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TO: The DSM-5 Task Force
FROM: 1boringoldman
RE: The DSM-5 Revisions
The APA’s responses to criticisms of the DSM-5 Task Force have changed over the last several years. The 2009 article [Setting the Record Straight: A Response to Frances Commentary on DSM-V] was a contentious ad hominem attack on the motives of their critics, Drs. Allen Frances and Robert Spitzer, who guided the previous revisions. Since then, cooler heads have prevailed. In both their response to the Society for Humanistic Psychology and the American Counseling Association, they’ve been more polite, launching into extensive descriptions of the processes followed by the Task Force. They seem to think that their critics just don’t understand, that the complaints that the Task Force is running a closed shop dominated by idiosyncratic views of mental illness are unfounded. They reassure us that they are indeed listening to what others are saying about their work and the repeated calls for an independent external review are unnecessary. While this improvement in tone is a welcome change, the problem remains. They are running a closed shop dominated by idiosyncratic views of mental illness – politely.
There has yet to be any sign from the American Psychiatric Association or its DSM-5 Task Force that they recognize that the criticisms aren’t directed at their processes or bred from a misunderstanding that can be cleared up by explanation. The criticisms are a vote of "no confidence" in the whole enterprise in its current form. And while there are abundant criticisms of specific changes proposed by the various Work Groups, things like the Attenuated Psychosis Syndrome or Disruptive Mood Dysregulation Disorder, the major complaint transcends these details. It’s not the critics who don’t understand, it’s the Task Force itself. And the request for external reviews are not based solely on a view of the existing DSM-5 internal workings. They arise from the general impression that the DSM-5 Task Force seems unable to see itself as others see it – to be self-reflective, even in the face of a growing outcry from most quarters. The people in charge said earlier:
Their dream was not realized, but they are proceeding as if it had been, or that it will be in short order. They are constructing the DSM-5 around that particular medical/biological view of mental illness. In their responses, they claim to be basing their "new disorders" on evidence and research, but their critics don’t buy that without seeing the evidence they’re talking about. I don’t either, by the way. Reassurances that they really have that evidence haven’t seemed to comfort anyone.
If they are basing their revisions on "external, empirical indicators," let’s hear about them. What we suspect is that they’ve simply replaced the "psychodynamic, a priori hypotheses" with some "neuroscientific, a priori hypotheses" of their own and that many of the changes fit the agenda of certain members of the committee and aren’t based on "external, empirical indicators" at all. At least that’s what I suspect.
There are two kinds of authority. Delegated authority is the weaker. "We do it my way because I’m a sergeant [supervisor, boss, king] and you’re a private [trainee, employee, subject]." It’s a kind of authority based on power and sometimes fear. There’s another kind of authority, as in "Einstein was an authority on physics." It’s an authority of knowledge, or wisdom, or experience – an authority based on earned respect. The DSM-5 Task Force speaks as if it has an authority to define the classification of mental illnesses because the APA [American Psychiatric Association] appointed them to the job. What they should be learning right now is that the power that once resided with the body of Psychiatry has eroded – in part because of the changes in mental health care and the rise of other disciplines, but also because of gross instances of misbehavior within psychiatry itself. Another obvious lesson is that the authority of wisdom or respect is something the DSM-5 Task Force is going to have to earn. It’s not the given they are assuming in either dimension.
Here, Kupfer and Regier criticize the DSM-III and DSM-IV, but try as I might, I can’t see how the revisions they propose relate to these criticisms. Instead of working to make the diagnostic entities more precise, if anything, they’ve loosened them and included some new ambiguous categories that just add to the confusion.
The DSM-5 Task Force can continue on its current trajectory and create the idiosyncratic document they seem dead set on creating. I expect that’s the most likely course. And no one will use it, no one except the small number of psychiatrists who are like minded with its creators. Everyone else will use the ICD [International Classification of Disease]. And maybe that’s the way things ought to proceed. I don’t personally care. But I think that outcome will simply postpone the inevitable. Neuroscience came into its own in the time of the DSM-III. Since then, the emphasis has been on the "neuro-". Anything "neuro-" is good. Other things are superfluous. The "-science" part has been corrupted in unimaginable and embarrassing ways. It’s time to emphasize the "-science" in "neuroscience." That’s what Allen Frances, the psychologists, and the counselors are asking for – "Show us the evidence" for the Attenuated Psychosis Syndrome or Disruptive Mood Dysregulation Disorder. If it’s truly science, you ought to be able to show it to us just like any other scientist is asked to produce the data for assertions. Otherwise, it’s just opinion or hypothesis. If the DSM-5 Task Force continues to assume that their delegated authority is all they need, they will not be considered scientists – no matter what they say. And the whole original point of the DSM-III revision will disappear, and ultimately the DSM-5 along with it. That will be a shame, because neuroscience belongs in clinical psychiatry, but not without scientific integrity and the requested transparency.
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