The Elephant in the Room Series Three: Further criticism of the DSM-V revision process


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The Elephant in the Room Series Three: Further criticism of the DSM-V revision process

There have been further exchanges on the Psychiatric Times website around concerns over transparency and process.  For earlier exchanges in this series see previous posting:

The Elephant in the Room Series Three: Criticism in Psychiatric Times of the DSM-V revision process

Psychiatric Times  maintains a page of resources for the current edition of DSM, DSM-IV, with updates, articles and commentary around the development of DSM-V.

06 July 2009
Psychiatric Times. Vol. 26 No. 7

Inside the DSM-V Process: Issues, Debates, and Reflections
Renato D. Alarcón, MD, MPH

Dr Alarcón is professor in the department of psychiatry and psychology at the Mayo Clinic College of Medicine, and a member of the Personality Disorders Work Group, DSM-V Task Force. He reports no conflicts of interest concerning the subject matter of this article.


07 July 2009
Psychiatric Times.

Criticism vs Fact: A Response To A Warning Sign on the Road to DSM-V by Allen Frances, MD
William T. Carpenter, MD

Dr Carpenter is professor of psychiatry and pharmacology at the University of Maryland School of Medicine and is Director of the Maryland Psychiatric Research Center.


Psychiatric Times BlogSpot

08 July 2009

Francis and Spitzer: A Message to the DSM-V Workgroup

Drs Francis and Spitzer write

“…our problem is with the conditions imposed on the work group members by the DSM-V leadership, particularly: (1) the confidentiality agreements; (2) the unwillingness to post on the DSM-V Web site the work done so far by the workgroups (i.e., the literature reviews, results of any of the secondary data analyses, and, most importantly, the exact wording of the proposed criteria sets or dimensions; and (3)the rush to prematurely start these field trials in order to meet an artificially imposed publication deadline…

…how can field trials begin now before any of the DSM-V options and supportive literature have been posted and time given for a thorough critique from the entire field? Would it not help Dr Alarcon and other work group members to get input from the largest possible number of reviewers before deciding on which suggestions deserve to move forward and which have too many previously unrecognized risky unintended consequences? Would Dr Alarcon and other work group members not prefer to be given sufficient time to make sure that DSM-V is as problem-free as possible?

There is no justification for a fixed publication date in 2012 now that ICD-11 will not appear before 2014. Let’s have everything posted and thoroughly reviewed first, and then it will be appropriate to plan field trials…”


09 July 2009
Psychiatric Times.

Dr Frances Responds to Dr Carpenter: A Sharp Difference of Opinion
Allen Frances, MD

Dr Frances was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

Dr Francis writes

“…Will [Carpenter] 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…”


14 July 2009
Psychiatric Times.

The “We Know Better/Holier Than Thou” Crusade: A Response To Drs Frances And Spitzer’s Comments
Renato D. Alarcon, MD, MPH

Dr Alarcón is professor of psychiatry at the Mayo Clinic College of Medicine.


15 July 2009
Psychiatric Times.

Frances Responds to APA: “Important Questions Need Answering”
Allen Frances, MD

Dr Frances was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

Dr Francis writes

“…Most worrying was the announcement that field trials were about to begin without any of the DSM-V options having been posted and vetted by the field – this is a recipe for damaging unintended consequences. Second, I learned that subthreshold and premorbid disorders were still being seriously considered. Third, I discovered that the DSM-V Task Force has had no reporting relationship to the Council on Research, which may explain its many missteps. I wrote the commentary out of a simple and disinterested concern that the work on DSM-V, unless corrected soon, would be harmful to patients, practitioners, and also to the APA…”

and suggests

1. Post all the suggested wordings for the DSM-V criteria sets well before considering field trials?

2. Post all the literature reviews supporting the changes?

3. Post the proposed methods for conducting field trials?

4. Postpone beginning field trials until there has been adequate time for the field to thoroughly review and critique the above postings and for the Workgroups to integrate the suggestions into the criteria sets that will then be field tested?

5. Eliminate the confidentiality agreements?

6. Greatly increase the numbers and diversity of the pool of advisors?

7. As with all previous DSMs, establish the usual reporting chain from the DSM-V Task Force to the APA Council on Research?

8. Eliminate the artificial and unrealistic publication deadline of 2012 in order to ensure adequate time for a quality DSM-V?


16 July 2009
Psychiatric Times.

DSM-V: Mind Made Up?
Richard P. Berkson, MD, DLFAPA

Dr Berkson is chief psychiatrist at the California Substance Abuse Treatment Facility and State Prison at Corcoran.

Dr Berkson writes

“…I very much share Dr. Frances’ concerns about the premature and ill-conceived creation of new “diagnoses”; the burden on practitioners working in the real world with regard to having to learn and apply the new concepts and nomenclature; the potential abuse of the DSM by pharmaceutical companies, insurance companies, and the legal system; the unnecessary stigmatization of those who fall into subsyndromal gray areas; and – especially – the evident secrecy and insularity of the process itself… “