FOR FILING A COMPLAINT ABOUT HARM FROM PSYCHIATRIC DIAGNOSIS
URGENT: Please do not EVER post this template publicly anywhere. The reason is that by doing so, it is possible that you could risk being said to have breached the confidentiality of the complaint proceedings, and that could lead to the name(s) of one or more complainants being revealed by the APA or the people against whom the complaint is filed. It is not that anything negative is assumed to be the case about them in this regard but only that all steps must be taken to protect the privacy of all complainants. Thank you.
If you know of someone else who wants to file a complaint, please ask them to send a message through the contact form at www.psychdiagnois.weebly.com
"No offense has ever been visited with such severe penalties as seeking to help the oppressed."
--Clarence Darrow (quoted in Irving Stone's Clarence Darrow for the Defense, p.83)
Since you are considering filing a complaint, this letter and template are intended to help you prepare it.
You can use this template if (1)you were harmed by being given one or more psychiatric diagnoses; OR (2)a loved one was harmed in this way; OR (3)you are an “interested party,” someone who in any capacity — employer, mental health system or medical worker of any kind, lawyer, teacher, etc. — has seen harm done through the assignment of a psychiatric diagnosis.
This template is very long, but do not be daunted, because you actually don’t have to do very much, just fill in a few things here and there and delete a few things that do not apply to you. Most of this is material that, if you choose, you can just include almost exactly as it is.
Many people have said that they learned a lot about the whole, hurtful system in which they were immersed by reading what is here, so you might consider this in part an experience of learning about the harm that has been done and how wrong it was.
At the very least, it is hoped that by reading through every word of what is here, you will learn that if you feel there was something wrong, unscientific, and harmful about the psychiatric label(s) you were given, and if you wondered whether the harm might have been prevented, you are absolutely right, and this material should be validating for you. If you wondered who might have had the power to take significant steps to prevent or redress that harm, you will find a partial answer to that question here.
Do not feel that you have to follow this template. It is provided only to give you an idea of one possible way to construct a complaint, but you should of course feel free to do it some other way.
And do not feel that you need to decide immediately whether or not to file a complaint. Take your time, mull it over, and keep this template in case you want to use it later. The people who have filed complaints up to now have sometimes found it deeply disturbing to go back in memory through what happened that led them to consider filing a complaint and/or to read back through files, charts, and documents in order to find the information they need in order to write a brief summary of the individual story as part of the complaint. But they have also said that they found it helpful and energizing to be able to write the truth and at least make the attempt to hold accountable those whose work has been the first cause of the harm, to say, “Your labels were applied to me [or a loved one or someone else whom I saw hurt], they were not scientifically based and were unlikely to help and likely to harm, they did harm, and the harm must be redressed.” Finding one’s voice can be a powerful thing, whether or not the American Psychiatric Association decides to consider any of the complaints to have merit. And if you file a complaint and want to tell anyone else that you have done so, they are likely to find that encouraging and strengthening for them, just to know that you did it.
After this introductory message, you will find below a sample complaint that includes:
(1)Some material you can probably use exactly as it is, because it will apply to anyone who has been harmed by being given a psychiatric diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM). That material will be in regular type. Note: If your complaint is about a loved one or other person to whom the harm was done, you will need to do a search for each place you see the words “I,” “me,” or “my,” and change those appropriately to apply to the person who was harmed.
(2)Some material in italics that provides instructions or suggestions for what you need to include at those spots
(3) Some material in boldface type that will be relevant for some complainants but not others, depending on what diagnostic label(s) you were given
Please do not be put off by the length of this template. If you just read through it a bit at a time, you will see that most of it you will be able to use exactly as it is, and most of what you need to fill in, you probably already know or can easily find out.
Now you are ready to begin reading through the template. Here is a sample of ONE WAY you might consider constructing your complaint.
Complaint Against the American Psychiatric Association and Various Individuals Within It
1. American Psychiatric Association’s Ethical Standards That Were Not Met and the Psychiatrists Who Failed to Meet Them
The DSM-IV and DSM-IV-TR publications and the actions of their editors, those American Psychiatric Association presidents and members of the Board of Trustees during the years from the time work began on DSM-IV in 1988 up to the present, the Work Group heads or members relevant to how I was labeled from the manual, and the American Psychiatric Association as an entity have individually and collectively contravened the standards established by "The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry." In addition, the APA as an entity is violating section (g) of its own Purposes and Objectives clause, which is:
(g) to promote the best interests of patients and those actually or potentially making use of mental health services.
Neither any APA president nor trustee, nor the APA as an entity can cede to any one or several persons (the DSM Task Force heads/editors) total responsibility for following the APA's ethical standards with regard to the creation, marketing, and multi-purpose uses of the DSM.
I submit this complaint in the spirit of the American Psychiatric Association’s statement that actions based on its ethical principles are intended to serve the purpose of lessening unethical conduct. I am complaining to the American Psychiatric Association about of violations of medical ethics in connection with the DSM-IV and DSM-IV-TR, violations that caused me harm when I was diagnosed with ________________[insert the label or labels from the DSM that you were given] in reliance on the DSM-IV or its successor publication (documentation available on request). I am complaining against the following (collectively, "respondents"):
· The American Psychiatric Association
· Dr. Harold Pincus, vice chair of DSM-IV Task Force and co-chair of DSM-IV-TR (Text Revision)
· Dr. Michael First, text editor of DSM-IV and co-chair of DSM-IV-TR
· ________[You may want to add here the names of the people who worked on the DSMs and were directly in charge of working on the diagnoses you were given. To find their names, go to www.psychdiagnosis.weebly.com, and open the file called “DSM diagnoses and Work Group members.” Follow the instructions at the beginning of that file, and that will enable you to find the names of some people you might want to list here.]
· APA Presidents: 1987-1988 Dr. George Pollock, 1988-1989 Dr. Paul J. Fink, 1988-1989 Dr. Herbert Pardes, 1989-1990 Dr. Herbert Pardes, 1990-1991 Dr. Elissa P. Benedek 1991-1992 Dr. Lawrence Hartmann, 1992-1993 Dr. Joseph T. English, 1994-1995 Dr. Jerry Weiner, 1995-1996 Dr. Mary Jane England, 1996-1997 Dr. Harold I. Eist, 1997-1998 Dr. Herbert S. Sacks, 1998-1999 Dr. Rodrigo A. Munoz, 1999-2000 Dr. Alan Tasman, 2000-2001 Dr. Daniel B. Borenstein, 2001-2002 Dr. Richard K. Harding, 2002-2003 Dr. Paul S. Applebaum, 2003-2004 Dr. Marcia K. Goin, Ph.D., 2003-2004 Dr. Michelle B. Riba, 2005-2006 Dr. Steven S. Sharfstein, 2006-2007 Dr. Pedro Ruiz, 2007-2008 Dr. Carolyn Robinowitz, 2008-2009 Dr. Nada L. Stotland, 2009-2010 Dr. Alan F. Schatzberg, 2010-2011 Dr. Carol Bernstein, 2011-2012 Dr. John L. Oldham, 2012-2013 Dr. Dilip V. Jeste
· APA Trustees: 1987-1988 Drs. Robert J. Campbell III, Frederick Gottlieb, Lawrence Hartmann, Linda Logsdon, Philip M. Margolis, Carol C. Nadelson, Pete C. Palasota, Robert O. Pasnau, Douglas A. Sargent, Chester W. Schmidt, Jr., John A. Talbott, Hugo Van Dooren, William L. Webb, Jr. ; 1988-1989 Drs. Robert J. Campbell III, Frederick Gottlieb, Shelly F. Greenfield, Merlin Johnson, Linda Logsdon, Rodrigo A. Munoz, Carol C. Nadelson, Pete C. Palasota, Robert O. Pasnau, George H. Pollock, Herbert S. Sacks, Douglas A. Sargent, Chester W. Schmidt, Jr., William L. Webb, Jr.; 1989-1990 Drs. Daniel B. Borenstein, Robert J. Campbell III, Paul J. Fink, Emanuel E. Garcia, Merlin Johnson, Linda Logsdon, Eliza W. Menninger, Rodrigo A. Munoz, Pete C. Palasota, Robert O. Pasnau, Roger Peele, George H. Pollock, Herbert S. Sacks, Douglas A. Sargent, Chester W. Schmidt, Jr.; 1990-1991 Drs. Karen A. Abrams, Harvey Bluestone, Daniel B. Borenstein, Robert J. Campbell III, Paul J. Fink, Emanuel E. Garcia, Merlin Johnson, Linda Logsdon, Eliza W. Menninger, Rodrigo A. Munoz, Pete C. Palasota, Herbert Pardes, Robert O. Pasnau, Roger Peele, George H. Pollock, Herbert S. Sacks, Harvey R. St.Clair, Douglas A. Sargent, Chester W. Schmidt, Jr., Jerry M. Wiener; 1991-1992 Drs. Karen Abrams, Elissa P. Benedek, Harvey Bluestone, Daniel B. Borenstein, Paul J. Fink, Merlin H. Johnson, Robert J. McDevitt, Andrea S. Moskowitz, Rodrigo A. Munoz, Herbert Pardes, Roger Peele, Herbert S. Sacks, Harvey R. St. Clair, Chester W. Schmidt, Jr., Jerry M. Wiener; 1992-1993 Drs. Elissa P. Benedek, Harvey Bluestone, Daniel B. Borenstein, Marian I. Butterfield, Lawrence Hartmann, Abram M. Hostetter, Merlin H. Johnson, Benjamin Liptzin, Robert J. McDevitt, Andrea S. Moskowitz, Rodrigo A. Munoz, Herbert Pardes, Herbert S. Sacks, Harvey R. St. Clair, Jerry M. Weiner;1993-1994 Drs. Harvey Bluestone, Daniel B. Borenstein, Charles L. Bowden, Joseph T. English, Gerald H. Flamm, Robert A. George, Gladys R. Gregory, Lawrence Hartmann, Abram M. Hostetter, Benjamin Liptzin, Maria T. Lymberis, Robert J. McDevitt, John S. McIntyre, Steven M. Mirin, Mary Kay Smith; 1995-1996 Drs. Carol A. Bernstein, Harvey Bluestone, Charles L. Bowden, Helen L. Egger, Joseph T. English, Gerald H. Flamm, Robert A. George, Edward C. Leonard, Jr., Maria T. Lymberis, Robert J. McDevitt, John S. McIntyre, Steven M. Mirin, Richard A. Shadoan, Mary Kay Smith, Jerry M. Wiener; 1996-1997 Drs. Carol A. Bernstein, Charles L. Bowden, Alisa Busch, Helen L. Egger, Mary Jane England, Gerald H. Flamm, Robert A. George, Edward C. Leonard, Jr., Maria T. Lymberis, Robert J. McDevitt, John S. McIntyre, Herbert Peyser, Michelle Riba, Richard A. Shadoan, Jerry M. Wiener; 1997-1998 Drs. Carol A. Bernstein, Charles L. Bowden, Alisa Busch, Norman A. Clemens, Diana L. Dell, Harold I. Eist, Mary Jane England, Marcia Kraft Goin, Edward C. Leonard, Jr., Kathleen M. Mogul, Michael Myers, Herbert Peyser, Michelle Riba, Richard A. Shadoan, Jerry M. Wiener; 1998-1999 Drs. Charles L. Bowden, Norman A. Clemens, Diana L. Dell, Harold I. Eist, Mary Jane England, Richard S. Epstein, Marcia Kraft Goin, Edward C. Leonard, Jr., Kathleen M. Mogul, Michael F. Myers, Herbert S. Peyser, Maurice Rappaport, Michelle Riba, Herbert S. Sacks, Julie K. Schulmann; 1999-2000 Drs. Jack W. Bonner III, Norman A. Clemens, Sandr M. DeJong, Harold I. Eist, Richard S. Epstein, Marcia Kraft Goin, Edward C. Leonard, Jr., Ann S. Maloney, Kathleen M. Mogul, Rodrigo A. Munoz, Michael F. Myers, Herbert S. Peyser, Maurice Rappaport, Herbert S. Sacks, Julie K. Schulman; 2000-2001 Drs. Jack Bonner III, Norman A. Clemens, Sandra M. DeJong, Richard S. Epstein, Edward C. Leonard, Jr., Avram H. Mack, Ann Maloney, Kathleen M. Mogul, Rodrigo A. Munoz, Herbert S. Peyser, Maurice Rappaport, Herbert S. Sacks, Allan Tasman, Albert V. Vogel, Keith W. Young; 2001-2002 Drs. Jack W. Bonner III, Daniel B. Borenstein, Norman A. Clemens, Patrice A. Harris, Avram H. Mack, Ann S. Maloney, Kathleen M. Mogul, Rodrigo A. Munoz, Susan L. Padrino, Roger Peele, Herbert S. Peyser, Maurice Rappaport, Nada L. Stotland, Allan Tasman, Albert V. Vogel, Keith W.Young; 2002-2003 Drs. Jack W. Bonner III, Daniel B. Borenstein, Norman A. Clemens, Daphne Dorce, David Fassler, Melva Green, Richard K. Harding, Angela Harper, Patrice A. Harris, Kathleen M. Mogul, Rodrigo Munoz, Susan L. Padrino, Roger Peele, Maurice Rappaport, Steven S. Sharfstein, Anne Marie Sullivan, Allan Tasman, Albert V. Vogel, Keith W. Young; 2003-2004 Drs. Paul S. Applebaum, Tanya R. Anderson, Renee L. Binder, Jack W. Bonner III, Daniel B. Borenstein, Thomas K. Ciesla, David Fassler, Marcia K. Goin, Richard K. Harding, Angela Harper, Patrice A. Harris, James E. Nininger, Donna M. Norris, Roger Peele, Maurice Rappaport, Susan D. Rich, Anne Marie T. Sullivan, Albert V. Vogel, Sidney H. Weissman; 2005-2006 Drs. Paul S. Applebaum, Tanya R. Anderson, Renee L. Binder, Thomas K. Ciesla, Mary Helen Davis, David Fassler, Marcia K Goin. Ph.D., Daniel T. Mamah, James E. Nininger, Donna M. Norris, Roger Peele, Michelle B. Riba, Anne Marie T. Sullivan, Albert V. Vogel, Sidney H. Weissman; 2006-2007 Drs. Renee L. Binder, Thomas K. Ciesla, Mary Helen Davis, David Fassler, Jeffrey L. Geller, Macia K. Goin, Roger Peele, Michelle B. Riba, Steven S. Sharfstein, Anne Marie T. Sullivan, Amy M. Ursano, Sidney H. Weissman, William M. Womack; 2007-2008 Drs. Thomas K. Ciesla, Mary Helen Davis, David Fassler, Jeffrey L. Geller, Roger Peele, Michelle B. Riba, Pedro Ruiz, Steven S.Sharfstein, Anne Marie T. Sullivan, John Chapman Urbaitis, Amy M. Ursano, Sidney H. Weissman, William M. Womack; 2008-2009 Drs. Thomas K. Ciesla, Mary Helen Davis, Melinda G. Fierros, Jeffrey L. Geller, Dilip V. Jeste, James E. Nininger, Roger Peele, Carolyn B. Robinowitz, Pedro Ruiz, Steven S. Sharfstein, Lauren M. Sitzer, John Chapman Urbaitis, Amy M. Ursano, Sidney H. Weissman, William W. Womack; 2009-2010 Drs. Becky Bay, Thomas K. Ciesla, Mary Helen Davis, Melinda G. Fierros, Dilip V. Jeste, James E. Nininger, Roger Peele, Kayla M. Pope, Carolyn B. Robinowitz, Pedro Ruiz, Jacqueline N. Smith, Joyce A. Spurgeon, Frederick J. Stoddard, Jr., Nada L. Stotland, John Chapman Urbaitis, John J. Wernert III, William M. Womack; 2011-2012 Drs. Carol A Bernstein, Brian Crowley, Marc David Graff, James A. Greene, Marilyn Griffin, Sarah Johnson, James E. Nininger, Alan. F. Schatzberg, Joyce A Spurgeon, Frederick L. Stoddard, Nada L. Stotland, John J. Wernert III, Alik S. Widge, William M. Womack; 2012-2013 Drs. Jeffrey Akaka, Carol Ann Bernstein, Brian Crowley, Jeffrey Geller, Marc David Graff, James Allen Greene, Judith F Kashtan, Molly K. McVoy, James Edward Nininger, John M. Oldham, Alan Schatzberg, Alik S. Widge, Erik R Vanderlip
