1 Boring Old Man

One Last Chance for the APA to Make the DSM-5 Safer
Huffington Post
by Allen Frances
12/17/2012

^{Two weeks ago the Trustees of the American Psychiatric Association made the serious mistake of approving and rushing to press a DSM-5 that has many unsafe and untested suggestions. The reaction has been unexpectedly heated: dozens of extremely negative news stories, many highly critical blogs and a number of calls for a DSM-5 boycott in the U.S., England, France, Australia, Spain and Italy…}

^{We are at the 11th hour. Is there a last-minute way for the DSM-5 to restore some of its lost credibility and save itself from the widespread rejection and ridicule that is being expressed by clinicians, the public and the press? A great deal of irrevocable damage has been done, but I have four simple suggestions that would help reduce the harm done by the DSM-5 and demonstrate that the APA has regained its integrity. Although the Trustees approved the broad outlines of the DSM-5, they did not settle the final wording. Last-minute editing of the DSM-5 can improve it significantly. Here are four simple steps that should be taken:}

1. The placement of a black-box warning in the text section of each of the dozen or so most controversial changes (e.g., temper dysregulation, grief, minor neurocognitive disorder, adult ADD, somatic, binge eating, behavioral addictions, etc). These would indicate the risks involved, tips on how to avoid overdiagnosis and an admission that the change is a hypothesis to be tested in a living DSM-5 document.
2. Criteria sets should have a thorough final review to tighten them and remove ambiguities. If the somatic symptom disorder has gotten this far in such a problematic state, it is likely that many other DSM-5 criteria sets also cry out for careful editing.
3. All the texts and criteria sets need a thorough forensic review. If any word in the DSM-5 can possibly be twisted in court, it will be.
4. A surveillance mechanism with staff, funding and teeth should be set up to identify and counteract the DSM-5 changes that lead to the fads and excessive treatments I have been warning about.

^{I know that it is late in the game and that these are band-aids that can only reduce, not totally eliminate, the risks of the DSM-5. But they would constitute a big step forward…}

^{On a personal note, it would be great for me if the APA were to provide its own realistic cautions concerning changes that the DSM-5 leaders have already acknowledged are no more than poorly tested hypotheses. If the APA takes on what should be its own appropriate cautionary responsibility, then I can relinquish my unpleasant role as constant prophet of DSM-5 doom. The sad truth is that all my dire predictions during the past three and a half years have turned out to seriously underestimate the degree to which the DSM-5 could get itself into, and cause, mischief. My final prediction: Unless the APA takes the time to tighten the DSM-5 and provide it with appropriate cautions, DSM-5 sales will be less than half what is projected. The DSM-5 will likely be a financial as well as a clinical, scientific and artistic flop. The APA has one last act to save the DSM-5 before the curtain drops.}

Dr. Frances is asking the DSM framers and the Board of Trustees to make some 11th hour, good faith changes that might soften the impact of some more blatant errors in judgement, and I hope they consider his suggestions. It’s easy to demonize psychiatrists. It has always been part of the package. I expect that Dr. Frances has the same problem I do. I know a lot of psychiatrists who do a lot of things right and who have had to survive in an environment of underfunding and difficult circumstances both within and without our ranks. It has been an environment that unfortunately fostered the growth of bad apples, and there hasn’t been much that could be done about that as they were supported by powerful industries. And this DSM-5 has been constructed behind closed doors, doors that should’ve been thrown wide open. But they weren’t. This was a time to reconsider, to rebuild, and the DSM-5 Task Force missed that opportunity.