"I don’t want to be lying on my deathbed and asking, ‘What was all that about?’"
attributed to Marlon Brando
We’re approaching the one year anniversary of the release of the DSM-5, an event shrouded in confusion, contention, and disappointment. I don’t recall many of us paying very much attention to it before the summer of 09, though the revision process was by then a decade old. In June 2009, the leaders published something of a state of the revision Commentary in the AJP. By then, the chairs had been appointed [April 2006], the Task Force [July 2007] and Workgroups [July 2008] populated, and work was underway. Although there had been an extensive series of symposia in the interim, this Commentary was little changed from their earlier book, A Research Agenda for the DSM-V, published in 2002:
by Darrel A. Regier, William E. Narrow, Emily A. Kuhl, and David J. Kupfer
American Journal of Psychiatry. 2009 166:645-650.
While a lot of this Commentary is about their processes of the previous decade, there are several things of note. They reviewed the creation of the DSM-III from the Feighner criteria and the RDC, attributing it all to the influence of Robins and Guze, the neoKraepelinians. They talked about a 1980 expectation that subsequent basic research would validate those categories – something that hadn’t happened. They pointed to the high rates of comorbidity, the heavy use of the NOS designation, the fact that medications were not diagnosis specific, and the failure to find biological markers for the categories. They saw these things as evidence that it was time for a change in direction – a paradigm shift. Their solutions included [as always] finding the missing biomarkers, including biological correlates with the diagnoses, and adding "dimensional" elements to the diagnostic system – "cross-cutting dimensions."
The single most important precondition for moving forward to improve the clinical and scientific utility of DSM-V will be the incorporation of simple dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between DSM-IV and DSM-V will be the more prominent use of dimensional measures in DSM-V.
Neither Dr. Spitzer [DSM-III, DSM-IIIR] nor Dr. Frances [DSM-IV] were mentioned in this article even in passing. Perhaps Dr. Spitzer’s ommission had to do with his earlier calling the DSM-V Task Force out for its secrecy policies, but the reason for their omission of Dr. Frances and their general negativity towards the DSM-IV wasn’t clear [maybe they had a premonition]. Another thing, in spite of heavily referencing elsewhere in the article, this comment is reference-free:
… we have come to understand that we are unlikely to find single gene underpinnings for most mental disorders, which are more likely to have polygenetic vulnerabilities interacting with epigenetic factors [that switch genes on and off] and environmental exposures to produce disorders.
Then, later that month, Dr. Frances spoke up. If you don’t know the story of why, it’s worth your time to read Gary Greenberg’s later article in Wired
that tells the story, Inside the Battle to Define Mental Illness
by Allen Frances
June 26, 2009
Frances summarizes his numerous concerns at the end of his article:
My concerns arise from the following:
Their ambition to achieve a paradigm shift when there is no scientific basis for one.
Their failure to provide clear methodological guidelines on the level of empirical support required for changes.
Their lack of openness to wide scrutiny and useful criticism.
Their inability to spot the obvious dangers in most of their current proposals.
Their failure to set and meet clear timelines.
The likelihood that time pressure will soon lead to an unconsidered rush of last-minute decisions.
This is the first time I have felt the need to make any comments on DSM-V. Even when the early steps in the DSM-V process seemed excessively ambitious, secretive, and disorganized, I hoped that I could avoid involvement and believed that my successors deserved a clear field. My unduly optimistic assumption was that the initial problems of secrecy and lack of explicitness would self-correct and that excessive ambitions would be moderated by experience. I have decided to write this commentary now only because time is running out and I fear that DSM-V is continuing to veer badly off course and with no prospect of spontaneous internal correction. It is my responsibility to make my worries known before it is too late to act on them…
Notice that in the Commentary and in Dr. Frances’ article warning of the pitfalls in the trajectory of the DSM-5 Task Force, so far we have heard next to nothing about any of the diagnostic categories themselves. The Co-Chairs are focused on their disappointments or dis-satisfactions with previous efforts. Dr. Frances is worried about the push for a paradigm shift, and the way they’re approaching the revision itself. But the actual diagnoses themselves are still not on the front burner. The APA response came less than a week later from the President of the APA [Alan Schatzberg], the APA Medical Director [James Scully], and the DSM-V Co-Chairs [David Kupfer and Darrel Regier]. They hardly took Frances’ critique as constructive criticism [to say the least]:
By Alan F. Schatzberg, James H. Scully Jr, David J. Kupfer, and Darrel A. Regier.
July 01, 2009
Let me get the rotten part out of the way at the beginning:
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.” It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV. Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V. 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.
That’s the low point of this story for me – a school playground bully response that has no place in any serious dialog. Dr. Frances shook it off, turned the other cheek, and moved on. I can’t seem to. I hear that nastiness in everything since. But I do want to mention something else from their article.
As documented in the recent American Journal of Psychiatry article [Regier, et al., 2009], the use of dimensional assessments to reconceptualize psychopathology represents the most practical and evidence-based way of moving our field forward. Recent studies underscore the readiness of clinicians in both primary care and specialty mental health settings to adopt dimensional instruments on a routine basis [Duffy et al., 2008, Trivedi et al., 2006].
The articles mentioned hardly represent any groundswell for "dimensional" diagnoses. Two are from Dr. Regier himself and the other is from the STAR*D team – Dr. Trivedi, long obsessed with measurement based care. Like the Commentary, this response is heavily focused on the Dimensional Diagnosis concept.
By Robert L. Spitzer
July 02, 2009
Literally, on the next day, Dr. Spitzer weighed in, again commenting on the closed shop way things were proceeding. By this point, the field trials were eminent, yet no one outside the Task Force knew what was even being tested, or how. By July of 09, the DSM-V/5 Revision had moved from esoterica in the background to the front page; the APA and the DSM Task Force had become entrenched in a bunker mentality; and the rest of the world was about to enter the dialog…