A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences
Psychiatric Times
By Allen Frances, MD
June 26, 2009…The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now 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 1 biological test is ready for inclusion in the criteria sets for DSM-V…
So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality. Indeed, there has been only 1 paradigm shift in psychiatric diagnosis in the past 100 years—the DSM-III introduction in 1980 of operational criteria sets and the multiaxial system. With these methodological advances, DSM-III rescued psychiatric diagnosis from unreliability and the oblivion of irrelevancy. In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III and, at best, DSM-V could only hope to join them in making a modest contribution. Descriptive diagnosis is simply not equipped to carry us much further than it already has. The real paradigm shift will require an increase in our knowledge—not just a “rearrangement of the furniture” of the various descriptive possibilities.
Part of the exaggerated claim of a paradigm shift in DSM-V is based on the suggestion that it will be introducing dimensional ratings and that this will increase the precision of diagnosis. I am a big fan of dimensional diagnosis and wrote a paper promoting its use as early as 1982. Naturally, I had hoped to expand the role of dimensional diagnosis in DSM-IV but came to realize that busy clinicians do not have the time, training, or inclination to use dimensional ratings. Indeed, the dimensional components already built into the DSM system (ie, severity ratings of mild, moderate, and severe for every disorder and the Axis V Global Assessment of Functioning scale) are very often ignored. Including an ad hoc, untested, and complex dimensional system in an official nomenclature is premature and will likely lead to similar neglect and confusion…
Setting the Record Straight: A Response to Frances Commentary on DSM-V
Psychiatric Times
By Alan F. Schatzberg, James H. Scully Jr, David J. Kupfer, Darrel A. Regier
July 1, 2009
Dr Schatzberg is President of the American Psychiatric Association.
Dr Scully is Medical Director, CEO, of the American Psychiatric Association.
Dr Kupfer is Chair, DSM-V Task Force
Dr Regier is Vice Chair, DSM-V Task Force…The DSM-III categorical diagnoses with operational criteria were a major advance for our field, but they are now holding us back because the system has not kept up with current thinking. Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism. Science has advanced, treatments have advanced, and clinical practice has advanced since Dr. Frances’ work on DSM-IV. The DSM will become irrelevant if it does not change to reflect these advances.
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.
Both of the two main topics from Dr. Frances’ initial criticism above – the paradigm shift to a biological basis for the DSM-5 and their complex dimensional system – were totally abandoned along the way [for the reasons he foretold]. In addition, also along the way, the APA DSM-5 Task Force has managed to alienate almost every one of the non-medical mental health professions by looking at mental illness through the monocular lens of a subset of psychiatrist neuroscientists.
While I obviously agree with Dr. Frances’ perspective and did when he first started talking about it in 2009, the thing about the road behind that bothers me is not just their inappropriate insertion of the biological agenda into the DSM-5 revision, it’s what they didn’t do. As I’ve gone through the Clinical Trial literature over the last twenty-five years, it’s abundantly clear that the imprecision of the DSM-III+ has made a mess of the drug trials that underlie our psychopharmacology literature, particularly in depression. In practice, the majority of antidepressant prescriptions are written based simply on a patient’s report, "I’m depressed," not on a careful evaluation. Worse, even in situations where a patient is thoroughly examined, the existing category of Major Depressive Disorder is so broad and overly-inclusive that the best cohort possible is still unacceptably heterogeneous.
In adults, it includes Melancholic Depression, the depressive affect of people with personality disorders, situational depressions, the culturally deprived, the traumatized, etc. etc. In kids, it’s worse. I’ve never personally seen a depressed adolescent that didn’t have an apparent reason to be depressed – and it’s usually a reason that needed to be addressed. We all know that Major Depressive Disorder was a political creation [as historian Ed Shorter puts it], and yet nobody took it on as an area in need of the intense study it deserves. I sure don’t blame just psychiatry for the depression problem, though we certainly have played our role. Both the third party carriers [insurance] and the pharmaceutical industry have a major part in the depression game – both driven by money, not mental health. But it’s ours to fix, and I don’t even think the DSM-5 Task Force looked at it. They kvetch about the problem of not being able to map their drugs or their neuroscience findings on clinical diagnoses, but matching anything with that category is like matching long words with a bowl of soggy alphabet soup. That’s the loudest example, but there are many others.
Don’t forget the journals. Found this today:
... Ioannidis describes a nightmare scenario, “Planet F345, Andromeda Galaxy, Year 3045268? in which the entire process of science is distorted by numerous perverse incentives placed on researchers by dictatorial journal publishers and financial officers “recruited after successful careers as real estate agents, managers in supermarket chains, or employees in other corporate structures where they have proven that they can cut cost and make more money”.
From a distance, it’s sort of funny.
What are the primary defenses of cluster B subtypes in Axis 2 disorders? In order of what the APA seems to be practicing before, during, and well likely after DSM 5 is on the shelves: Denial, rationalization, projection, and minimization. Makes you wonder what are the requirements to be in leadership for organizations like the APA.
Sometimes you just have to acknowledge that the people on the other side of a discussion are both stupid and malevolent. That’s how Alan Schatzberg, James Scully, David Kupfer, and Darrel Regier come across in their vicious ad hominem attack on Dr. Frances and Dr. Spitzer. They have had over three years to reconsider and apologize for this self defeating blunder. Don’t hold your breath, anybody.
