American Psychiatry Is Facing "Civil War" over Its Diagnostic Manual

Yesterday, the American Psychiatric Association announced that it is pushing back the publication of DSM-V until 2013. The APA tried to put a good face on this rather embarrassing admission—embarrassing, because several spokespeople for the organization had insisted, quite recently, that they were on-track for publication in 2012 and that nothing would deter them. They maintained that position even as an increasingly acrimonious quarrel between current and former editors of the manual spilled onto the pages of Psychiatric News.

"Extending the timeline will allow more time for public review, field trials and revisions," APA President Alan Schatzberg declared, conveniently omitting that most of the field trials have yet to begin because the working groups can't agree on their criteria. "The APA is committed to developing a manual that is based on the best science available and useful to clinicians and researchers." Owing to Dr. Schatzberg's statement, several news services played down the announcement, perhaps fearing to make too much of it.

They may not know that an explosive article and editorial is due to appear in the print edition of New Scientist two days from now (December 14th). It's been up on the journal's website since Wednesday, and it's already had a significant effect. The article is called "Psychiatry's Civil War," and it documents in fairly exhaustive detail the DSM editors' public feud, which sank so low at one point that the current editors accused Allen Frances, editor of DSM-IV, of raising questions about scientific and editorial procedure simply to continue earning royalties from DSM-IV (DSM sales since 2000 have exceeded $40 million). "Both Dr. Frances and Dr. Spitzer have more than a personal 'pride of authorship' interest in preserving the DSM-IV and its related case book and study products," the same Dr. Schatzberg insinuated darkly in Psychiatric News last July. "Both continue to receive royalties on DSM-IV associated products."

Yet Frances raised legitimate questions about the scandalous lack of transparency surrounding the DSM discussions and the damaging pledge to secrecy that DSM consultants have legally agreed to uphold—allegedly to protect intellectual property, though the manual is already copyrighted.

Given the embarrassing evidence in the New Scientist article, whose associated editorial is called "Time's Up for Psychiatry's Bible," the timing of the APA announcement raises significant flags. As the New Scientist put it in a rider that appeared on its website yesterday, "Since [the] article was first posted [last week], the American Psychiatric Association has announced that the publication of DSM-V will be delayed until May 2013."

You'll find the article and editorial here and here. The article was written by Peter Aldhous, bureau chief of the New Scientist's San Francisco office. (Disclosure: I was interviewed for the article, based on my knowledge of the unpublished documents and memos that went into the creation of DSM-III, -IIIR, and -IV and the dozens of new disorders they added to those editions of the manual. I've also written about the editorial feuding for the Los Angeles Times and Slate.)

Perhaps the most significant implications for the APA, right now, concern the New Scientist's argument that the DSM should cease to be known as the discipline's "bible." Given the acrimony and scale of disagreement, that sounds quite reasonable. If even the manual's editors have profound disagreements over its content and criteria, then it ceases to be an authority that psychiatrists, doctors, social workers, lawyers, health insurers, and others using it can cite and consult "chapter and verse." As the editors at New Scientist put it, "This week we report on a volume that has outlived its usefulness."

They aren't saying that the manual's diagnostic importance has disappeared altogether. "The final wording of the new manual," they concede, "will [still] have worldwide significance." But the New Scientist urges the APA to update the manual online, with full transparency and somehow without the influence of drug companies who fund much of the research and supplement the salaries of way too many DSM consultants. As the New York Times noted in May 2008, "More than half" of the writers of DSM-V "have ties to the drug industry" as paid consultants.

David Kupfer, chair of the DSM-V Task Force, has also given very mixed signals about the direction he intends to take the manual, telling the Chicago Tribune last December, "If currently listed maladies fail th[e] test, they'll be dropped," before he signaled far more loosely to the Los Angeles Times, five months later, "There are no constraints on the degree of change."

"No constraints"? The phrasing may be more than unfortunate; it also points to an underlying truth about the task force and the serious risks of manipulation by drug companies who are eyeing every poorly conceived idea and proposal—bitterness disorder, apathy disorder, internet addiction disorder, and quite a few others—like hawks.

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Although I've had serious disagreements with Drs. Spitzer and Frances over past DSM publications, I share their concern over the lack of transparency to the revisions and the serious implications for public health of including so-called "subthreshold" diagnoses. As Frances put it in Psychiatric News,

"Undoubtedly, the most reckless suggestion for DSM-V is that it include many new categories to capture the milder subthreshold versions of the existing more severe official disorders. The . . . DSM-V Task Force has failed to adequately consider the potentially disastrous unintended consequence that DSM-V may flood the world with new false positives. . . . The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments—a bonanza for the pharmaceutical industry but at a huge cost to the new false positive 'patients' caught in the excessively wide DSM-V net."

For more information on earlier revisions to the DSM, visit www.christopherlane.org.