For a number of years the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) has garnered the attention of psychologists both as scientists and practitioners. It was a topic of discussion for several years, but that did not prepare many of us for the reality of implementing the DSM-5.
When it arrived in the mail, I dutifully set about preparing to use this new manual in my practice. I was immediately struck by how different it was. The axis system was gone, the term Not Otherwise Specified was gone, the distinctions between related and unrelated clients suffering from developmental disabilities were gone as well as many other diagnostic touchstones. I bristled at these changes then realized something much more important was missing.
Gone too were the tenets on which this manual was published in the first place, tenets such as inter-rater reliability, fundamental reliability and validity. The literature had groaned with citations that spoke to those losses, not just our discipline-related literature but magazines and newspapers disseminated to the general public.
There were many warnings prior to the DSM-5 publication, including concerns expressed as early as 2011 by the American Psychological Association. By the spring of 2012 the developers of the DSM-5 acknowledged receiving more than 8,600 comments on the deliberations. Even before that, in 2010, the former chairman of the DSM-IV task force, Allan Francis, M.D., warned in an article in Psychology Today,
“The flaws in the DSM-5 process were apparent early and resulted from an unfortunate combination of unrealistic ambition, unnecessary secrecy and weak methodology.”
These and other criticisms boiled down to the fact that an overreaching “medicalized” paradigm the DSM supporters were attempting to achieve and an active effort to put aside other compelling and contradictory information that did not fit the “schema” the work group had constructed.
The result echoed across the nation in headlines such as these:
- Psychology Today: “Does NIMH Want to ‘Fail Better’ than the DSM-5 Already Has?”
- Scientific American: “New DSM-5 Ignores Biology of Mental Illness.”
- The Huffington Post: “Newsflash From APA Meeting: DSM-5 Has Flunked Its Reliability Test.”
- USA Today: “Books blast new version of psychiatry’s bible.”
In the litany of comments preceding and following the DSM-5 publication, Frances once again went to the heart of matters: “The hard-won credibility of psychiatric diagnosis is compromised by the abysmal results reported by the DSM-5 field trials. This failure was clearly predictable from the start.”
Frances then supplied a table showing a cross-section of 20 of DSM-5’s major diagnoses. Only four passed a reliability marker of 5.5 (a little better than chance agreement) and eight were in the 0.2 to 0.4 range. It would seem that the DSM-5 had failed the fundamental tenets of describing the qualities associated with rubrics such as a diagnostic criteria’s basis for inclusion, exclusion and outcomes in delineating diagnoses, no less considering inter-rater reliability.
It becomes a realistic possibility that the DSM-5 may not — actually should not — be in use for very long once these realities have been recognized. Even the National Institute of Mental Health (NIMH) seemingly withdrew its support in April of 2013.
For the time being, there is this very different DSM-5 framework psychologists must contend with both with regard to their clinical work but also with regard to practicing in an ethical fashion. We are called upon to address ethical matters as scientists and practitioners. Per the “Ethical Principles of Psychologists and Code of Conduct,” we are duty bound to address the inadequacies of the DSM-5 since we will be called upon to put it to use, at least until such time as support is withdrawn for its use by the organizations that shape the health care industry.
With these matters clearly in mind and a quandary that took some time for me to resolve, I prepared a statement for inclusion in the diagnostic section of all documents coming out of my practice that would make use of the DSM-5’s framework. Those who read this statement are appraised of the shaky state of affairs surrounding the DSM-5 in a rather lengthy footnote, while at the same time offering a diagnosis consistent with the current and future demands in the field commensurate with the DSM-5’s system.
This is clearly an interim step for practitioners, and I have heartened my colleagues to institute similar cautionary notes, which actually was the impetus for this article as my humble suggestions apparently spread from one listserv to another and another and so on. The next step lies in the hands of major health care organizations and governmental agencies such as CMS.
As practitioners and scientists, psychologists have a unique subset of skills and abilities. I would encourage each of you to make your concerns known so that we might all tend to the welfare of our clients and patients as well as the integrity of the field.
Michael R Butz, Ph.D., operates Aspen Practice P.C. in Billings, Mont., specializing in clinical psychology. His email is:firstname.lastname@example.org.