Dr Frances Responds to Dr Carpenter: A Sharp Difference of Opinion

I have the highest respect and affection for Will Carpenter, MD, who wrote a recent response ("Criticism vs Fact: A Response To A Warning Sign on the Road to DSM-V by Allen Frances, MD," Psychiatric Times, July 7, 2009) to my earlier commentary, but we do differ sharply on the following points.

1. His suggestion to include premorbid diagnoses as official categories in DSM-V is by far the most important difference in our perspectives about DSM-V.  In fact, it was my concern about this issue that made me realize that I had to write the commentary.

I fully understand Will's hope for a method of early identification of those individuals who are at risk for later developing a psychosis.  Treating them before they suffer full-blown disorders might well help reduce their overall lifetime symptomatology and impairment.

What Will greatly underestimates, however, is the huge and insurmountable cost occasioned by false positives. It is impossible to imagine a criteria set so specific that it would not pick up a large percentage (perhaps an overwhelming majority) of individuals who would never become psychotic. These innocent bystanders might then be subjected to decades of treatment with the same medications that are associated with drastically reduced lifespans in individuals with schizophrenia.

The additional unpredictable, but quite likely, problems of stigma, insurance ineligibility, and forensic misuse are not life or death, but still occasion a very significant concern.  Finally, there is no way to field test premorbid disorders in any context that would at all resemble the real field - in large community samples of adolescents with different ethnicities and socioeconomic backgrounds.  As we have seen many times before (eg, ADHD and bipolar disorder in children), diagnoses have a tendency to take on an independent life of their own and grow wildly in popularity, especially in primary care settings and when nourished with drug company interest. Every teenager who says or does something weird, perhaps under the influence of drugs, may seem a likely candidate. Of course, this is not at all what Will has in mind, but it is important to fully anticipate how a proposal furthered with the best intentions can, and probably, will be misused in real life. A diagnosis with low specificity and high potential for harmful treatment consequences will likely do far more harm to the false positives than whatever good it does for those who might benefit.

2. Will seems to think that his presentations at professional meetings in front of relatively small audiences provide a sufficiently open DSM-V process. Let me try to explain just how far this is from the total transparency that is needed, especially at this crucial time as DSM-V field trials are about to begin. We, the field, still know almost nothing about the content of what is being considered for DSM-V or how the options still in play are justified by the literature reviews and data reanalyses.  What information should be available by now?

We should have every wording of every proposed criteria set or dimension. Why not post these now to allow for the widest review well before field trials are started? I cannot imagine going to the trouble and expense of field testing before there is confidence that the diagnostic concepts make sense and that they are appropriately worded. Equally puzzling is the lack of posting of the literature reviews and of the methods of the proposed field trials. The DSM-V leadership has made the truly bizarre claim that they have provided the "most open process" of all the previous DSM revisions, but they have not posted any explicit or detailed indication of what they are doing and why. What possible harm can come from posting every change that is being considered? If the real reason for not posting is that the material is not yet in a presentable form, admit this and postpone the field trials until everything can be posted and fully vetted. 

3. As I referenced in the commentary, I am a long-time critic of the limitations of categorical diagnosis and a proponent of the increased precision of dimensional ratings. I hope that there may be some modest role for such ratings in DSM-V-just as I had hoped they might be more represented in DSM-IV. The problem with dimensional measures is that they are too cumbersome for everyday clinical practice so clinicians simply ignore the ratings.  Both DSM-III-R and DSM-IV offered clinicians dimensional components (mild, moderate, and severe severity specifiers for all diagnoses and the 100-point dimensional GAF scale), but they are rarely used except in those situations in which they are explicitly required, such as the VA.  It is hard to imagine how introducing a set of new scales will not be similarly perceived by clinicians as an administrative burden.   Perhaps a bigger problem is that from what I understand most of the dimensions being considered were created de novo by the DSM-V workgroups with virtually no input from the field at large and no extensive prior testing  by the research community. I would love to be proven wrong on my concern that any dimensional system introduced by DSM-V will either be ignored and/or give dimensions a bad name. Again, why are the dimensions not posted with the literature supporting them? Then we could all be part of the evaluation of whether formal field trials of these particular dimensions make sense or whether these suggestions are better relegated to the research appendix for future study.

4. Dr Carpenter suggests that I resist change because of a narcissistic attachment to DSM-IV. As proof, he cites my detailed outlining of the DSM-IV methodology - in fact, I did this only to suggest ways the DSM-V methodology could be tightened and improved.  He also quetions whether, by my standards, DSM-IV was itself necessary.

In reality, I was never particularly proud of my work on DSM-IV, nor did I feel it was much of a contribution to psychiatry. The major rationale for publishing DSM-IV in 1994 was to coordinate its development with ICD-10, which was to appear at the same time. I realized well before accepting the appointment that descriptive psychiatry had reached its limits of usefulness and that the best we could hope to accomplish was to "do no harm," come as close to ICD-10 as possible, and establish a high standard of empirical proof so as to avoid arbitrary changes. It is indeed disappointing that we do not yet have the foundation for a paradigm shift in psychiatric diagnosis, but this is where things stand. My modest hopes for DSM-V would be that it makes minimal mistakes, integrates fully with ICD-11, providess much enriched text sections on the biology for those disorders where something is known, and has a rich appendix for future research. My work on the last three DSMs has taught me how limited is descriptive psychiatry and how modest should be our claims.

I believe that the  best hope ever for the field achieving a paradigm shift is the NIMH RDoC (Research Domain Categories) project just about to get underway. RDoC aims to develop a nosology based on identifiable brain circuits and gene variants. Unfortunately, its results will likely trickle in slowly and over many years.

I am commenting about DSM-V now not out of any particular pride in DSM-IV, but rather because I fear that DSM-V (if uncorrected) may do serious damage to psychiatry and to our patients.  Dr Carpenter wrote his response out of his sense of responsibility, I wrote my commentary out of my sense of responsibility. We disagree, but I hope we are still friends. Whether either one of us is more accurate in predicting the future of DSM-V can only be judged when its current options finally become available to the field. I think Dr Carpenter knows me well enough to realize that I would actually be relieved to be wrong about DSM-V. Perhaps it will turn out that there is a secret, wonderful master plan and that my concerns about DSM-V were premature and exaggerated. Unfortunately, the odds against this happy outcome are far too long to earn my bet.