DSM5 in Distress
The DSM's impact on mental health practice and research.
A Users Revolt Should Capture APA Attention
Published on October 24, 2011
Several divisions of the American Psychological Association have just written an open letter highly critical of DSM 5. They are inviting mental health professionals and mental health organizations to sign a petition addressed to the DSM5 Task Force of the American Psychiatric Association. You can read the letter and sign up at http://www.ipetitions.com/petition/dsm5/ It is an extremely detailed, thoughtful and well written statement that deserves your attention and support.
The letter summarizes the grave dangers of DSM 5 that for some time have seemed patently apparent to everyone except those who are actually working on it. The short list of the most compelling problems includes: reckless expansion of the diagnostic system (through the inclusion of untested new diagnoses and reduced thresholds for old ones); the lack of scientific rigor and independent review; and dimensional proposals that are too impossibly complex ever to be used by clinicians.
The American Psychiatric Association has no special mandate or ownership rights giving it any sovereignty over psychiatric diagnosis. APA took on the task of preparing DSM's sixty years ago because it then seemed so thankless that no other group was prepared or willing to do it. The DSM franchise has stayed with APA only because its products were credible enough to gain widespread acceptance. People used the manual only because it was useful.
DSM 5 has strained that credibility to the breaking point and (unless radically changed) will be much more harmful than useful. We have reached a turning point that will soon become a point of no return. A near final version of DSM 5 must be ready by next spring and all final wording will be set in stone within a year. Time is running out if DSM 5 is to be saved from itself.
Rescue attempts and pushback are coming from numerous directions and are fast gaining in momentum. The American Psychological Association's petition was preceded by an even harsher critique by the British Psychological Society. The Society of Biological Psychiatry has wondered why we need a DSM 5. Experts in personality disorder have universally decried the proposed revisions in DSM 5. And the American Counseling Association will soon weigh in with its own statement.
Meanwhile DSM 5 has lived in a world that seems to be hermetically sealed. Despite the obvious impossibility of many of its proposals, it shows no ability to self correct or learn from outside advice. The current drafts have changed almost not at all from their deeply flawed originals. The DSM 5 field trials ask the wrong questions and will make no contribution to the endgame.
But the DSM 5 deafness may finally be cured by a users' revolt. The APA budget depends heavily on the huge publishing profits that accrue from its DSM sales. APA has ignored the scientific, clinical, and public health reasons it should omit the most dangerous suggestions- but I suspect APA will be more sensitive to the looming risk of a boycott by users.
Here are best case and worst case scenarios. Best case: APA opens up DSM 5 to external, independent review and only those suggestions that pass muster are included. DSM 5 becomes safe, usable, and widely used.
Worst case: DSM 5 stumbles along blindly as it has and includes most or all of its harmful suggestions. DSM 5 loses its status as a useful and standard guide to psychiatric diagnosis, creating an unnecessary and unfortunate babel of diagnostic practice and research habits. And the American Psychiatric goes broke.
The APA Trustees and Assembly have thus far been almost completely and puzzlingly passive in exercising their governance role over DSM 5. I believe they can wait no longer if they are to fulfill their fiduciary responsibility to the public, to the mental health field, and to their own membership. It is pretty much now or never.
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