A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences

By Allen Frances, MD | June 26, 2009

Dr Frances was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

For more on the DSM-V debate also visit www.newscientist.com

I have little confidence that the DSM-V leadership will do the kind of careful risk-benefit analysis of each proposed change that is necessary to avoid damaging unintended consequences.

My concerns arise from the following:

• Their ambition to achieve a paradigm shift when there is no scientific basis for one.

• Their failure to provide clear methodological guidelines on the level of empirical support required for changes.

• Their lack of openness to wide scrutiny and useful criticism.

• Their inability to spot the obvious dangers in most of their current proposals.

• Their failure to set and meet clear timelines.

• The likelihood that time pressure will soon lead to an unconsidered rush of last-minute decisions.

This is the first time I have felt the need to make any comments on DSM-V. Even when the early steps in the DSM-V process seemed excessively ambitious, secretive, and disorganized, I hoped that I could avoid involvement and believed that my successors deserved a clear field. My unduly optimistic assumption was that the initial problems of secrecy and lack of explicitness would self-correct and that excessive ambitions would be moderated by experience. I have decided to write this commentary now only because time is running out and I fear that DSM-V is continuing to veer badly off course and with no prospect of spontaneous internal correction. It is my responsibility to make my worries known before it is too late to act on them.

What is needed now is a profound midterm correction toward greater openness, conservatism, and methodological rigor. I would thus suggest that the trustees of the American Psychiatric Association establish an external review committee to study the progress of the current work on DSM-V and make recommendations for its future direction.

Visit Psychiatric Times' DSM-V Topic Center for the latest articles, blogs, and resources

Pages: 1 2 3 4

by Ulrik Fredrik Malt | February 07, 2011 12:50 AM EST

Being responsible for training of Norwegian psychiatrists in diagnostic assessments (with the help of MINI), I agree with the comments from Frances. Many psychiatrists apply diagnostic labels rather uncritically even when they administer interviews. They do not challenge the validity of "yes"or "no" answers, but take them at face value. Whenever new diagnostic categories are added, they will automatically be used, valid or not. Before making major changes to the current classification systems (ICD-11, DSM-IV), we need more data.

Ulrik Fredrik Malt,

Professor of Psychiatry, University of Oslo, Norway

by Michael Lehman | January 18, 2011 8:23 PM EST

My cousin, who was diagnosed as a schizophrenic, spent 15 to 20 years at the Arizona State Institution in Flagstaff before being rediagnosed as bi-polar. What a waste. And shame on the doctors who made an "easy" diagnosis rather than the correct one. Just before her release it took one gutsy professional to challange the original findings. But all of those years the rest just let it slide.

Follow the DSM Debate

Alert to the Research Community—Be Prepared to Weigh in on DSM-V

Setting the Record Straight: A Response to Frances Commentary on DSM-V

A Response to the Charge of Financial Motivation

Criticism vs Fact: A Response To A Warning Sign on the Road to DSM-V by Allen Frances, MD