It was a vicious comment. It set a tone that any criticisms were going to be met with either silence or some contemptuous retaliation. They did it again in March 2012 in Time Magazine using an APA hired PR man, “Frances is a ‘dangerous’ man trying to undermine an earnest academic endeavor.” [see dangerous men…]…
It seems quite likely the APA has turned itself into a sort of business, to sell the DSM and promote pharmaceuticals for profit.
I recall the APA even filed a SLAPP suit to silence a blogger of the DSM5 revisions [1].
Lots of unpleasant things happened with the DSM5. There were Task Force members who resigned from the Board and went on various published journals to accuse the DSM-5 board of ‘Ignoring science” and increasing prescriptions [2]. The APA actually spent $25 million and put themselves $350,000 into a financial hole [3].
Marketing the DSM and promoting pharmaceuticals to gain funding from sponsors is the only way out of that hole.
A few months ago, I used the wayback machine (archive.org) to determine membership decline at the APA between 2001 and 2013.
The results were that membership declined from 40,500 in 2001 to 33,000 in 2013. The most significant changes were recent.
2010/Dec 7 38,000
2011/Nov 13 36,000
2012/Nov 19 36,000
2013/Jan24 33,000
2001-2002 represents the largest drop in membership, of -3.5k to ~37,000.
2007-2008 represents the largest gain in membership, of +3k to ~38,000.
2012-2013 represents the 2nd largest drop in membership, of -3k to 33,000
What is interesting is that the decline in the number of Psychiatrist physicians is almost twice the decline in APA membership. That numbers really add up.
Using the 35k remaining psychiatrists in the USA figure (2012), the decline of psychiatrist physicians is > 22% from 2003-2013 (45k to 35k), and an 11% decline in APA membership between 2003-2013.
Unless membership by the APA has been increasing worldwide, the APA must have 10% retired or non-psychiatrist members.
In any case, i wonder if psychiatry would benefit from getting rid of the APA altogether. I’m unsure if that would mean suicide for the field, or if it is an option psychiatry may want to consider. The profession has definitely been hijacked, and the APA has become an abomination.
It’s possible the APA will kill the field itself by worsening the progressive decline in recruitment.
[1] http://www.reportingonhealth.org/blogs/2012/02/29/slap-american-psychiatric-association-targets-one-dsm5-critic-ignores-others
[2] http://www.psychologytoday.com/blog/dsm5-in-distress/201207/two-who-resigned-dsm-5-explain-why
[3] http://www.psychologytoday.com/blog/dsm5-in-distress/201205/dsm-5-costs-25-million-putting-apa-in-financial-hole/
I thought these guys were supposed to be doctors!
They spend all their time classifying symptoms (and collections of symptoms), so they can justify their existence as a medical specialty.
If they spent a *fraction* of that (wasted) time learning about how to assess and treat the *underlying* causes of these symptoms, they could help people heal. –
http://psychoticdisorders.wordpress.com/bmj-best-practice-assessment-of-psychosis/
In the event the symptoms are caused by emotional distress, they are best treated by counselors, psychotherapists on the professioal-side, and peers, survivor groups on the non-professional side.
Doctors should be treating underlying *physiological* conditions.
… Is there a shrink anywhwere un this country who uses a stethoscope?
“Doctors”… Give me a break!
Duane
Psychiatrists need to begin to look beyond the brain for these root causes, particularly the thyroid, intestines, etc…
We *already have* doctors who are skilled at treating brain disorders.
They’re called *neurologists*!
Duane
For the record, the recently launched new APA webpages has this new figure of 33,000 membership on this page:
http://www.psychiatry.org/about-apa–psychiatry
“The American Psychiatric Association, founded in 1844, is the world’s largest psychiatric organization. It is a medical specialty society representing more than 33,000 psychiatric physicians from the United States and around the world…”
There are financial charts on Page 25 of this document:
http://www.nxtbook.com/nxtbooks/apa2/annualreport2011/#/24
The “APA Assembly Notes Spring 2012” are available, here:
http://alabamapsych.org/wp-content/uploads/2012/02/apa_assembly_notes_may_2012.pdf
Powerpoint slides, here, of finances:
“APA Treasurer’s Report May 2012” [.ppt compatible PowerPoint reader required]
https://docs.google.com/file/d/0BzWdENl1wkVSYk5aXzRZelFYUjA/edit?pli=1
Speck writes:
“I recall the APA even filed a SLAPP suit to silence a blogger of the DSM5 revisions [1].”
Still blogging, Speck, though under another domain.
This week on Psychiatric Times:
http://www.psychiatrictimes.com/blog/frances/content/article/10168/2128069
“Mislabeling Medical Illness As Mental Disorder” Allen Frances, MD, with Suzy Chapman
The “Somatic Symptom Disorder” issue was reported on, this week, by Keith Ablow,, MD, for Fox News Health:
http://www.foxnews.com/health/2013/02/14/does-somatic-symptom-disorder-really-exist/
“Does somatic symptom disorder really exist?”
Christopher Lane, on the SSD issue, at Side Effects, on Psycholgy Today:
http://www.psychologytoday.com/blog/side-effects/201302/dsm-5-has-gone-press-containing-major-scientific-gaffe
“DSM-5 Has Gone to Press Containing a Major Scientific Gaffe”
David J Kupfer, MD, DSM-5 Task Force Chair, defended the new SSD Dx, at Huff Po, on February 8:
http://www.huffingtonpost.com/david-j-kupfer-md/dsm-5_b_2648990.html
“Somatic Symptoms Criteria in DSM-5 Improve Diagnosis, Care”
@Suzy Chapman
Thank you for the additional references,
Glad to see you would not be silenced. Looks like you really put the screws to them.