By Allen Frances
April 13, 2010
DSM5 first went wrong because of excessive ambition; then stayed wrong because of its disorganized methods and its lack of caution. Its excessive and elusive ambition was to aim at a “paradigm shift”. Work groups were instructed to think creatively, that everything was on the table. Accordingly, and not surprisingly, they came up with numerous pet suggestions that had in common a wide expansion of the diagnostic system – stretching the ever elastic concept of mental disorder. Their combined suggestions would redefine tens of millions of people who previously were considered normal and hundreds of thousands who were previously considered criminal or delinquent.
Then came the disorganized DSM5 method. The work groups were meant to find empirical support for their suggestions in reviews of the literature and in data reanalyses. But they were given no guidance on the methods to be used and there was no quality control or editing of their efforts. Again not surprisingly, the different work groups varied widely in the methods, thoroughness, quality,and clarity of their reviews (and the resulting rationales for the proposals offered). The anarchy was worsened by the absence of any agreed upon criteria for the threshold that had to be met before changes could be made. These were not developed until just before the first DSM5 draft was due to be posted – they should have been available as a guide and as a governor even before any work on DSM5 had begun.
Then we get to the lack of caution. However diverse in other ways, the rationales for DSM5 changes all have two things in common: 1) an uncritical and “cheer leading” presentation of the data and arguments that would support the proposal; and, 2) a failure to give an adequate risk/benefit analysis of the shortcomings and dangers that might shoot it down. This fatal flaw would have been self correcting had the work group suggestions and reviews been subjected to an open and searching interchange with the field at large. But the secrecy of the DSM5 process kept them under wraps and prevented a timely correction of the worst errors and omissions.
Each of the work group rationales provides a statement only of the benefits expected from the proposal. These have in common that “patients” presenting with a set of symptoms not currently covered by the diagnostic system will be identified, presumably so that they can be provided with a suitable treatment they would otherwise not get. Uniformly, the scientific evidence supporting each suggestion is undeveloped, weak, and unconvincing. Most remarkable though is the fact that none of these suggested new disorders has a proven effective treatment. In sum, even the “benefit” side of the equation for each of the new proposals provides little support for its inclusion.