Dr Frances Responds to Dr Carpenter: A Sharp Difference of Opinion

Advice to DSM-V . . . Change Deadlines and Text, Keep Criteria Stable

Advice to DSM-V: Integrate with ICD-11

Coming Along With the DSM-5: Hybrid Models of Psychiatric Diagnosis

References

1. Frances AJ, Widiger TA, Pincus HA. The development of DSM-IV. Arch Gen Psychiatry. 1989;46:373-375.
2. Frances A, Pincus HA, Widiger TA, et al. DSM-IV: work in progress. Am J Psychiatry.1990;147:1439-1448.
3. Widiger TA, Frances AJ, Pincus HA, et al. Toward an empirical classification for the DSM-IV. J Abnorm Psychol. 1991;100:280-288.
4. Widiger TA, Trull TJ. The scholarly development of DSM-IV. In: Costa e Silva JA, Nadelson CC, eds. International Review of Psychiatry. Vol 1. Washington, DC: American Psychiatric Press; 1993:59-78.
5. First MB, Vettorello N, Frances AJ, Pincus HA. Changes in mood, anxiety, and personality disorders. Hosp Community Psychiatry. 1993;44:1034-1036, 1043.
6. Widiger TA, Frances AJ, Pincus HA, Davis WW. DSM-IV literature reviews: rationale, process, and limitations. J Psychopathol Behav Assess. 1990;12:189-202.
7. Frances AJ, First MB, Widiger TA, et al. An A to Z guide to DSM-IV conundrums. J Abnorm Psychol. 1991;100:407-412.
8. Widiger TA, Frances AJ, Pincus HA, et al. Toward an empirical classification for the DSM-IV. J Abnorm Psychol. 1991;100:280-288.
9. Kline M, Sydnor-Greenberg N, Davis WW, et al. Using field trials to evaluate proposed changes in DSM diagnostic criteria. Hosp Community Psychiatry. 1993;44:621-623.
10. Task Force on DSM-IV. DSM-IV Options Book: Work in Progress. Washington, DC: American Psychiatric Association; 1991.
11. Widiger TA, Frances AJ, Pincus HA, et al. DSM-IV Sourcebook. Vol 1. Washington, DC: American Psychiatric Association; 1994.
12. Widiger TA, Frances AJ, Pincus HA, et al, eds. DSM-IV Sourcebook. Vol 2. Washington, DC: American Psychiatric Association; 1996.
13. Widiger TA, Frances AJ, Pincus HA, et al, eds. DSM-IV Sourcebook. Vol 3. Washington, DC: American Psychiatric Association; 1997.
14. Widiger TA, Frances AJ, Pincus HA, et al, eds. DSM-IV Sourcebook. Vol 4. Washington, DC: American Psychiatric Association; 1998.
15. Spitzer RL, Williams JB, Skodol AE. DSM-III: the major achievements and an overview. Am J Psychiatry. 1980;137:151-164.
16. Klerman GL. The significance of DSM-IIIin American psychiatry. In: Spitzer RL, Williams JB, Skodol AE, eds. International Perspectives on DSM-III. Washington, DC: American Psychiatric Press; 1983:3-26.
17. Frances AJ. Categorical and dimensional systems of personality diagnosis: a comparison. Compr Psychiatry. 1982;23:516-527.
18. Frances AJ. Dimensional diagnosis of personality—not whether, but when and which. Psychological Inquiry. 1993;4:110-111.
19. Zimmerman M. Why are we rushing to publish DSM-IV? Arch Gen Psychiatry. 1988;45:1135-1138.
20. Regier DA, Kaelber CT, Rae DS, et al. Limitations of diagnostic criteria and assessment instruments for mental disorders. Implications for research and policy. Arch Gen Psychiatry. 1998;55:109-115.
21. Volkmar FR, Klin A, Siegel B, et al. Field trial for autistic disorder in DSM-IV. Am J Psychiatry. 1994;151:1361-1367.
22. Lahey BB. DSM-IV field trials for oppositional defiant disorder and conduct disorder in children and adolescents. In: Widiger TA, Frances AJ, Pincus HA, et al, eds. DSM-IV Sourcebook. Vol 4. Washington, DC: American Psychiatric Association; 1998:661-686.
23. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961;265:885-892.
24. Green LA, Fryer GE Jr, Yawn BP, et al. The ecology of medical care revisited. N Engl J Med. 2001;443: 2021-2025.
25. First MB, Frances A. Issues for DSM-V: unintended consequences of small changes: the case of paraphilias [published correction appears in Am J Psychiatry. 2008;165:1495]. Am J Psychiatry. 2008;165: 1240-1241.
26. Roen S. Psychiatrists rewriting the mental health bible. Los Angeles Times. May 26, 2009. http://www.latimes.com/news/nationworld/nation/la-sci-mental-disorder26-2009may26,0,3081443.story. Accessed June 24, 2009.
27. Spitzer RL. DSM-V: open and transparent? Psychiatr News. 2008;43(14):26.
28. Carey B. Psychiatrists revise the book of human troubles. New York Times. December 18, 2008. http://www.nytimes.com/2008/12/18/health/18psych.html. Accessed June 24, 2009.
29. Grossman R. Psychiatric manual’s update needs openness, not secrecy, critics say. Chicago Tribune. December 29, 2008. http://www.ajc.com/services/ content/health/stories/2008/12/29/mental_manual_critics.html. Accessed June 24, 2009.
30. Lane C. Wrangling over psychiatry’s bible. Los Angeles Times. November 16, 2008. http://www.latimes.com/news/opinion/commentary/la-oe-lane16-2008nov16,0,5678764.story. Accessed June 24, 2009.

FROM PHYSICIANS PRACTICE

Primary Care Can't Thrive Without Nurse Practitioners
Courtney H. Lyder, ND, May 17, 2013
With a projected shortfall of primary-care physicians, it's time for alternate solutions to patient care. Nurse practitioners are one logical remedy.

VWhat Physicians Can Learn from the Allscripts EHR Lawsuit
Marisa Torrieri, May 16, 2013
Lawsuit prompts question: What should physicians do to ensure they end up with a great EHR instead of buyer’s remorse?

Eight Ways ICD-9 Will Still Matter to Medical Practices
Brenda Edwards, CPC, May 15, 2013
What should your medical practice do with your ICD-9-CM book after October 1, 2014? Keep it.

Seven Ways Technology Can Speed Up Patient Collections
Cheyenne Brinson, May 15, 2013
Failing to adopt widely available billing and collections technology can cost medical practices big. Here's how to do it right.

Four Reasons Private Medical Practice is Becoming Extinct
Carol Stryker, May 15, 2013
It’s becoming increasingly difficult for private medical practices to thrive. Here’s what’s driving the trend toward consolidation.

A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences

Join the Conversation