1 Boring Old Man

DSM 5 Against Everyone Else
Its Research Types Just Don’t Understand The Clinical World
DSM5 in Distress: Psychology Today
by Allen J. Frances, M.D.
November 1, 2011

…

Strikingly, there seems to be virtually no support for DSM 5 outside the very narrow circle of the several hundred experts who have created it and the leadership of the American Psychiatric Association [APA] which stands to reap large profits from its publication. There is no group and precious few individuals outside of APA who have anything good to say about DSM 5. And even within the DSM 5 work groups and the APA governance structures, there is widespread discontent with the process and considerable disagreement about the product…

There is obviously a huge, growing, and so far totally unbridgeable gulf between the researchers who have prepared DSM 5 and the clinicians who will have to use it. The experts, if they see patients at all, tend to do so only in the ivory tower of university research clinics. Clinicians have to apply the DSM under more difficult real life circumstances and often have a much clearer understanding of how it can be misused – with loose diagnosis often leading to excessive use of medication…

The experts are well intentioned and are making very bad decisions for the purest of reasons. Their conflict of interest is purely intellectual, not financial. Experts overvalue their pet diagnoses and their own research – and greatly underappreciate how an idea that works well in their own research setting may be disastrously misunderstood and misused in clinical practice…

If DSM 5 remains at war with its users, it won’t be used. Why buy an expensive book if it is likely to be more harmful than helpful when the official ICD-10-CM codes will be freely available on the internet. DSM 5′ s stubborn refusal to abandon risky suggestions is a foolish gamble not only for clinicians and patients, but also with its own future.

^{So far, opposition to DSM 5 has been expressed by the following organizations: British Psychological Society; American Counseling Association; Society for Humanistic Psychology [APA Division 32]; Society for Community Research and Action: Division of Community Psychology [APA Division 27]; Society for Group Psychology & Psychotherapy[ APA Division 49]; Developmental Psychology [APA Division 7]; UK Council for Psychotherapy; Association for Women in Psychology; Constructivist Psychology Network; Society for Descriptive Psychology; and the Society of Indian Psychologists.}

^{The users are more than 500,000 thousand mental heath clinicians [and probably, on an occasional basis, about an equal number of primary care physicians]. Of the mental health workers, about 202,000 are social workers; 120,000 are mental health counselors; 93,000 are psychologists; 75,000 are psychiatric nurses; 55,000 are marriage & family therapists; 38,000 are psychiatrists; and an unknown additional number are occupational therapists, educators, experts in forensics, researchers etc.}

I agree with the idea of "a classification of psychiatric illnesses based not on psychodynamic, a priori hypotheses." Unfortunately, in the DSM-III, they didn’t just throw out psychoanalytic theories, they threw out a psychodynamic thread in psychiatry that belonged to psychiatry itself, not psychoanalysis. It was a rich tradition that the analysts certainly influenced, but so did Adolf Meyer, Harry Stack Sullivan and countless others who taught us how to talk with and listen to our patients [no apologies for the influence of the analysts intended]. So, the framers of the DSM-III threw out psychodynamic psychiatry too – the baby with the bathwater. In fact, they essentially threw out "the mind" altogether. That was a huge mistake – probably an irredeemable mistake. And they said they created "a classification of psychiatric illnesses based not on psychodynamic, a priori hypotheses but rather on external, empirical indicators," but that’s not true either. They created a classification based on another "a priori hypotheses," that all mental illness is biologic. It would’ve been okay for them to say all mental illness that psychiatrists are going to treat is biological. Or it would’ve been fine for them to say that our classification was only going to include known or suspected biological conditions [it would’ve been a very small book]. They said neither. They tried to hold on to the whole ball of wax. So they talked "external, empirical indicators" but lived biology, and they preached evidence-based medicine but practiced expert opinion [or at least the opinion of declared experts].

• "The users are more than 500,000 thousand mental heath clinicians [and probably, on an occasional basis, about an equal number of primary care physicians]" = 500,000 to 1,000,000
• "38,000 are psychiatrists" = 38,000
• ergo 38,000/500,000 = 7.6%
• ergo 38,000/1,000,000 = 3.8% 

This guy is standing on the corner clapping.
Someone asks, "Why are you clapping?"
He says, "It keeps the elephants away."
"But there haven’t been any elephants around here for thousands of years."
He says, "See, it works! Don’t it?"

^{Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.}