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AMHCA Contributes Comments to APA's DSM-5 Draft
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AMHCA Contributes Comments to APA's DSM-5 Draft


AMHCA’s DSM-5 Task Force has submitted comments to the AmericanPsychiatric Association during its third period of public comment on the fifth edition of theDiagnostic and Statistical Manual of Mental Disorders (DSM-5), which is expected to be published in May 2013.

AMHCA’s comments addressed 12 disorder categories as well as the Cultural Formulation Interview Guide. 

“The task force was impressed by the extent to which feedback from the first and second periods of public comment have been incorporated into subsequent revisions of the draft,” said Gary G. Gintner, PhD, task force chair. “AMHCA believes this type of feedback will strengthen the manual’s ultimate contribution to research and practice and hopes that more field trial results will be released soon.” 

However, members of the task force felt the following areas are still in need of improvement. The AMHCA task force comments are summarized below. 

Download the full compilation of the comments submitted by the AMHCA DSM-5 Task Force.
Neurodevelopmental Disorders
Autism Spectrum Disorder
There were questions initially on how the new spectrum criteria would affect base rates for Autism Spectrum Disorder; however, the field trial results that have been released so far show comparable rates using DSM-IVversus DSM-5 criteria. The reported Kappa score of .69 indicates good reliability for the DSM-5 criteria set.  Despite these encouraging data, lingering issues remain:
  • First, no data is yet available about the reliability of the severity rating score (1-3). This is an important issue as access to medical and social services may be tied to these ratings.
  • Second, some researchers have questioned whether the DSM-5 criteria are sensitive enough to capture those who were formerly classified with Asperger’s.
  • Finally, the committee should consider real-world complications of adopting a spectrum diagnosis. Those in the more benign end may be dissuaded from seeking treatment because of the stigma attached to the label “autism.” Asperger’s could be retained as a separate category for those with high-functioning autistic symptoms. 
The former ADHD proposals considered various options with regards to sub-typing, age of onset, and adult manifestation of symptoms. The current proposal has wisely decided not to lower the diagnostic threshold for “adult” ADHD. It would be very helpful to provide information on differences in age-related presentation in the text portion.
 The field trials indicated a Kappa of .61, which is in the good range. But what was the reliability relative to coding the different types of ADHD? One concern is that there are now two variations of inattention. The Inattentive Presentation (Restrictive) can have no more than two hyperactivity-impulsivity symptoms, while the Predominantly Inattentive Presentation can have no more than three of these types of symptoms. Clinically, this is a rather fine distinction, which may not be reliably distinguished.

Schizophrenia Spectrum and Other Psychotic Disorders  
Chapter Organization
A new chapter organization is introduced that orders the disorders by increasing severity. However, there are potential conceptual and clinical utility concerns about this change:
  • If diagnostic hierarchies are employed, then substance-induced and psychosis secondary to a medical condition should be listed first.
  • Delusional Disorder is listed as a less-severe disorder than Brief Psychotic Disorder. This seems counterintuitive considering factors such as prognosis, duration of symptoms, and the fact that Delusional Disorder may now have bizarre delusions.
  • The new organization seems less clinically useful. Schizophrenia—the most common of these disorders—is buried in the middle of the chapter.
  • Unlike some of the other chapters, there is no clear developmental sequencing.
A strength of the current proposal is the distinction of affective flattening and avolition as two dimensions of negative symptoms. The decision to eliminate disorganized behavior as a positive symptom was understandable. However, will disorganized behavior be discussed as an important associated symptom? 
Attenuated Psychosis Syndrome
During the past two periods of public comment periods, we voiced our concerns over including this disorder due to the lack of empirical support and the potential for subjecting individuals to unnecessary treatment. Following a poor showing in the field trials, the decision was made to relegate this proposed disorder to Section III of the manual for further study. We applaud this decision.                                                                                                      
Depressive Disorders
Major Depressive Episode—Bereavement Exclusion Criteria
Previous versions of the draft proposed that the bereavement exclusion for a Major Depressive Episode be deleted. However, there has been considerable opposition to this proposal because it runs the risk of inflating false positives and potentially subjecting individuals to unnecessary treatment. The current revision attempts to address this concern by adding a Note that depressive-like symptoms often follow many significant loss events (e.g., bereavement, loss of property associated with a natural disaster). The note also includes a statement regarding the difference between normal reactions and those that have been complicated by MDD. Our major recommendation is to put more teeth into this note by actually listing it as one of the formal criteria for a Major Depressive Episode. 
Dysthymic Disorder
The previous drafts included Chronic Depressive Disorder (CDD), which merged Dysthymic Disorder and Chronic Major Depression. The current proposal does not include CDD, although it is referenced in the criteria for MDD under the specifiers. This is confusing and should be explained in the rational section. The reappearance of Dysthymic Disorder further muddles the issue as it is not clear how five or more symptoms of MDD that persist for over two years will be coded. 

Disruptive Mood Dysregulation Disorder
The title of this disorder has undergone a name change in response to public comment regarding the former terminology, “Temper Dysregulation.” The committee should be commended for making this change. Placing it with unipolar depressive disorders is consistent with data showing that these children are much more likely to develop depression later in life. 
Bipolar Disorders
Bipolar I Disorder
The evidence presented for including the core symptom of increased energy and activity for both a manic and hypomanic episode is compelling. This addition should help to strengthen diagnostic accuracy. 

Bipolar Disorder I, Most Recent Episode Manic
Our previous comments noted some inconsistencies in the use of specifiers that have been corrected in the current revision.  

Bipolar I Disorder, Most Recent Episode Hypomanic
The previous proposal listed both catatonic and psychotic features as potential specifiers for a hypomanic episode, which are both considered exclusions for hypomania. This discrepancy has been corrected in this most recent revision. 


