Akron, Ohio – Two psychologists who were integrally involved in the development of the DSM-IV are critical of secrecy surrounding the DSM-V revision process.
Peter E. Nathan, Ph.D., and Thomas A. Widiger, Ph.D., who held sessions on the history and development of the DSM at an April conference hosted by the Archives of the History of American Psychology, were among four psychologists on the task force overseeing revisions for the 1994 publication of the DSM-IV.
Widiger said in contrast to work on the DSM-IV, those working on the DSM-V are required to sign confidentiality agreements, meaning only those on the task force or its working groups have any knowledge of changes under consideration for the diagnostic manual of mental disorders.
“I think that’s a big mistake,” Widiger said. “All you do is create suspicion.”
Nathan said it is not difficult to create suspicion among psychologists about how the American Psychiatric Association (ApA) is guiding the manual because many psychologists already see psychiatrists as the enemy camp.
There is some justification for that, Nathan said, pointing out that before the DSM-IV was published, one group of ApA members suggested that it should carry a preface defining mental illnesses as a subgroup of physical illnesses, which could have made the treatment of mental illness the exclusive turf of psychiatrists and other medically trained providers.
“That was dropped after the American Psychological Association (APA) threatened to sue,” Nathan said. Widiger cited another historical example of heavy-handedness in the ApA’s oversight of the manual. He said before the DSM-IV was published, the ApA board of directors – which had no direct involvement in the revision process – arbitrarily eliminated four disorders approved for inclusion by the task force: premenstrual dysphoric disorder, self-defeating personality disorder, sadistic personality disorder and paraphilliac rapism.
Although critical of the process, both men adopted a wait-and-see attitude toward the product of the revision. An early draft is scheduled for release later this year, which will allow public review before the 2012 publication of the DSM-V.
Psychologists are not alone in criticizing the shroud of secrecy surrounding the revision process, Widiger said. One of the most vocal critics is Robert L. Spitzer, M.D., a psychiatrist who also served on the DSM-IV task force but has no input to current considerations.
Widiger said he agrees with the criticism of the secrecy but some discount Spitzer’s concerns because he has a reputation for stirring controversy. “Some say if there’s not one there, he’ll create it.”
Nathan said the DSM is no stranger to controversy. When the DSM-III-R was published in 1987 there were many who felt it overpathologized many unusual but normal behaviors, such as shyness, and inappropriately stressed disordered brain mechanisms, in effect endorsing psychopharmacological treatment over psychosocial treatment.
Psychologists had considerably more input in preparing the DSM-IV, which has reduced some of that criticism, Nathan said.
Widiger said in contrast to the DSM-IV process when four psychologists were included on the revision task force, there is only one psychologist on the DSM-V task force: Kenneth J. Zucker, Ph.D., who is chair of the work on sexual and gender identification disorders.
Historically, Narthan said, the DSM is an outgrowth of World War II, when the widespread number of soldiers suffering battle fatigue or shell shock – which would now be termed PTSD – demonstrated that traumatic experiences can create serious mental disorders in non-psychotic patients.
The result was the DSM-I adopted in 1952 and refined by the DSM-II in 1968. The DSM-III published in 1980 tripled the number of diagnoses and outlined explicit syndromes for 16 disorders, Nathan said.
It was at that point that the DSM – the Diagnostic and Statistical Manual – became a valuable textbook, Nathan said. Widiger pointed out that the “statistical” material included is important to another use of the manual – providing information for the U.S. Census.
Widiger said the DSM-III was largely produced “by researchers for researchers” and was met with some criticism because its definitions did not always correspond well with those in the ICD, the International Classification of Diseases under the oversight of the World Health Organization (WHO).
“We didn’t make a lot of friends with our international colleagues,” Widiger said. He added that the DSM-IV made many definitions more compatible with ICD classifications and further work is expected toward that end in the DSM-V.
Another concern of WHO is the profits the ApA will derive from the DSM-V, Widiger said, adding there are talks in progress on sharing those profits. That concern also is long-standing, he said. “Some suggested the DSM-IV came out simply as a way to make money.”
Widiger said his chief concern is that there are no psychologists involved in several important areas under consideration, including delirium and dementia, multiaxial disorders, schizophrenia and sleep disorders. He said he fears the result will be a “medicalization” of many diagnoses.
Psychological practitioners have reason to be apprehensive, he said. “There’s nobody who represents practicing psychologists on the DSM.”