DSM-5 Stubbornly Circles The Wagons Against Opposition From The Field

Aug 10, 2011

Bob Spitzer was prophetic 4 years ago when he warned that the closed DSM-5 process would lead to a flawed DSM-5 product. He advised the DSM-5 leadership to end its secrecy-- that a lack of openness would inevitably would lead to bad decisions not amenable to self-correction.

Bob Spitzer was prophetic 4 years ago when he warned that the closed DSM-5 process would lead to a flawed DSM-5 product. He advised the DSM-5 leadership to end its secrecy-- that a lack of openness would inevitably would lead to bad decisions not amenable to self-correction. Bob also warned that a noninclusive DSM-5 would eventually stimulate widespread opposition from the field.

The DSM-5 leadership shrugged off Bob's wise advice and dismissively claimed his would be a lonely voice of external criticism. Things certainly have not worked out this way. Time has conclusively proven 3 things: Bob's warnings were right on; DSM-5 has remained stubbornly dismissive of outside advice; and the result has been widespread opposition both to its process and its product.

As we approach the endgame, many of the DSM-5 Work Groups are in an unfortunate face off with the field they were meant to serve. They have circled the wagons to defend truly indefensible proposals against near universal outside opposition. I will highlight just the 3 most egregious examples:  

1. Personality Disorders: Without outside consultation, the Work Group developed an ad hoc, idiosyncratic, and  unworkably complicated dimensional system that is opposed by the entire body of outside experts in personality disorder diagnosis. The outside experts have made their implacable opposition known in letters to the DSM-5 Work Group and in numerous publications. In response to this outcry, the Work Group has made only small and meaningless changes-- completely missed the glaring point that their complex and byzantine system is simply unsuitable for clinical practice.

2. "Psychosis risk"(AKA "attenuated psychotic symptoms") is another case of DSM-5 stubbornly holding out against the world. There has always been considerable opposition to its premature inclusion in DSM-5-- even among researchers who have devoted their careers to studying it (see www.medscape.com/viewarticle/727682 and the August 2011 issue of the American Journal of Psychiatry). The nail in the coffin occurred last month when the world's 2 leading experts on "psychosis risk"-- Patrick McGorry and Alison Yung-- publicly withdrew their support for its inclusion in DSM-5. But this vampire refuses to die and still seems fated for inclusion in DSM-5.
 
3. The Work Group on sex disorders was badly constituted from the outset--its leadership comes from the one research group that has performed the very few studies ever done on paraphilia. With such idiosyncratic beginnings, it is not surprising that the Group came up with 3 unsupportable suggestions- "coercive paraphilia," "hypersexuality," and "hebephilia." They have finally come to their senses and dropped the first 2, but are clinging stubbornly to "hebephilia" despite near unanimous outside opposition. At the annual meeting of the American Association of Psychiatry and Law, forensic psychiatrists took a straw vote on "hebephilia"-- 31 to 2 against. A straw vote at the International Association for the Treatment of Sexual Offenders was 100 to 1 against. How long can the Work Group hold out?

These are only the most obvious examples of ingrown DSM-5 deafness and intransigence to outside voices attempting to protect it from risky decisions. This deadlock with the field never would not have occurred had the DSM-5 leadership followed Bob Spitzer's original advice to keep everything open and inclusive. It is now very late in the DSM-5 day-- but hopefully not too late.

The DSM-5 Work Groups must finally learn the obvious lesson-- if the rest of the world is against your idea, maybe it is not such a good idea (or at least it is premature). Drop it for this revision and get on with all the other work that needs to be done to produce a usable DSM-5.

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