Why is the new revision of Diagnostic and Statistical Manual of Mental Disorders (the “DSM-V”) — the reference book used to diagnose mental disorders in the U.S. — being updated in secrecy?
That’s a legitimate question, and one asked by the previous head of the other modern DSM revisions (III, III-R and IV), Dr. Allen Frances in an upcoming Psychiatric Times article:
The secretiveness of the DSM-V process is extremely puzzling. In my entire experience working on DSM-III, DSM-III-R, and DSM-IV, nothing ever came up that even remotely had to be hidden from anyone. There is everything to gain and absolutely nothing to lose from having a totally open process…
You’d have to ask Dr. David Kupfer, the head of the DSM-V revision process, or the American Psychiatric Association, the folks responsible for the update, but they aren’t talking. We last wrote about this issue in November 2008, and apparently little has changed in the past seven months.
Dr. Doug Bremner has the continuing saga of the groups of dozens of professionals and researchers who have been sworn to secrecy in their work on revising this important book. But even more disturbing is that people are so upset about being called out on the lack of openness and transparency in the process, they are now using intimidation and “blacklisting” to try and silence the DSM critics:
Add to Dr. Kupfer’s [the head of the DSM-V revision] strategy of: 1) keep everything a secret; 2) make members sign confidentiality agreements; 3) allow no note taking; 4) ignore outside experts and comments; we can now add, 5) intimidate and ostracize academic psychiatrists whom you can’t ignore.
Dr. Bremner was dis-invited by email in co-authoring a research paper on an unrelated topic because of some very indirect criticism he posted in a previous blog entry. The email came from “someone on the DSM Anxiety, OCD, PTSD and Dissociative Disorders committee:”
What was particularly chilling about this episode is that the email was copied to all the members of the committee, implying that I was now persona non grata and should be shunned by what are in fact my peers in the anxiety disorders and trauma community of academic psychiatry.
Reasoned and thoughtful criticism is the hallmark of science. The whole point of publishing in a peer-review journal isn’t just to get the information out there — it’s to get it out there in a form that other scientists and researchers can understand and reproduce (if they want), so the entire field can move forward in their knowledge. That also means criticizing the work when it is lacking, cannot be reproduced, or has obvious flaws in methodology or logic.
Sadly, academics who can’t take criticism are more common than you might imagine. And the more senior you become in a particular research field, it seems the less able you are to take criticism or feedback.
Sure, it can be difficult to see your methods or procedures being dissected or criticized on a blog, such as Dr. Bremner’s. But that comes with the territory.
But Dr. Bremner’s case is not necessarily unique. You anger the wrong people in a passing sentence in a blog entry, and you can be denied professional opportunities. Dr. Carlat suffered a similar fate not because of something he wrote on his blog, but because a commenter wrote something critical of the DSM-V process that Dr. Carlat did not remove quickly enough to the satisfaction of those in power at the American Psychiatric Association. It seems that if you publicly criticize the DSM-V process, you are going to anger folks at the American Psychiatric Association.
These episodes — and the amount of politics one must play — are key reasons I have little interest in academia. If I have to worry about every word I write might be mis-portrayed or misunderstood by someone who could deny me a future professional opportunity, I’d just quit writing. (Of course, things I’ve written have likely denied me certain opportunities anyway, but at least my career doesn’t depend on them.)
I’m not certain this is what Dr. David Kupfer, the head of the DSM-V revision process, had in mind when he originally implemented these policies of secrecy surrounding the revision of the DSM. Perhaps he thought it was in the APA’s best interests to keep it as private a process as possible, but in this era of increasing openness and transparency, the APA made the worst decision possible.
Dr. Kupfer could still redeem himself, if he had any interest in doing so. So I’d like to call on Dr. Kupfer and the American Psychiatric Association to answer these issues, and explain to the public — the folks who will suffer for better or worse as a result of the DSM-V — why such an important reference manual is being updated in such secrecy.
Philip Dawdy over at Furious Seasons also has a good summary of these two issues, which is also worth the read.
Read Dr. Bremner’s article: DSM-V Shadow Team: Retaliations & Beware of Consequences
Read Dr. Carlat’s article: The APA, Power and the Exclusion of Dissent
Read Philip Dawdy’s take on it: Psychiatrists Attacking Psychiatrists For Blogging On Disclosure Controversies
11 comments
I am very concerned about the secrecy of the APAs work on the DSMV. Appalled in fact. It is anathema to the development process of such a work that will affect thousands of patients and providers to keep this process secret. Such a process is susceptible to group think and decidedly unscientific processes that are more dependent on the personalities of committee members than science. Furthermore, shame on those on the working group of the DSMV for signing such a gag agreement in the first place. Such a paranoid attitude, however, should not surprise us coming from a discipline, i.e. psychiatry which is has been taken over by the drug industry. The DSM V should be rejected out of hand because of this secretive process on the grounds of its serious violation of scientific inquiry. And it is irrelevant if a comment period will be allowed by the APA as it will only serve to give face acquiescence to the reasonable critics of the secretive process. The APA’s gag process has changed years of reasonable practice in the development of the DSM and should be viewed as a serious violation of scientific ethics.