Anxiety Disorders    
Generalized Anxiety Disorder (GAD)
GAD did poorly in the field trials, yielding a Kappa of .20. Understandably, there is considerable co-morbidity associated with GAD, which can confound diagnostic accuracy. However, a Kappa score in this range is not acceptable and warrants scrutiny of the proposed criteria. 
Other Anxiety Disorders
The addition of criteria for Substance-Induced Anxiety Disorder, Anxiety Disorder  Attributable to Another Medical Condition, Anxiety Disorder Attributable to Another Medical Condition (with specifiers), and Anxiety Disorder Not Elsewhere Classified appears to be logical and reasonable. 
Anxiety Disorder Not Elsewhere Classified
There is an inconsistency in the criteria for this disorder, which states, “There are four situations in which the diagnosis may be appropriate, …” but only three situations are identified. 


Obsessive Compulsive and Related Disorders
The addition of new criteria for Hair-Pulling Disorder (Trichotillomania) and Skin-Picking Disorder that address the individual’s attempt to decrease or stop the behavior seems warranted. The addition of criteria for Substance-Induced Obsessive-Compulsive or Related Disorders, Obsessive-Compulsive or Related Disorder Attributable to Another Medical Condition, and Obsessive-Compulsive or Related Disorder Not Elsewhere Classified appears to be well-conceived. 
Trauma- and Stress-Related Disorders    
Acute Stress Disorder
The work groups in this area have improved the organization and specification of criteria. In addition, the minimum duration of symptoms has been lengthened from two days to at least three days. While the work groups should be commended for taking a step in the right direction, more attention in either the criteria or text may be needed to caution clinicians about pathologizing reactions that may be transient and respond to internal resources and social and cultural supports.
Posttraumatic Stress Disorder
The major Posttraumatic Stress Disorder (PTSD) revisions include adding a Dissociative subtype and a Preschool Children subtype that was formerly proposed as a separate disorder. Both of these subtypes will add greater specificity and acknowledge differences in how PTSD can present. In terms of clarity, however, we recommend that the Preschool subtype explicitly state that criteria A through G listed for the subtype replace the general criteria for PTSD.  The text should also provide information about how PTSD can present in school-age children as well as potential manifestations of issues like sexual abuse (e.g., bedwetting, or regressive behaviors). Another consideration for the text portion is to include substance use as a possible avoidance behavior (Criteria C).  
Persistent Complex Bereavement Disorder
We support the decision to move Complex Bereavement to section III for further study. 


Disruptive, Impulse Control, and Conduct Disorder
Oppositional Defiant Disorder
The proposal includes explicit frequency criteria that replace DSM-IV’s term, “often.” This change may under-identify preschoolers in the less severe end of the ODD spectrum, many of which were from under-represented groups (e.g., African Americans). The term “often” does a better job of identifying these children.


Somatic Symptom Disorders
Somatic Symptom Disorder
A major change in this revision is the merger of Complex Somatic Symptom Disorder and Simple Somatic Symptom Disorder into one disorder, Somatic Symptom Disorder.
The increased emphasis placed on cognitive distortions (along with the presence of somatic symptoms) provides greater clarity about the nature of the disorder. However, the notion that a single B.2 criteria could be used as the sole basis for identifying these cognitive aspects seems to open the door to diagnosing individuals who have legitimate “high anxiety” about their symptoms. We recommend considering “two of three” criteria under B be required.
Factitious Disorder
The Factitious Disorder criteria and rationale are clear as well as the reasons for placing this disorder in this chapter.


Substance Use and Addictive Disorders
The simplification of remission specifiers from four types to two is welcome and better fits with the concept of “remission.”
Stimulant Use Disorder
The current revision merges drugs such as amphetamines and cocaine into one category, Stimulant Use Disorder. While the pharmacological rationale is clear, it may be useful to clarify the specific drug that is being abused. 
Polysubstance Use
In DSM-IV, Polysubstance Dependence was the designation for use of multiple substances that together would meet the threshold of dependence. This is no longer listed in DSM-5. It would be useful to clarify how this situation would be coded.


Neurocognitive Disorders
Major Neurocognitive Disorder
A valuable addition is the description of how impairment can be manifested across the cognitive domains. We would encourage that criteria for depression and psychosis be attached to each relevant subtype, perhaps as specifiers, rather than just fifth-digit coding.

We support the need for balance between the A.1 and A.2 criteria in terms of assessment criteria options. Formal neuro-psychological assessment will always be important in differentiating difficult cases, and in providing additional assessment verification. 
Mild Neurocognitive Disorder
While there is merit in identifying cognitive problems early in their progression, it will be critical to distinguish situational and normal age-related changes from mild cognitive impairment.


Personality Disorders
The proposal to add levels of personality functioning, a Personality Disorder Trait Specified category, and the six personality disorder types has merit and provides the potential for a more descriptive assessment. Over the past revisions, the criteria set has become progressively more user-friendly. 

The field trial results were mixed, however. While Borderline Personality Disorder yielded an adequate Kappa score (.58), Antisocial (.22) and Obsessive-Compulsive (.32) Personality Disorders did not do nearly as well.

Cultural Formulation Interview Guide
The Cultural Formulation Interview is a valuable contribution to the manual that builds on DSM-IV’s Cultural Formulation Outline. It does a good job of operationalizing the issues that the Outline identifies, such as cultural definition of the problem, contextual factors, and the client-clinician relationship. The 14-question guide, as well as the intent behind each question, are clear and nicely labeled. Unlike DSM-IV, where the Outline is in the Appendix, we recommend putting this guide in the introduction/use of the manual section. 

Learn more about the DSM-5.