DSM5 in Distress

The DSM's impact on mental health practice and research

My Debate With The DSM 5 Chair

More Translations From 'Newspeak'

Recently, I voiced my concerns about DSM 5 in a Medscape interview with Dr Stephen Strakowski. DSM-5 Task Force Chair David Kupfer then entered the debate and provided his defense.

Here is my reply to Dr Kupfer:

I think 'Newspeak' is the best way to characterize the APA defense of DSM 5. For those who haven't read George Orwell's '1984' lately, 'Newspeak' was his term for the kind of bureaucratic upside-down language that attempts to turn night into day. The idea is that if you say something enough times, the repetition will magically make it so.

Let's do a quick back-translation from APA 'newspeak' to DSM 5 reality.

APA Newspeak: DSM 5 has been open and "transparent to an unprecedented degree."

DSM 5 Reality: APA forced work group members to sign confidentiality agreements; has kept its 'scientific' review committee report secret; tries to censor the internet using bullying threats of trademark litigation; keeps secret the content of public input; and has not, as promised, provided more complete data sets from its failed field testing.

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APA Newspeak: DSM 5 has been an "inclusive" process.

DSM 5 Reality: APA has rejected the input of 51 mental health associations requesting an open and independent scientific review of the controversial DSM 5 proposals; has not responded to highly critical editorials in the Lancet, New England Journal, New York Times, and many other publications; has ignored the unanimous opposition by the leading researchers in the field to its unusable personality disorder section; has ignored the opposition of sexual disorder researchers and forensic experts to its forensically dangerous paraphilia section; has brushed off outrage by consumer groups representing the bereaved and the autistic; has not made any changes in DSM 5 that can be associated with outside input- professional or public; and is unresponsive even to its own APA members, dozens of whom have told me they can't get a straight (or any) answers from a staff whose salaries come from their dues. 

APA Newspeak: "The stakes are far reaching: the first full revision since 1994 of the DSM, a document that influences the lives of millions of people around the world."

DSM 5 Reality: APA quietly cancelled its own planned Stage 2 of field testing. Stage 2 was to provide quality control with much needed editing and retesting to demonstrate improved reliability. Canceling quality control was a crucial mistake and was done for one reason only-money. Because Stage 1 of the field trial was completed 18 months late, DSM 5 was running out of time in meeting its arbitrarily imposed publishing deadline. Given the choice of striving for quality or cashing in on publishing profits, APA went for the cash. Definitely dispiriting, but not surprising. APA is in deficit, has a budget that is totally dependent on the huge publishing profits from its DSM monopoly; and has wasted an absolutely remarkable $25 million in producing DSM 5 (DSM IV cost only one fifth as much). The simple reality is that APA is rushing a poor quality and unreliable DSM 5 to press purely for financial reasons and totally heedless of the detrimental effect this will have on "the lives of millions of people around the world.

APA Newspeak: "Charges that DSM-5 will lower diagnostic thresholds and lead to a higher prevalence of mental disorders are patently wrong. Results from our field trials, secondary data analyses, and other studies indicate that there will be essentially no change in the overall rates of disorders once DSM-5 is in use."

DSM 5 Reality: DSM 5 made a fatal and unaccountable error in its field testing- it failed to measure the impact of any of its changes on rates and APA therefore has no meaningful data on this most important question. With the exception of autism, all of the suggested DSM 5 changes will definitely raise rates, some dramatically. Adding Binge Eating Disorder by itself would add more than ten million new 'patients'; adding Disruptive Mood Dysregulation Disorder and Minor Neurocognitive Disorder would add millions; as would removing the bereavement exclusion to MDD and lowering thresholds for ADHD and GAD.

Read the full Medscape exchange for more Newspeak from Dr Kupfer, but you get the idea. It is not at all clear to me if APA talks Newspeak cynically, because of naivete, or because Newspeak is the language its expensive public relations consultants put in its mouth.

It doesn't really matter why. Newspeak is devastating- not because anyone outside DSM 5 believes it (DSM 5 defenses are too transparently out of touch with reality to fool outsiders), but because APA may believe its own Newspeak or at least acts as if it does. Reflexive Newspeak, substituting for insight, has prevented DSM 5 from the serious self correction that would have saved it from itself. Bob Spitzer presciently predicted five years ago that a secretive, closed, defensive DSM 5 process would lead inevitably to this failed DSM 5 product. 

Medscape has opened a physician-only discussion on the proposed DSM revision. If you are an MD and want to add your thoughts, you can do this at:

http://boards.medscape.com/forums/.2a3285ea/39 

If you are a non-MD health care worker with an interest in psychiatric diagnosis, please add your thoughts at: medscape.com 

The public has a big stake in the outcome and can participate by commenting below. DSM 5 is very close to being set in stone. It may or may not do any good to speak up now, but this is a last chance for people to have their say. 

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

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