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The issue with DSM V being secretive is beyond inappropriate. I offer this to readers to consider: Social Anxiety Disorder is NOT a diagnosis found in the DSM IV-TR, and yet it is used to this day in literature. And, who basically was behind this term? SmithKlineBeecham, who made Paxil, who pushed for the indication for Social Phobia, a diagnosis in the DSM. Social Anxiety disorder is more vague and elusive, sort of like the Sith in Star Wars.
You think being vague and elusive serves the patients and responsible physicians, or perhaps, the cronies at DSM V headquarters who have much to gain by coming up with new terms and symptoms for the pharma heads to push for new indications?
You be the judge. Have your light sabers handy.
Let’s face it, psychiatry is based more on politics and financial gain for the pharmaceutical companies than on science.
The Diagnostics and Statistical Manual (DSM), the Shrink’s bible, has been around for over 50 years. Within this manual, there are now possibly nearly 300 mental disorders.
As a dictionary of suspected mental illnesses, many redefined diagnoses are added to this manual with each edition, and how such disorders are classified and assessed.
On occasion, a mental disorder is deleted from the DSM, such as homosexuality in the early 1970s. Its purpose, this manual, is to assist mental health professionals to diagnose and classify mental disorders.
How a group sponsored by for profit pharmaceutical industry corporations that promote psychotropic drugs for various mental issues that may or may not fully exist make the determinations that they do while maintaining objectivity is a phenomenon.
Published and designed by the American Psychiatric Association (APA), the DSM is also used, I understand, for seeking mental diagnostic criteria to assure reimbursement.
The DSM is organized in part by the following:
I- Mental disorders
II- mental conditions
III- Physical disorders/syndromes, medical conditions (co-morbidity)
IV- Mental disorder suspected etiology
V- Pediatric assessments
The APA has historically directed the creation of each edition of the DSM, and assigns selected task force members to create this manual. This situation has proven to be controversial.
The next DSM involves 27 people. About 80 percent of these individuals are male, and only 4 members are not medical doctors. Most have had relationships with the NIH, and about 25 percent of these task force members have had relationships with the WHO.
Historically, at least a third of task force members have had, or do, have often monetary pharmaceutical industry ties in some way.
This makes sense, as about one third of the APAs total financing is from the pharmaceutical industry.
The APA required this task force for the next DSM edition to sign non-disclosure agreements- which is rather absurd and pointless. Lack of transparency equals lack of credibility because of these agreements of the content of the next DSM. It opposes any recovery model necessary regarding such disorders, I believe.
The DSM should be evaluated by another unrelated task force or a peer review of sorts to assure objectivity. This is particularly of concern presently, as many more are diagnosed with mental dysfunctions presently at a concerning rate- with very young children in particular.
Dan Abshear
The DSM-V involves a *lot* more than 27 people. See this press release for the names of all the folks involved in the DSM-V revision process:
http://www.psych.org/MainMenu/Newsroom/NewsReleases/2008NewsReleases/dsmwg.aspx
There are 28 people on the primary task force, and then 13 work groups who are doing that actual work for each different disorder area (like mood disorders), and each work group has approx. 15-20 members each. That’s hundreds of professionals.
I agree, however, that this DSM-V revision process has become very political and secretive for no good reason, and if you want to continue following the ongoing foibles and lack of transparency over at the American Psychiatric Association, I highly suggest subscribing to Dr. Carlat’s blog, as he updates regularly on the process:
http://carlatpsychiatry.blogspot.com/
Thanks, Dr. Grohol, for providing us with the link to the list of DSM-V revision task force.
I noticed most members are MDs, PhDs, and/or professors connected with clinical practice or research.
Why are many critical stakeholders missing from the task force/committees? Mental health advocacy groups and similar organizations, patients, and policymakers should be part of this process. So many lives are affected by this mental health bible, and I am shocked at the lack of representation and diversity of the task force.
Another concern is that Western Psychiatric hospital associated with the leader of this project–Dr. David Kupfer. While Western Psych and its affiliated medical school, the University of Pittsburgh, both have a good reputation for academics, Western Psychiatric hospital has a terrible reputation for patient care. Clinicians and other health care workers have noted this.
Link to the task force and committees:
http://www.psych.org/MainMenu/Newsroom/NewsReleases/2008NewsReleases/dsmwg.aspx
Any informed historian of the DSM or unbiased critical thinker about psychiatry would acknowledge that the DSM, with its poor validity and reliability, is not a scientific document, but rather a political one. Our article at http://www.zurinstitute.com/dsmcritique.html discusses the economic forces behind the construction of the DSM, which also explains the lack of transparency.