Wheels come off psychiatric manual; APA blames road conditions

I have suspected for some time now that the band oddly close process designed to produce the DSM-V --- the diagnostic statistical manual that is psychiatry's diagnostic guide and Bible --- would create an explosion of some sort. But I didn't think it would explode quite so soon.

As Daniel Carlat outlines in a wonderful post â a must read, very high infotainment value â this is a pretty entertaining missing match. We have Allen Frances, a prominent psychiatrist who helped produce the previous edition of the DSM, leveling some very harsh criticisms of the process designed to produce a new edition by 2012. And we have that critique answered harshly by the American Psychiatric Association (APA) in a memo that essentially accuses Frances of being either stupid or a liar -- and corrupt or greedy.

To wit, Frances, among other things, argues that

"The simple truth is that descriptive psychiatric diagnosis does not need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM-5."

He also argues that the broadening of categories underway will aggravate existing problems with overdiagnosis and overmedication:

The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatment--a bonanza for the pharmaceutical industry but at a huge cost to the new false positive "patients" caught in the excessively wide DSM-V net. They will pay a high price in side effects, dollars, and stigma, not to mentions the unpredictable impact on insurability, disability, and forensics.

The APA fires back by questioning Frances's integrity and motives.

This won't do much to shine up psychiatry's reputation, which has been tarnished and scratched enough lately. But something like this was virtually inevitable once the APA perversely decided to make the process of revising the DSM closed and secretive. They did so, mind you, when a) the world in general is moving toward open source, transparent means of decision-making and b) psychiatry in particular is in very hot water â a major crisis, really â because of hidden conflicts of interest and a growing feeling that too many diagnoses are being shaped and applied because they are friendly to pharmaceutical companies rather than true to science and human nature. As soon as I heard about the closed system by which the EPA proposed to revise the DSM, I was astonished that they would take such a vital process behind closed doors. No matter what the quality of the work done, they were begging for trouble. And with both psychiatry and the implications of its ever-expanding diagnostic list under fire, the move struck me as rather self-destructive. I would open the DSM-IV to find some suitable diagnoses -- but that would be too easy.

I think -- I hope -- this early explosion will turn out to be a good thing. Maybe it will convince the APA to open things up so that the inevitable critiques and argument can be made as part of the process of settling on a new diagnostic framework rather than after the fact. As I've argued before, psychiatry stands at an awkward but crucial spot right now . Having left Freud behind to embrace biological psychiatry, it finds itself holding in its arms a disgraced goddess of pharmacology. Devising a theoretical framework that is empirical but not overly based on an increasingly discredited neurochemical model of psychiatric dysfunction is going to require a more vigorous and open discussion â and despite all the progress in neuroscience and neurogenetics, Frances may be right in saying it's just too soon.

In any event, resolving these issues and selling the result to the world -- not just psychiatrists but to many people who rely on this difficult but vital discipline -- will be impossible if it looks like the new book has been forged in secret. The APA needs to punch the reset button.

I hope to visit this some more, but in the meantime, you'll want to keep tabs via Carlat, as he'll probably stay on it more closely than I. And Doug Bremner â my earlier spat with him about PTSD notwitthstanding â is worth a follow on this as well.


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