Allen J Frances M.D.

Saving Normal

Why DSM 5 Won't Meet The Press

It Is Counting On A Captive Audience

Posted Feb 26, 2013

The people working on DSM 5 refuse to speak to reporters or enter into any debate to defend its controversial suggestions. They are betting on having a captive audience forced to buy DSM 5, no matter how bad its press.

I have heard the very same story from dozens of reporters. They call the American Psychiatric Association asking to get its side of the argument so they can provide balanced reporting on DSM 5- how does DSM 5 defend itself against the criticisms I have raised? The reporters all get stonewalled. No one is available to speak to them. There will be no comment. No defense.

Same thing with the many conferences or media discussions I have done. The organizers want a debate and invite APA to send a DSM 5 defender, but DSM 5 refuses to defend itself.

The only venue of DSM 5 defense is within the sheltered safety of an APA house organ- the American Journal of Psychiatry, Psychiatric News, or the public relations inspired DSM 5 website. The bland apologias never mention or address the many and detailed critiques of DSM 5 changes.

When more than 50 mental health associations petitioned DSM 5 for an independent scientific review of its most controversial proposals, they were shrugged off. When hundreds of thousands of consumers were outraged by DSM 5 changes that would turn grief into 'Major Depression Disorder'' and worry about medical illness into 'Somatic Symptom Disorder', they were ignored.

Predictably and deservedly, APA has gotten the worst possible press. There have been hundreds of articles in all the major newspapers of the world, dozens of editorials in major medical and psychiatric journals, and an internet blood bath. Even its expensive public relations firm could not turn this sow's ear into a silk purse.

APA doesn't seem to care much about how DSM 5 is perceived. And it doesn't rise to the defense of DSM 5 for two reasons: 1) because there are really no convincing defenses, and; 2) because it doesn't think it has to.

The APA bet is on a captive audience of people forced to buy DSM 5 for institutional reasons- whether they like it or not. Any loss of sales will be made up by price gouging- DSM 5 will set you back an astounding $199 per copy for hardcover and $149 for paper.

What APA loses in volume, it hopes to make up in revenue generated by its monopoly pricing power.

The more knowing and cynical among my friends think the smart money is on APA- that DSM 5 will be a cash cow no matter how reckless its suggestions, how bad its reviews, how inscrutable its writing. They see me as a naïve Quixote tilting at windmills and don't understand how a detached and lazy beach bum could suddenly turn into such an impassioned crusader for a lost cause.

They may be right, but I wouldn't bet on it. As honest Abe put it: "you can fool some of the people all the time, and all the people some of the time, but you can't fool all the people all the time." I am impassioned because I think that DSM 5 can lead to massive over diagnosis of people who aren't mentally ill and to their massive over treatment with medicine they don't need and should not take. And I am hopeful this can be largely prevented because I don't think the audience is all that captive.

Here is why. No one needs to buy DSM 5 to code their patients for billing purposes. The DSM codes used for insurance purposes are not DSM codes at all- they are ICD-9-CM codes that are freely available on the internet.

I find the DSM 5 writing so densely and dreadfully obscure that it is hard to believe that anyone will want to buy DSM 5 to learn about psychopathology or abnormal psychology.

And foreign sales will plummet. Clinicians in other countries often already use the ICD system and will be scared off DSM 5 by all the negative controversy it has stirred up.

So, what if they gave a DSM 5 party and nobody came? Our patients would be safer, our mental health professionals would get better results, our students would be less confused and misled, and our mental resource misallocation would be less exacerbated.

Call me a wild eyed optimist, but I think people may be protected from the worst harms of DSM 5 because it is so bad and has already been so widely discredited.

But there is another troubling danger that lurks in the opposite direction. Collateral damage. The loss of faith in DSM 5 may (and likely will) hurt the more general credibility of psychiatry and all the other mental health professions.

This is unfair and could have potentially tragic implications. DSM 5 is an aberration, a strange departure from common sense that in no way represents the core of the mental health arts and sciences. Psychiatric diagnosis and treatment are remarkably effective when they are done well and are provided for people who really need them.

My nightmare scenario- patients who desperately need medication refuse to take it because the DSM 5 follies have raised so many doubts.

The delicate balance- we need to discredit those changes in DSM 5 that will lead to unnecessary diagnosis and treatment without discrediting the proper practice of psychiatry.