A History of the DSM5 Controversy

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.

Prof. Decker has gotten all the facts right and sticks very close to them. Writing so contemporaneously to the events and well before their culmination, she has wisely chosen to withhold judgment on the merits of the opposing arguments. Hers is a narrative rather than an interpretive history-except in one way.

Prof. Decker does make the interpretive point that the Internet promoted an active DSM5 debate that otherwise would not have been of any moment (she gives the Internet the same transformative role as the printing press which furthered a far more earthshaking attempt at reformation 650 years ago). She also seems to credit Dr Spitzer and me with cleverly using the Internet in our effort to improve the DSM5 process and products.

Here Dr Decker has made one small false assumption (in my case at least)-but it does ironically serve to confirm her larger point. I am a helpless and hapless technophobe who can't use a computer and acquired my now beloved blackberry 3 years ago (only after I was forcibly blackmailed into the email world by friends and family). Which is to say that what I don't know about the Internet is almost everything. The first blog I ever saw was the first one I wrote myself. I would never have thought of blogging at all if invitations had not come almost simultaneously from Education Update, The Psychiatric Times, and Psychology Today. My only other contacts with the Internet are Wikipedia and literature reviews.

Anyone who knows me and has suffered through my dreary incompetence would find extremely amusing any implication that I am some sort of Internet guru. If there has been an Internet volley of interest partly stimulated by my comments, this was by accident, not design, and I have not myself much attended to it. Which I guess precisely illustrates Prof. Decker's point. The power of the Internet to spread information and stimulate debate is great enough to provide an open forum, even for those of us who don't know much about it or the first thing about using it well.

This leads to an interesting, if unanswerable, corollary question. Has the Internet debate on balance helped or hurt DSM5-or has it had no meaningful effect at all? It is, of course, too early to tell how this very small piece of history will play out. The attention drawn to the DSM5 process has led to some improvements in its methods and a more realistic timetable. But on the larger substantive issues, it is my view that DSM5, despite all the debate, remains stubbornly lost in the wilderness.

Let's go further and ask whether the Internet debate may have done harm to the effort to reform DSM5? Conceivably, the unwanted scrutiny might have stiffened even further the already considerable resistance to outside ideas and influence that has always been characteristic of the DSM5 leadership. Certainly, they show a stubborn persistence in defending against common sense suggestions that appear to be totally indefensible (eg, psychosis risk, hypersexuality, paraphilic rape, etc) and in their continued avoidance of needed interchange with the field (as in the current field trial fiasco). Might DSM5 have evolved a less fortress-like mentality if it were not (as they perceived it) facing attack from without? Who knows?

Next and related question. Could I have intervened more effectively by keeping below the Internet radar? When I decided, one year ago, that I could not responsibly stay on the sidelines and let DSM5 drift into even more serious trouble, I had a choice between trying to exert external public pressure on the process versus seeking an informal and backdoor internal advisory role. I didn't have much hope that either avenue would be very effective (and still don't). But it seemed to be my job to point out the obvious risks, even if the process seemed very closed to either type of influence. I couldn't try both in steps sequentially (which would have been the optimal approach) because the field trials were then just about to begin without there having been the necessary review by the field of the proposed DSM5 criteria sets. Something had to be done immediately to stop this fatally flawed, cart-before-the-horse plan.

I decided to go with external pressure because this seemed more likely to work in the limited time available and would require much less effort. What I had in mind was a single commentary that presented as a cautionary tale the lessons learned from the negative unintended consequences of DSM-IV and a warning about the many problems that could unwittingly be caused by DSM5. The DSM5 workers might find this useful or might (more likely) ignore it completely-either way, at least I would have tried. But one thing led to another (furthered greatly, as noted by Prof. Decker, by the Internet) resulting in a more active participation than I expected or wanted. The external pressure seemed to pay off well in the short run-resulting in a posting of the criteria sets, a delay in both the field trials and in the publication date, and the appointment of an Oversight Committee.

But the long term pluses and minuses of Internet versus private influence remain unclear. The Internet certainly played a large role in stimulating debate-but the resulting debate has not so far accomplished anything of lasting value. It is an open question whether things might have gone better if there were no public debate and I instead quietly proffered advice to the DSM5 leadership, the Work Group members, and the APA Trustees? In all likelihood, the private approach would not have had any influence whatever (I think all were pretty resistant and, on the down side, DSM5 might then have gone ahead with the premature field trial). But we will never know.

To Prof. Decker's interpretive point, the Internet can certainly quicken and dramatize issues and mobilize discontent, but just as with the printing press, it is not always certain whether this works to the best result. By the time DSM5 is published, we may be in a better position to evaluate the efficacy of Internet pressure, but we will never be able to compare it with private influence since the latter never had time to be tried.

As the greatest historian (Thucydides) first pointed out-historical forces and general trends are easy to define, but any given specific outcome is contingent on complex, unpredictably interacting events. And you only get to play each historical moment once-so you can never know for sure which play had the best chance of success. In this test case, it is probably unknowable whether the Internet debate helped or hurt DSM5-most probably, in the long run, it will not have mattered much either way.