Allen J Frances M.D.

DSM5 in Distress

The User's Revolt Against DSM 5

will it work?

Posted Nov 10, 2011

When it comes to DSM 5, experience has proven conclusively that the American Psychiatric Association (APA) will not attend to the science, evaluate the risks, or listen to reason. A user's revolt has become the last and only hope for derailing the worst of the DSM 5 suggestions.

Why might this work? The APA budget depends heavily on publishing profits. DSM's sell over one hundred thousand copies and generate about five million dollars of profit even in a dull year. This is multiplied several fold at the golden moment when any new DSM is introduced. Meaningful reform will occur only if DSM 5 faces the serious risk of a user's boycott (replacing it with what will be the freely available ICD-10-CM). Certainly, in any sensible world, this threat should have no part in the way diagnostic decisions are made. But DSM 5 is more of an Alice in Wonderland world- what should count least (or not at all) may now count most.

Will the petition work? It certainly faces an uphill struggle. APA will have to be shaken out of its inherent leaden complacency which has been further enhanced by the fact that DSM-IV-TR is still selling extremely well even though presumably it will soon be obsolete. The accepted APA wisdom is that the DSM monopoly over diagnosis is so strong and its audience so captive (particularly among students) that criticisms about DSM 5 content, however widespread and damning, can be simply and safely ignored.

The only serious challenge to this APA obstinacy is the Petition To Reform DSM 5. But the petition poses a significant threat to sales only if so many people sign that DSM 5 finds itself thoroughly discredited in the eyes of both the mental health professions and the general public. I don't know what is the magic number of signers- but probably it is somewhere between 10,000-50,000. Ten thousand signers would almost certainly be too few- treated by APA as merely a drop in the huge book buyers' market. My guess is that fifty thousand would seal the deal and force APA to throw in its weak DSM 5 hand by eliminating its riskiest suggestions. The actual tipping point is probably somewhere in between-who knows where?

The APA stance will also be influenced by how devastating is the media response and the public reaction. Reporters quickly come to understand the great public health risks posed by the DSM 5 suggestions uniformly promoting the diagnostic inflation that leads to loose prescription habits. Actually anyone not working on DSM 5 seems to appreciate this almost instinctively. News stories about DSM 5 are uniformly negative unless they are generated by APA press releases or appear in its own house organ. The question will be how much and how prominent will be the press coverage generated by the DSM 5 petition. My guess is that it will be extensive and extremely critical of DSM 5 and may embarrass it into reform. But this remains to be seen.

And there is an important caveat here. My hope is that press coverage doesn't tar all of psychiatry (and feed the harmful antipsychiatry movement) just because DSM 5 is such a mess. Psychiatry is essential and extremely helpful- DSM 5 is no more than an unfortunate and temporary aberration. The petition is targeted against DSM 5, not against psychiatry. APA's likely defensive response to the petition will be to dismiss it as the work of anti-psychiatry agitators. This should not be taken seriously. The effort is intended to save psychiatry from the harm being done to it by DSM 5.

This bring us finally to the numbers game. The petition was introduced in the most obscure way possible - on Saturday, October 22 with no fanfare, no Facebook, no Twitter, no website, no press release, nothing but a naked announcement. It was launched by extremely well meaning people who had correctly identified the problems posed by DSM 5, but who did not have the resources or technical expertise to launch a well organized media and social networking campaign. The petition gained the support it has largely on its own spontaneous steam.
At first, almost no one noticed the petition but soon it began attracting an average of over 250 signers/day and has collected a total of more than 5000 signatures.

The good news is that this steady growth has occurred by the (to me mysterious) method of spontaneous electrical word of mouth. Many blog sites have picked up the petition, a large number of additional mental health organizations have endorsed it, and people must be busy passing it on to their colleagues. This informal beginning is now slowly being augmented by more sophisticated Facebook, Twitter, and website methods. Press interest has already emerged spontaneously with very favorable stories in Nature News and Medscape and many others seem sure to follow.

The DSM 5 petition clearly has legs- but whether it can fly is still an open question. Its reach will depend on two things- how many people sign on and then how many additional colleagues each signer recruits. It is unknowable whether there will be a weak or powerful network effect. If each signer encourages only one (or none) other colleagues, growth will be slow and linear and may top out at 10,000-20,000. This is a very substantial number of professionals frightened by DSM 5 and should certainly should chasten APA to much greater caution- but given past performance it probably won't have much effect. In contrast, let's suppose each signer encourages two or more others to sign. Then growth will become rapid and exponential and will soon force APA into a serious and much belated rethink of its worst suggestions.

These are very early days. It is far too soon to predict the fate of the DSM 5 petition and the magnitude of its potential impact. It is certainly quite encouraging that its early growth has been steady without really trying- and that additional opportunities for internet and media dissemination have not yet been fully exploited. Clearly, there is room for substantial upside growth.

But there is no room whatever for complacency- only a really massive response will force APA to take the corrective action of rejecting the riskiest of the DSM 5 proposals. For anyone seriously concerned about the unintended consequences of DSM 5, the bottom line is clear. Send the petition ( ) to as many of your colleagues as may also be interested -so that they may judge whether they would like to join. Exponential growth is the essential key to the petition's success- and so far the petition's growth has been no more than linear. Only the resounding voice of the people will save DSM 5 from itself.

About the Author

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

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