We have already gone past the midway point of the time allotted for the preparation of DSM-V. I realized that not enough has been accomplished and that most of what is being suggested is headed in a very wrong direction. Particularly troubling is the almost total lack of recognition that changes in an official manual of diagnosis can have devastating unintended consequences. Before it is too late, I feel a responsibility to help DSM-V avoid mistakes by sharing the lessons learned during the past 30 years working on the 3 previous revisions of the DSM. Perhaps my comments may help the DSM-V Task Force avoid some of the hidden landmines I think they are dancing around.
Q: This is the first time you have commented on DSM-V. Why did you decide to speak up now?
A: We have already gone past the midway point of the time allotted for the preparation of DSM-V. I realized that not enough has been accomplished and that most of what is being suggested is headed in a very wrong direction. Particularly troubling is the almost total lack of recognition that changes in an official manual of diagnosis can have devastating unintended consequences. Before it is too late, I feel a responsibility to help DSM-V avoid mistakes by sharing the lessons learned during the past 30 years working on the 3 previous revisions of the DSM. Perhaps my comments may help the DSM-V Task Force avoid some of the hidden landmines I think they are dancing around.
Q: In your opinion, what has gone wrong in the DSM-V process?
A: The most fundamental errors have been its completely inexplicable secrecy and the lack of openness to outside influence and criticism. I simply can’t recall a single moment of work on the DSM-III, DSM-III-R, or DSM-IV when there was anything remotely worth keeping secret. Restricting the free flow of ideas creates enormous blind spots that greatly increase the risk of damaging unintended consequences. Specifically, it was a huge mistake to require that the DSM-V work group members sign a confidentiality agreement. It was also unwise to avoid having any institutional memory of how and why decisions were made in prior revisions. The advisory group is far too small and select to reduce, rather than encourage, heated debate. In producing a new edition of the DSM, your harshest critics eventually turn out to be your best friends because they are most likely to help you avoid pitfalls. My own highly critical comments on DSM-V are offered, and I hope will be taken, in this spirit.
Q: What are the risks you are so concerned about?
A: The work on DSM-V suffers from the unfortunate combination of being heavy on ambitious goals for change and light on the methodological rigor necessary to avoid the many problems that such change may cause once the system is in wide use. Unless DSM-V changes course dramatically, it will introduce numerous new, relatively untested categories that will greatly jack up the rates of mental disorders. Many people will be inappropriately identified as mentally ill and will receive excessive treatment. The pharmaceutical industry will have a field day. Two necessary forms of protection should have been established to prevent this: (1) a requirement that all changes be supported by a high threshold of systematically gathered empirical evidence, and (2) a careful risk-benefit analysis of the potential negative impact of each and every change.
Q: Is it too late to get DSM-V back on track in time for its scheduled publication date?
A: I am afraid it might well be. DSM-V is projected to be published in May 2012. That means it has to be finalized by late 2011. My experience with DSM-IV tells me that this is an unrealistic timeline-given the enormous amount of work that remains to be done and how little has been accomplished to date. If the publication deadline is not postponed, the result will likely be a very sloppy DSM-V with lots of unfortunate, post-publication surprises.
Q: How do you think those who are working on DSM-V will react to your comments?
A: I expect the DSM-V leadership will react defensively, just as they have to all past criticisms by others. They will probably claim that the DSM-V process is open, innovative, on time, and evidence-based and has all the safeguards needed to avoid the risks I am warning about. I don’t think they realize the problems they are about to create, nor are they flexible enough to change course. I do hope for a much more open hearing and a positive reaction from the DSM-V Task Force and work group members. Perhaps they will succeed in bringing more caution and transparency to future DSM-V decisions.
Q: How much impact on DSM-V do you expect your intervention to have?
A: It is hard to say-but I would guess probably not much. The closed, tightly controlled, and inflexible structure of DSM-V has so far prevented it from learning and improving. There has been way too little internal and external scrutiny of the DSM-V goals, methods, organization, timelines, and products-and thus no built-in means for self-correcting. I also know how difficult it is to change this kind of institutional culture. I really can’t have much hope that my comments will accomplish a whole lot, but I still felt I definitely had a responsibility to at least give it one try.
Q: Are there any ways that DSM-V could have made a substantial contribution?
A: There is one obvious way. This would be the perfect time to unify DSM-V and the section covering mental disorders in the next edition of the International Classification of Diseases (ICD-11) into just 1 system. The differences between the two are arbitrary and trivial, but nonetheless create needless confusion all around the world. Unfortunately, the goal of consolidating the DSM-V and ICD-11 appears to have been given little priority and there is no evidence that any progress has been made in harmonizing the 2 systems, despite the fact that the Task Force is at the halfway point of the revision. This opportunity is fast slipping away.
Q: What else do you think needs to be done now?
A: The problems with DSM-V are deeply embedded and unlikely to be corrected from within. I think that the American Psychiatric Association trustees need to establish an external review committee charged with studying the progress on DSM-V and recommending what the next steps should be. Serious consideration should also be given to having a more flexible publication deadline, to make sure that DSM-V will not be an embarrassment and a burden to the field. I fear that problems not solved before publication will haunt the manual and psychiatry for many years to come.
Q: Do you plan to write additional future commentaries on DSM-V?
A: I’m not sure, but probably not. I will comment again only if 2 conditions are met. First, that DSM-V continues to include proposals that strike me as just too risky to ignore. Second, that I have something useful to say and some reasonable hope that saying it will make a difference. My purpose in speaking out now is to stimulate an open and searching discussion of the work on DSM-V before it is too late to set it right.