The American Psychiatric Association's Trial Balloons

The DSM-5 approval process is not transparent at all.

Posted Nov 12, 2011

With the number of signatures to the petition about DSM-5 at 5,584 and the list of its sponsors extending to 12 divisions of the American Psychological Association and 12 other independent organizations in clinical psychology, the American Psychiatric Association has drafted a response to the petition's organizers that is both conciliatory in tone and unambiguous in its intention to press ahead regardless with the revisions and publication.

The letter clears up some confusion about the state of play over DSM-5, indicating that disorders such as Parental Alienation Syndrome "were proposed by outside groups but have not been proposed for inclusion by the Task Force." But of the remaining would-be disorders, on which the Task Force is still on the fence, especially "Disruptive Mood Dysregulation Disorder," "Attenuated Psychosis Syndrome Disorder," and "Complex Somatic Symptom Disorder" (all accompanied by acronyms to make them seem like already existing conditions), the APA states that they are "being tested in the 11 large academic field trial centers that have enrolled over 2,000 patients." "Based on the results of these field trials," the letter tries to reassure, "the DSM-5 Task Force and Work Groups will review the criteria for any necessary changes."

So we've no longer anything to fear about the next DSM, right? All will be clear and transparent? Unfortunately no, the real problems with the new edition are only just beginning to become apparent.

The APA's letter is meant to sound firm but respectful, official without seeming officious, but it's hard to shake the impression that the proposed revisions to the manual aren't at this point also trial balloons subject to the field trial data, which of course aren't yet known and should in any case be the horse pulling the cart, not the cart put before the horse, if I can mix metaphors. But the revisions will also be subject to the inevitable push and pull of committees weighing their own professional interests alongside the external responses, including the 5,584 petition writers, many of them representing a single division of the American Psychological Association and thus hundreds more mental health professionals. DSM-5 is being touted as the most transparent DSM going, which may be true, but alas that's still not saying much.

To be clear, I'm not complaining that mental health professionals and the general public are permitted to weigh in at various preassigned moments, presumably with feedback that won't ever be published or released in its entirety, so as to foster the illusion that the Task Force cares what we think and isn't entirely heedless of public or professional dissent, even when it's sufficiently strong for 12 divisions of the American Psychological Association to sign up.

But just as it's difficult not to suspect that major diagnostic decisions have already been made and will go through more or less regardless, including most fundamentally that a mental disorder is also a medical disorder, so it's striking that the APA essentially acknowledges in its letter the rather arbitrary, even contingent fashion by which new disorders are baptized and rendered official while other problems are renamed, shunted into disuse (into the ever-helpful DSM Appendix), or have their thresholds lowered, for reasons we're told to trust as entirely scientific, even when the science is woefully lacking and/or deeply ambiguous.

Parental alienation syndrome didn't make the final cut, we're told in the letter, though it's still represented there as a "disorder," so a question-mark presumably hangs over the decision not to include it. Meanwhile, "Disruptive Mood Dysregulation Disorder (DMDD)" is now apparently to be distinguished at all costs from "Temper Dysregulation Disorder (TDD)," an earlier trial balloon that DMDD now replaces, though it reads like an almost identical phenomenon.

DMDD, the DSM-5 website tells us, is "characterized by severe recurrent temper outbursts in response to common stressors," including ones that are "grossly out of proportion ... to the situation or provocation." Yet the DSM-5 website is still listing an 11-page justification for Temper Dysregulation Disorder, complete with bibliography and proposed criteria of their own, an attempt to get that approved as a bona fide mental disorder in children. The problem is that the would-be disorder attracted so much justified concern, even disbelief, including that it could easily pathologize children's tantrums and meltdowns, that the Task Force (offering no explanation or rationale for the replacement) decided a new name for the behavior would work instead.

What concerns me—beyond the inevitable false positives and the medication of yet more American children—are the APA's ongoing smoke and mirrors, with the organization insisting that its moves are at all times transparent and driven by science when they're clearly more about PR, the concern for good press, and committees more or less beholden to corporate sponsorship (their own and their organization's). So the APA wheels out an 11-page justification for a new disorder of childhood anger, only to decide (post-media frenzy) that it needs ... a different name instead.

There's every possibility the proposal will find a way into DSM-5 or, if not then, the inevitable DSM-6, along with a rider referring to earlier "recognition" of the problem. But despite all the apparent transparency, we're not told why TDD has come to be replaced by a (presumably) less contentious disorder, DMDD.

What of other developments justifying the concern about TDD/DMDD? The current Task Force has decided to throw its weight behind Premenstrual Dysphoric Disorder (PMDD), one of Robert Spitzer's pet diagnoses in the 1980s, which he managed to sneak into the Appendix to DSM-IIIR in 1987, complete with the all-important diagnostic code, despite fierce objections by his DSM colleagues and the resignation of several of his committee members. The issue caused quite a furor at the time. One very detailed account of the controversy attests to final reassurances to the DSM committee that PMDD wouldn't be listed in it after all, though when DSM-IIIR appeared and PMDD was right there in the Appendix, Spitzer blamed it all on a printing error ... (see for instance Joan C. Chrisler and Paula Caplan, "How PMS Became a Cultural Phenomenon and a Psychiatric Disorder," American Review of Sex Research 13 [2002]: 264-306.) The condition remained in the Appendix also of DSM-IV.

Still, that all-important diagnostic code (300.90 Unspecified Mental Disorder [Late Luteal Phase Dysphoric Disorder]) meant that drug companies could soon repackage antidepressants with the trademark green-and-yellow pill recast as an attractive lavender-colored one and promoted, as one commentator noted wryly, "with images of sunflowers and smart women" (see Vince Perry, "The Art of Branding a Condition," Medical Marketing and Media [May 2003], 49).

Seemingly confident that the dust has now settled, the DSM-5 Task Force is trying again, with more or less the same criteria and even a few pre-emptive barbs, just in case anyone might be concerned that it is somehow suggesting that women with heavy periods (and related pain and impairment) might be mentally ill.

"There may be concerns on the part of some stakeholders that this category is proposed as a new diagnosis," the website declares in its rationale section, apparently tone-deaf to concern with its word "stakeholders." "In particular, some groups have felt that a disorder that focuses on the perimenstrual phase of the menstrual cycle may ‘pathologize' normal reproductive functioning in women."

How reassuring to see "pathologize" there in empty scare quotes! Of course, the DSM doesn't pathologize anything ...

"In fact," the website tries to reassure brightly, "a DSM diagnostic category for women who experience marked symptoms and impairment perimenstrually highlights the fact that most women do not experience such symptoms."

Right, of course it does. And we'll all be thinking that, I'm sure, the next time we're treated to a raft of ads featuring sunflowers, smart women, and lavender-colored pills, all urging women at roughly 15-minute intervals each TV hour to ask their doctor whether their PMS isn't something stronger and more debilitating—something perhaps like Premenstrual Dysphoric Disorder, the disorder that came into existence, according to its architect, because of a printing error.  Follow me on Twitter: @christophlane