I sent the letter to the Trustees of the APA on April 8, 2010. It contains an urgent plea that the Trustees move immediately to correct the increasingly wayward course of DSM5. The DSM5 Task Force is about to begin a field trial that is a complete mistake:
1. It is unnecessarily expensive (a self-financed $2.5 million or more).
2. It is unnecessarily complicated and will cause additional delays.
3. It fails to address the most important questions concerning the impact of proposed DSM5 changes on prevalence rates and on false-positive diagnoses.
4. It is so poorly designed that the results are very likely to discredit psychiatric diagnosis.
I write directly to you now because this may be a last chance tipping point to save DSM5—and because the APA leadership has so far proved itself consistently unable to provide adequate supervision. You need to be informed of the many crippling DSM5 problems before it will be too late for you to influence your leaders to take the decisive actions needed to solve them.
Nine months ago, Dr Robert Spitzer and I wrote to alert you that DSM5 had gone badly off track. We warned that its process was unsupervised, poorly planned, secretive, disorganized, and was falling far behind schedule. You took the appropriate steps of appointing an Oversight Committee and delaying for 1 year the target dates for field trials and for the publication of DSM5.
Unfortunately, this extra year is being used very inefficiently and a major disaster lurks just ahead. The first DSM5 draft is of surprisingly poor quality, making it questionable whether a usable manual can emerge even within the expanded time line. And the news gets worse. The recently posted plans for field trials are a prescription for disaster. The project will cost a fortune, cause further delays, ask the wrong questions, and produce embarrassing results.
If you are to save the day, you must first fully understand just how serious the defects are in the DSM5 products and future plans:
1. By now, the criteria sets should have been carefully edited to ensure complete clarity and consistency. Inexplicably, after all this time, they remain in a rough and disorganized state, not close to being fit for the field testing that is about to begin. DSM5 urgently needs a thorough and painstaking editing that will eliminate all its many errors, ambiguities, and inconsistencies. It is apparent that no one working on DSM5 knows how to write or edit clean criteria. [Editor’s Note: Please see “The DSM5 Draft: Can the Poor Writing Be Salvaged?” which is posted on the DSM5 section of www.psychiatrictimes.com.]
2. The failure to do any risk/benefit analysis has allowed the survival of many quite far out suggestions that would cause disastrous unintended consequences. These are an ongoing distraction and put DSM5 and the field in a bad light. The worst of the proposals should have been eliminated much earlier and should be washed out now. [Please see “The Missing Risk/Benefit Analyses for DSM5” on our Web site.]
3. The failure to do a forensic review has allowed the survival of a number of changes that will create nightmares for forensic psychiatrists and for the legal system. [Please see www.jaapl.org/cgi/content/full/38/1/11.]
4. Everything about the proposed DSM5 field trial design is completely wrongheaded. The project is shockingly overpriced (my guess is at least between $2 and $3 million). It creates an unnecessarily complex logistic quagmire (3000 subjects, 3 assessments per subject, 10 different centers with 10 different IRBS, 3 separate clinicians involved in the evaluations, videotaping 20% of the interviews, etc) If the field trials get very far behind schedule (trust me, they definitely will), the APA will likely yet again be forced to delay publication of DSM5. But worst of all, the field trial is a risky red herring that will answer a question that nobody is raising—ie, what is the reliability of psychiatric diagnosis? As Dr Kupfer himself stated (in his 2008 article “On the Road to DSM-V and ICD-11” in the European Archives of Psychiatry and Clinical Neuroscience), “The reliability of DSM as a clinical tool has been upheld but less emphasis has been given to its validity.”
The DSM5 field trial design will unnecessarily reopen the reliability question and come up with an embarrassing answer—low reliabilities caused by its unfocused design and ambiguously written criteria sets. Meanwhile, the questions that do count have been completely ignored—ie, what are the effects of DSM5 changes on rates, false positives, and diagnostic validity? The failure to include comparisons with DSM-IV makes it impossible to know what impact the changes will have on caseness and prevalence. The failure to do these assessments in nonclinical populations (which could be done by telephone in an inexpensive random-digit-dialing paradigm) makes it impossible to assess the risk of false positives.
1. Rettew DC, Lynch AD, Achenbach TM, et al. Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews. Int J Methods Psychiatr Res.2009;18:169-184.