Many people associated with DSM-5 have privately expressed their serious doubts to me, but felt muzzled into public silence by constraining confidentiality agreements and loyalty to the process. Gary Greenberg's recent DSM-5 piece in Wired offers a set of dispirited quotes from discouraged work group members-but again he elicited them only under the promise of strict anonymity. Until now, the only people connected to DSM-5 to express public displeasure were the two who have resigned from it.
John Livesley, a highly respected member of the Personality Disorders (PD) Work Group, has now broken this fortress defensiveness and enforced wall of silence. He has published a brilliantly reasoned critique titled "Confusion and Incoherence in the Classification of Personality Disorder: Commentary on the Preliminary Proposals for DSM-5."
The title says it all -- the PD proposal is a pretentious emperor without any clothes. Dr. Livesley systematically catalogs all its many defects: breathtakingly radical change based on questionable empirical support, lack of reasonable rationale, mind-boggling and incoherent complexity, poor taxonomic methods and inconsistency among components. This is a proposal that will never be used by clinicians, will greatly hamper personality disorder research, and will blacken the reputation of dimensional diagnosis. It will reduce the credibility of personality disorder as an important clinical issue, leading patients with severe personality problems to be misdiagnosed and hence mistreated or not treated at all.
Opposition to the proposal is virtually unanimous among personality disorder experts. Strong critiques have been, or soon will be, published in the American Journal of Psychiatry; the Journal of Abnormal Psychology; the Journal of Personality Disorders; and Personality Disorders: Theory, Research, and Treatment. Only a very flawed and unnecessarily closed DSM 5 process could have allowed the survival to this late stage of such bizarrely misguided and idiosyncratic suggestions.
Clearly, breaking with his colleagues was not an easy step for Dr. Livesley, or one he took lightly. The confidentiality restrictions turned out not to be a problem -- he bypassed them simply by using only information that is already available in the public domain. His more difficult choice was whether to expose the follies of the PD work group -- given his understandable bond of loyalty to colleagues on the committee. Fortunately, this was trumped by four much stronger and even more admirable loyalties -- "to intellectual honesty, respect for empirical findings, and concern for the future of the field and patient care."
I know that many other DSM-5 workers are similarly disturbed by the lack of organization in the DSM-5 process and the wayward nature of many of its proposals. They have heretofore been frozen into immobile public silence by some combination of team spirit, passivity, the confidentiality agreements, distaste for controversy and fear of retaliation. Dr Livesley's well-reasoned dissenting opinion provides DSM-5 participants with a model of responsible behavior under difficult circumstances. Principled and open dissent is a time-honored way reconciling the conflicting pressures they must feel. If this is a good enough approach for the Supreme Court, why not have it inform a DSM-5 process that has become the supreme court of diagnostic judgment?
Everyone involved with DSM-5 should follow Dr. Livesley's example and at last feel encouraged to speak openly. They needn't worry about confidentiality agreements if comments focus on information that is posted and public. Intellectual honesty and concern for patient welfare trump narrow loyalties to colleagues or guild interest.
It is not too late to save DSM-5 from itself -- if only those working on it will finally break free of groupspeak and share their thoughts with the field -- as they should have been encouraged to do from the very outset. The current sad state of DSM-5 has been caused by secrecy and defensiveness. The only salvation is completely frank and open discussion. Great thanks are owed to Dr. Livesley for having demonstrated the wisdom, responsibility, and courage to light this path for his colleagues.
Dr. Livesley's article can be found online in the current issue of the journal Psychological Injury and the Law. I recommend it highly to anyone interested in the conceptual issues that underlie personality disorder diagnosis and, more broadly, to those concerned with the problems that have bedeviled the development of DSM-5. He will be publishing additional thoughts in a spring issue of the Journal of Personality Disorders devoted to the DSM-5 suggestions.
NIMH vs. DSM 5: No One Wins, Patients Lose