DSM5 in Distress

The DSM's impact on mental health practice and research

Am I a Dangerous Man?

No, but I do raise twelve dangerous questions

According to this week's Time magazine, the American Psychiatric Association has just recruited a new public relations spokesman who previously worked at the Department of Defense. This is an appropriate choice for an association that substitutes a fortress mentality and  warrior bluster for substantive discussion. The article quotes him as saying: "Frances is a 'dangerous' man trying to undermine an earnest academic endeavor." Fresh from DOD, it may be difficult for the new spokesman to leave behind combat cliches and perhaps he is not the best judge of academic endeavors. He enthusiastically extends the APA policy of shooting the messenger because it can't argue the message. Who knows—I may have become a picture card in his deck of high value targets.

In fact, my criticisms of DSM 5 arise precisely from its obvious failure to be an impartial, meticulous, and consensus academic endeavor. DSM 5 has suffered from a fatal combination of excessive ambition, sloppy method, and closed process. It fully deserves the concerted opposition it has generated from forty-seven professional organizations, the world press, the Society of Biological Psychiatry, the Lancet, and the general public. It has pretty much come down to DSM 5 against the world—not just me.

The piece in Time magazine manages to raise again the silly APA suggestion that my objections to DSM 5 are motivated by a feared loss of royalties. Let's set the record straight—hopefully for the last time. The royalties on my DSM IV handbook are about $10,000 a year—not at all commensurate with all the time I have spent trying to protect DSM 5 from making all its repeated mistakes.

My motivation for taking on this unpleasant  task is simple—to prevent DSM 5 from promoting a general diagnostic inflation that will result in the mislabeling  of millions of people as mentally disordered. Tagging someone with an inaccurate mental disorder diagnosis often results in unnecessary treatment with medications that can have very harmful side effects. I entered the DSM 5 controversy only because I had learned painful lessons working on the previous three DSM's, seeing how they can be misused with serious unintended consequences. It felt irresponsible to stay on the sidelines and not point out the obvious and substantial risks posed by the DSM 5 proposals.

I don't consider myself a dangerous man except insofar as I am raising questions that seem dangerous to DSM 5 because there are no convincing answers. My often repeated challenge to APA—provide us with some straightforward answers to these twelve simple questions:

1) Why insist on allowing the diagnosis of Major Depressive Disorder after only two weeks of symptoms that are completely compatible with normal grief?

2) Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder when its rates have already tripled in just fifteen years?  

3) Why include a psychosis risk diagnosis which has been rejected as premature by most leading researchers in the field because it risks exacerbating what is  already the shameful off-label overuse of antipsychotic drugs in children?

4) Why introduce Disruptive Mood Dysregulation Disorder when it has been studied by only one research team for only six years and risks encouraging the inappropriate antipsychotic drug prescription for kids with temper tantrums?

5) Why sneak in Hebephilia under the banner of Pedophilia when this will create a nightmare in forensic psychiatry?

6) Why lower the threshold for Generalized Anxiety Disorder and introduce Mixed Anxiety Depression when both of these changes will confound mental disorder with the anxieties and sadnesses of everyday life?   

7) Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?

8) Why label as a mental disorder the experience of indulging in one binge eating episode a week for three months?

9) Why introduce a system of personality diagnosis so complicated it will never be used and will give dimensional diagnosis an undeserved bad name?

10) Why not delay publication of DSM 5 to allow enough time to complete the previously planned and crucial second stage of field testing that was abruptly cancelled because of the constant administrative delays in completing the first stage?

11) Why should we accept ambiguously worded DSM 5 diagnoses whose reliability barely exceeds chance?

12) And most fundamental. Why not allow for an independent scientific review of all the controversial DSM 5 changes identified above—proposed by forty-seven mental health organizations as the only way to guarantee a credible DSM 5? What is there to hide and what harm is done by additional careful review?  

If I am a dangerous man, it is because I am exposing DSM 5's carelessness and thus putting at risk APA's substantial publishing profits. During the past three years, I have made numerous attempts, private and public, to warn the APA leadership of the troubles that lay ahead and to implore them to regain control of what was clearly a runaway DSM 5 process. This has had no real effect other than delaying publication of DSM 5 for a year and the appointment of an oversight committee that turned out to be toothless. I am reduced now to just one means of protecting patients, families, and the larger society from the recklessness of the DSM 5 proposals—repeatedly pointing out their risks in as many forums as possible.

Previous APA responses to criticism provide the bland and unsatisfying reassurance that we should trust DSM 5 on faith because it has been prepared by experts who have toiled long and hard. This simply won't wash—this emperor really has no clothes. It is long past time for DSM 5 to abandon phoney attempts at public relations and instead allow itself to be subjected to a rigorous independent scientific review. We need a safe and scientifically sound DSM 5—not a third rate product that is universally opposed and lacks all credibility.    

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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