blurred vision…

Posted on Tuesday 31 January 2012

APA Should Delay Publication Of DSM-5
Pschiatric Times
By Allen Frances, MD
January 31, 2012

My three criticisms of DSM-5 have been:

  1. risky suggestions;
  2. bad writing;
  3. poor planning and disorganization.
I have pretty much failed to have any real impact other than perhaps getting APA to delay publication from May 2012 to May 2013. The one-year extension was wasted, the risky suggestions and bad writing remain, and my constant warnings that missed deadlines would lead to a mad and careless race at the end were ignored. With less than a year remaining before DSM-5 is scheduled to go to print, the signs are clear that it cannot possibly be completed on time unless we are willing to settle for a third rate product. The unmistakable red flag is the recent embarrassing admission that DSM-5 will accept diagnoses that achieve reliabilities as unbelievably low as 0.2-0.4 [barely beating the level of chance agreement two monkeys could achieve throwing darts at a diagnostic board]. This dramatic departure from the much higher standards of previous DSM’s is a sure tip-off that many DSM-5 proposals must be failing to achieve adequate diagnostic agreement in the much delayed and yet to be reported field trials. Unable to meet expected standards, the DSM-5 Task Force is drastically and desperately trying to lower our expectations…

The wise, safe, and responsible thing for APA to do now is to delay publication of DSM-5 until the missing second stage of rewriting and retesting can be completed. The wordings that do poorly in the first stage of field testing should be rewritten to finally attain the clarity and consistency necessary in an official manual of psychiatric diagnosis. The newly revised (and hopefully final) versions should then undergo the second stage of field testing as originally envisaged to ensure that they now work. The extra time will also allow for the independent scientific reviews of controversial DSM-5 proposals called for in a petition that has already been signed by more than 11,000 mental health professionals and is endorsed by 40 professional organizations (including many divisions of the American Psychological Association, the American Counseling Association, and the British Psychological Society)…

… The May 2013 publication date appears to be completely unrealistic unless we are to settle for a DSM-5 so poorly done that its reliabilities will return us to the dark ages of DSM II. DSM-5 is in a very deep hole with very few remaining options. My recommendations:

  1. Make the publication date flexible and contingent on delivery of a quality product that the field can trust;
  2. Subject the current drafts and texts to extensive editing for clarity and consistency;
  3. Drop the controversial suggestions that risk harmful unintended consequences or at least subject them to external scientific review;
  4. Have the rewritten drafts reviewed word for word by many experts in the clinical, research, and forensic uses of DSM-5;
  5. Field test again to make sure the new versions work adequately.
One last point. Many critics use the obvious failures of DSM-5 as justification to attack psychiatry as a whole. I strongly disagree. DSM-5 is no more than an unfortunate aberration reflecting the temporary state of weak and misguided APA leadership. The work on DSM-5 went off track because of unrealizable ambitions; a closed and secretive process; and insufficient attention to the day to day details of prudent planning, efficient organization, and careful writing. Because of its poor performance on DSM-5, APA has probably forfeited its right to sole control of future revisions. But all this represents only the specific failure of DSM-5, not a general reflection on what psychiatry is and what it can accomplish. Done well and within its reasonable limits, psychiatry is an extremely helpful, indeed essential profession. It would be a shame to throw the valuable baby out with the bath water or discourage patients from getting the psychiatric help they need and can benefit from. Admittedly, DSM-5 is an embarrassment and a serious hit to our credibility, but we will recover and our patients should not lose faith.
Of course, what Dr. Frances says about putting the DSM-5 Revision on hold it true. The work to date is shoddy, and I would emphasize "misguided." This is not a time to allow a particular subset of psychiatry to dominate the DSM-5 Revision as it has. The DSM-III and DSM-IV at least paid genuine attention to the descriptive, non-ideological credo. The DSM-5 Task Force has not. Their every discussion has "advances in neuroscience" included – down to adding "biological" to the definition of mental illness. How can they expect for a document so clearly ideologically driven be accepted by disciplines like counseling or psychology – much less even the whole body of psychiatry? Their hypotheses are duly noted, but are not close to the level of universal "fact" as they seem to believe. But my opinion on that topic is well covered and not why I reproduced parts of Dr. Frances’ article. It’s that last paragraph, in red, that I want to speak to.

I worked in the clinics today. In the morning, I saw adults – a lot of them. I had three patients where the central issue was unrecognized anti-depressant withdrawal syndromes. I had three patients who’d been told to they were "bipolar" [who weren’t]. I had a patient who had been labeled a drug seeking "character disorder." He was, instead, a 49 year old guy who had been thrown through a car window in a wreck at age six, been in a coma for six months, been passed through the seventh grade in Special Education [social promotion], and could sort of read using his finger, one word at a time [all the short words]. He’s never worked ["can’t be still"] and lives with aging parents worrying about what he’ll do when they are gone. Given the scrambled brain he lives with, I thought he was doing the best he could. It was that kind of morning – frustrations. In the afternoon, I was at a children’s clinic – doing ADHD med checks, arguing with Medicaid providers, the stuff of modern medicine that I do as a volunteer [but wouldn’t do if paid]. My last patient was an adult, a woman with persistent PTSD from a terrible event eight years ago that involved the death of her son. The tension of undoing bad diagnoses and bad treatments all day just disappeared as I talked to this woman about her illness, something I know about. I felt like a doctor instead of someone putting out brush fires, a case-worker in a social agency, or a med-check doctor. As one of my patients once quipped, "I felt my efficacy."

