DSM5 in Distress

The DSM's impact on mental health practice and research

DSM-5 Continues To Ignore Critics

A recent letter from DSM-5 reform petition

The petition to reform DSM-5 speaks with the powerful voice of more than fifty mental health associations. Perhaps more important to APA's publishing ambitions and budgetary needs, it represents a significant percentage of the potential customers who eventually will have to decide whether or not DSM-5 is worth buying and using. Displaying its usual  'the customer is always wrong' arrogance, APA has previously been dismissive of the completely reasonable recommendation that there be an independent scientific review of all controversial DSM-5 suggestions.

Here is an excerpt of the  petition' most recent letter to the APA and DSM-5 leadership by the authors of the petition. Full text of the letter is available at: dsm5-reform.com

The letter: "We remain concerned about a number of the DSM-5 proposals, as well as the apparent setbacks in the development process.

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  •  The proposal to include new disorders with relatively little empirical support and/or research literature that is relatively recent (e.g., Disruptive Mood Dysregulation Disorder)
  •  The lowering of diagnostic thresholds, which may result in diagnostic expansion and various iatrogenic hazards, such as inappropriate treatment and stigmatization of normative life processes. Examples include the newly proposed Minor Neurocognitive Disorder, as well as proposed changes to Generalized Anxiety Disorder, Attention Deficit/Hyperactivity Disorder, Pedophilia, and the new behavioral addictions.
  • The perplexing Personality Disorders overhaul, which is an unnecessarily complex and idiosyncratic system that is likely to have little clinical utility in everyday practice.
  • The development of novel scales (e.g., severity scales) with little psychometric testing rather than utilizing established standards.

In addition, we are increasingly concerned about several aspects of the development process. These are:

  • Continuing delays, particularly in the drafting and field testing of the proposals.
  •  The substandard results of the first set of field trials, which revealed kappas below accepted reliability standards.
  • The cancellation of the second set of field trials.
  • The lack of formal forensic review.
  • Ad hominem responses to critics.
  • The hiring of a PR firm to influence the interpretation and dissemination of information about DSM-5, which is not standard scientific practice.

We understand that there have been recent attempts to locate a "middle ground" between the DSM-5 proposals and DSM-5 criticism. We believe that, given the extremity and idiosyncrasy of some of the proposed changes to the manual, this claim of a "middle ground" is more rhetorical and polemic than empirical or measured. A true middle ground, we believe, would draw on medical ethics and scientific standards to revise the proposals in a careful way that prioritizes patient safety, especially protection against unnecessary treatment, above institutional needs.

Therefore, we would like to reiterate our call for an independent scientific review of the manual by professionals whose relationship to the DSM-5 Task Force and/or American Psychiatric Association does not constitute a conflict of interest.

As the deadline for the future manual approaches, we urge the DSM-5 Task Force and all concerned mental health professionals to examine the proposed manual with scientific and expert scrutiny. It is not only our professional standards, but also --and most importantly-- patient care that is at stake."

DSM 5 is taking the foolhardy step of alienating its users. Its responses to critics are framed in public relations jargon convincing to no one outside its own inner circle. Instead of PR, we need straight answers to four questions: 1)  How can you rush a DSM 5 to print with such low reliability? 2) Why don't you delay publication to allow time for the quality control step that was part of your own original plan? 3) Was quality control cancelled for reasons other than your pressing need for quick DSM profits to meet budget projections? and, 4) Why not agree to an independent scientific review of all controversial proposals to salvage the badly tarnished credibility of DSM 5?

APA's high priced, public relations geniuses never address these questions, because not even the cleverest 'image consultants' can turn this sow's ear into a silk purse.

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

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