan focus into the manual.
Following is a sample of chapters that have a new look:
- “Neurodevelopmental Disorders” (e.g., autism spectrum disorder, communication disorders, ADHD, etc.)
- “Trauma- and Stressor-Related Disorders” (e.g., PTSD, PTSD in Preschoolers, Acute Stress Disorder, and Adjustment Disorder)
- “Obsessive Compulsive and Related Disorders” (e.g., OCD, Body Dysmorphic Disorder, Hoarding Disorder)
- “Personality Disorders” (10 types have been reduced to six, and this version adds a rating for level of personality functioning and maladaptive traits)
In response to the posting of APA’s updated revision last May, the AMHCA DSM-5 Task Force also in May alerted members via AMHCA’s website that the second period of public comment was now open. The alert explained that AMHCA members could either respond directly on the APA website or send their comments to the task force.
The AMHCA Task Force prepared a systematic review of the newest draft and submitted 23 review pieces to APA. Despite a number of improvements, a major concern was the number of places in which disorders or symptom rating scales were being proposed for inclusion without sufficient empirical support. For example, Attenuated Psychosis Syndrome attempts to identify young people at risk for developing later psychotic disorders. The cardinal features are toned-down delusions, hallucinations, or disorganized speech in the context of “intact reality testing.” This casts the net of potential behaviors so broad that it could include culturally inappropriate, non-conforming, and rebellious behaviors common among the very groups this syndrome would target: adolescents and young adults.
AMHCA’s task force felt that any benefits of early identification appear to be outweighed by the risks of misdiagnosis and exposure to treatments like antipsychotic medications, which have significant side effects.
The AMHCA Task Force recommended that disorders and rating scales without sufficient empirical support be subjected to more rigorous testing before being included in the manual. The complete report was presented at AMHCA’s Annual Conference in San Francisco and is available upon request from email@example.com.
To test the feasibility and clinical utility of the proposed changes, APA has been conducting field trials in large academic settings and routine clinical practices. Clinicians include psychiatrists, social workers, licensed mental health counselors, and marriage and family therapists.
After a fairly extensive training period, mental health professionals select one new and one existing client to follow for several weeks. Dr. Camille Clay, an AMHCA task force member who is also participating in the field trials, states that she has been impressed with the level of contact with APA and APA’s willingness to provide training and responses to any questions.
As these trials are finishing up, results are beginning to come in. According to a recent report at the DSM site, the initial data is showing that DSM-5 prevalence rates are somewhat lower than those of DSM-IV.
Check Online for the Posting of the Final Revision, and Dates of the Final Period of Public Comment
We are starting to make the big turn toward the home stretch and actual publication of the DSM-5. Before spring, the last major revision should be posted, which will include the field trial findings.
A third and last period of public comment is anticipated in the spring. Drafting of the actual text has begun and should be complete by November, with the publication anticipated in May 2013.
I urge all members to visit the DSM-5 site and become familiar with the updates. Look on the right-hand side of the home page for a section that highlights “What’s New.” Currently in that section are links to a description of the preliminary field trial results, and to new criteria proposed on Jan. 20 for autism spectrum disorder that would incorporate several previously separate diagnoses—including autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. You’ll also find there a link to the Nov. 21, 2011, response from APA to a letter from the American Counseling Association (ACA).
For information or answers to frequently asked questions about the development of the DSM-5, see APA’s FAQ page.
AMHCA’s DSM-5 Task Force
I closing, I want to acknowledge the hard work and scholarly efforts of AMHCA’s DSM-5 Task Force members. In February 2010, AMHCA’s then-President Linda Barclay, PhD, PCC-S, LICDC, NCC, created AMHCA’s DSM-5 Task Force to ensure that mental health counselors’ perspective is represented in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Members of AMHCA’s DSM-5 Task Force include:
- Gary G. Gintner, PhD, LPC (Chair),
- Linda Barclay, PhD, PCC-S, LICDC, NCC,
- Gray Otis, PhD, LPC, NCC, CCMHC,
- Camille Clay, Ed.D, LPC,
- Jason H. King, LPC, CCMHC, and
- LaMarr D. Edgerson, LMFT.
In addition to chairing AMHCA’s DSM-5 Task Force, Gary Gintner, PhD, LPC, is a past AMHCA president and a current member of the AMHCA Foundation board of directors. An associate professor and program leader of Counselor Education at Louisiana State University, Gintner has 30 years of clinical experience. He was appointed chair of MAHCA's DSM-5 Task Force because of his expertise on the DSM. He has been a national trainer on theDSM for more than 20 years, and he has written numerous publications on the subject.He may be reached at firstname.lastname@example.org.