The DSM-IV Process (and Result) Was Flawed and Biased Too
Lest anyone think that the last time the DSM underwent a major revision, it went without a hitch, all one need do is review the research literature to see otherwise. We often have such short memories when it comes to history. The last revision was led by Allen Frances, M.D., who is now a critic of the same book that has his name on it.
For instance, one criticism of the DSM-IV working groups was it was hardly representative of people who actually treat and research mental disorders every day (Duffy et al., 2002). Only 22 of the 125 people on the DSM-IV working groups didn’t hold an M.D. degree — a general medical degree which has no specialized training in either research or mental disorders (without specific specialization in psychiatry). An M.D. without a Ph.D. is someone who has no particular scientific research training.
The DSM-5 working groups are composed of 143 people by my count, 49 of which hold only a Ph.D., and only 90 of which hold an M.D. (16 of which also hold a Ph.D.). That’s a significantly more diverse representation of the psychological and psychiatric fields than we saw last time around.
Livesley (1995) devotes a whole chapter on the inadequacies and shortcomings of the DSM-IV personality disorders category, which makes for illuminating reading lest anyone complain about the DSM-5’s attempt to reorganize the current mess of personality disorders. Boggs et al. (2005) found gender bias in the symptom criteria for borderline personality disorder — of little surprise to anyone who tries to read the DSM-IV criteria and think of a man.
And among the dozens of other published criticisms and critiques of the DSM-IV over the decades, it apparently suffered from cultural bias to boot (Dana, 2001). In a culturally diverse nation as the U.S., it’s odd that such a reference manual describing supposedly unbiased, scientific phenomenon should suffer from such a bias.
The DSM-5 is the result of 14 years worth of preparation and work by hundreds of professionals and researchers. And it is so easy to disparage such work from afar, when you’re not a part of the process.
But disparagement is hardly helpful from a scientific standpoint. The “Open Letter” petition was created, in private, by a three-member ad-hoc committee of a division of a competitive professional association, the American Psychological Association. And while I agree with some of the points raised in the petition, I have no reason to put my faith in these three people’s reading of the scientific literature over that of the 143 people in the working groups of the other APA.
And I can’t help but think there’s some sour grapes here, when the person who is predicting the failure of the DSM-5 is also the one person who claims he has a plan to save it:
The user revolt against the DSM-5 has emerged as a major challenge to the document, Frances says, and its future is looking unclear. He and Elkins are proposing that an independent committee of experts review the proposed draft and make recommendations.
Given all the flaws with the DSM-IV, why should I or any other mental health professional trust Frances over the current group of people overseeing the DSM-5 revision process?
The answer is simple, but not one anyone wants to hear — there is no “perfect” process, and there’s no process that isn’t going to be flawed or criticized by others. I’ve argued time and time again how the DSM process should always be more transparent — as it should have been back when the DSM-IV was being updated as well.
It’s far too late to “fix” the DSM 5 now (and I don’t believe it needs much fixing in the first place). But the APA has always said and will likely publish far more timely updates to the manual in the future. So we can wait and see.
Meanwhile, I’ll hold the hyperbole while we hold our breaths that no “epidemic” of mental disorder diagnoses will occur while we wait. There’s no “war,” there’s no “revolt,” and professionals will go on using the DSM-5 just as they use the DSM-IV, because insurance companies and those paying the bills will leave them little choice.
Read the full article: Therapists revolt against psychiatry’s bible
Boggs, Christina D.; Morey, Leslie C.; Skodol, Andrew E.; Shea, M. Tracie; Sanislow, Charles A.; Grilo, Carlos M.; McGlashan, Thomas H.; Zanarini, Mary C.; Gunderson, John G. (2005). Differential impairment as an indicator of sex bias in DSM-IV criteria for four personality disorders. Psychological Assessment, 17, 492-496.
Caplan, P. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. Reading, MA: Addison-Wesley.
Dana, R.H. (2001). Clinical diagnosis of multicultural populations in the United States. In: Handbook of multicultural assessment: Clinical, psychological, and educational applications (2nd ed.). Suzuki, Lisa A. (Ed.); Ponterotto, Joseph G. (Ed.); Meller, Paul J. (Ed.); San Francisco, CA, US: Jossey-Bass.
Duffy, M., Gillig, S.E., Tureen, R.M., Ybarra, M.A. (2002). A critical look at the DSM-IV. The Journal of Individual Psychology, 58, 363-373.
Livesley, W.J. (1995). The DSM-IV personality disorders. New York, NY, US: Guilford Press.