April 8, 2010
Board of Trustees
American Psychiatric Association
1000 Wilson Blvd.
Suite 1825
Arlington, VA 22209
Dear Trustees:
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 timeline. 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 are the defects in the DSM5 products and future plans:
| Attachments to this letter: • The DSM Draft: Can the Poor Writing be Salvaged? • The Missing Risk/Benefit Analyses for DSM5 |
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 (see attachment 1).
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 (see attachment 2).
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.
4. Everything about the proposed DSM5 field trial design is completely wrongheaded. The project is shockingly overpriced (my guess is at least between $2-3 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), APA will likely yet again be forced again 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, the reliability of psychiatric diagnosis. As Dr Kupfer himself stated (in On the Road to DSM-5 and ICD-11), “The reliability of DSM as a clinical tool has been upheld but less emphasis has been given to its validity."
