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A Turning Point for DSM 5: Will the APA Trustees Finally Step Up to the Plate?

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Up until now, the leadership of the American Psychiatric Association has stubbornly defended the indefensible DSM 5 proposal that would turn normal grief into clinical depression. APA has blithely ignored the contrary scientific evidence, the unified opposition of 47 professional organizations, two eloquent editorials in the Lancet, and critical articles in more than 100 newspapers from all around the world. The meager counterarguments offered by the APA and DSM 5 leadership reveal how badly they have lost touch with clinical common sense, with the larger community of mental health professionals, and with the general public.

Recently, Dr. Joanne Cacciatore wrote a moving blog opposing the DSM 5 plan. Within days, she had unexpectedly attracted more than 100,000 viewers. Encouraged by the display of overwhelming support, Dr. Cacciatore has now written a powerful letter to the APA Trustees demanding that they take immediate action to protect normal grief from inappropriate DSM 5 medicalization.

I think her letter could be the crucial turning point in the development of DSM 5. If the APA Trustees respond to it positively and finally exert appropriate governance of DSM 5 on this one point, they may feel empowered to review and revise other equally reckless DSM 5 proposals. If, instead, the Trustees again fall meekly into line backing this hopelessly foolish proposal, it is unlikely that DSM 5 will ever be a safe or scientifically sound system of psychiatric diagnosis.

Here is Dr. Cacciatore's letter:

Open Letter to the Board of Trustees of the American Psychiatric Association and to the DSM 5 Task Force



Two weeks ago, I wrote a blog opposing the DSM 5's proposal to reduce the DSM IV bereavement exclusion.



This blog has since gone viral in the most incredible way -- 100,000 readers within its first few weeks. It seems that this proposal is experienced as an outrageous insult by the very people it is intended to help.



I have more than sixteen years experience dealing with tens of thousands of grieving people whose children die or are dying at any age and from any cause. To my knowledge, there is no empirical standing for the arbitrary two-week time frame, and thus this proposal not only contradicts good common sense but also rests on weak scientific evidence.



One thing in which the literature is clear: long-term psychological distress is common in this population and other populations suffering traumatic deaths. In my experience both as a researcher and clinician in the field and also as a bereaved parent, the DSM 5 proposal is radical, unnecessary, challenges what it means to be human, and for some may be dangerous.



Those with severe depressive symptoms distinguishable from normal grief can already be diagnosed as soon as is needed using the DSM IV criteria. In contrast, DSM 5 would require a distinction between normal grief and mild depression shortly after the death of a loved one that is often impossible to discern for even the most experienced clinicians. The DSM 5 may well create problematic false positives -- and thus cause further harm, to an already vulnerable population. There are many more reasons we oppose these changes, many of which are outlined in my blog.



Our international organization (MISS Foundation) has 77 chapters around the world and has helped countless grieving families and the professionals who serve them. All our services are free and we are a volunteer-based organization. Our website gets more than one million hits per month and we have 27 online support groups. We oppose this change with our minds, with our hearts, and with our numbers.



I speak on behalf of the MISS Foundation's grieving families: Should the DSM 5 stubbornly ignore the evidence and the mounting professional and public opposition, our last alternative will be to call for more direct action -- in the short term, our organization will rally the support of Congressional leaders; in the longer term, we will have no choice but to join a concerted boycott against the use of the DSM 5 in treating bereaved families facing the death of a child.



Process transparency is also important. Please respond promptly with an indication of the next steps and timetable in the APA review process; what is the organizational table for making this decision; on what grounds will it be made; when will it be announced; and, is there an appeal process?



On behalf of hundreds of thousands of bereaved people around the world, I implore you to reverse this poorly conceived and unnecessary decision. My more than 100,000 readers and I hope to hear from you soon.

Thank you, Dr. Cacciatore. Heretofore, the APA leadership has provided no direction, creating a vacuum that allowed DSM 5 full freedom to chart its risky course. But expertise can come from many and unexpected quarters -- in this case it arrives in the surprising form of a spontaneous outpouring from 100,000 people who understand the topic of bereavement from the inside. The DSM 5 grief proposal was never needed, doesn't make sense, is gratuitously off-putting, and has placed psychiatry in the worst possible light. APA's misguided defense of it simply has no traction and has already dealt an unnecessary blow to the credibility of psychiatry.

Dr. Cacciatore's well-reasoned letter is a clear (and perhaps final) wake-up call to the APA Trustees. It is long past time for them to do some reality testing and also to show some gumption and responsible governance. Psychiatry is an essential and wonderful profession that deserves much better leadership than it has so far received throughout the DSM 5 fiasco. It has come down to a now-or-never moment for the leaders of APA to finally come to plate and curb obvious DSM 5 excess. They should not force those seeking a safe DSM 5 to the extremes of political action or boycott. This is the turning point for the APA leadership -- perhaps its last chance to set DSM 5 right.

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.