1 Boring Old Man

Psychiatry’s DSM-V Process: Now A Bar Room Brawl

The Carlat Psychiatry Blog

by Danny Carlat

June 30, 2009

[full text online]

Psychiatry’s diagnostic manual is due for a revision. But what began as a group of top scientists reviewing the research literature has degenerated into a dispute that puts the Hatfield-McCoy feud to shame. The latest installment in this remarkable episode of American psychiatry involves an editorial by Dr. Allen Frances, the chairman of the committee that created the current version of the the DSM, the DSM-IV. The editorial has not even been officially published [it is in press at Psychiatric Times] but already it has made the rounds of the blogs and is being read and debated widely. Now, the APA has just released this rather stunning response…

In his editorial, Dr. Frances criticizes the evolving DSM-V on multiple levels, and makes the following claims:

• The process of writing the manual is less transparent and less inclusive than the process he oversaw when he chaired the DSM-IV committee.

• The underlying science of psychiatry has not advanced enough to merit the kind of extreme makeover proposed by the DSM-V chairpeople:

"The simple truth is that descriptive psychiatric diagnosis does not need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM-5."

• The main change being proposed—the official inclusion of a series of rating scales into the diagnostic criteria—is poorly conceived because busy clinicians will reject this extra paper-work.

• Other proposed changes in DSM-V will make it too easy to over-diagnose a range of conditions:

“The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatment–a bonanza for the pharmaceutical industry but at a huge cost to the new false positive "patients" caught in the excessively wide DSM-V net. They will pay a high price in side effects, dollars, and stigma, not to mentions the unpredictable impact on insurability, disability, and forensics.”

Frances’ article is compelling, not only because of the substance of his arguments but because of his clear and forceful writing style. With each sentence, you get a sense that this man has carefully thought through all of these issues and is passionately concerned about the future of his field.

“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.”

"It is, however, completely unclear that his lack of enthusiasm is based on any scientifically rigorous foundation. Indeed, his knowledge of these methods seems lacking. Finally, Carroll is quick to point out the acknowledged potential conflicts of others as if they have led to bias in reporting of scientific information. In this case, it is Carroll who has the overwhelming conflict of interest. As developer, owner, and marketer of the Carroll Depression Scale–Revised, a traditional fixed-length test, it is not surprising that the paradigm shift described in our article would be of serious concern to him."

In our military, we have an article, Article 113: Conduct Unbecoming an Officer and a Gentleman [shortened now to Conduct Unbecoming an Officer]. Uncharacteristically, considering the usual military penchant for details, it’s very loosely defined. We don’t need a definition, because we all know what it means. It refers to the fact that we hold our leaders to a higher standard of conduct than the simple standards of the civil and criminal laws. There’s a similar implicit standard in Medicine.