DSM5--The “We Know Better/Holier Than Thou” Crusade: A Response To Drs Frances And Spitzer’s Comments

July 14, 2009

I appreciate Drs Spitzer and Frances’ prompt response to my article, which was published in the July issue of Psychiatric Times. I also thank them for their good wishes and thoughts about what we are doing as members of the DSM-V workgroups-membership whose rules we all knew and freely accepted.

I appreciate Drs Spitzer and Frances’ prompt response to my article, which was published in the July issue of Psychiatric Times. I also thank them for their good wishes and thoughts about what we are doing as members of the DSM-V workgroups-membership whose rules we all knew and freely accepted. 

Drs Spitzer and Frances insist that their “problem” is with the DSM-V committee leadership which, in their opinion, has imposed stringent conditions on us and has created a peevishly hypersensitive atmosphere of “secrecy” in our work. This sounds more like a bad movie script than like the realities of the work we do. They immediately state that my article is a “defense” of the DSM-V process. Regrettably, this assertion touches only on one aspect of my piece. I was not defending the process; that is the job of Drs Kupfer, Regier, Schatzberg, and others-and they have done it. My purpose was and is to share an experience from a comprehensive, objective perspective, and to move the debate away from its “ugly” (to use Dr Spitzer’s description) and sterile edge.

The DSM-V process is longer and older than Spitzer and Frances say. We face a huge task and knew that it was going to be eminently guided by scientific and technical principles. We are searching for a modern nosological perspective, not running away from debatable, conflicting, unclear, or difficult issues. In my article, I stated pointedly what I think are the areas that the new manual needs to address decisively and unequivocally. So, not much “defense” there.

I am sure that David Kupfer and Darrel Regier would be the first to say that the process’ road is not without bumps. But that is correctable. On the other hand, to say that there is a clamorous absence of information about the process; that more advisors or consultants are needed (who knows what “the largest possible number of reviewers” is?); that the DSM-V options and the literature reviews require “a thorough critique from the entire field”; and that a “quality-control committee” to do “hands-on work” and “a lot of reading” is needed, is tantamount to disbanding the entire DSM-V committee and starting over. Spitzer and Frances do not say how long such a “thorough review” would be, or even how much it would cost. In addition, they do not seem to acknowledge (actually, they minimize), the value of the work made so far, the credentials of the researchers whose studies have been and are being scrutinized (and that are of public knowledge, of course), or ultimately the accomplishments of most of the Work Group members. 

The Work Groups have examined evidence-based alternatives, have emphasized clinical practicality and utility, and are aware of clinical, financial, and logistic realities. By the way, they also have psychologists and other mental health professionals as outstanding members. Sure, input is needed, but it is untrue to say that opportunities for such input have not existed.

We already know that literature reviews will be disseminated, that the field trials will be as methodologically sound as possible, that being realistic and pragmatic (not conservative, please) is better than abusing rhetoric, missing glorious pasts, and letting nostalgia and passion obstruct clarity of vision. It is a case of “secrecy being in the eye of the secrecy-seeker.” DSM-V will not do what was done in the DSM-III process when 3 people met for a few hours to decide whether a clinical entity was to be included or rejected (as an anecdote in Spiegel’s 2005 New Yorker piece on Robert Spitzer reports). I take the opportunity to also remind the readers that DSM-III and DSM-IV rejected or downgraded cultural input and content in the corresponding manuals; actually DSM-IV relegated solid documents prepared by a group of distinguished psychiatrists, psychologists, and social scientists to the back of the manual, the next-to-last of a long list of appendices.

In short, we should stay away from what some would call a “We know better” type of crusade, a condescending, bordering on arrogant demagoguery. Such approach is like telling the APA Board of Trustees: “Even if you don’t yet understand or share all of our concerns, it would be reckless for you to bet the house on the premise we are completely wrong -especially since all the logic really is on our side of the argument.” Let’s hope that the focus will move from “holier than thou” declarations to the responsible evaluation of alternatives, and issues of substance and lasting impact on the march of psychiatry and mental health in our country.