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The “We Know Better/Holier Than Thou” Crusade: A Response To Drs Frances And Spitzer’s Comments

(PSYCHIATRIC TIMES) - I appreciate Drs Spitzer and Frances’ prompt response to my article, which was published in the July issue of Psychiatric Times. I also thank them for their good wishes and thoughts about what we are doing as members of the DSM-V workgroups—membership whose rules we all knew and freely accepted.

Drs Spitzer and Frances insist that their “problem” is with the DSM-V committee leadership which, in their opinion, has imposed stringent conditions on us and has created a peevishly hypersensitive atmosphere of “secrecy” in our work. This sounds more like a bad movie script than like the realities of the work we do. They immediately state that my article is a “defense” of the DSM-V process. Regrettably, this assertion touches only on one aspect of my piece. I was not defending the process; that is the job of Drs Kupfer, Regier, Schatzberg, and others—and they have done it. My purpose was and is to share an experience from a comprehensive, objective perspective, and to move the debate away from its “ugly” (to use Dr Spitzer’s description) and sterile edge.

The DSM-V process is longer and older than Spitzer and Frances say. We face a huge task and knew that it was going to be eminently guided by scientific and technical principles. We are searching for a modern nosological perspective, not running away from debatable, conflicting, unclear, or difficult issues. In my article, I stated pointedly what I think are the areas that the new manual needs to address decisively and unequivocally. So, not much “defense” there.

I am sure that David Kupfer and Darrel Regier would be the first to say that the process’ road is not without bumps. But that is correctable. On the other hand, to say that there is a clamorous absence of information about the process; that more advisors or consultants are needed (who knows what “the largest possible number of reviewers” is?); that the DSM-V options and the literature reviews require “a thorough critique from the entire field”; and that a “quality-control committee” to do “hands-on work” and “a lot of reading” is needed, is tantamount to disbanding the entire DSM-V committee and starting over. Spitzer and Frances do not say how long such a “thorough review” would be, or even how much it would cost. In addition, they do not seem to acknowledge (actually, they minimize), the value of the work made so far, the credentials of the researchers whose studies have been and are being scrutinized (and that are of public knowledge, of course), or ultimately the accomplishments of most of the Work Group members.

The Work Groups have examined evidence-based alternatives, have emphasized clinical practicality and utility, and are aware of clinical, financial, and logistic realities. By the way, they also have psychologists and other mental health professionals as outstanding members. Sure, input is needed, but it is untrue to say that opportunities for such input have not existed.

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