This complaint is in part against the APA as an entity, because what an individual psychiatrist should do ought even more to be done by an entity, the APA, that advocates for the thousands of psychiatrists who are its members. It is morally and professionally reprehensible for a nonprofit corporation that has prescribed ethical standards for its individual members to operate itself as though it were exempt from those same standards. Indeed, if the APA continues to operate as though it is exempt from those standards, and if this complaint against the APA and the other respondents were not to lead to disciplinary and other actions including major changes in its functioning, it would make a mockery of those ethical standards. APA functions in an important sense as the royal court of the mental health system, the organization that hands down from the mountain the word about the nature and varieties of what it calls mental disorders. Because of its position of influence in the health, insurance, and education systems, various governmental systems (including but not limited to Medicare, Medicaid, the military and Department of Veterans Affairs mental health systems), employment, and the court system, it has a special obligation as an entity to ensure that anything represented as coming from the APA is done according to its own ethical principles. This is even more the case, because psychiatric diagnosis — unlike other corporations — is totally unregulated by any other entity, giving the APA a degree of power over people's lives through pathologizing them that is unmatched anywhere. Furthermore, it uses its own diagnostic manual as the basis for choosing certain labels and categories and creating its "Practice Guidelines" about how professionals should treat each of these alleged disorders. Thus, some of the harm comes directly from the APA itself as the fraudulent producer, marketer, and profitmaker (the profits from the current edition reputedly reaching $100 million) of a manual whose diagnostic labels can and have directly cause(d) harm and also from the use of the contents of that manual to make treatment recommendations that can and have cause(d) harm because the manual itself is seriously flawed and because patients and professionals have not been fully informed of its flaws and the risks of harm. And as noted, the APA as an entity has also been violating section (g) of its own Purposes and Objectives clause:
(g) to promote the best interests of patients and those actually or potentially making use of mental health services.
The APA presidents and trustees, in light of their positions of responsibility for the official actions of this nonprofit corporation called the APA, knew or ought to have known that the marketing of the DSM-IV and IV-TR involved false advertising and knew or ought to have known that the manuals were not solidly grounded in science, that they are rarely helpful to suffering patients, and that indeed they often cause them harm. Further, the APA presidents and trustees failed to take steps to make all of the above known to the public and professionals, to solicit (as the Food and Drug Administration requires the drug companies to do and as the APA is ethically bound to do as well) reports of harm, to take significant steps to prevent harm, or to use any of its monumental profits from the manuals to redress any of the harm. The respondents who are or were DSM editors, Work Group Chairs, or Work Group Members are guilty of the same failings.
The statements and writings of Allen Frances have been since 1988 and still -- despite his no longer being a member of APA, a fact not widely disseminated -- remain the most public representative of the APA's diagnostic manual, because what is widely known is that he was head of DSM-IV, on which the vast majority of the revisions and additions that remain in the current edition, DSM-IV-TR, were done, and he was the most visible, prominent face of both editions. All of the respondents knew or ought to have been aware of the public messages and claims that he has made since 1988 and continues to make, which include repeated assertions that his editions were based on scrupulously scientific procedures, and these claims would clearly be taken to represent the APA as well as himself. The respondents have not publicly taken steps to contradict or correct these claims. Any of the respondents over these many years could individually or collectively at any point have spoken the truth and taken steps to reduce and redress the harm. By failing to do so, they failed in their ethical responsibility both to (1) take account of what the high-quality scientific research shows and (2) put patients' welfare first, allowing to stand the impression that the DSM-IV and DSM-IV-TR are scientific and does not cause harm. This is all the more reprehensible, given that Allen Frances' widely publicized attacks on the DSM-5 are made as though the current edition of the manual is not dangerous, except for the three of its 374 diagnoses which Frances acknowledges have caused harm. . Since 2009, when his attacks on DSM-5 began, the respondents have failed to make it known that Allen Frances has been condemning the DSM-5 editors for doing the very kinds of things that he himself did in his editions, with cavalier disregard for both science and harm. The presidents and trustees who served from 1988 to the present and thus who knew or ought to have known about the major problems with the work on the DSM-IV and then DSM-IV-TR have also been in a position to warn the public and professionals that the edition currently in use contains the vast majority of the same risks as the DSM-5 is likely to contain. The APA presidents, trustees, DSM editors and Work Group Chairs and Members and APA as an entity individually and collectively ought to have come clean publicly to correct the whitewashed impression Dr. Frances is giving about the current edition, for which he and Drs. Pincus and First had primary responsibility for creating, which every day ruins more people's lives. The fact of no longer being an APA president, trustee, or head or member of the Task Force or a Work Group for IV or IV-TR does not absolve the respondents of the responsibility for speaking out even when they left those offices or positions.
The problems about which I am complaining began in 1988, when the DSM-IV Task Force was first appointed. From that time to the present, the respondents working directly on the DSM-IV and then the slightly revised DSM-IV-TR, as well as the presidents and trustees of the APA and the APA itself have had the responsibility to follow ethical guidelines in the manuals' creation and in the creation of communications of all kinds to various audiences about them, including advertising and other marketing.
I allege that the conduct of each respondent involved: (1) their respective failures to maintain, oversee, and/or ensure the use of scientific rigor in construction of the manual or parts of it, and they knew or ought to have known that the manuals included diagnoses that lack scientific reliability or validity; (2) their respective failures to use, oversee, and/or ensure the use of proper procedures in compiling the manuals; (3) their respective failures to ensure the use of a clear definition of “mental disorder”; and (4) their respective failures to respond diligently and responsibly to legitimate concerns raised about the foregoing and about the harm that has come to people who have been given labels from their editions of the manual.
My story, recounted here below, reflects the harm that came to me because of the actions and inactions of the respondents individually and collectively, because each failed to meet many of the criteria from the American Psychiatric Association’s “The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.” The harm that I suffered began in the year [ fill in the first year you got a diagnostic label; if it was before 1994, then confine the complaint to the ones you got in 1994 or afterward] , when I was first diagnosed with [fill in here the first DSM-IV label you were given] , and as a result of the failure of these doctors to meet the APA’s ethical standards, the harm [fill in here either: has continued to the present day, with no sign of abating or if the harm has been reduced or has disappeared, say when it began to abate or when it stopped]. The harm done to me could have been lessened or prevented if they had kept to APA's ethical principles -- even one of those cited in this document.
Despite the manual’s multiple failings, including its silence concerning alternative causes of emotional suffering, its promotion as established science answers the wish of real-world actors for the guidance of determinate standards. This scientific patina assures that clinicians, employers, government agencies, insurance companies, and courts rely on the manual as though it possessed a rigorous scientific grounding. Hence the manual’s proponents at once reap massive revenues for the sale of their product while escaping responsibility for the consequences of third-party reliance. For those of us damaged by such pseudoscientific labeling, the manual is a loaded gun placed knowingly in the hands of clinicians, agencies, employers, insurers, and lawyers having strong incentives to pull the trigger.
2. My Story
[fill in here your story, ideally following the guidelines that were previously sent to you. Try to keep it as brief and clear as possible while including the elements described in the introductory instructions you received earlier, and make sure that every element’s relationship to the harm you suffered from getting diagnosed is crystal-clear. Also, make sure to consider every conceivable kind of harm you genuinely suffered, ranging from plummeting self-confidence to shame to fear to loss of hope to loss of a job, an education, income, various kinds of rights, loss of insurance, loss of child custody, loss of physical health, etc.]
3.The American Psychiatric Association’s Ethical Principles Relevant to This Complaint
The relevant standards from the American Psychiatric Association’s “The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry” which apply to my case relate primarily to the misrepresentation of the DSM-IV and DSM-IV-TR as scientific and to the failure to act to prevent or redress harm caused by the manuals. These standards are:
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self.
Section 1 A physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights.
Section 2 A physician shall uphold the standards of professionalism, be honest in all professional interactions and strive to report physicians deficient in character or competence, or engaging in fraud or deception to appropriate entities.
Section 3 A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
Section 4 A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
Section 5 A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
Section 7 A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
Section 8 A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
In addition, the APA as an entity is violating section (g) of its own Purposes and Objectives clause, which is:
(g) to promote the best interests of patients and those actually or potentially making use of mental health services.
3.1 Standards related to the unscientific nature of DSM-IV and DSM-IV-TR
Covered in the Preamble and in Sections 1, 2, 3 (which includes the need to avoid deceptive or fraudulent representation that this document is scientifically grounded), 4 (which applies [A] to the respondents' responsibility to respect patients’ right either to be diagnosed on the basis of the highest-quality science or to be fully informed that psychiatric diagnosis in general and also specific labels are not scientifically based, and [B] to the respondents' responsibility to inform all professionals who are credentialed to assign psychiatric diagnoses that psychiatric diagnosis in general and also specific labels are not scientifically based), 5, 6, and 8 are the necessity for the respondents to ensure that the diagnostic manuals produced, promoted, advertised, and profited from by the APA be characterized by appropriate, thoughtful, and responsible uses of good scientific knowledge and rejection of poor-quality research. This same necessity is covered in section (g) of the APA's Purposes and Objectives, given that the use of scientific rigor in producing the manual or alternatively the refusal to make false claims that it is scientific would clearly have been in "the best interests of patients and those actually or potentially making use of mental health services."
The documentation presented in the all of the following sections is easily available, and much has been widely publicized. Thus, it was known or ought to have been known to all of the respondents and ought to have moved them individually and collectively to take action to stop the fraud and false advertising and to prevent future harm and redress past harm.
