The recent mass murders in Arizona are the latest in our country's epidemic of horrible, hate inspired crimes. The 24/7 media punditry and political spinning has been disappointingly off point in a way suggesting that once again we will learn nothing from our mistakes and that such tragedies will continue to recur with distressing frequency.
Last week, I had a brief, but heated debate with a friend who is on the DSM-5 Task Force. He is strongly supporting a proposed new diagnosis for DSM-5 that I oppose just as strongly.
The New York Times of Dec 20,2010 carried an alarming story. It seems that during the past decade, college students have suddenly become much more mentally ill.
Many people associated with DSM-5 have privately expressed their serious doubts to me, but felt muzzled into public silence by constraining confidentiality agreements and loyalty to the process.
December 17, 2010 was a special day in the history of psychiatric diagnosis. Bob Spitzer retired after a remarkable 52 year career.
We are delighted that you have appointed a DSM-5 Scientific Review Work Group and charged it with assessing the quality of evidence supporting the DSM 5 proposals.This is great news, probably the last hope to weed out proposals that could do great harm to the Association, our field, and to our patients.
The ideal field test would study how the diagnostic manual will eventually perform under conditions most closely approximating its future everyday use. The goal is to avoid unpleasant surprises in translation from what has been written on paper to what is practiced in real life. No field test can ever approach the ideal.
Eventually, DSM-5 will be a rushed patch-work. The only hope for a usable DSM-5 is for the Trustees to exert their authority to correct an errant process. But they will act only if there is mounting outside pressure and widespread public concern.
The DSM-5 Work Group that first suggested the inclusion of “Psychosis Risk Syndrome” has halfway come to its senses. It has dropped this stigmatizing name in a last ditch repackaging effort to salvage the proposal.
We can take one further step toward finding common ground in my ongoing debate with Drs Pies and Zisook.
The most disturbing turbulence at the boundary between psychiatry and the law is the misuse of a makeshift psychiatric diagnosis to justify the involuntary, indefinite psychiatric commitment of rapists. This is a disguised form of preventive detention and an abuse of psychiatry.
Before jumping the gun to a premature and potentially harmful diagnosis, why not watchfully wait a few more weeks to determine if the grief is severe and enduring enough to warrant the label of mental disorder.
The furor surrounding the recently proposed Alzheimer's Guidelines was provoked by their premature attempt to introduce early diagnosis, well before accurate tools are available. The same laudable, but currently clearly unrealistic ambition has propelled two of the worst suggestions for new diagnoses in DSM-5: Psychosis Risk and Mild Neurocognitive.
In July, panels sponsored jointly by the National Institute of Aging and the Alzheimer's Association presented controversial proposed guidelines for diagnosing Alzheimer's at three different stages of its progression.
Previously, I have been quite critical of the DSM-5 suggestion to introduce a new diagnosis-- Minor Neurocognitive Disorder--on the grounds that it would create a large false positive problem and would lead to unnecessary worry and cost with no useful intervention.
The basic problem is that the body is extremely complicated and most diseases don't arise from anything resembling simple genetic causes. We are the miraculous result of an exquisitely wrought DNA engineering that has to get trillions and trillions of steps just right. But any super-complicated system will have its occasional chaotic glitch.
Fads in psychiatric diagnosis come and go and have been with us as long as there has been psychiatry. The fads meet a deeply felt need to explain, or at least to label, what would otherwise be unexplainable human suffering and deviance.
Why not define mental disorder just on the presence or absence of the characteristic cluster? Why was it felt to be necessary to also require distress or impairment?
Every month or so, someone (usually very smart and passionate) sends me a detailed proposal for a new diagnostic system offered as an alternative to the jumbled, pedestrian, atheoretical, and purely descriptive method used in DSM.
Professor Hannah Decker, a distinguished historian by trade, has posted a thorough, fair, and sprightly history of the DSM5 controversy. We are all lucky to have her as chronicler.
As an officer of the APA, I was one of the prime movers of the limitations on, and vetting of, potential participants in the preparation of the DSM5.
I sent the letter that begins on page 4 to the Trustees of the APA on April 8, 2010. It contains an urgent plea that the Trustees move immediately to correct the increasingly wayward course of DSM5. The DSM5 Task Force is about to begin a field trial that is a complete mistake:
The recently posted draft of DSM5 makes a seemingly small suggestion that would profoundly affect how grief is handled by psychiatry.
The problems in the preparation of DSM5 have arisen from its unhappy combination of excessive ambition and poor execution. A prime example is the totally unrealistic ambition to provide diagnostic rating scales for each section of DSM5. The goal is to help standardize interviewing in order to increase diagnostic reliability. Surely, it would be nice to have clinicians gather the most pertinent information in a consistent and systematic way.
Time is running out on DSM5 and the mistakes keep piling up. The latest puzzling misstep is the design for the DSM5 field trials. The APA will conduct a remarkably complex and expensive reliability study to determine whether 2 raters can agree on a diagnosis. It will devote enormous resources to answer a question that once mattered greatly but is now of quite limited interest. Meanwhile, DSM5 will perversely avoid the one question that does really count: ie, what will be its likely impact on the rates of psychiatric diagnosis? At least $2.5 million and 1 year later (or possibly 2, if things get delayed as I expect they will), DSM5 will still be flying completely blind on the safety of its proposals.
DSM5 first went wrong because of excessive ambition; then stayed wrong because of its disorganized methods and its lack of caution. Its excessive and elusive ambition was to aim at a “paradigm shift.” Work groups were instructed to think creatively, that everything was on the table. Accordingly, and not surprisingly, they came up with numerous pet suggestions that had in common a wide expansion of the diagnostic system-stretching the ever elastic concept of mental disorder. Their combined suggestions would redefine tens of millions of people who previously were considered normal and hundreds of thousands who were previously considered criminal or delinquent.
The recently posted criteria sets for DSM5 are a mess. The writing is unclear, inconsistent, and imprecise. Unless they are edited and drastically improved, any field testing based on them will be a waste of time, effort, and money- and DSM5 may not be usable.
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.
I often get asked if practical consequences should play an important role in DSM5 decisions. It was posed again yesterday in response to my blog "Bipolar II Revisited" which tangentially raised the issue.
The recently posted first draft of DSM-5 has suggested a whole new category of mental disorders called the "Behavioral Addictions." The category would begin life in DSM-5 nested alongside the substance addictions and it would start with just one disorder (gambling).
