What Should Counselors do about DSM-5?
I’ve spent the last year writing about the DSM-5, which is slated for publication in May 2013. I admit, the more I’ve read and learned about the proposed revisions and how they’re being developed, the less optimistic I’ve become about the final product.
I’ve described several of the problematic proposed revisions in previous blogs and in the DSM-5 Update column in Counseling Today. The most worrisome proposals involve diagnoses with lowered symptom requirements and the inclusion of “subthreshold” disorders. For example, the DSM-5 proposals that reduce the symptom requirements in existing disorders – like Major Depressive Episode, Generalized Anxiety Disorder, Substance Use Disorder, ADHD, and others – have the potential consequence of dramatically increasing the prevalence rates of disorders.
The new “subthreshold” disorders – such as Attenuated Psychosis Syndrome (i.e., Psychosis Risk Syndrome), Mixed Anxiety Depression, Mild Neurocognitive Disorder, and Disruptive Mood Dysregulation Disorder (i.e., Temper Dysregulation Disorder) – have generated more concerns. A subthreshold disorder is not, by itself, considered a disease or disorder. Instead, it represents some, but not all, of the symptoms of a mental disorder. The problem with subthreshold disorders is that they blur the boundaries between pathology and normal behavior.
The main fears about the inclusion of diagnoses with lowered symptom requirements and subthreshold disorders are
a. the potential for drastically increased prevalence rates;
b. the medicalization of normal behavior;
c. increased stigma; and
d. unnecessary treatment that frequently includes medications that sometimes cause harmful side effects and complications.
But I wouldn’t have a problem with any of the DSM-5 proposed revisions if I was assured that they were supported by strong scientific evidence. Renowned researchers and experts in diagnosis have publicly expressed many concerns about the DSM-5, such as
a. lack of an independent, systematic, transparent, and evidence-based method for reviewing the empirical support for changes;
b. inadequate field trial research design; and
c. proposals to include untested dimensional assessments that lack information about scale development procedures or psychometrics
With over 500,000 mental health professionals in the U.S. that use the manual (197,000 social workers; 115,000 mental health counselors; 54,000 marriage & family therapists; 93,000 psychologists; 75,000 psychiatric nurses; 38,000 psychiatrists), the DSM greatly impacts counselors’ work in assessing, diagnosing, and treating clients. In fact, the American Psychiatric Association (APA) is the sole group that revises the DSM, despite representing only 7% of all mental health professions. For years, counselors and other mental health professionals have relied on APA and the DSM for guidance in the diagnosis process. Yet, the DSM-5’s questionable research methodology leaves me wondering if we should continue.
But what can counselors do if we don’t like the DSM-5 final product?
I’ve recently been writing about the International Classification of Diseases (ICD-10-CM). My purpose has been to educate counselors that DSM is not mandatory for most clinicians unless specifically required by their institutional settings. In fact, the ICD is the only classification system approved by HIPAA – not the DSM. As such, ICD codes meet all insurer-mandated and HIPAA coding requirements. The reason why mental health professionals can use the DSM-IV for diagnosis is because the DSM derives its code numbers from the ICD.
Currently, the DSM-IV code numbers reflect the ICD-9-CM codes. However, the DSM-5 codes will have to reflect those from the ICD-10-CM because use of the ICD-10-CM becomes mandatory by all health professionals in October 2013.
I’ve been publicizing the use of ICD as an alternative to DSM so that counselors know they are not confined to using the DSM-5 – especially if they find that the DSM-5 lacks credibility. And, to use ICD-10-CM, counselors do not have to learn a whole new classification system. In fact, counselors can continue to use their DSM-IV and simply look up and use the new ICD-10-CM codes numbers (available free online).
Personally, I want the DSM-5 to be a quality product that I can trust for diagnosis. I’ve used the DSM during my entire career as a counselor, and I feel some allegiance to this classification system. But the inclusion of potentially dangerous, scientifically unfounded diagnoses scares me enough to possibly abandon the DSM.
I do have some recommendations for APA and the DSM-5 Task Force that would assure the credibility of the DSM-5. I suggest that for mental health professionals to endorse and purchase the DSM-5, that APA should take the following actions:
1. All evidence from the DSM-5 Task Force should be (a) immediately made public and (b) submitted for independent review. The DSM-5’s credibility will remain questionable unless it is subjected to systematic, comprehensive, independent, and multidisciplinary external review. As such, all evidence and data needs to be reviewed by experts in evidenced-based decision-making who are completely independent of the DSM-5 process. This includes all evidence and data from (a) the DSM-5 Scientific Review Group, (b) the work groups, (c) the field trial data, and (d) the dimensional assessments development procedures. The Cochrane Collaboration, an international network recognized for its high quality reviews of health care research, would be the ideal group for conducting this independent review.
2. Any suggested DSM-5 revisions deemed to lack strong empirical evidence by independent review should not be approved for DSM-5.
3. Eliminate the untested dimensional assessments from DSM-5 and publish them as a separate document.
4. Delay publication of DSM-5. If having external review means that DSM-5 cannot be completed on schedule, the DSM-5 publication date will have to be delayed.
I believe these recommendations are critical to producing a credible and safe DSM-5 that all mental health professionals can use and support.
K. Dayle Jones is a counselor and associate professor at the University of Central Florida. She is chair of the American Counseling Association’s DSM-5 Proposed Revisions Task Force, which was formed to provide feedback to the American Psychiatric Association on proposed revisions to the DSM-5. Contact her at email@example.com