3.1.1 The DSM-IV and DSM-IV-TR Are Not Scientifically Grounded, and Its Editors, the APA Presidents and Trustees, Work Group Members, and the APA Itself Have Long Known That That Is The Case
As recently as a few months ago, Dr. James Phillips, the lead author of a three-part discussion involving writers who hold various perspectives about the DSM — including respondents Dr. Pincus and Dr. First — summarized the discussion in part as follows: "The authors of DSM-III, DSM-IV, and DSM-5 intend the manuals to be useful for both clinicians and researchers.... What we know is that the goals of DSM-III and DSM-IV have not been achieved." Dr. Phillips further referred to "the startling failure of research to validate the DSM categories of DSM-III and DSM-IV" and described the diagnoses as "shaky creations with uncertain scientific backing; they are a motley group that can't be neatly grouped together around one clear definition of mental illness." Neither Dr. Pincus nor Dr. First challenged these statements in their portions of those three articles, and no respondent named in this complaint has tried to make widely known that those goals have not been achieved. There follows here a great deal of documentation of the failure to attain these goals.
Before moving on, it is important to look at what Dr. Pincus did write in the published discussion coordinated by Dr. Phillips. Dr. Pincus wrote that "the management of information has become the pre-eminent task of a classification system, overshadowing (but also enhancing) the clinical, research and educational goals of a classification." He does not appear to have initiated or urged the APA to take any action that would inform the public or professionals that information management is the DSM's primary task, nor did he provide evidence for his "motherhood" claim that its information management function would enhance the other purposes. To educate the public and professionals about this drastic change of claims about the main task of the DSM would require mammoth efforts, but had he done so, I would have learned much sooner that the diagnosing of me as mentally ill was neither scientifically grounded nor likely to be useful clinically, i.e., to make my life better. In fact, it is stunning that when Dr. Pincus goes on to say that in the future, changes in classifications should be made only if there is "strong evidence" that they "1. Enhance overall communication among the 'tribes'; 2. Enhance clinical decision-making; 3. Enhance patient outcomes," he seems unaware that the focus in DSM-IV and DSM-IV-TR on aim #1 interfered seriously with aim #2 (focus on good science) and with aim #3 (at the very least avoiding harm to patients). Indeed, he writes straight out that his approach "gives up the ideal (or even a focus) on validity," quite something for a DSM head to advocate, since without validity, there is absolutely no way to know how using the labels will affect what he calls "patient outcomes" but which are our lives.
As for Dr. First's contribution to the same examination of the manual coordinated by Dr. Phillips, Dr. First refers to the categories in the DSM as "man-made psychiatric constructs," which is certainly true but is worlds away from the claims made by many of the respondents in the promotion of his editions of the DSM and never before contradicted by him. Furthermore, Dr. First neither in that published discussion nor elsewhere proposes measures to educate the public and professionals about the unscientific nature of the manual or the harm it causes or to redress the harm, nor have the other respondents. In that same publication, the third member of the DSM-IV and DSM-IV-TR triumvirate, Allen Frances, also described the categories as "no more than currently convenient constructs or heuristics that allow us to communicate with one another.... Mental disorders are no more and no less than constructs." In light of all those realizations — all of which had been written about for decades by people outside the APA and had been communicated in many cases directly to many of the respondents — where have the respondents been in taking actions based on them?
According to the introductions to both the DSM-IV and DSM-IV-TR, the manual’s highest priority is to provide a helpful guide to clinical practice, with additional goals listed as to facilitate research, improve communication between clinicians and researchers, improve the collection of clinical information, and be an educational tool for teaching psychopathology and a tool for collecting and communicating public health statistics. Indeed, in a “Fact Sheet” the DSM-IV editors issued in 1993, they represented the DSM-IV as essential in deciding what treatment a person needs. To achieve those aims, scientific rigor is essential. However, scientific rigor does not characterize the DSM. The DSM-IV Sourcebook is advertised as the compilation of the empirical foundation of DSM-IV. But the author of recent reviews of the Sourcebook’s Volumes 1 and 2, which include Drs. Pincus, and First among their editors, contends that nowhere in those volumes do the authors address “foundational issues of concern,” including the general concept of mental disorder and the appropriateness of a medical model. Further, consideration of both volumes reveals a vast array of manifestations of the unscientific nature of the process supporting the fourth edition of the manual. (See Schedule A for excerpts from Dr. Jeffrey Poland’s detailed explication of these manifestations.)
Please read include any of the following sentences that are about any of the DSM labels that you were given. If any label you were given is not mentioned here, please send a note through the contact form on our website to ask if we can send you anything to insert about whatever label(s) you were given:
--The DSM-IV Sourcebook, Volume 1, and other works show the lack of scientific basis in the labeling of me. This includes the following:
--The Psychosis has no solid scientific basis.
--The Schizoaffective Disorder label has no scientific basis.
--The Schizophrenia label has no scientific basis.
--A special project aimed at examining the research basis of a category applied to me — Obsessive-Compulsive Disorder — showed that there was no high-quality science to support the criteria listed for it or the cutoff point.
--A plethora of work showing the lack of scientific rigor behind a category applied to me — Major Depressive Disorder — shows the wealth of serious flaws in the science and even the conceptualizing of the construct of MDD, to the point that research using “depression” or MDD is virtually uninformative if not totally useless.In the absence of a solid scientific foundation, it is important that in the current edition of the DSM, none of these categories carries a warning to avoid applying them if there is as obvious and powerful an explanation for the problems I was experiencing.
The APA as an entity has in many of its publications over the decades misrepresented the manuals as scientific. A typical example is the following, which comes from an APA publication which it titled Fact Sheet:
Psychiatrists depend on accurate diagnostic tools to help them identify precisely the mental illnesses their patients suffer, an essential step in deciding what treatment or combination of treatments the patient needs.... DSM-IV is based on decades of research and the input of thousands of psychiatric experts from across the country and in every subspecialty.... DSM-IV has been carefully written and exhaustively researched.
As research has increased psychiatry's understanding of mental illnesses and sharpened its ability to diagnose and treat them, the DSM has changed to reflect this greater level of sophistication.
According to Dr. Allen Frances, Chair of the DSM-IV Task Force, "The major innovation of DSM-IV lies not in any of its specific content changes, but rather in the systematic and explicit process by which it was constructed and documented. More than any other nomenclature of mental disorders, DSM-IV is grounded in empirical evidence.
...The Task Force set high standards for evaluating proposals for changes in the new manual. Recommended changes had to be substantiated by explicit statements of rationale, supported by the systematic review of relevant empirical data."
The same Fact Sheet included the claim that for DSM-IV, "a three-stage empirical review" was carried out, beginning with 150 reviews of the scientific literature on which decisions about IV were based. But there is a world of difference between "reviews of the scientific literature" and scientifically rigorous reviews of that literature, and as shown repeatedly in this complaint, the work lacked scientific rigor. The same Fact Sheet includes the report that twelve field trials were carried out and were funded by the National Institute of Mental Health, National Institute on Drug Abuse, and National Institution of Alcoholism and Alcohol Abuse, all of which carry great scientific weight. But veering far from accepted scientific methodology, in the Fact Sheet no information is given about how the field trials were designed or executed or how the information from those trials was analyzed. Dr. Pincus, who at the time in addition to being one of the DSM-IV heads was also director of the APA's Office of Research, claimed in the Fact Sheet, "The process of systematically examining the empirical data has enabled us to reach remarkable consensus on the literally hundreds of decisions made by the Task Force." That carefully-worded statement again gives the strong impression that the procedures hewed to stringent scientific standards but -- to those in the know -- actually provided a clever "way out," enabling him to say that he had confessed that the decisions were actually based on consensus rather than on science. However, the wording clearly paints a picture of such a careful, thorough examination of the empirical data having been made that everyone agreed on what the science showed. Nothing could be further from the truth, and indeed, they repeatedly reached consensus by ignoring or excluding those who disagreed with them. In fact, DSM-IV and DSM-IV-TR co-head Allen Frances even now continues to claim publicly (despite occasionally issuing mea culpas about a very small number of errors he acknowledges that he and his colleagues made) that for DSM-IV, which differs minimally from DSM-IV-TR, they required "substantial scientific evidence" to make changes, aiming "to keep the diagnostic system from expanding wildly." Given that only seven years passed between publication of III-R and IV, yet the number of categories and subcategories listed zoomed from 297 to 374, this claim about high scientific thresholds does not hold water, and the respondents individually and collectively have failed to educate professionals and the public to that effect.
Why have the respondents failed to correct these patently false but widely believed claims? Not only have they failed to make those corrections, but many of the respondents have made explicit claims that the manuals are scientifically grounded. As just one example here, consider this statement from John McIntyre, the APA president in 1993-94, which begins the APA's advertising flyer and order form for the DSM-IV, which was published during his tenure as president: "Perhaps no other work in APA history has been the subject of such rigorous review as has DSM-IV."
Please include any of the following sentences that are about any of the DSM labels that you were given. If any label you were given is not mentioned here, please send a note through the contact form on our website to ask if we can send you anything to insert about whatever label(s) you were given:
--The DSM-IV Sourcebook, Volume 2, and other works show the Bipolar Disorder II label I was given to have no scientific basis.
--The DSM-IV Sourcebook reveals a plethora of work showing the lack of scientific rigor behind the other category applied to me — Major Depressive Disorder — shows the wealth of serious flaws in the science and even the conceptualizing of the construct of MDD, to the point that research using “depression” or MDD is uninformative if not totally useless.In the absence of a solid scientific foundation, it is important that in the current edition of the DSM, none of these categories carries a warning to avoid applying them if there is are clear reasons for the way the person is feeling that should by no means be considered signs of mental disorder. I fit the description of Major Depressive Disorder, which was neither scientifically derived nor developed with adequate attention to the damage that can result from calling someone mentally ill although their reactions to a sad situation clearly do not come from a medical disorder.I was sad. [change the previous word “sad” or add to it anything you felt, such as “lonely,” “grieving,” “helpless,” “hopeless,” “forlorn,” etc.] I was not depressed. The term Major Depressive Disorder is not scientifically derived nor developed with adequate attention to the damage that can result from labeling an individual who is labeled as mentally ill although their reactions to a sad situation clearly do not come from a medical disorder.
--The DSM-IV Sourcebook, Volumes 1 and 2, and other works show that the category of Bipolar Disorder, which I was given, has no scientific basis.
--The DSM-IV Sourcebook, Volumes 1 and 2, and other works show that the category of Psychosis, which I was given, has no scientific basis.
-- The DSM-IV Sourcebook, Volumes 1 and 2, and other works show that the category of Dissociative Identity Disorder, which I was given, has no scientific basis.
--The DSM-IV Sourcebook, Volumes 1 and 2, and other works show the Schizophrenia label I was given to have no scientific basis.
-- The DSM-IV Sourcebook, Volumes 1 and 2, and other works show that the category of Adjustment Disorder, which I was given, has no scientific basis.
--A plethora of work demonstrating the lack of scientific rigor behind another category applied to me — Major Depressive Disorder — shows the abundance of serious flaws in the science and even the conceptualizing of the construct of MDD, to the point that research using “depression” or MDD is virtually uninformative, if not totally useless.
In the absence of a solid scientific foundation, it is important to note that in the current edition of the DSM, none of these categories carries a warning not to apply them if there are clear reasons for the ways the person is feeling/behaving that should by no means be considered signs of mental disorder.
Dr. Frances has recently said he learned lessons about the need for scientific rigor during the development of the edition that he edited, including “in particular…the importance of obtaining and publishing critical reviews, restraining the unbridled creativity of experts, conducting field trials that address key issues and concerns, and conducting forthright risk-benefit analyses.” In this statement, he gives the mistaken impression that his edition was scientific, despite the fact that the history of this work shows that it was not based on serious scientific procedures and failed to meet conventional scientific standards. Dr. Frances has listed some of the problems a diagnostic manual’s authors confront, and all of these DSM-IV and DSM-IV-TR unscientific, “including (but not limited to) an elusive definition of mental disorder, the limits of neuroscience, the limits of descriptive psychiatry, an unclear epistemology, the absence of a unified theoretical model, pragmatism, and fads." The problems of the DSM-IV, perpetuated in DSM-IV-TR and well on their way to being perpetuated in DSM-5 include, as written in 1995, "designing and conducting studies in sloppy ways, ...distorting their findings to make them look better than they are,...not revealing some of their findings or revealing them too late to give non-DSM people time to respond before the next edition" would be published, and conducting some DSM research "at sites supervised by or employing DSM committee members, whose stake in the DSM's success might well have affected the ways they did their part of the study."
126.96.36.199 Lack of Reliability and Validity
As heads of the Diagnostic and Statistical Manual of Mental Disorders, editions IV (published in 1994) and IV-TR (published in 2000), respectively, Drs. Pincus, and First created new categories and retained categories from previous editions without regard to what the relevant, high-quality science shows about the validity (does it measure or reflect what it is claimed to do?) or even reliability (for instance, do two therapists examining the same patient assign the same label?) of those categories. The unscientific nature of these editions of the DSM has been documented by many, but Drs. Pincus, and First have made public and private claims that their work was scientific and have done so despite knowing this was not the case and at other moments even having acknowledged its unscientific nature.
