Can the Press Save DSM 5 from Itself?

DSM 5 has suddenly become a star press attraction. In just the last three weeks, more than 100 news stories featuring DSM 5 appeared in major media outlets located in more than a dozen countries. (For a representative sample see Suzy Chapman’s post on Dx Revision Watch.) The explosion of interest started with a flurry when The New York Times published two long DSM 5 articles and three DSM-5-related op-ed pieces, all within a few days. An unrelated press conference in London then generated a widely distributed Reuters story and also many independent pieces. Several other reporters had also been working on their own DSM 5 stories that just happened to arrive at the same time.

The intense press scrutiny of DSM 5 is really just beginning. I know of at least 10 additional reporters who are preparing their work now for publication in the near future. And many of the journalists whose articles appeared during these last few weeks intend to stay on this story for the duration — at least until DSM 5 is published, and probably beyond. They understand that DSM 5 is a document of great individual and societal consequence — and that its impact and risks need a thorough public airing.

The press coverage has been almost uniformly and devastatingly negative. The two most common themes are 1) DSM 5 will radically expand the boundaries of psychiatry, medicalising normality and leading to unneeded and harmful treatment; and 2) DSM 5 decisions are being made arbitrarily, based on narrow input and lacking sufficient scientific support. The DSM 5 proposals that have elicited the most concern are changes in the definition of autism and the expansion of major depressive disorder to capture much of normal grief.

The articles sometimes contain small inaccuracies and sometimes emphasize peripheral issues. And the most dangerous DSM 5 proposals get far too little mention. I will discuss in later blogs how DSM 5 will worsen the over-diagnosis of attention-deficit disorder and the over-prescription of antipsychotic mediation. But the press has gotten the main points just right and somehow manages to see the risks of DSM 5 much more clearly than do the people working on it.

Will the American Psychiatric Association finally listen to this concentrated chorus of criticism? At a critical 11th hour, when all else has failed, will the world’s reporters save DSM 5 from itself? Is the power of the pen mightier than the thick walls that have so far protected DSM 5 from self-correction? Can the irresistible force of the press move the previously immovable DSM 5 object?

The initial DSM 5 responses are not encouraging — the usual brew of inaccurate, misleading, and unconvincing statements that never tackle any of the issues in a substantive way. And APA has previously proven itself to be remarkably oblivious, dogged, and stubborn. During these past two years, DSM 5 has made almost no changes in its proposals — despite their having received widespread criticisms. APA has also casually shrugged off a petition opposing many DSM 5 proposals and requesting that they be subjected to an independent scientific review. The fact that the petition is endorsed by no fewer than 47 different and substantial mental health organizations seems to have carried no weight whatever. And APA dismisses the plan of many previous users to boycott DSM 5 by substituting the alternative coding system of ICD-10-CM (which will be freely available on the Internet).

Will the unfavorable press result in a more favorable DSM 5 outcome? Surely we must hope so — because so few other corrective options are available. DSM 5 remains steadfast and rigid in its support of really bad proposals with extremely dangerous unintended public health consequences. A very small group of out-of-touch DSM 5 experts is now extremely close to achieving what amounts to a radical coup — redefining a greatly expanded psychiatry at the expense of a quickly shrinking normality. The many expressions of professional and public opposition from outside this hermetically sealed inner circle have been ignored almost completely.

But I have some hope that this concentrated press barrage may succeed where previous efforts have failed. It is fair to say that DSM 5 has become an object of general public and professional scorn. Perhaps now at last, prodded by the world press, DSM 5 will have to heed the unanimous cautionary warnings. Let’s hope it will finally come to its senses and cut its losses by rejecting the worst proposals. This will be a service to psychiatry and, most important, to our current and future patients. Paradoxically, the terribly embarrassing press it is receiving now may save DSM 5 and APA much greater embarrassment in the future and, more importantly, prevent the mislabeling as mentally ill of literally millions of people, and their potential exposure to unnecessary and risky medications.

Allen Frances is Professor Emeritus at Duke University and former Chair of its Department of Psychiatry. He was Chair of the DSM IV Task Force. Follow him at his blog on Forbes.

2 replies »

  1. “Self-injurious behavior in Autism Spectrum Disorder” is something DSM-5 has yet to acknowledge.

  2. The APA is a living example of the Titanic. It boasts it can be indestructible and never sink, yet the captain(s) are so busy crowing how wonderful their craft is they are either in frank denial or intellectualizing how the iceberg dead ahead is not their problem. Unfortunately, this ship has basically the public on it and will be harmed WHEN the ship hits the ice. But, as we saw in true reality per this ship metaphor recently, captains don’t go down with their ship these days, do they? And true to form, the leaders of the APA and academic psychiatry don’t want you to know that they have their lifeboat ready and able when disaster strikes, and no one, let me repeat, NO ONE who is not a crony or buddy is allowed on.

    Sad isn’t it. Psychiatry has allowed the 2 headed hydra of big pharma and health care insurers to metastasize into the multiheaded beast that has cornered the profession into the cowards and whores too many providers have become.

    I don’t know if Dr Frances, if he reads this thread, would appreciate this last comment, but taken from the DSM 4 case book regarding the antisocial personality disorder vignette in there, if this sounds pessimistic, it was meant to be!