DSM5 in Distress

The DSM's impact on mental health practice and research

Two Who Resigned From DSM-5 Explain Why

They spell out the defects in the personality section

Roel Verheul and John Livesley both felt compelled to resign from the DSM-5 Personality Disorders Work Group. Here is an email from them describing what went wrong in the preparation of this section:

"We resigned from the DSM-5 Personality and Personality Disorder Work Group in April 2012 with a mixture of sadness and regret. We believed that the construction of DSM-5 afforded an important opportunity to advance the study of personality disorder by developing an evidence-based classification with greater clinical utility than DSM-IV. The data and conceptual tools for such an undertaking have been available for some time and the field seemed to recognize the need for change. Regrettably, the Work Group has been unable to capitalize on the opportunity and has advanced a proposal that is seriously flawed. It has also demonstrated an inability to respond to constructive feedback both from within the Work Group and from the many experts in the field who have communicated their concerns directly and indirectly. We also regret the need to resign because we were the only International members of the Work Group which is now without representation from outside the US.

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Early on in the DSM-5 process, we developed major concerns about the Work Group's mode of working and its emerging recommendations that we communicated to the Work Group and Task Force. We did not resign earlier because we continued to cherish the hope that eventually science and common sense would prevail and that there would be an opportunity to construct a coherent, evidence-based classification that would help to advance the field and facilitate patient care. In the spring of this year, it became apparent that is was not going to happen. We considered the current proposal to be fundamentally flawed and decided that it would be wrong of us to appear to collude with it any longer.

 As we see it, there are two major problems with the proposal. First, the proposed classification is unnecessarily complex, incoherent, and inconsistent. The obvious complexity and incoherence seriously interfere with clinical utility. Although the proposal is touted as an innovative and integrative hybrid system, this claim is spurious. In fact, it consists of the juxtaposition of two distinct classifications (typal and dimensional) based on incompatible models without any attempt to reconcile or integrate them into a coherent structure. This structure also creates confusion since it is not clear whether the clinician should use one or both systems in routine clinical practice.

 Second, the proposal displays a truly stunning disregard for evidence. Important aspects of the proposal lack any reasonable evidential support of reliability and validity. For example, there is little evidence to justify which disorders to retain and which to eliminate. Even more concerning is the fact that a major component of proposal is inconsistent with extensive evidence. The latter point is especially troublesome because it was noted in publication from the Work Group that the evidence did not support the use of typal constructs of the kind recommended by the current proposal. This creates the untenable situation of the Work Group advancing a taxonomic model that it has acknowledged in a published article to be inconsistent with the evidence.

 For these and other reasons, we felt that the only honest course of action was to resign from the Work Group. The current proposal represents the worst possible outcome: it displays almost total discontinuity with DSM-IV while failing to improve the validity and clinical utility of the classification. Not surprisingly, the proposal has received widespread criticism to which the Work Group seems impervious."

 As it stands now, the DSM 5 personality section is not readable, much less usable. It will be ignored by clinicians and will do grave harm to research. This is the sad product of small group of cloistered DSM 5 "experts" stubbornly ignoring the sharp criticism from within their own group and the near universal rejection of their proposals by everyone else in the field. Drs Verheul and Livesley have performed a service in trying to stop this runaway train and in now explaining how it went off the tracks.

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

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