DSM5 in Distress

The DSM's impact on mental health practice and research

One Last Chance For APA To Make DSM 5 Safer

Other wise there will likely be a buyer's revolt.

Two weeks ago the Trustees of the American Psychiatric Association made the serious mistake of approving and rushing to press a DSM 5 that has many unsafe and untested suggestions.

The reaction has been unexpectedly heated: dozens of extremely negative news stories, many highly critical blogs, and a number of calls for a DSM 5 boycott in the US, England, France, Australia, Spain, and Italy.

I have since written two blogs. The first 'DSM-5 Is a Guide Not a Bible: Simply Ignore Its Ten Worst Changes' outlined the reasons why DSM 5 has failed so badly and warned clinicians and the public about the worst dangers it will pose. (http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5... )

The blog must have touched a raw nerve. Despite the fact that I don't know how to Twitter or Facebook or do whatever it is people do to promote a blog, this one has received 100,000 hits on Psychology Today and was also a most popular view on Huffington Post. This level of concern is not because I am that good a writer- it is all because DSM 5 is that bad. The 10 worst changes all flunk the simple common sense test. Only the highly specialized DSM 5 experts (wearing blinders to possible unintended consequences) could have come up with this rogues' gallery of risky diagnostic suggestions.

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It turned out that I had made one serious omission. Many respondents to my first blog noted that I had left out another DSM 5 change that deserved to be at, or near, the top of the list of its bad ideas. Suzy Chapman has eloquently summarized how the DSM 5 criteria set for Somatic Symptom Disorder is wildly over-inclusive and the harms that result. (http://www.psychologytoday.com/blog/dsm5-in-distress/201212/misla... )

DSM 5 would turn a significant proportion of medically ill people into psychiatric patients- somewhere between about 15-25% depending on the disease. Most of the time, the diagnosis of mental disorder will be incorrect and harmful. Beyond the stigma and hurt, encouraging the quick and mistaken reflex that physical symptoms are really just psychiatric is a big mistake- leading both to missing the underlying medical cause and to overtreating the trumped up psychiatric problem.

We are at the eleventh hour. Is there a last minute way for DSM 5 to restore some of its lost credibility and save itself from the widespread rejection and ridicule that is being expressed by clinicians, the public, and the press? A great deal of irrevocable damage has been done, but I have four simple suggestions that would help reduce the harm done by DSM 5 and demonstrate that APA has regained its integrity.

Although the Trustees approved the broad outlines of DSM 5, they did not settle the final wordings. The last minute editing of DSM 5 can improve it significantly. Four simple steps:

1) The placement of a black box warning in the text section of each of the dozen or so most controversial changes (eg temper dysregulation, grief, minor neurocognitive, adult ADD, somatic, binge eating, behavioral addictions, etc). These would indicate the risks involved, tips on how to avoid over diagnosis, and an admission that the change is a hypothesis to be tested in a living DSM 5 document.

2) Criteria sets should have a thorough final review to tighten them and remove ambiguities. If the Somatic Symptom Disorder has gotten this far in such a sorry state, it is likely that many other DSM 5 criteria sets also cry out for careful editing.

3) All the texts and criteria sets need a thorough forensic review. If any word in DSM 5 can possibly be twisted in court, it will be.

4) A surveillance mechanism with staff, funding, and teeth should be set up to identify and counteract any DSM 5 changes that lead to the fads and excessive treatments I have been warning about.

I know that it is late in the game and that these are band aids to salvage a failed process. They can only reduce, not totally eliminate, the risks of DSM 5- but together would constitute a big step forward.

APA will argue that there is no time. This makes no sense. Everything is happening now, at what seems the last minute, only because DSM 5 has previously missed every deadline. And the May publication date has been set arbitrarily only to meet the APA budget projections- there is no reason (except financial) that it can't be delayed a few months to allow APA time to produce a safer DSM 5. APA is on the spot. It needs to choose between publishing profits and public trust.

I believe that radical damage control is in APA's own best long term interest. Publishing a third rate DSM 5 will lose it the support of the field and also risk APA's continuing control of the DSM franchise.

On a personal note, it would be great for me if APA were to provide its own realistic cautions concerning changes that the DSM 5 leaders have already acknowledged are only poorly tested hypotheses. If APA takes on what should be its own appropriate responsibility, then I can relinquish my unpleasant role as constant prophet of DSM 5 doom.

The sad truth is that all my dire predictions during the past three and one half years have turned out to seriously underestimate the degree to which DSM 5 could get itself into, and cause, mischief. My final prediction- unless APA takes the time to tighten DSM 5 and provide it with appropriate cautions, DSM 5 sales will be less than half what is projected. DSM 5 will likely be a financial as well as a clinical, scientific, and artistic flop. APA has one last act to save DSM 5 before the curtain drops.

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

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