Reliability of psychiatric diagnoses indicates, among other things, the degree to which two therapists, given the same information about the same patient, assign the same diagnostic label to that patient. Reliability is the sine qua non of diagnosis, for if two therapists are not highly likely to agree about what category applies to a patient, then no legitimate claims can be made that the diagnostic manual and its contents have validity; that is, they cannot to be said to indicate anything helpful or important. Although the DSM-III Task Force had conducted studies of the reliability of categories and subcategories in their edition, the reliability was poor and had been extensively critiqued by research methodology experts, and they knew or ought to have known about the poor inter-therapist reliability for assigning DSM-III labels. Accordingly, they ought to have conducted inter-therapist reliability studies of every category in the DSM-IV and IV-TR, but they did not do so. Instead, the DSM-IV Task Force “largely ignored” the matter of reliability, and the only investigation of reliability for DSM-IV involved “asking individual clinicians to make diagnoses of videotaped vignettes that are systematically varied in their degree of clinical ambiguity,” and this has been criticized as “unlikely to produce any information about the actual reliability of DSM-IV.” It is noteworthy that the failure of any of the respondents named in this complaint to make the facts widely known to the public and to professionals has resulted in such statements as the following being made even today as though they were true: "[the DSM categories achieved] the reliability that was their goal."
As editors of manuals claimed to be based on scientific research, Drs. Frances, Pincus, and First (as editors of the DSM-IV Sourcebook, another moneymaking product for the APA) knew or ought to have known that without reliability there is no validity of any kind. That is a fundamental scientific principle. In spite of this lack of evidence for reliability of DSM-IV and IV-TR categories, Dr. Frances wrote in 2009 that “DSM-III rescued psychiatric diagnosis from unreliability and the oblivion of irrelevancy. In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III.” This is a disturbing claim, given the lack of reliability of DSM-III, and it is one that all of the respondents ought to have challenged publicly. And as recently as January, 2012, Dr. Frances mocked the DSM-5 heads for planning to include categories with reliabilities as low as 0.2 but failed to mention that his DSM-IV Task Force did not even conduct reliability studies of its new categories, nor did it conduct updated reliability studies of the categories from DSM-III that had yielded poor reliability and that they included in IV. There is no evidence that any of the respondents has taken steps to correct the mistaken impression that the editions IV and IV-TR are scientifically grounded.
In contrast, several recent expressions of doubt concerning the validity of categories in DSM-III, III-R, and IV have come from visible individuals with considerable standing in the world of psychiatry (including former NIMH Director, Stephen Hyman, as well as Andreassen, Insel, Kendell, and Jablensky), and some of their statements are excerpted in Schedule A here below. The case against the unscientific nature of the DSM rests on both problems of reliability and problems of validity, and it is significant that problems of validity are now being openly recognized, including by former DSM advocates, and used as a basis for changes in research and clinical practice. In addition, Dr. Joel Paris has written:
While in principle, science should be the basis of any diagnostic system, DSM has been seduced by the illusion that advances in neuroscience provide empirical validity for a new system. In reality, we do not know whether conditions like schizophrenia, bipolar disorder, or obsessive compulsive disorder are true diseases.... Current diagnostic concepts tend to be more pragmatic than scientific but have become reified with constant use.
It is impossible not to wonder why none of the respondents has made public the kind of information about the manual's validity to which Frances on one occasion admitted:
The DSM-IV experience with the personality disorders was a rude and disheartening awakening. I very much hoped to include a (at least optional) dimensional personality rating scale. We were able to gather together in one room the proponents of all the competing dimensional systems to attempt the selection of one or some compromise among them. It didn't work – we could not forge a consensus because each participant remained wedded to his own scale (however minimally different it was from its near neighbors).
All of the respondents from 1988 onwards knew or, in their positions, certainly ought to have known that that was how the work was being done and should have taken steps to prevent the public face of the DSM process from being represented as scientifically grounded.
The compelling case against the unscientific nature of the DSM rests on both problems of reliability and problems of validity, and it is significant that problems of validity are now being openly recognized, including by former DSM advocates, and used as a basis for changes in research and clinical practice.
Drs. Pincus and First are surely aware that their work on the manuals has been far from scientific. A few examples of this awareness are provided here, and it is hard to believe that the other respondents have been unaware of them; more are available on request. Dr. Frances has written that clinicians are free to decide for themselves on a case-by-case basis if “enough” distress or social disability is present to warrant diagnosing of mental disorder:
As with the specific criteria sets, the intent for the NOS was to allow the clinicians to use their judgment for each individual as to whether the symptom cluster caused enough distress and/or impairment to be a mental disorder. There were no guidelines as to how such judgments [of mental disorder] should be made and no hard and fast rules; it was left to the clinician to make the determination on a case-by-case basis. This vagueness in guidelines is intentional so as to permit the clinician flexibility in using the Manual.
That vagueness seriously reduces any scientific merit the diagnostic categories might have had, and it is clear that they had little to begin with.
A DSM-IV consultant informed one of the DSM-IV committee heads, Dr. Susan Fiester, with a copy of the letter to the DSM-IV Task, that Dr. Fiester’s review of the research relevant to a proposed category was exceedingly poor and sloppily done. The same consultant repeatedly wrote to the Task Force to point out the lack of scientific integrity of the process by which DSM-IV was being compiled and the serious biases and procedural problems that tainted it. This consultant has also written about the highly political, rather than scientific, nature of that process and its resistance to open and honest critique, as well as about the failures of those in charge to curb public misrepresentations and outright lies about whether the work is scientific and about the harm it caused.
A recent article reveals the extent to which Dr. Frances is acutely aware of the unscientific nature of psychiatric diagnosis and the harm it has caused; reporting an interview with Dr. Frances, psychologist Gary Greenberg writes:
Every so often Al Frances says something that seems to surprise even him. Just now, for instance, in the predawn darkness of his comfortable, rambling home in Carmel, California, he has broken off his exercise routine to declare that “there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.” Then an odd, reflective look crosses his face, as if he’s taking in the strangeness of this scene: Allen Frances, lead editor of the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders…, the guy who wrote the book on mental illness, confessing that “these concepts are virtually impossible to define precisely with bright lines at the boundaries.” 
It hardly seems possible that the respondents named in this complaint sincerely held a totally different view, given that they either were directly involved in creating the manuals or were the top officers of the corporation that produced, marketed, and benefited from them.
Please read include any of the following sentences that are about any of the DSM labels that you were given. If any label you were given is not mentioned here, please send a note through the contact form on our website to ask if we can send you anything to insert about whatever label(s) you were given:
--And note that as quoted above, in 2010 there was public acknowledgement of the “terrible consequences” of the Bipolar category, but none of the respondents has since then taken steps to gather information about or redress the harm.
--The Borderline Personality Disorder label, which was applied to me, has also been shown in numerous ways not to be scientifically grounded, including to lack validity and to be highly likely to be inappropriately, disproportionately applied to women. Review of the empirical research relevant to this category led to this conclusion first about the quality and validity of the science at the time the category first went in a DSM edition: at the time that [Borderline Personality Disorder] was first included in the DSM, in light of the fact that there was only one empirical study on the topic and that it was riddled with methodological and interpretive problems, we conclude that: (1) there was no good empirical research indicating that BPD was a real entity, a valid category; (2) there was no good empirical research to support the choice of criteria for BPD; and (3) there was no good empirical basis for the choice of a cutoff point for BPD.
Given the lack of proven validity of BPD at the time of its entry into the DSM, it is interesting to note that recent research supports the view that BPD is not a real entity or that, if it is, at the very least it has been wrongly defined and classified: Two years and more after being diagnosed with BPD, only 44% of these patients retain the diagnosis (Grilo, Shea, Sanislow, Skodol, Gunderson, Stout, Pagano, and Yen cited in Oldham, 2005). This is a particularly important finding in light of the fact that BPD, as a personality disorder, is assumed to characterize patients throughout their lives.
Related to this is the description of Borderline Personality Disorder in a recent article by Dr. James Phillips as having "heterogeneous presentation" and "excessive comorbidity."
In a very recent article, Dr. Frances continues in many ways to attack the DSM-5 as though his criticisms were not exactly the kinds that have justifiably been leveled at his editions, and this is yet another instance of the respondents taking no steps to correct the impression, given in a publication for the general public, that the current edition is scientific and safe. Please read include any of the following sentences that are about any of the DSM labels that you were given. If any label you were given is not mentioned here, please send a note through the contact form on our website to ask if we can send you anything to insert about whatever label(s) you were given:
--In light of all of this documentation about the lack of scientific foundation for DSM-IV it is especially important to note the following about the Post-traumatic Stress Disorder label that was given to me. When this label first went into the DSM, it included a statement that PTSD was a normal reaction to an abnormal situation. Although it was strange to call anything listed as a mental disorder in the manual a normal reaction, at least that sentence provided some opportunity to make it clear that the person’s reaction of upset because of trauma should not be called a mental disorder. Drs. Pincus and First could have included that important sentence in the description of PTSD in the DSM-IV and/or IV-TR, but they chose not to do so. As a result, my normal reactions to both deeply disturbing information and physical violence fit the listing for PTSD at the time I was diagnosed. In this way, my experience is one story in uncounted numbers of stories of people whose normal reactions to trauma have been pathologized, as many, including military top brass, have pointed out. --Keeping in mind that because of being diagnosed as seriously mentally ill, I lost child custody, it is important that "The writing of diagnostic criteria has to be precise enough to withstand the rigors of future unanticipated forensic misunderstanding; every word should be vetted by forensic experts; if something can possibly be misunderstood, it will be misunderstood; even small changes can cause big, bad consequences."
188.8.131.52 Absence of a Solid Definition of “Mental Disorder”
It is not surprising that the reliability figures are so poor, given that the overarching construct of “mental disorder,” on which the manuals are based and of which each diagnostic category listed is presented as one type, has never been adequately defined, as even Drs. Pincus, and First report in their introductions to the manuals. The degree to which their manuals are unscientific is further revealed by the “Limitations of the Categorical Approach” section, where they admit that the boundary between mental disorder and no mental disorder can be specified. Their definition of mental disorder leans on “clinical significance,” and Dr. Pincus and Dr. First acknowledge that they cannot specify what they mean by clinical significance. In essence, then, what mental disorder is supposed to refer to cannot be specified. In fact, the DSM-IV and IV-TR simply fail to provide a solid definition of the term. For each separate disorder section there is a definition of the essential features of the disorder and a list of diagnostic criteria. If the diagnostic criteria are present, and they are "clinically significant" then the person is considered to “have” that “mental disorder.” Little or no consideration is given to why the symptoms are present, to distinguishing between reactions to adverse events which should not be considered evidence of mental disorder and actual or real mental disorder, however they might define “mental disorder” (the editors themselves have written that they were not able to come up with a good definition of that concept). Although the manual includes Axis IV, on which professionals may record “psychosocial stressors,” which could help make it easier to distinguish the absence from the presence of “real mental disorder” (were it possible to define the latter adequately), Drs. Pincus and First have done little to emphasize the importance of considering psychosocial stressors, instead repeatedly emphasizing the allegedly empirical, objective nature of the categories and criteria. In fact, their manual explicitly permits users to ignore Axis IV if they don't want to use it, and in their listings of the descriptions and criteria for each disorder, reference to psychosocial stressors that might cause the criteria are largely missing.
Related further to the matter of when a criterion is judged to apply to a particular patient is the following observation:
A highly touted virtue of all criteria employed in defining DSM categories is that they are "operationalized" in terms of readily observable clinical attributes and other conditions, and, hence, that they are allegedly more scientific than the criteria employed in earlier diagnostic systems. It should be noted, however, that many of the criteria are highly inferential in character (e.g., hallucinations, delusions, loss of interest, depressed mood)…
The DSM editors’ admission that it is not possible to say what mental disorder means is so important: The formal definition offered in their Introduction is vague and circular. “Mental disorder” is supposed to be a psychological dysfunction, but since “psychological dysfunction” is neither defined nor discussed, in effect one unknown is being defined by another unknown. A similar problem applies to their concept of “clinical significance,” which is to be the standard of many of the criteria for the various disorders. Given that "mental disorder" is the foundational concept underlying the entire DSM, all of the respondents ought to have known the serious problems to which the lack of an adequate definition of it would give rise. They ought also to have known that adding to a problematic definition of "mental disorder" the encouragement to individual therapists to decide what constitutes clinical significance could only increase the scope for subjectivity and bias, thereby leading far away from science and broadening the scope for harm.
Add the following if it applies to you:
--One (of many) important examples of the kinds of considerations just described is that by Horwitz and Wakefield concerning the overinclusiveness of DSM-IV criteria for depression, thus making it highly likely that what should by no stretch of the imagination be considered anything beyond normal sadness in response to serious loss will instead be labeled mental disorder. This label was given to me.
