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Setting the Record Straight: A Response to Frances Commentary on DSM-V

(PSYCHIATRIC TIMES) - The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., submitted to Psychiatric Times contains factual errors and assumptions about the development of DSM-V that cannot go unchallenged. Frances now joins a group of individuals, many involved in development of previous editions of DSM, including Dr. Robert Spitzer, who repeat the same accusations about DSM-V with disregard for the facts.

The facts are:

The process for developing DSM-V has been the most open and inclusive ever. The process began with a planning session that led to 13 NIH-supported international research conferences and a series of monographs. These conferences included more than 400 scientists, clinicians and others in the field. The DSM-V Task Force and Work Groups include more than 150 experts in various specialties and sub-specialties from 16 countries, including both scientists and clinicians. Over 200 advisors have thus far been asked to share expertise with DSM Work Groups. The DSM-V Task Force established a Web site,, to accept comments and provide work group updates. Unfortunately, to bolster his unjustified ad hominem attacks, Dr. Frances used the readily available DSM-V updates and misrepresented them as final decisions, rather than as statements of work in progress.

“Confidentiality agreements” Frances and his colleagues cite as evidence of secrecy around DSM-V are in reality legal documents designed to protect intellectual property. Attorneys for the APA worked with the DSM-V Task Force and Work Groups to develop these agreements to protect the work product of these volunteers. As a matter of practice, these agreements have clearly not inhibited free discussion. Task force and work group members have presented and participated in open discussions at psychiatric, subspecialty, and major medical meetings around the world. They have also published in peer-reviewed journals and trade publications and have given countless interviews to the medical and mainstream press about the DSM-V process.

The DSM-V development process is scientific, and it contains the same elements as the DSM-IV process described by Dr. Frances, including literature reviews, secondary data analyses, and field trials. This is in addition to the comprehensive pre-revision scientific review conferences. A key difference in the DSM-V process versus the DSM-IV process is that our focus is not on keeping things as they are but instead on determining what is working with the current DSM, what is not working, and determining how to correct what is not working. The DSM-V revision groups are looking for ways, for example, to better deal with high levels of co-occurring disorders and Not Otherwise Specified (NOS) diagnoses, to better specify treatment targets for routine clinical practice as well as for treatment development, and to dispense with imprecise criteria and unused/poorly used features. Although the DSM-V work groups were freed from the constraints inherent in DSM-IV’s conservative process, three principles were clearly stated to them from the beginning: the highest priority in modifying DSM-V should be optimizing clinical utility, recommendations should be guided by research evidence, and continuity with previous editions should be maintained.

As documented in the recent American Journal of Psychiatry (AJP) article (Regier, et al., 2009), the use of dimensional assessments to reconceptualize psychopathology represents the most practical and evidence-based way of moving our field forward. Recent studies underscore the readiness of clinicians in both primary care and specialty mental health settings to adopt dimensional instruments on a routine basis (Duffy et al., 2008, Trivedi et al., 2006). Interestingly, Dr. Robert Spitzer’s work in developing such measures as the PHQ-9, the GAD-7, and the PHQ-15 actually bolster the support for a dimensional approach to diagnosis, as noted in the above AJP article and in an article he co-authored (Löwe et al., 2008). Such assessments will inform a measurement-based approach to patient care that will improve clinician tracking of symptom threshold, severity, and treatment outcomes.

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