1 Boring Old Man

APA Should Delay Publication Of DSM-5
Pschiatric Times
By Allen Frances, MD
January 31, 2012

^{My three criticisms of DSM-5 have been:}

1. risky suggestions;
2. bad writing;
3. poor planning and disorganization.

^{I have pretty much failed to have any real impact other than perhaps getting APA to delay publication from May 2012 to May 2013. The one-year extension was wasted, the risky suggestions and bad writing remain, and my constant warnings that missed deadlines would lead to a mad and careless race at the end were ignored. With less than a year remaining before DSM-5 is scheduled to go to print, the signs are clear that it cannot possibly be completed on time unless we are willing to settle for a third rate product. The unmistakable red flag is the recent embarrassing admission that DSM-5 will accept diagnoses that achieve reliabilities as unbelievably low as 0.2-0.4 [barely beating the level of chance agreement two monkeys could achieve throwing darts at a diagnostic board]. This dramatic departure from the much higher standards of previous DSM’s is a sure tip-off that many DSM-5 proposals must be failing to achieve adequate diagnostic agreement in the much delayed and yet to be reported field trials. Unable to meet expected standards, the DSM-5 Task Force is drastically and desperately trying to lower our expectations…}

^{The wise, safe, and responsible thing for APA to do now is to delay publication of DSM-5 until the missing second stage of rewriting and retesting can be completed. The wordings that do poorly in the first stage of field testing should be rewritten to finally attain the clarity and consistency necessary in an official manual of psychiatric diagnosis. The newly revised (and hopefully final) versions should then undergo the second stage of field testing as originally envisaged to ensure that they now work. The extra time will also allow for the independent scientific reviews of controversial DSM-5 proposals called for in a petition that has already been signed by more than 11,000 mental health professionals and is endorsed by 40 professional organizations (including many divisions of the American Psychological Association, the American Counseling Association, and the British Psychological Society)…}

^{… The May 2013 publication date appears to be completely unrealistic unless we are to settle for a DSM-5 so poorly done that its reliabilities will return us to the dark ages of DSM II. DSM-5 is in a very deep hole with very few remaining options. My recommendations:}

1. Make the publication date flexible and contingent on delivery of a quality product that the field can trust;
2. Subject the current drafts and texts to extensive editing for clarity and consistency;
3. Drop the controversial suggestions that risk harmful unintended consequences or at least subject them to external scientific review;
4. Have the rewritten drafts reviewed word for word by many experts in the clinical, research, and forensic uses of DSM-5;
5. Field test again to make sure the new versions work adequately.

^{One last point. Many critics use the obvious failures of DSM-5 as justification to attack psychiatry as a whole. I strongly disagree. DSM-5 is no more than an unfortunate aberration reflecting the temporary state of weak and misguided APA leadership. The work on DSM-5 went off track because of unrealizable ambitions; a closed and secretive process; and insufficient attention to the day to day details of prudent planning, efficient organization, and careful writing. Because of its poor performance on DSM-5, APA has probably forfeited its right to sole control of future revisions. But all this represents only the specific failure of DSM-5, not a general reflection on what psychiatry is and what it can accomplish. Done well and within its reasonable limits, psychiatry is an extremely helpful, indeed essential profession. It would be a shame to throw the valuable baby out with the bath water or discourage patients from getting the psychiatric help they need and can benefit from. Admittedly, DSM-5 is an embarrassment and a serious hit to our credibility, but we will recover and our patients should not lose faith.}

I worked in the clinics today. In the morning, I saw adults – a lot of them. I had three patients where the central issue was unrecognized anti-depressant withdrawal syndromes. I had three patients who’d been told to they were "bipolar" [who weren’t]. I had a patient who had been labeled a drug seeking "character disorder." He was, instead, a 49 year old guy who had been thrown through a car window in a wreck at age six, been in a coma for six months, been passed through the seventh grade in Special Education [social promotion], and could sort of read using his finger, one word at a time [all the short words]. He’s never worked ["can’t be still"] and lives with aging parents worrying about what he’ll do when they are gone. Given the scrambled brain he lives with, I thought he was doing the best he could. It was that kind of morning – frustrations. In the afternoon, I was at a children’s clinic – doing ADHD med checks, arguing with Medicaid providers, the stuff of modern medicine that I do as a volunteer [but wouldn’t do if paid]. My last patient was an adult, a woman with persistent PTSD from a terrible event eight years ago that involved the death of her son. The tension of undoing bad diagnoses and bad treatments all day just disappeared as I talked to this woman about her illness, something I know about. I felt like a doctor instead of someone putting out brush fires, a case-worker in a social agency, or a med-check doctor. As one of my patients once quipped, "I felt my efficacy."

On the way home, I was thinking about why I’m at volunteer clinics in my retirement doing things I refused to have anything to do with as a practitioner – talking to some young guy working for Medicaid Managed Care getting "pre-cert" for medication, calling Social Security Disability about Mr. non-character-disorder’s real diagnosis, talking to a special ed teacher about a school plan for a teenager with a crippling social phobia who was in trouble for truancy [rather than being "served" by the school system]. It’s not that such things aren’t needed – the need is yawning. But why me? There are several reasons I do it. One is if I don’t, it won’t get done. But another is that there’s never a clinic day when I don’t see one or more people who help me remember why I did this in the first place – like the lady with PTSD. And there’s never a day when I don’t see some case that’s being mis-managed or mis-diagnosed, and I can get things on a better track. But an important side effect is that these clinic days are an antidote to reading and writing in this blog about the DSM-5 Task Force, or the Pharmaceutical intrusions into academia, or the "weak and misguided APA leadership", or the overvaluing of some dreamed-of future for "clinical neuroscience", or the insightful but painful truths in Dr. Healy’s Pharmageddon.