184.108.40.206 False Claims and Misleading Practices Created an Unwarranted Aura of Scientific Precision
None of this has stopped the respondents who are the editors of the current edition of the manual from listing hundreds of categories and subcategories, each with numerous criteria and each allegedly comprising a mental illness, nor has it stopped them or the other respondents from in many other ways at many other times creating an aura of scientific precision around their editions of the manual or failing to reveal that that aura is unwarranted. That aura of scientific precision is enhanced by the use of the word “statistical” in the manual’s title, the books’ sheer weight, the listings of hundreds of categories and subcategories of alleged mental illness, the use of multi-number codes complete with decimal points for each diagnosis, the lists of criteria for each diagnosis, and the specification of cut-off points requiring patients to meet a specified number of criteria in order to qualify for a particular diagnosis. In 2002, Dr. First and Dr. Pincus wrote that the DSM-IV-TR was published to keep the manual from becoming “increasingly out of step with the psychiatric database” and that a primary objective of IV-TR was to “review the DSM-IV text and make changes to reflect information newly available since the close of the initial DSM-IV literature review process….” (p.288); such statements again imply that the manual is scientifically-based. And as recently as 2008, Dr. First and Dr. Frances made the stunning statement that the DSM-IV-TR “contains only one outright mistake: in criterion A of the paraphilia section.” All of the respondents ought to have acted on their responsibility to counteract for the public and professionals the mistaken assumptions to which this aura of scientific precision leads. The same is true of their responsibility to reveal the truth in contrast to the following statements, which come from one of the major publications of the APA itself.
In June, 2009, Dr. Frances wrote, “As head of the DSM-IV Task Force, I established strict guidelines to ensure that changes from DSM-III-R to DSM-IV would be few and well supported by empirical data.” In the same article, despite having known for two decades about the unscientific nature of his edition of the manual, he stated:
We established a rigorous 3-stage procedure of empirical documentation to filter out mistakes. This consisted of systematic and extensive literature reviews, data reanalyses, and field testing conducted under well-controlled conditions and in a wide variety of settings. The null position was always to keep things stable: any change had to meet a high burden of empirical proof and risk-benefit analysis.
The work on DSM-IV was transparent and widely inclusive. We knew how important it was to get as many critical comments as possible to assist us in spotting pitfalls and blind spots. To this end, we enlisted the help of more than 1000 advisors, seeking particularly those opinions most opposed to the changes being considered. To recruit as many comments as possible from users at large, we also prepared a regular and widely distributed newsletter and journal column.
There was explicit accountability for decision making on all changes. We published many articles to establish the methodology of the DSM-IV empirical review, to indicate ways of judging the value and risks of “innovations,” and to determine the pluses and minuses of the particular diagnostic changes that were under review.
… After DSM-IV was completed, we published 4 sourcebooks, laying out in great detail the process and rationale for all the decisions that had been made, as well as their empirical support.
Note that in the above quotation, DSM-IV is presented as exquisitely scientifically based. Note also the citation in the above quotation of the four DSM-IVSourcebooks, which are presented as compilations of the “empirical support” for the manual. Drs. Pincus, and First are two of the six editors of each volume of these Sourcebooks. Once again, all of the respondents are responsible for neglecting to counteract these wrong impressions about the DSM-IV being solidly scientific that are given in the Sourcebooks the APA publishes and from which the APA profits.
Openness of discussion, debate, and critical thinking is part of the essence of the scientific method. Criticizing the secrecy that has surrounded the construction of DSM-5, Dr. Frances wrote: “In my entire experience working on DSM-III, DSM-III-R, and DSM-IV, nothing ever came up that even remotely had to be hidden from anyone.” However, there are countless examples of the secrecy and gatekeeping techniques used by those in charge of the DSM-IV process that have been well-documented (one author listed 25 such techniques based on her direct experience on two DSM-IV committees) and have been available since 1995 to the respondents.. These are in addition to their decades of concealment of harm to patients by DSM-IV diagnoses that are described in the next section of this complaint.
Considering the questions, “What did the respondents know about the unscientific nature and harm caused by their work on psychiatric diagnoses, and when did they know it?” the above reveals that they violated at least of Section 2 of the APA’s ethical principles. That is, the editors knowingly and willfully misrepresented as facts what they knew to be false, unjustifiably portraying falsehoods as though they were facts, committing what clearly goes beyond negligence and reaches the level of deliberate indifference, and the other respondents neglected to carry out their responsibility to make sure that products issued by their corporation were created and marketed with integrity and honesty. Furthermore, all of this took place. In disregard of risks of and actual harm about which they had been informed and in contradiction of Dr. Frances’ 2012 claim to have conducted risk-benefit analyses. Their actions amounted to unnecessary and wanton infliction of pain, effected through the leading of others to “detrimental reliance” on their claims.
Had the respondents carried out their individual and collective responsibilities to document accurately and disseminate widely to professionals and the public the information about the lack of science underlying and the harm resulting from diagnoses contained in DSM-IV and IV-TR, much of the harm to me and to others might have been prevented.
3.2Standards related to consideration of patients’ welfare and causing of harm
With regard to consideration of patients’ welfare, the respondents have failed to follow the APA’s ethical principles as presented in the Preamble and Sections 1, 2, 3, 4, 5, 7, and 8, and the APA as an entity has failed to follow section (g) of its Purposes and Objectives.
Some of those against whom this complaint is filed have on occasion, though far from consistently, acknowledged the serious lack of solid scientific support for what goes in the manual, but none has taken anything close to adequate steps to redress the harm that has been caused by or to prevent future harm from the use of unscientific labels in their manuals that they have so often and publicly represented as scientifically grounded. It is common knowledge that most professionals and laypeople believe, or act as though they believe, that the manual is scientifically grounded, and the respondents have a responsibility to take more steps to educate professionals and the public that that is not true, and to take other steps to redress and prevent harm.
3.2.1 The Respondents Knew That the DSM-IV and DSM-IV-TR Were and Are Causing Harm But Denied It or Failed to Warn About It
It has long been documented that as early as the late 1980s, the DSM-IV Task Force had been directly given evidence of harm that was being caused by labels in the existing DSM edition that were slated to be retained in their edition and/or were proposed for their then-forthcoming edition. In spite of this, they continued both privately and publicly to deny that there had been any harm. That the editors have known for more than 25 years that there had been harm and therefore was likely to be harm to patients in the future has been documented. It is distressing that the emphasis in Frances’ published articles since 2009 has been on likelihood of problems in the DSM-5, given his and his co-editors’ failure to act from the late 1980s, when they began work on DSM-IV, to the present day, while that edition and the slightly “Text Revised” edition of IV have continued to be so widely used that it is called the psychiatrist’s Bible. It is further distressing that all of the respondents have failed to act to reveal the truth about the harm caused by DSM-IV and DSM-IV-TR. For as Dr. Phillips has written:
The first and last principle here is: First, do no harm. Thus, when considering change to the nosology, we should consider the relevant science, but we should also consider the practical effects on patients.
Because of the poor reliability of the labels of these editions, as is clear from any introductory textbook about research methodology and statistics, there can be no validity of any kind, and thus both professionals and patients need to be fully informed about these facts. Further, the “Limitations” section of their manual includes the admission that the boundaries between disorders are not real. In spite of this, the APA continued to publish and subsequently to push the manual as well as to advertise it with no highly visible, strong warnings. Where there is a lack of solid scientific support showing reliability and validity, a vacuum is created, and into that vacuum can go every conceivable form of bias and subjectivity, with the attendant, increased risks of harm. These, too, are matters about which it was incumbent upon all of the respondents to inform professionals and the public.
Drs. Pincus and First created diagnostic categories and retained categories from previous editions with insufficient regard to likely harm to patients. Then, when informed of harm that had in fact been done, they failed to issue warnings to those who had been or might be harmed, and to this day, they have failed to take reasonable steps to help those who had been harmed. The other respondents are guilty of the same failures.
In 2009, Dr. Frances sounded warnings of risk and harm, including “problems caused already by an overly inclusive DSM4 [sic],” but these appear not to have led to his or any of the respondents' taking of any of the above kinds of steps. It seems highly likely that all of the respondents have been aware of Dr. Frances’ knowledge about harm as made clear in this article or articles by others, especially those published in official APA vehicles, and they do not appear to have taken steps to redress or prevent harm. Were they not aware, there is no excuse for that blindness, given their positions of authority and responsibility.
In a 2010 Los Angeles Times opinion piece titled “It’s Not Too Late to Save ‘Normal,’” Dr. Frances acknowledged that “As chairman of the task force that created the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994, I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended, damaging consequences. Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics"—attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many ‘patients’ who might have been far better off never entering the mental health system.” It is impossible to conclude that Drs. Pincus and First would not have been aware of all of these problems as well. In the same article, Dr. Frances made the point that his DSM-IV Task Force contributed to the shrinking of the domain of what is considered normal and writes:
This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day—despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
The manual, prepared by the American Psychiatric Assn., is psychiatry's only official way of deciding who has a "mental disorder" and who is "normal." The quotes are necessary because this distinction is very hard to make at the fuzzy boundary between the two. If requirements for diagnosing a mental disorder are too stringent, some who need help will be left out; but if they are too loose, normal people will receive unnecessary, expensive and sometimes quite harmful treatment.
Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status—to say nothing of stigma and the individual's sense of personal control and responsibility.
What are some of the most egregious invasions of normality suggested for DSM-V? …. Grieving after the loss of a loved one could frequently be misread as "major depression." "Mixed anxiety depression" is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.
Please include any of the following if it applies to you:
--In the abovequoted article, Dr. Frances speaks directly to Bipolar Disorder, a category that was applied to me, as a problematic category and describes in detail some of the kinds of harm the problematic categories have caused, which clearly fit with the kinds of harm I experienced, as described in my story. Although he refers to this as possible for the forthcoming edition, the same is true for DSM-IV and IV-TR. Any of the respondents, by making a public statement of willingness and intention to reduce or help redress the harm done to those of us because of the existence of Bipolar Disorder in the diagnostic manual, could have provided some reduction of my suffering, but none has done so.
-- In the abovequoted article, Dr. Frances directly names Major Depression, one of the categories applied to me, as easily causing one of the “egregious invasions of normality,” and although he refers to this as possible for the forthcoming edition, the same is true for DSM-IV and IV-TR. In IV and IV-TR, there is wide scope for applying the MDD label to what should by no means be considered anything other than a normal, understandable response to loss. Any of the respondents, by making a public statement of willingness and intention to reduce or help redress the harm done to those of us because of the existence of Major Depressive Disorder in the diagnostic manual, could have provided some reduction of my suffering, but none has done so.
--Dr. Frances describes in detail some of the kinds of harm that concern him, including what can come from mislabeling as mental disorders what by no stretch of the imagination should be categorized that way. This is what happened to me.
In another 2010 piece, this one for his Psychology Today blog, Dr. Frances described the “many detrimental implications” of “the medicalization of everyday problems and symptoms”:
Scarce medical resources…diverted from those who really need them to those for whom treatment may do more harm than good. Diagnosing and treating ever increasingly large segments of the population implies a lack of tolerance for variability and for the inherent imperfectability of human existence. There is also an implied lack of faith in the resilience of our species if every problem has to have a medical label and be offered a medical treatment. Medicalization also reduces personal responsibility and sense of control. It seems patently absurd to create a diagnostic system which makes normality an endangered species.
Dr. Frances’s statements about harm include the following comments about the negative consequences of DSM-IV:
… although many other factors were certainly involved, the sudden increase in the diagnosis of autistic, attention-deficit/hyperactivity, and bipolar disorders may in part reflect changes made in the DSM-IV definitions. Note this.… The crucial lesson here is that even careful field testing is never completely accurate in predicting what will happen when the system is eventually used in the actual field. This issue becomes particularly relevant when one considers the skillful pressure likely to be applied by the pharmaceutical industry after the publication of DSM-V. It has to be assumed that they will attempt to identify every change that could conceivably lead to a marketing advantage—often in ways that will not have occurred to the DSM-V Task Force. To promote sales, the companies may sponsor “education” campaigns focusing on the diagnostic changes that most enhance the rate of diagnosis for those disorders that will lead to the increased writing of prescriptions.
Include the following IF it applies to you:
Here again, Dr. Frances specifically names Bipolar Disorder as causing negative consequences for patients and acknowledges that this may at least in part reflect his own DSM-IV definitions.No respondent has taken steps to redress the harm done to me because of this label and its unscientific nature.
In the same 2009 article quoted above, Dr. Frances wrote:
In my experience, experts on any given diagnosis always worry a great deal about missed cases but rarely consider the risks of creating a large pool of false positives—especially in primary care settings. The experts’ motives are pure, but their awareness of risks is often naive. Psychiatry should not be in the business of inadvertently manufacturing mental disorders.
“Manufacturing mental disorders” and continuing to list in their editions those that were unscientifically manufactured, harmful ones from previous editions is exactly what Drs. Pincus and First have done and what no respondent has taken steps to stop.