On the way home, I was thinking about why I’m at volunteer clinics in my retirement doing things I refused to have anything to do with as a practitioner – talking to some young guy working for Medicaid Managed Care getting "pre-cert" for medication, calling Social Security Disability about Mr. non-character-disorder’s real diagnosis, talking to a special ed teacher about a school plan for a teenager with a crippling social phobia who was in trouble for truancy [rather than being "served" by the school system]. It’s not that such things aren’t needed – the need is yawning. But why me? There are several reasons I do it. One is if I don’t, it won’t get done. But another is that there’s never a clinic day when I don’t see one or more people who help me remember why I did this in the first place – like the lady with PTSD. And there’s never a day when I don’t see some case that’s being mis-managed or mis-diagnosed, and I can get things on a better track. But an important side effect is that these clinic days are an antidote to reading and writing in this blog about the DSM-5 Task Force, or the Pharmaceutical intrusions into academia, or the "weak and misguided APA leadership", or the overvaluing of some dreamed-of future for "clinical neuroscience", or the insightful but painful truths in Dr. Healy’s Pharmageddon.

So I’m not an anti-psychiatrist. I see myself as the opposite. The criticisms are of a specialty on a dubious trajectory in part driven by the tsunami of managed care and an avaricious industry, and in part internally off the course on its own. But there were plenty of psychiatrists out there today doing what I did, trying to help people with their mental illnesses, the systems they have to negotiate, their misdirected treatments, their iatrogenic symptoms, their medications, their insurance or its absence, their lives in a recession, and sometimes even those afflictions of the mind brought on by life experience in childhood and beyond. So, even though the DSM-5 Revision process and its product are too flawed to continue to completion without a serious DSM-5 Revision – as in "re" "vision" – that’s not  an indictment of psychiatry or psychiatrists. It’s a specific indictment of the current DSM-5 Task Force and its blurred "vision"…
    February 1, 2012 | 1:01 AM


    It’s late and I’m tired. And yet I still find the time & energy to read your posts.

    Meanwhile, my co-workers and colleagues are enjoying time with their wives, husbands, children, and dogs (I know this because I see their Facebook updates), blissfully unaware of the challenges ahead for psychiatry, and, more likely than not, of their own “bad diagnoses and bad treatments.”

    Some days I just want to say “f*** it all” and grab that nice fat paycheck which I know is mine, as long as I sign on the dotted line and do what the bureaucrats tell me to do. (I learned today of a psychopharmacologist friend– younger than me and two years out of residency– working for the California correctional system, who just bought a share of a private jet.)

    But then I talk to the middle-aged guy in my office who was misdiagnosed with bipolar disorder, fellated by his father at 8 years of age, went to prison 3 times, endured painful trials of 5 or 6 antipsychotics for what were most likely symptoms resulting from his chronic meth use, lost custody of his only son, and assaulted his girlfriend after he overdosed on Klonopin, and realize that it’s the money-grabbers who put him into this position, and that he’s actually a really nice guy who’s afraid he’ll die soon because of severe coronary disease and lack of access to good cardiology care thanks to his mercurial, evanescent Medi-Cal benefits. And then I log on to your blog to realize (again) how incredibly corrupt our field is, even though both you and I were led to believe that those antipsychotics (and his Klonopin) were the “future of psychiatry.”

    You, my friend, can afford to work in a charity clinic. I cannot. And while there’s always a “lady with PTSD” who desperately needs (and deserves) our care– and who was the reason I entered this field in the first place– the money (and the house, the college tuition, and, yes, the private jet) lies in rapid diagnosis & med management, precisely the sort of thing that the DSM-5 will encourage more of. Not to folks like you and me, of course, but to the 95% of our colleagues who are absolutely oblivious to what you’ve written.

    Someday, psychiatry (or whatever it becomes after its demise) will look back at your writing and take notice of your prescience, but until then, there’s money to be made, and most of us just don’t care.

    February 1, 2012 | 11:45 AM


    I am too tired to come up with an elegant response. I just wish to god I had a psychiatrist like you during my 15 wasted years on psych meds. It could have saved me alot of grief.

    Thank you for what you do. And I hope to god the people you help appreciate how lucky they are.

    February 1, 2012 | 11:50 AM


    Don’t give up your dream of practicing psychiatry, the right way. You might want to email Robert Whitaker who might be able to put you in contact with other psychiatrists who feel as you do.

    Also, as I am sure you are well aware, there is huge demand for psychiatrists who are willing to learn with the patient about psych med withdrawal issues. Too many us have had to deal with psychiatrists who weren’t supportive.

    Don’t give up.


    Joel Hassman, MD
    February 1, 2012 | 9:20 PM

    Just remember folks, about 75%+ of antidepressant prescriptions in the US are now written by non-psychiatrists, and I know that Abilify, Seroquel, Zyprexa, and I would bet at least one of the newer three antipsychotics out in the past 2 years are being marketed to PCPs/Fam Docs/NPs. So, you all can worry that a sizeable portion of our colleagues are sucking at the pharma teet with reckless abandon, but, what do we do about our non-psychiatric colleagues who are just buying the false message of hope(lessness) these reps are selling?

    My instinct is this, PPACA (Obamacare) is going to do a fine job of marginalizing the field of psychiatry to such a limited degree, we will only be working in acute care or state hospitals, the few remaining state run community mental health clinics, VA programs, correctional facilities, or insurance programs like Kaiser.

    Private practice psychiatry will be basically extinct by 2016. Why would the US government pay for a specialty deemed irrelevant for the general population? Some antipsychiatry commenters will smile with glee reading this now, but, when the crap hits the fan and appropriately needing people are underserved by non psychiatry clinicians, and such people these psychiatry bashing zealots truly care about then see are being ruined even worse than alleged by us now, who will rush in and save the day?

    The people railed against now that should be locked up or banished from our society?

    Good luck if you all think the status woe, er, quo, is left as planned now!

    Just one man’s opinion. One of 20 years of watching stupid is as stupid does.

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