Psychiatrists may be more reluctant than are other mental health clinicians to sign a petition questioning the safety and value of DSM-5. After all, it is the American Psychiatric Association that is sponsoring DSM-5 and there is a natural tendency to want to trust the wisdom of one’s own Association. We also tend to feel the greatest loyalty to our profession when it seems to be under sharp attack from without.
All this is completely understandable to me. I have not felt the least bit comfortable assuming the role fate assigned me as critic of DSM-5 and of the APA. It was a case of responsibility calling and my feeling compelled to answer. If DSM-5 were not proposing some really dangerous changes, I would have stayed comfortably on the sidelines. But I think DSM-5 is too risky to ignore and that all psychiatrists should feel the same call that I did to restrain it before it is too late.
What needs top be done to get a safe and credible DSM-5? Clearly, an independent review is needed to evaluate about a dozen of the most radical DSM-5 proposals—the ones that are bad for patients and bad for the credibility of APA and psychiatry. The petition urges that APA to take the necessary step of reevaluating the most questionable proposals before they are set in stone. The APA’s own internal review process has failed to be rigorous or independent enough to convince anyone outside of the small (and out of touch) circle of the DSM-5 and APA leadership.
Here are some of the issues that scare me about DSM-5 and I think should also scare you:
1) DSM-5 is suggesting many new and untested diagnoses and also markedly reduced thresholds for old ones. This will result in inaccurate diagnosis, massive diagnostic inflation, unnecessary stigma, harmful misuse of medications, and misallocation of resources.
2) Overprescription of psychotropic medications (particularly by primary care physicians) is already out of control. Remarkably, antipsychotics have become the number one revenue producer of all classes of drugs. Antidepressants are fourth and antianxiety meds are eighth. 11% of the population are on antidepressants; 4% of kids are on stimulants. There are now more ER visits for overdoses with prescription meds than with street drugs. Most of the prescribing is done by primary care docs who have little training, no time, and are susceptible to drug company ‘education’ and patient pressure. Psychiatrists must take the lead in advocating for more careful diagnosis and responsible prescribing habits. The DSM-5 suggestions all go in just the wrong direction of promoting loose diagnosis and loose prescribing.
3) DSM-5 has been sloppily organized and wastefully done. Every single deadline has been badly missed—leading to a mad rush at the end. The field trials will cost APA several million wasted dollars and will yield no useful information. The scientific review has been cursory and has no credibility. The extended persistence of really foolish suggestions is a great embarrassment to DSM-5 and to APA.
4) The APA leadership has been passive and unresponsive to warnings that DSM-5 has been running off the rails. They will awake from their leaden stupor and take responsible fiduciary action only under pressure from the membership.
You may be asking yourself—how could Frances possibly be right and all those DSM-5 experts be so wrong? The answer is simple. The people preparing DSM-5 are well meaning, smart, and expert in their highly specialized fields—but they are mostly ivory tower research types who have not had much real world clinical experience and don’t understand what will be the unintended consequences of their DSM-5 suggestions. Bob Spitzer and I have been through the mill with DSM III, DSM IIIR, and DSM IV and know what are the pitfalls and dangers—because we have lived through them. DSM-5 has been running blindly into a whole series of unnecessary minefields and is paying a heavy price for its inability to chart a safe course.
Here is the worst example among many bad DSM-5 suggestions for new diagnoses (indeed, this is the one that got me alarmed enough to speak up 2 years ago). ‘Attenuated psychosis syndrome’ will have a ridiculously high false positive rate ( 80-90%), no effective treatment, would promote unnecessary exposure to harmful antipsychotics, and would cause needless worry and stigma. Since studies prove conclusively that the symptoms are so very rarely predictive of psychosis, why in the world would DSM-5 give someone the stigmatizing and absurdly misleading label ‘attenuated psychosis syndrome’ and open the door to inappropriate antipsychotic use. Recognizing all these risks, a large portion of schizophrenia and prodromal researchers are sensibly opposed to the inclusion of ‘attenuated psychosis syndrome’ in DSM-5. But unaccountably, the work group stubbornly clings to its proposal and, without the petition, there is a good chance it may sneak into DSM-5.
This one really dreadful proposal should be enough to motivate your signing the petition, but there are a dozen more that are almost as frightening. And the other DSM-5 workgroups have been equally intransigent in defending proposals that are almost equally indefensible.
I am just one among many, many psychiatrists who fear the negative impact of a misguided DSM-5 on our patients and profession. The Society Of Biological Psychiatry published an editorial suggesting DSM-5 be scrapped. All psychiatrists who care about personality disorders are appalled by the DSM-5 personality disorders section. And here is a telling statement made by James Dillon, MD, as he was signing the DSM-5 petition—“I am the chief psychiatrist in the Department of Community Health for Michigan . . . I will be discussing with my colleagues the merit of abandoning the DSM altogether in favor of the ICD system if DSM-5, as currently proposed (It is November 2011), is formally adopted.” The APA leadership must hear from the members it is supposed to represent just how alarmed they are by the reckless DSM-5 proposals and the embarrassment they are causing our field.
What are the risks to DSM-5 and to APA if DSM-5 is not reformed? Unless corrected, DSM-5 will be bad for patent care, may cost APA stewardship of future DSM revisions, and will do grave harm to the credibility of APA and psychiatry. The APA leadership has been asleep at the wheel and should never have allowed DSM-5 to become such a public embarrassment.
But what is the most compelling reason for signing the petition to reform DSM-5? This is easy. Our first responsibility as physicians is to DO NO HARM!!! DSM-5 will do grave harm to the people who are misdiagnosed and then often receive unnecessary medication (especially the widely overprecribed antipsychotics that can cause such dangerous weight gains).
On a personal note, I was enjoying a peaceful and happy beach retirement and had several times resisted Bob Spitzer’s early entreaties to join him in pointing out that DSM-5 was headed for serious trouble. I saw it as Bob’s fight, not mine. Only years later was I forced to speak when it became clear that the harm caused by DSM-5 was too egregious to ignore. I have complete empathy for anyone who prefers the sidelines—I’d like to be there myself. But this one is not a close call and it is important that we all do the right thing for our patients and for psychiatry.
The petition can be accessed at: http://www.ipetitions.com/petition/dsm5/.