Include the following sentence IF it applies to you:
In a 2010 interview quoted earlier, Dr. Frances publicly acknowledged that he knew of the “terrible consequences” of the Bipolar Disorder category, which had been applied to me:
“We made mistakes that had terrible consequences,” [Allen Frances] says. Diagnoses of autism, attention-deficit hyperactivity disorder, and bipolar disorder skyrocketed, and Frances thinks his manual inadvertently facilitated these epidemics—and, in the bargain, fostered an increasing tendency to chalk up life’s difficulties to mental illness and then treat them with psychiatric drugs.
Dr. Frances has written extensively about his concerns about the upcoming DSM-5, specifically with regard to what he has described as the lack of science involved and the harm that he believes will result. Dr. Frances wrote to the APA trustees, urging them to respond to increasing concerns expressed about the DSM-5 by cutting their losses “to prevent [DSM-5’s] inflicting further damage on APA, on psychiatry, and most importantly on our patients.” But after suggesting a mere five changes in DSM-5’s huge number of proposals, the ways he states his concerns strongly suggest that the concern about patients is a dead last, because his focus is clearly on power and benefits to the APA from accepting his proposals:
the press quiets down; mental health professionals find DSM-5 less unpalatable; the risk is reduced of having the government investigate APA’s exclusive control of psychiatric diagnosis; the credibility of psychiatry is less tarnished; patients receive fewer inappropriate medications (and I get to drown my cursed blackberry in the ocean).
As the responsible leaders of the APA, you cannot avoid your fiduciary responsibility to regain control of the staff and to rein in a runaway DSM-5 process. Continuing to do nothing means further loss of public and professional faith, dramatically reduced DSM-5 sales, APA budget shortfalls, declining membership, and potential loss of the DSM-5 franchise. … and the risks mount that the DSM’s will no longer be considered the standard for psychiatric diagnosis.
This is another publication which gave the respondents a perfect opportunity to make public statements to warn the public and professionals that Allen Frances' warning about the need for the trustees to "regain control" of those compiling the next DSM was sorely needed for Frances' own editions, one of which continues even today to put patients at risk for damage. I have not seen any evidence that any of the respondents did so.
Very recently, Dr. Frances implicitly acknowledged his grasp of the vast responsibility placed on those in charge of the manual for minimizing harm when he described the DSM as providing “the authoritative list of what are considered to be mental disorders. This list has a tremendous impact on research, funding, and treatment, as well as a variety of civil and forensic decisions. The development of this diagnostic manual is an enormous responsibility.” Related to this, he wrote: “Because it has such a powerful influence on real-life (and occasionally even life-or-death) decisions, the DSM can't ignore practical consequences—intended or unintended.” In light of this acknowledgement, all the more striking are the failures of all of the respondents to take leading roles in teaching professionals about the potential for harm from use of their categories, the known kinds of harm, and ways to try to reduce the harm and protect patients, as well as their failures to take steps to gather information about (what Dr. Frances would call risk-benefit analyses but which have not been made public, if they have been done) and undo the harm that has been done. Anyone who has been an APA President or Trustee or Work Group Chair or Member has the stature to command public and professional attention if they take action to expose the unscientific nature or the harm of the DSM.
Dr. G. Scott Waterman, after pointing out that "the current approach to psychiatric nosology is simply dying of its own flaws," notes that "despite its weaknesses, its influence is strong and persistent in (among other contexts) psychiatric education and training — precisely those venues to which we must look for hope for the future of the discipline. Judging from the time devoted to it and the examination questions asked about it, imparting to students and residents the algorithms by which DSM diagnoses are assigned is a major curricular commitment." Thus, Dr. Waterman demonstrates how powerful and influential the DSM-IV remains, and it is clear how important it is for the respondents individually and collectively to take action to ensure that the education of students and residents will begin to include accurate information about the manual, its limitations, and its risks.
3.2.2 The Respondents Failed to Warn of or Redress the Harm
There is no evidence that any respondent has made any attempt to warn professionals or the public of the known risks of harm; to take steps to learn about harm done to others, not even the most minimal step of making it widely known to professionals and laypeople that they wanted to receive reports of harm from diagnoses listed in their manual; or to develop and disseminate to professionals guidelines for ways they could reduce or prevent harm from diagnoses (see Caplan & Cosgrove, 2004, for suggestions to reduce harm, made quite publicly in 2004 from someone not on DSM-IV or DSM-IV-TR Task Forces in that year) or for the public, for past, current, and potential patients about how to minimize the harm that might come to them because of being diagnosed with labels from the manual. There is no evidence that any respondent took steps to notify professionals that, for instance, they could not expect—and needed to inform the patients that they could not expect—that assigning a patient a DSM diagnosis would result in the patient feeling better or lead to a more reasonable, scientifically-based choice of treatments, given the lack of scientific evidence that the categories were founded on high-quality research proving that they were either reliable or valid.
In their fiduciary positions, the respondents knew or ought to have known (ethical standards requiring attention to the science) that the diagnostic labels in DSM-IV and DSM-IV-TR do not have predictive validity, and thus it was further incumbent on them to inform professionals and the public that use of their labels would not be correlated with future benefits; had they done so, patients could from an educated position have made choices about whether, in light of diagnostic labels not being of use, they wanted to incur the risks of harm that the labels carry. This is all the more the case, because scientific study has not shown DSM diagnoses to be helpful in reducing the suffering of those who receive the labels. However, there is no evidence that any respondent has made any attempt to educate either professionals or past, current, or potential consumers of mental health services about that fact.
In principle, Dr. Frances grasps the need to avoid causing harm, for he writes: “It has to be workaday—trying very hard not to make mistakes that will hurt people, rather than having fancy but untested paradigm-shifting ideas that can very easily wind up doing more harm than good.” His understanding, of which the respondents are surely aware, needs to lead to steps to redress past harm and prevent future harm.
Today, Allen Frances increasingly intensively pursues his campaign to critique the DSM-5, taking the focus off the fact that his own editions — co-edited with Drs. Pincus and First and promoted by the APA as an entity and the other respondents who implicitly or explicitly endorsed but certainly failed to halt the false advertising and fraud — were responsible for by far the most enormous increases in numbers of people diagnosed with labels that are not scientifically grounded and that cause harm. Consider the kinds of things Allen Frances said in a public lecture in mid-2012, a videotape of which is available to anyone online, and keep in mind the responsibility of every respondent to counteract this by making the truth publicly known. Still the face most associated in the minds of the public and professionals with the DSM and the APA, Dr. Frances continues to make false statements about the scientific nature of the work, and these cry out to be corrected by all of the respondents. In the abovereferenced video, he says, for instance:
When I took over DSM-IV, I was very concerned about diagnostic inflation. So we established very strict criteria for change to stabilize the system. You had to have extensive literature reviews proving that there were scientific data that would justify a change, we analyzed data sets that were available but hadn't been published, we had to have convincing evidence from them, and we did rigorous field trials. The idea was to discourage new diagnoses. And for the most part we succeeded.... Of the hundred or so diagnoses that were suggested, we added only two.
This last statement is stunning and damages the credibility of anyone associated with the current DSM and the APA, given that between DSM-III-R and DSM-IV, the number of diagnoses listed skyrocketed from 297 to 374. As just one more example, railing against DSM-5, he says that "In DSM-5 normal grief would be turned into Major Depressive Disorder" and makes the claim that, according to DSM-IV (his edition), one assigns the MDD label only if the person is about to kill themselves. The latter claim is simply false.
Finally, it appears as though huge (unscientific and harmful) portions of the current edition will be retained in DSM-5, and not one respondent is raising concerns publicly about that. All of this makes it even more incumbent on any and all of the respondents to speak the truth and to do so immediately, and it is at the very least irresponsible, unprofessional, immoral, and inhumane that they have failed to do so. The APA's Ethical Standards require them to change.
3.3 A Longstanding and Pervasive Pattern of Deception in the Creation and Public Presentation of the Manual
All of the respondents in their fiduciary positions ought to have informed themselves about the ways the work on the manuals was carried out and to have put in place — especially with the wealth of information made public about these various deceptions — structures and procedures for ensuring a hewing to genuine openness and honesty.
There is a strikingly pervasive pattern of deceptive in the methods of operation of those constructing, marketing, and benefiting from the DSM, including the respondents named in this complaint. As Dr. Paula J. Caplan, has written, she has been asked why she has continually expressed surprise each time a new instance of deception has appeared. Her response has been that each time she has learned of a new such instance, she has assumed that now has heard the worst, so that when a subsequent one becomes apparent, she is in fact surprised. There follow here just a few examples of these deceptions.
As these examples are described, it should be kept in mind that each one — and the harmful consequences to which it led — was made possible by the failures to act and regulate the process of creating and marketing the manual of the respondents named here who are or have been APA presidents; trustees; DSM editors or other Task Force, Work Group, and committee or subcommittee members; and psychiatrists involved in other ways and named as respondents. The examples are listed in alphabetical order.
Based solely on Dr. Caplan’s direct interactions with people involved in the DSM process, she wrote a chapter in her 1995 book and co-authored with Dr. June Larkin a journal article in which they documented no fewer than 25 different techniques by which they keep out of the manual those things they want to keep out but include in it those things they want to include. Just a few of those techniques are: designing and conducting studies in sloppy ways, distorting their findings to make them look different than what they are, not revealing some of their findings and decisions at all or revealing them too late to give people outside the inner circle time to respond before the next edition is published, and appointing dissenters to consult with their committees but failing to take their input seriously and even failing to inform them of times and dates of scheduled meetings and deadlines. In spite of their use of these last techniques, many of the respondents have claimed that their process involves extensive consulting with and review by outsiders. Here is the full list with the introduction from the Larkin and Caplan article:
DSM Gatekeeping Techniques
It is important for us to understand the nature and the sheer number of ways used by the DSM makers to control what does and does not go into the DSM. Their correspondence with Caplan (described by Caplan, 1995) revealed no fewer than 25 different gatekeeping techniques. These were:
1. not responding to requests for
(i) information regarding deadlines and procedures,
(ii) copies of unpublished studies which only they had in their possession (or
knew who had them,
(iii) the bibliography they had put together and planned to use for their literature
review — although they were sent a bibliography early on by Caplan and
2. later, sending some of the unpublished studies but not stating that those were not the only ones they intended to use in their own review;
3. promising to send Caplan their own review of the SDPD literature but delaying doing so until after their deadline for receiving feedback on their review had passed;
4. claiming to have high standards for empirical research to support their DSM decisions — but only applying those standards to new diagnoses they don't want to include;
5. claiming that Caplan and Gans' review of the literature (on SDPD) arrived too late to be considered in their deliberations....
6. contradicting previous statements: For example, writing that Caplan and Gans' review had not been considered by the committee, Gunderson wrote in a later letter that the review had been "an important source of material for the discussion we had about the fate of...SDPD" (J.G. Gunderson, personal communication, November 14, 1989, p.1)
7. telling Caplan, within several days, both that SDPD would probably stay in the DSM-IV and that it probably would not;
8. dismissing the review by Caplan and Gans by calling it polemical....
9. having some people who are in high positions on the DSM Revisions Task Force also belong to the editorial boards of journals where these issues ought to be aired;
10. not informing the feminist/critical reviewers about each other's work (either while the reviews were being written or after they were completed — thus failing to save these reviewers time and effort, and thus making it more difficult for the reviewers to join forces with each other);
11. falsely attacking Caplan and Gans' critique (e.g., claiming that Spitzer has never said the DSM categories are based on good research, although Caplan and Gans had cited the place in the DSM version edited by Spitzer where he said they were);
12. making psychological interpretations of Caplan's objections instead of treating them on their merits....
13. asserting divine or natural right for the DSM process...;
14. saying there is little enthusiasm for SDPD while actually preparing detailed modifications of the specific criteria and justifications for them;
15. questioning the seriousness of Caplan and Eichler's intentions in proposing [a new] diagnostic category [which highlighted the sexism involved in some DSM categories];
16. saying they would review the empirical work [on the proposed new category from Caplan and Eichler] if Caplan and Eichler would assemble it, although their own people do the literature reviews for other categories;
17. refusing to specify the exact standards and criteria which they use in deciding whether to include or exclude categories;
18. dismissing with no explanation Caplan's point that there is a great deal of existing research which is relevant to [the category and she Eichler proposed];
19. explicitly discouraging [Caplan and Eichler] by following up a comment about the need for Caplan and Eichler to provide empirical support [for their proposed category] with the statement that, "if this sounds discouraging, I'm afraid it is meant to"...;
20. insinuating that [Caplan and Eichler] would not want to provide them with the empirical support [for their proposal], although they had offered to do so;
21. dismissing [Caplan and Eichler's proposal] before seeing the relevant review of the literature;
22. failing to assign any Task Force member to coordinate the review of the...category [proposed by Caplan and Eichler];
23. stating that they are against adding new diagnostic categories [although they added 77 new ones in a seven-year interval];
24. claiming to be unaware of research relevant to [the proposed new category], although [Caplan and Eichler] had informed members of the DSM-IV Revisions Task Force about their research and entioned those bodies of literature in a letter to them;
25. dismissing the research on violence against women, attribution theory, and many other [well-documented] topics as irrelevant to [the proposed new category] while continuing to include research on "masochism" as support for [Self-defeating Personality Disorder] despite the differences in criteria for masochism and SDPD.
