1 Boring Old Man

I’m running out of titles – all quiet on the western front, the sounds of silence, the silent treatment – ways to describe the status of the DSM-5 Revision. There’s suddenly nothing to say. The full report on the field trials has yet to appear. The PR site, DSM-5 Facts, won’t even come up right now, but on my last fly-by, it looked the same as it looked in May. Google news finds neither David Kupfer nor Darrel Regier in anything recent. My understanding is that the DSM-5 Task Force is to present the final product to the APA Board of Trustees in November, a month or so hence. Dr. Allen Frances has gone quiet. Suzy Chapman’s blog, dxrevisionwatch.com, the usual resource for matters DSM-5 is likewise quiet. She did report that HHS announced a delay until October 2014 for the implementation of the ICD-10-CM –

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– and wondered if the HHS decision might spark a delay with the DSM-5, but it didn’t. Apparently the DSM-5 is on schedule. As for the DSM-5 site, if it has been updated recently, I can’t find where. During these several months of silence, I’ve thought about the DSM-5 off and on. Silence would be a good space for pondering, but there’s nothing much to ponder.

^{In the ongoing quest to improve our psychiatric diagnostic system, we are now searching for new approaches to understanding the etiological and pathophysiological mechanisms that can improve the validity of our diagnoses and the consequent power of our preventive and treatment interventions venturing beyond the current DSM paradigm and DSM-IV framework. This thought-provoking volume produced as a partnership between the American Psychiatric Association, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse represents a far-reaching attempt to stimulate research and discussion in the field in preparation for the eventual start of the DSM-V process, still several years hence. The book:}

• Explores a variety of basic nomenclature issues, including the desirability of rating the quality and quantity of information available to support the different disorders in the DSM in order to indicate the disparity of empirical support across the diagnostic system.
• Offers a neuroscience research agenda to guide development of a pathophysiologically based classification for DSM-V, which reviews genetic, brain imaging, postmortem, and animal model research and includes strategic insights for a new research agenda.
• Presents highlights of recent progress in developmental neuroscience, genetics, psychology, psychopathology, and epidemiology, using a bioecological perspective to focus on the first two decades of life, when rapid changes in behavior, emotion and cognition occur…

What happened? Academic Psychiatry and the Pharmaceutical Industry were increasingly implicated in a series of scandals culminating in a Senate investigation of prominent academic psychiatrists for payola and suits against the companies for fraud. "Psychiatric Expertise" was under suspicion. What didn’t happen? The anticipated neuroscience breakthroughs failed to materialize – the best that came from research was still promising or less. And the large NIMH drugs trials were hardly inspiring. The lofty goals from A Research Agenda for DSM-5 didn’t materialize. Had they noticed along the way, they could’ve changed gears and taken on improving the DSM-IV [their task in the first place]. But that’s not what they did. They added a bunch of idiosyncratic things and didn’t do much to fix the DSM-IV’s problems. When they began to talk publicly about where they were headed, their predecessors were aghast  and sounded alarms. Even then, they could’ve still turned things around. But that’s not what they did.

So it became too late. Their research agenda went nowhere – a failed enterprise. The delegated task of actually revising the DSM-IV stayed on the back burner too long and didn’t get done – so much for the other half which became an equally failed endeavor. The one-shot Field Trials were embarrassing. Throw in some arrogance in a time for humility and those peculiar diagnoses, and you have a perfect storm. The DSM-5 revision has allowed itself to become associated with the general disappointment in an oversold psychopharmacology, a lack of palpable progress in neuroscience, and the waves of scandal involving the the relationship between commercial enterprises and academic psychiatry.