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Psychiatry
DSM 5 Disorganization, Disarray, and Missed Deadlines
Beware The Final Mad Rush
Posted December 29, 2011
Dr Dayle Jones has become one of the world's leading experts on DSM 5 and on psychiatric diagnosis. As Chair of the American Counseling Association's DSM 5 Task Force, she closely follows the DSM 5 process and trenchantly critiques the DSM 5 proposals (see her blogs at http://my.counseling.org/category/dayle-jones/).
Dr Jones just sent me the following alarming email: "DSM 5 keeps missing its own deadlines and the DSM 5 publication date is fast approaching. I am afraid there is insufficient time left for thoughtful preparation or adequate public input. Here's a brief history of DSM 5's consistent failure to deliver on time.
On the DSM-5 Field Trials in Academic/Large Clinic Settings: These were originally scheduled to begin in 2009, prior even to the draft proposals being reviewed and vetted by outside mental health professionals. But, after much criticism, the DSM-5 Task Force wisely postponed the start date to June 2010. Unfortunately, the Task Force then came up with an impossibly complicated field trial design that was roundly criticized for missing the relevant questions and having a completely unrealistic timetable. Not surprisingly, the start and end dates have been repeatedly delayed. The study was originally planned for completion in early 2010, then in early 2011, and now we are entering 2012 with still no end in sight. This expensive field trial will be essentially worthless because of its lateness, its poor design (which doesn't test the impact of DSM 5 on diagnostic inflation), and its failure to test final DSM 5 wordings because these were not always ready on time.
On the Routine Clinical Practice Field Trial: I have serious concerns whether this will ever get done. I just received a flyer by APA's Practice Research Network called "Inside the DSM-5 Field Trials" (December, 2011), which stated that since July 2011, "clinicians from around the globe" have volunteered to participate in the trial. But APA surreptitiously avoided mentioning that the volunteer selection and training process was originally to have been completed by August 2010 and has been delayed first to 2011 and now to 2012. The whole effort has been wrought with confusion, disorganization, ineptitude, and constant delays. I applied to be a volunteer clinician in November 2010 and was accepted April 29, 2011. Between April and late August, I experienced numerous problems: no contact about training; no responses to repeated emails or phone calls; inability to access field trial information online; APA losing my consent form; and being informed three times that training materials would be emailed 'in a few weeks'- which never happened. Finally, after these many miscues, the field trials 'officially' began in September 2011. In November, APA announced it was extending the field trials to March 2012 in order to recruit more participants. There's a desperate failure motivating this extension- according to the APA flyer, out of "over 5000 clinicians" eligible to participate, only 195 have completed the training, and a mere 70 (1.4%) are enrolling patients.
This field trial is clearly a total bust.
On The Open Periods For Public Comment: APA has repeatedly bragged about the "unprecedented" open comment periods whereby clinicians can post comments about the DSM-5 proposals online during specified time periods. Ironically, the first comment period in February/April 2010 was initiated only after outside pressure insisted that all proposed revisions be reviewed and vetted by the field before field trials could begin. And, interestingly, very few substantive changes have been made in response to public comments since the first drafts were posted- despite the fact that so many DSM 5 proposals have been so heavily criticized. The final public comment period was originally scheduled for September/October 2011, but has been twice postponed because everything is so far behind- first to January/February 2012 and recently to May 2012. Given this late date, new public feedback will almost certainly have no impact whatever on DSM-5 and appears to be no more than a public relations gimmick."
Dr Jones provides a concise description of DSM 5 disorganization and record of failed promises. It remains a puzzlement that the Trustees of the American Psychiatric Association continue to sit passively on the sidelines, fiddling while DSM 5 fizzles. In our 6/9/09 warning letter, Bob Spitzer and I pointed out to them that the poor DSM 5 planning and surprisingly sloppy execution had made completely impossible the then scheduled publication date of May 2012. Soon after, APA wisely postponed publication for one year.
In various blogs since, I have warned that the DSM 5 process has suffered from continued disarray- with constantly missed deadlines, reckless proposals, and a poorly written product. I have long predicted that there would be a headlong and heedless rush at the end to meet the new deadline of May 2013 - with the inevitable mistakes, inconsistencies, and poor quality.
The lack of progress on DSM 5 has disappointed even my seemingly quite pessimistic expectations. The current DSM 5 postings continue to contain many dangerous suggestions as well as (mostly) poorly written, ambiguous, and inconsistent criteria sets. The DSM 5 field trials are so poorly designed and so late in coming that they cannot serve as the much needed filter to eliminate the most egregious problems - instead they seem intended to provide no more than transparent window dressing for a failed process and a defective product.
And here is another warning. Although we never once missed a deadline in preparing DSM IV, we still had great difficulty at the end completing all the many steps of writing and rectification necessary to have a clean and consistent final product. Every single word in any DSM is a potential target of misuse in forensic settings, of confusion for researchers, of puzzlement for clinicians, and of despair for teachers and students. The final steps of preparation of any DSM require an abundance of unrushed time, care, patience as well as continual cross-checking and meticulous editing- none of which will be available for DSM 5.
Given all that is undone and poorly done and the ongoing remarkable state of disarray, the May 2013 publication date for DSM 5 has itself become impossibly premature. In any sensible world there would be yet another year's delay to clean up the current mess. But because projected DSM 5 publishing profits are essential to the meeting the projected APA budget, May 2013 will almost certainly be the one and only deadline DSM 5 will ever meet. It now seems clear that DSM 5 will be born well before its time in an impossibly ragged and possibly unusable state.
