1 Boring Old Man

An aspect rarely commented on is that the DSM-5 leaders didn’t seem enthusiastic about the basic principles of the earlier revisions. In A Research Agenda for DSM-V, they said:

^{Questions have been raised by many critics that the DSM’s descriptive approach may have outlived its usefulness and is in fact potentially misleading. Although there is a large body of research that indicates a neurobiological basis for most mental disorders, the DSM definitions are virtually devoid of biology. Instead, DSM-IV definitions are based on clusters of symptoms and characteristics of clinical course.}

^{We realized from our Research Agenda conference series that we would not be able to accomplish by DSM-5’s deadline all of the things we set out to and, in fact, that portions of that agenda related to advances in neuroscience were already being addressed in other arenas. A logical extension of those discussions, as detailed in our Research Agenda articles, is the Research Domain Criteria [RDoC] initiative recently launched by the National Institute of Mental Health [NIMH]. A commentary by Insel and colleagues introduced readers to the working principles behind the RDoC, whose proposed reclassification of mental disorders for research purposes is predicated on a neuroscience-based framework that can contribute to a nosology in which disorders are grouped by underlying pathophysiological similarities rather than phenomenological observations. This NIMH objective is consistent with our research planning conferences and conclusions, which underscored our commitment to examining evidence from neurobiology and assessing the readiness of proposed revisions for DSM-5.}

But there was another paradigm shift in the wings. There is a reasonably large symptom overlap among the various psychiatric syndromes disorders. In addition, they had difficulty mapping neuroscience findings or  functional impairment onto the disorders. So they came up with the idea of a "cross-cutting" or a "dimensional" system to replace the not much used Axial system of the DSM-III/DSM-IV manual. This is going to be a short paragraph because I never really got it [nor did anyone else]. It was too complex for most of the mortals using the manual and was dropped in the approval process. I mention it because it was another attempt to escape the confines of the descriptive principles underlying the earlier revisions.

Another explanation for the zeal to change things might possibly have been an attempt to keep psychiatry honest. It’s hard to imagine that the DSM-5 leaders [Kupfer, Regier, and Scully] didn’t know about the widespread alliances between the pharmaceutical companies and some of the more prolific academic psychiatrists and chairmen, and about the shady science filling our journals. It occurs to me that there might have been some wish to put psychiatry on a more solid biological carriage than the speculative and jury-rigged fare that was frequently haunting our journals. Just a thought that maybe they were trying to prevent the shaming that escalated during their tenure in spite of their efforts. Maybe they saw what was coming.

My own bias covers the third possibility. In my view, psychiatry has traditionally been at its best when it has focused on the caretaking aspect of doctoring, and most of its foibles have historically come with the overzealous forrays into medical therapeutics. I’m not anti-therapeutics, but our story says we should walk very softly. But I think mine is an idiosyncratic view. I don’t mind that psychiatry lives on the edge of medicine and I don’t feel envy about the solidity of science in medicine proper. But I’m acutely aware that for most of my colleagues, the drive to sit firmly among their medical peers is strong – and envy is one of the more powerful motivators on the planet. So my take is that one of the drivers of the DSM-5 is medical/therapeutic envy run amok.

Whatever the origins, the DSM-5 Task Force was hell-bent to do something new – put the DSM-5 on a solid biological footing, add a new cross-cutting dimensional axis, be innovative, or add a dose of early detection and treatment – and came up short on every count. But worse, they were remarkably inattentive to everything old. The two biggest categories, MDD and GAD [also most in need of attention] were untouched except for the silliness with the bereavement exclusion. This was not a revision. It was something else. They just didn’t get around to doing their assigned task, and the poor performance of MDD and GAD in the field trials bears testimony.

So it has gone to press accompanied by all it’s ancillary books all with their exorbitant price-tags to find its place in history. Reading Dr. Sabshin’s book, Changing American Psychiatry: A Personal Perspective, it’s clear that the "Aw Shucks" myth about the DSM-III’s place in making a paradigm shift is silly – it was planned to do exactly what it did. I don’t know who thought that they could bring off another paradigm shift with the DSM-5, but they badly miscalculated. While they were having thirteen expert conferences between 2004 and 2008 making their plans, a lot was happening. Allen Jones blew the whistle on TMAP. Dr. Nemeroff and others were recurrently busted for undeclared conflicts of interest. Suits against PHARMA grew in number and success, producing internal documents that were incriminating, revealing widespread ghost-writing and PHARMA influence on our literature and practice. There was a lot more attention to the exaggerated  claims of efficacy and downplaying of adverse effects. And the black box warning made its way to every Antidepressant label – potential suicidality in kids. By the time of Senator Grassley’s investigation of academic psychiatrists in 2008, the climate was changing at a rapid pace. Then the pipeline dried up. Both previous DSM gurus, Dr. Spitzer and Dr. Frances began to ask, "what’s going on?" 

And people like me and you also began to wake up and ask, "what’s going on?" But the DSM-5 leaders were in a bunker, meeting in something pretty close to secret conclave. Behind schedule, they cancelled plans for a second checkup round of field trials. As things progressed, they had to admit that the grand plan of basing the DSM-5 on neurobiology wasn’t going to work – the science just wasn’t there [class action in the air…]. By this time, they’d released an early draft and the reaction was uniformly negative. Dr. Frances was writing a blog in Psychology Today essentially pleading with them to change their course [DSM-5 in Distress], joined by an impressive list of other organizations.