In addition to these gatekeeping techniques, in an article whose authors included Drs. Pincus and First, they used the technique of claiming that disagreement with them indicated a failure to "understand" their procedures and also used namecalling against Dr. Caplan for pointing out problems in their work.
These gatekeeping techniques and more are precisely the kinds of things which all of the respondents ought to have taken care to regulate, but they did not, so that this is one of many arenas in which the APA's obligation to self-regulate is not being carried out.
3.3.2 Drs. Ming Tsuang, Mauricio Tohen, Jane Murphy, and Gerald Klerman about Reliability
In 1988, Drs. Ming Tsuang, Mauricio Tohen, and Jane Murphy wrote in their chapter in The New Harvard Guide to Psychiatry that the DSM's "highly specific operational criteria have made comparability in case identification an achievable goal." This is simply untrue, for as noted earlier, the reliability and validity are both poor.
In the same book, Dr. Gerald Klerman wrote that "[The] judgment [to put Self-defeating Personality Disorder in the provisional appendix] did not involve controversy over the reliability or validity of the syndrome.
3.3.3 Drs. Susan Fiester, John Gunderson, Fred Kass, R.A. MacKinnon, Robert Spitzer, and Theodore Millon about Self-defeating Personality Disorder:
The details of the way Self-defeating Personality Disorder (SDPD), a category particularly dangerous to women, was handled deceptively are more comprehensively given in Dr. Caplan’s 1995 book, but some will be given here. In February, 1989, Dr. Caplan received a telephone call from Dr. Fiester, chair of the SDPD subcommittee, to which Dr. Caplan had been appointed a consultant. Dr. Fiester told Dr. Caplan that she would send her copies of unpublished data sets relevant to SDPD, so that Dr. Caplan and her graduate student could include them in their review of post-DSM-III-R research for Dr. Fiester's committee. In May, having heard nothing further from Dr. Fiester and having received none of these materials, Dr. Caplan informed her that she and her student wanted to work with her group but were not sure how to proceed without further word from her. Dr. Caplan said that she and her student had completed the preliminary work for their review and found that, so far, there was still very little empirical research about SDPD, and what there was was poorly done and did not warrant inclusion in the next edition of the manual. At the end of May, they received a few unpublished articles from Dr. Fiester and began to write their review on the assumption that now they had all the materials she had promised to send. On July 10, Dr. Fiester wrote to them that she was doing her own review of SDPD research and would send them a list of unpublished work "within the next week." Dr. Caplan reports that they never received that list and thus had no idea who had collected the unpublished data and could not contact them for information to include in our review. She only sent them her review of the literature after the Personality Disorders Work Group, chaired by respondent Dr. John Gunderson, had met and the deadline for sending feedback about her review had passed.
Dr. Caplan reports that they had never been given a deadline for sending our own review in order to be useful to the SDPD subcommittee but they sent it as soon as possible to Drs. Fiester, Gunderson, and Frances. On October 16, Gunderson wrote to inform them that their review "arrived right after our Work Group had met and discussed issues relevant to its inclusion or exclusion." In other words, their review was not even considered. He wrote further that "existing evidence is insufficient to move it [SDPD] in either direction." It was in an appendix for provisional categories, so he was saying it would not be either removed from the manual altogether or placed in the main text for presumably scientifically-grounded categories. Dr. Frances wrote to Dr. Caplan on October 26 to express his pleasure that SDPD "does not engender enthusiasm in the Personality Disorders Work Group, and I feel hopeful that it will not appear at all in DSM-IV." Confused by the apparent contradictions in Dr. Gunderson's and Dr. Frances's letter, Dr. Caplan wrote to ask for clarification: Was their review discussed at the Personality Disorders Work Group meeting, or had it arrived too late? And was it likely not to be moved either way or to be left out? She received no reply. Furthermore, Dr. Gunderson, who had expressed regret that our review arrived too late for the committee to consider it, wrote on November 14 that their review "was an important source of material for the discussion we had about the fate of ... SDPD." He had clearly contradicted himself on an important matter. The minutes he sent Dr. Caplan of that meeting, though long and detailed, include no mention whatsoever of either their review or that of Dr. Judith Herman, another consultant to the committee who was opposed to inclusion of the category.
On November 17, Dr. Fiester sent Dr. Caplan her review of the SDPD research. The Personality Disorders Work Group's minutes from October had included the reminder that comments about Dr. Fiester's review should be sent to her by October 24, so she only sent her review weeks after that deadline. Her letter included the promise to call Dr. Caplan "to further discuss your views on Self-defeating Personality Disorder and your critique of my review." However, Dr. Caplan never again heard from her.
Quickly, Dr. Caplan sent feedback to her, Dr. Gunderson, and Dr. Frances about her review, including observations about the inadequacy of her paper, as well as her pro-SDPD conclusions that were unsupported by the very work she both cited and partially described elsewhere in her paper. For instance, she cited as though it were methodologically sound a study that had been shown in published work to have nine major methodological errors. She also presented as though they were comprehensive only a few of the concerns about SDPD that the APA's own Committee on Women had raised. And she made numerous other errors of varying complexity and subtlety. She did make the important point in her paper that it would do no good to include a clause in the SDPD listing to specify that the label should not be given if abuse had led to the symptoms, because, as she said, clinicians tend not to ask about abuse, and patients tend to repress their memories of abuse. Neither then nor at any time afterward did she or Dr. Gunderson, Dr. Kass, Dr. MacKinnon, Dr. Millon, or Dr. Spitzer (about whom more will shortly be described) warn the public or professionals about this concern, though much harm to abuse victims given that label could have been prevented if they had done so.
Dr. Caplan considered it important to make publicly available a review of the research about SDPD that was scientifically sound and straightforward, so she and her graduate student submitted theirr review to the American Journal of Psychiatry, an APA journal, and heard in January that it had been rejected. They then submitted it to the Journal of Personality Disorders, and it was rejected. They had submitted the article to Dr. Millon, who was listed as the journal's editor. The letterhead of his rejection letter showed that the coeditor was Allen Frances, and the editorial board (who might have included the unnamed individuals who reviewed and rejected their submission) included Drs. Fiester, Gunderson, and Spitzer. The reviews' comments on their paper included the statement that the authors of the paper "have a bias. They are opposed to SDPD as a category." Clearly, those running the journal also had a bias, though it was in the opposite direction. They were not told the reviewers' identities, but a reviewer referred to the papers' authors as "they," indicating knowledge that there was more than one author; clearly, the reviewer was not blind to the authors' identities, although blind reviews are accepted practice to guard against bias. The same reviewer said that the authors "often use affectively toned descriptors to exaggerate their points" in the paper, but the examples that reviewer gave of this problem their words, "all of these measures have highly unsatisfactory or nonexistent data on their reliability and validity," with the italics used by that reviewer. The citation of statements about the inadequacy of research as though they were "affectively toned" and exaggerations is itself clearly biased.
The other reviewer of their article commented that their statement that Dr. Spitzer had said that DSM categories must be solidly based in good research was wrong, because "Spitzer has never asserted that all of the DSM categories are based on or can be justified by good empirical research." However, he had in fact claimed in writing exactly what they said. It was also interesting that that reviewer apparently felt familiar enough with Dr. Spitzer (was it perhaps Dr. Spitzer himself?) to claim unequivocally that he had "never" made a particular assertion. The ethics of choosing a reviewer with such intimate knowledge of Dr. Spitzer, who strongly advocated SDPD, are problematic.
The minutes of the March 1990 Personality Disorders Work Group included a detailed description of small changes to be made in SDPD criteria, so that despite mention in the same minutes of the lack of empirical support, it was clearly headed for inclusion in the manual. Some years later, a well-publicized lawsuit headed for a public hearing was filed by a woman who had been damagingly diagnosed with SDPD, and soon after it was announced that major media were planning to cover the hearing, the Work Group suddenly announced that it was going to exclude SDPD from the next edition of the manual. The reason they gave was that the research did not warrant including it, but the timing was suspicious. Many years later, Dr. Caplan obtained an internal APA memo saying that the insiders knew that the decision had not been based on the research but rather had been "politically" motivated.
Another aspect of the deception related to SDPD was that, also as reported in her book, as Dr. Caplan entered the ballroom of the APA convention to participate as a speaker in a debate about SDPD, she saw Dr. Kass and introduced herself, saying that she was looking forward to the debate, in which he was going to speak in support of SDPD. He looked around the room and said to her, "I sure hope my patients don't hear what I'm about to say in this debate." This stunning reflection of the willingness to deceive patients who can be harmed by what APA psychiatrists believe and promote speaks volumes. And it is consistent with the way that Dr. Caplan saw all of the respondents fail to act to prevent harm like that which they knew had been caused by the inclusion of SDPD in their manual and which has continued to happen, as she has seen, by the informal use of the label even though it no longer appears in the manual. When an entity as powerful as the APA and a product as influential as the DSM conveys what it purports to be such "truths" as that there is such an entity as SDPD, those responsible for the entity and the product have an ethical responsibility to undo the harm they have done. This responsibility goes well beyond the simple withdrawal of the label from the manual, for once such a "truth" is sent forth, it takes a great deal of work to prevent it from being used, and I often speak with people — especially women — who continue to this day to be told that they suffer from SDPD.
3.3.4 Dr. Judith Gold and Drs. Nancy Andreasen, A. John Rush, and Robert Spitzer about Premenstrual Dysphoric Disorder/Late Luteal Phase Dysphoric Disorder:
Dr. Judith Gold headed the Late Luteal Phase Dysphoric Disorder (LLPDD) committee to which Dr. Caplan had been appointed. The label was in the appendix for provisional categories, those considered unsupported by adequate research, and the committee was to decide what to do about it based on the recent studies.
From the moment Dr. Caplan was appointed in 1988 until she withdrew from the DSM committees in late 1990, she received only six brief communications from Dr. Gold. They included a formal request to serve as an advisor to her group; a statement that her group would inspect all of the relevant literature and "come to some conclusion as to what clinical entity, or entities, if any, exist"; a promise to look at the sociocultural and political issues involved; a promise to send Dr. Caplan her group's literature review — which she never did but which Dr. Caplan obtained in another way once it was made public; a statement that she looked forward to receiving Dr. Caplan’s review of the research and Dr. Caplan’s comments on theirs; and a thank-you to Dr. Caplan for sending her their bibliography. Dr. Caplan and two graduate students studied the LLPDD-related research and sent her their review of it in the spring of 1990 but never received a reply.
After Dr. Caplan resigned, she learned that the LLPDD group had not been able to reach a consensus. This was troubling, because in their lengthy review of more than 400 studies, they had concluded that the research was filled with methodological problems and that the existing research that bore on the question of whether there was a premenstrual mental illness was very preliminary. Had deception, perhaps combined with other barriers, not been at play, clearly such a conclusion ought to have led to the recommendation to remove the category from the manual.
When the committee failed to make a recommendation, Dr. Frances had appointed two other people to decide what to recommend about including it in the DSM-IV. He refused to disclose these for months, expressing concern that if he did so, they would be "deluged with questions." When the names of the two people were learned, it emerged that they — Dr. Nancy Andreasen and Dr. A. John Rush — were by no means experts on anything premenstrual or on women generally. This was particularly ironic and deceptive, given the APA's proud claims previously to have appointed to the LLPDD committee the top experts about premenstrual matters. Furthermore, there were clear conflicts of interest involved in the appointment of Drs. Andreasen and Rush: Both had close connections to Dr. Spitzer, an ardent advocate of the category, Dr. Andreasen having co-authored published work with Dr. Spitzer and having served with him on two committees for the manual's previous edition, and Dr. Rush having served on a committee for Dr. Spitzer's previous edition. Dr. Rush had also, it emerged, been paid a great deal of money by drug companies manufacturing products to treat depression, so perhaps it was not surprising that Drs. Andreasen and Rush decided to list LLPDD (now PMDD) in the manual under Depression, even though the LLPDD committee had not even suggested in their massive literature review and list of options that depression was a particularly relevant classification.
Further relevant to this point is that the only specifically psychiatric treatment that Dr. Gold recommended for LLPDD was anti-depressant medication, again despite the fact that one need not be at all depressed in order to meet LLPDD criteria. Antidepressants have long been used to mask feelings of upset that women have had when targets of harassment, violence, or other forms of mistreatment, making it less likely that they or others will identify the real causes of their upset and pave the way for them to move to better circumstances. Even so, when Drs. Andreasen and Rush made their recommendation, Dr. Gold publicly defended it. In fact her own committee's review of the research had not yielded much work that was even on the topic of depression. And dismissing implications of the way that societal sexism would undoubtedly interact with the existence of this category, leading to women being colloquially called "crazy" when they were said to have PMDD, she avoided responding to that important point and instead made the irrelevant, diversionary claim that that would not happen, because PMDD was not consistent with the courts' definition of insanity. Similarly trying to cloud the truth, on the "Midday" show, when Dr. Caplan pointed out that Dr. Gold had just remarked that people of both sexes have hormonal cycles but that only women's cycles make them mentally ill, Dr. Gold's response was: "I didn't say that women's hormones make them mentally ill. I said that men and women are different and that women get into a severe depression that incapacitates them." She had just made it clear that that kind of depression was exactly what she was calling mental illness. (And for an additional fillip, recall that one need not be depressed to fit the PMDD criteria, so she was not even addressing the full contents of the category.)
