Psychological Warfare: The DSM-5 Debate

Controversy has surrounded the fifth revision to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders(DSM-5) since its development began with the assigning of task force members in July 2007, with things really picking up steam last year when the proposed revisions were made public. Many physicians have voiced concerns over the revisions and how they’ve been developed thus far, while members of the DSM task force have defended their actions, and still others have said that the concerns are much ado about nothing.

In this ongoing series, we’ll be talking with key players who’ve spoken out on both sides of the argument, including lead editors on previous revisions of the DSM, task force members, and well-known psychiatrists. This month, Robert Spitzer, MD, professor emeritus, psychiatry, Columbia University, New York, NY, and lead editor, DSM-III, shares his insights on DSM-5.

What was the experience like developing DSM-III?

It was an all-consuming process that started in 1974 and ended when it came out in 1980. Then we did a revision, which started in 1984 and came out in 1987. It was a huge effort that involved many different people and comities.

We’ve been criticized for many different things, but I think everybody acknowledges that DSM-III represented a significant change for American psychiatry. The major change was that DSM-II and DSM-I only had brief descriptions of a few sentences each for conditions and didn’t really tell you what needed to be present when you made a diagnosis. That all changed with the finer criteria, which came out in 1973. That was a big change because researchers at Washington University in St. Louis developed specific criteria that they said needed to be present before you made a diagnosis. So, we adopted that strategy, and it meant that DSM-III required more scientific and facilitated research, because if you’re doing a research study on a diagnosis, you want to make sure you know just what that patient’s characteristics are.

DSM-III permitted one to be much more involved. We had about 15 committees that ranged from five to 20 members, and these were all experts in different areas. We encouraged people to critique what we did. As soon as we had a draft, we published it, and people critiqued it. And there were many things that were controversial. The most controversial part of DSM-III was the elimination of the “neurosis” category. The notion of neurosis is a psychoanalytic concept that implies an unconscious conflict that is resolved by the neurotic symptoms. It’s an interesting theory, but it’s only a theory, and we believed that DSM-III, to move ahead, had to be a descriptive system that organized the classification on the basis of symptoms that are present. So, if the symptoms are predominantly mood symptoms, it becomes a mood disorder—if they’re predominantly anxiety, an anxiety disorder. Whereas, in DSM-II, there would be one category: anxiety neurosis or depressive neurosis. Psychoanalytically oriented people felt we were anti-Freudian, that we were ignoring a great body of knowledge. We believed that for DSM-III to really be acceptable and advanced, it had to be descriptive and avoid theories that were untested.

How did you react when Dr. Darrel Regier, APA director of research and vice chair of the DSM-5 task force, refused to show you the minutes from the task force meetings?

I was dumbfounded. It was outrageous that something like that has never been presented. People have asked me, “Did you have minutes for DMS-III?” We didn’t have minutes, but everything we did was totally open. We encouraged people to critique what we did, and we answered each critique. So, there was no issue of transparency. But with DSM-5, for reasons that are not entirely clear, the APA leadership decided that there had to be confidentiality. So in order to be on the work task force, they required that you sign a confidentiality agreement in which you said you would not divulge any information about DSM-5, to anybody, even after DSM-5 is published, which is totally absurd. Most people when they hear about this, realize it doesn’t make sense for a scientific document to be a kept a secret as it’s being developed. The question is, “What was the motivation?” The APA says the motivation was to keep property rights of the manual; they were concerned that people who were on the work group might publish their own version of it, and therefore they had to prevent that from happening. But I think that really doesn’t make much sense, because nobody could just publish their own version of DSM-5; it’s copyrighted. I think the real motivation was to keep control and minimize critiques. If people can’t talk about it, they can’t critique it.

Regardless of why the APA made the decision to require the confidentiality forms, how do you feel that affects DSM-5?

Well, I think it affects it in terms of credibility. I think many people feel that DSM-5 in its development has not been as open as it could be. It is true that they have made efforts now that there is a draft of proposals to encourage people to review those proposals. So, it is possible to see what DSM-5 is going to look like, but it is not possible to know what the controversies were, who said what, and how these things were decided. There have always been critiques of DSM; one critique is that it classifies as disorders things that are really just normal reactions. So, I think the credibility of the enterprise is what’s at stake.

In 2008, you wrote a letter to Psychiatric Timesregarding DSM-5. What did you say, and how did the APA respond?

I said that DSM-5, with this confidentiality agreement, lacked transparency and that it was to the detriment of the final version. Their reply essentially said that the members of the task force are giving scientific presentations and writing articles, so there will be no problem of the people knowing what’s going on.

What impact do you feel that you, Dr. Allen Frances, lead editor of DSM-IV, and others have made on the development of DSM-5, and do you feel that DSM-5 is truly the most transparent DSM revision ever, as suggested by James Scully, APA medical director?

I think what we’ve done is highlight the need for more transparency, and in some ways, what they’ve done more recently in publishing draft proposals does go a long way toward transparency. And they have a website (www.dsm5.org)—it’s really quite a technological wonder—where they list all the categories and what changes are proposed. They invite comments, and I understand they’ve had more than 1,000 comments, and that’s all good. I like to think that their website has something to do with the criticism that Dr. Frances and I have made about the transparency.

Do you have any other concerns with DSM-5?

I think there are many condition categories that are problematic. Probably the most problematic is the revision of personality disorders, where they’ve made major changes; and the changes are not all supported by any empirical basis. Also, the personality disorders section is extremely complicated to use; it’s so complicated that I don’t think clinicians will actually use it, and I think that’s now widely recognized by the DSM-5 personality work group, and they are now working on ways to simplify it.