Dr. Caplan appeared repeatedly with Dr. Gold on national and international television broadcasts, and she repeatedly and seriously misrepresented how many women would receive this label, saying that it would only be applied in extreme cases. When Dr. Caplan said on these broadcasts that using the percentages that she herself had given in an APA publication, she had come up with a conservative estimate that at least half a million North American women would receive the label, Dr. Gold spoke the words, "That's not true" and stated that the category would by applied to only "a tiny percentage" of women. As she knew, because Dr. Caplan had told her, it was using that very percentage that we reached the figure of 500,000. Because of her lie, Dr. Caplan reports that she reached the point of arriving at broadcasts carrying the document in which her figures were cited and, when she repeated "That's not true," held up to the camera that very document.
Also in media interviews, when Dr. Caplan reported that, based on her review of the research, there was no scientific justification for claiming, as Dr. Gold and her colleagues were doing, that there was an extreme form of Premenstrual Syndrome that warranted having a category calling it a mental disorder, she falsely asserted that new studies proved Dr. Caplan wrong. It is always easy to make such an assertion on a brief show, when one is unlikely to be required to document it.
Another instance of deception by Dr. Gold is shown in her committee's review of the relevant research. There, they cite an expertly conceived, designed, and executed piece of research that showed that, using the DSM criteria for LLPDD, one could not distinguish among the reports of mood changes among women who had been given the label, women who said they had no premenstrual problems, and men. Of the hundreds of studies they listed in their review, this was the single most relevant and important piece of research, and of course it ought to have led their committee to recommend that the category be removed from the manual, given that it had no validity whatsoever. But they glossed over that study and did not make that recommendation.
Dr. Gold blatantly contradicted herself on the "Donahue" and "CBC Midday" shows on which we appeared just weeks apart. On "Donahue" she had fully agreed that research had revealed no hormonal link to what was being called LLPDD and that hormone treatments did not help women who were labeled in this way. On "Midday," she completely reversed her position on a hormonal link. At another point on the "Donahue" show, her attempts to cover up the realities related to this category were evident in her statement that "The link [between mental illness and PMS] is not hormonal. It just happens during that time of the month." And after Dr. Caplan resigned but was not taken off her mailing list, Dr. Gold sent her a letter to her committee in which she stated that the name of the category was being changed from LLPDD back to Premenstrual Dysphoric Disorder because there may be no hormonal connection. Her mutually exclusive statements not only are inconsistent with accurate reporting of scientific research but are so blatant as to constitute actual deception in one or another claim.
On "Donahue," Dr. Gold claimed that her committee was not planning to move the category into the main text of the manual, which is supposedly reserved for categories fully supported by solid science, but were only moving it to "Depression Unspecified" (her words). She did not tell the audience that "Depression Not Otherwise Specified" is indeed in the main text.
"Depression NOS" was in fact where the category was ultimately moved, a curious choice, given that one need not be depressed in order to meet the criteria of the category.
A colleague of Dr. Caplan’s had remarked that the decision to list the category in the main text without listing its criteria but to keep the criteria listed in the provisional appendix was seriously problematic. It gave the appearance that "the DSM Task Force is so certain that there is such a disorder that they put it the label in the fully-approved section, but after all these years of research they still don't know what it consists of, so they have to have the criteria stay in a provisional appendix." This could be considered simply evidence of careless thinking on the part of Dr. Gold and of Drs. Pincus and First, who had to give their agreement to the decision, but given that they are considered experts about diagnosis, it looks more like deception.
Dr. Caplan and her colleagues drew the attention of Dr. Gold, her committee, and the APA Assembly to the fact that, as Dr. Gold had publicly acknowledged, research has shown men to have hormonally-based mood cycles but her committee never suggested pathologizing men with a category of their own or getting rid of LLPDD and instead creating a nonsexist category of hormonally-based mood changes. This demonstrates the deep-seated sexism in the whole set of procedures and principles. So in a strange way does Dr. Gold's comment on the national CBC radio show "Sunday Morning" that her committee's decision (her committee of course did not make the decision) could not have been bad for women, because all the committee members were female.
After the APA Board of Trustees gave final approval for keeping PMDD in the provisional appendix and listing it in the main text as a Depressive Disorder, Dr. Caplan appeared live on NBC on the "Today" show with Robert Spitzer. When interviewer Katie Couric introduced the segment by announcing that the APA was moving PMDD into the main text, he "corrected" her and said that they were only "continuing" to list it in the provisional appendix. A look at the DSM-IV shows that that was a deceptive statement.
The deceptions reported here have been particularly alarming because of the ease with which this label has now been applied to women, unwarrantedly pathologizing them, and used in child custody disputes, for instance, and used to medicate and cover up situational factors such as abuse and harassment that were the actual causes of the women's suffering. Furthermore, anti-depressants were known then and have increasingly become known to have serious negative effects. Dr. Caplan had personally given Dr. Gold information about women being harmed by the use of this category and by the drugs prescribed for it, but she nevertheless continued to state publicly that her committee had found no evidence of harm and apparently has not publicly stated otherwise to this day. As just one example, of "Midday," after Dr. Caplan had described some of the ways that women have suffered because of being diagnosed as premenstrually mentally ill, Dr. Gold claimed that her committee "went through all sorts of legal documents and case reports, and since the diagnosis was first introduced in 1967, there are no instances in which the diagnosis has been abused." In whatever sense the diagnosis might have been "abused," that is not a response to the statement that women had known to have been harmed by its application to them. On another occasion, she said that her group had found no criminal cases in which a woman had been harmed by use of the label, but she failed to mention that the concern was how it would be used in such civil cases as child custody and employment disputes.
3.3.5 A "Mole"
Dr. Caplan had said publicly that I was willing to allow anyone wishing to learn about psychiatric diagnosis and the DSM to have access to all of her files about the subject. She was contacted by a young man who told her his name and said simply that he was an undergraduate history major writing about the DSM and would like to look at her files. She welcomed him to her home, gave him free access to my DSM files, and agreed to his request to be allowed to take all of the documentation out to be photocopied. She allowed him to take the files out for that purpose. She asked him what specifically his thesis would be about. He was evasive. He asked what she thought were the reasons the DSM people were acting as they were, and she told him what she told everyone who asked that question, i.e., that she thought some genuinely believed they were helping people, some wanted power and money, and some did not know how to understand scientific research. She asked him to send her a copy of what he would write. He never did. Some time later, a journalist called to interview her and mentioned that Dr. Frances had urged her to speak to his nephew, who was writing his thesis about the manual. When she told Dr. Caplan the nephew’s name, Dr. Caplan learned that that was the young man who had been sent, as a “mole,” to inspect my documentation.
From the time that DSM-III-R was being prepared, Dr. Caplan observed that for that edition and each successive one, when whoever was editor at the time was asked, "Why do we need a new edition?" they would invariably reply "Because the previous one was not really scientific." The next one, they invariably asserted, would be solidly based in good science. Sometimes the respondents who made this statement were the same people who had made it for the edition before that one.
3.4 Official APA Positions and Actions Fail to Include Responsible Action about the DSM-IV and DSM-IV-TR
3.4.1 American Psychiatric Association Presidents and Presidents-Elect Neglect to Take Responsible Action about the DSM-IV and DSM-IV-TR
The presidents and trustees of the American Psychiatric Association have ethical obligations to correct mistaken impressions that professionals and the public have about the corporation's actions and the products that they sell. Their failures to follow the APA's ethical standards and purposes and objectives over the decades have resulted in suffering I experienced during the past ten years. If any respondent had at any time starting in 1988 taken any of the actions described above, the harm that I experienced as a result of being psychiatrically diagnosed could have been substantially reduced, because to be told that one is mentally ill and to believe that that classification is solidly based in science, is likely to help, and is unlikely to harm carries significant risks of harm that being told honestly that the classification is unscientific, easily subject to bias, unlikely to help (if you think diagnosis is scientific, and you don't get better, you think it's your own fault or that you are "sicker" than you realized), and likely to harm (you can take steps to prevent or minimize the harm if you are forewarned).
To read the presidential addresses and the responses to presidential addresses — the latter delivered by the presidents-elect — between 1988, when the DSM-IV Task Force was appointed through the appointment of the DSM-IV-TR Task Force and up to 2012 is to be struck by the almost total omission of any mention of the manual and by the failures of one president and president-elect after another to call for those who work on the manual to meet strict standards for scientific rigor and to make publicly and professionally known the paucity of evidence that getting a DSM label is helpful to the patient (other than getting insurance companies to pay the treating professionals) and the evidence of the vast array of kinds of harm that getting a DSM label can cause. Also completely absent is any proposal that the APA use its vast monetary profits (estimated to be at least $100 million) from sale of the manual and its associated products to gather evidence of the extent and kinds of harm caused to patients, to make that information public, and to begin to redress the harm.
These massive lacunae are unconscionable, given that by 1988, when the DSM-IV Task Force was appointed, the DSM-III and DSM-III-R had patently been shown to be characterized by poor reliability, lack of validity and other scientific foundation and to have caused patients harm, and in the years since 1988, the tidal wave of legitimate critiques of previous and current editions of the manual render it inexcusable that no APA president created any form of oversight of the work of the manuals' staffs, no major initiative to increase their use of scientific rigor, to name clearly the lack of scientific foundation and thus likelihood of usefulness, and the major risks and known kinds of harm.
Since the APA is totally unregulated or overseen by any body of any kind, it is perhaps unsurprising but is seriously problematic that it does not even go as far as the drug companies are required to do, i.e, to record instances of harm, to ask that such instances be reported to them, and to make that information public.
The manual is in both professional and public arenas the single product most widely associated with the APA, so it might have been expected that the top APA officers would have taken the steps suggested above. It appears that the APA has been satisfied to have a manual that has wide influence, that is often misunderstood to be scientifically grounded and helpful to patients and to cause no harm but that, in combination with the many DSM-associated products the APA sells, is hugely profitable financially and effective in enhancing the APA's public image. Both finances and public image have been named as top priorities by many APA presidents who are named as respondents here.
Another major priority cited by numerous APA presidents involves ways of dealing with what they present as the bugaboo of managed care. What they uniformly fail to mention is that managed care for mental health problems is founded on, one might even say deeply entrenched in, the DSM. What, then, has kept and continues to keep the APA from promoting the optimizing of truly good care of patients in managed care systems by bringing daylight to the dark and damaging secrets of the DSM?
That the presidents and presidents-elect have been so completely neglectful is all the more striking in light of frequent claims that the APA's work or even the DSM itself is scientific, as well as claims or clear implications that it is helpful to patients and not harmful, when all of the evidence to the contrary (see previous sections of this complaint) has long been available and continues to be produced. It is striking in light of the fact that the manual affects about half of United States citizens in their lifetimes and enormous numbers of the citizens of the dozens of other countries where it is used. It is particularly disturbing, given the many presidential addresses that include "patient care" and "help for the suffering" as top priorities, because the sine qua non of everything bad that happens to people in the mental health system is diagnosis: It all begins there, and what follows may be helpful or may be harmful but does not emerge from a scientifically-grounded system or one that includes safeguards against harm. There is all the difference in the world between stating that one cares for patients and actually taking steps to ensure at least that one's own "Bible" does not increase their suffering. Furthermore, it is noteworthy that enormous numbers of column inches in the presidential addresses and responses are spent on the importance of creating good press for the APA: Ann Landers' resumption of recommending psychiatric treatment was named as a sterling accomplishment, and the current APA leadership has apparently not stood in the way of the DSM-5 Task Force hiring a PR firm to mediate between the APA and the public and professionals and polish the public image of the forthcoming edition of the manual. The patterns of what the top officials of the APA have for decades chosen to address and not to address is telling and troubling.
Here are some of the salient details from the presidential addresses and the responses from the presidents-elect that illustrate the above. Let it be said that some of the people whose omissions are noted here took steps unrelated to the DSM that showed their compassion and concern for people in general and for social justice. That was admirable but made their failures to address diagnosis and the DSM all the more noticeable and perplexing. It is not suggested here that their omissions were conscious and purposeful, and in many cases one assumes that they were not, but the top APA officers should have recognized that ethical use of their considerable power ought to have included maximizing the benefits and reducing and redressing the harm from the organization's biggest-selling product and at the very least to have insisted on full disclosure to professionals and the public about the DSM's limitations and problems.
1988: President George Pollock in this year, when the DSM-IV Task Force was appointed, did not mention the DSM in his address, therefore certainly suggesting nothing in the way of quality control or evaluation of its effects, including harm.
President-elect Paul Fink in a lengthy response to the presidential address movingly bemoaned the failure of psychiatry as a profession to consider the psychosocial aspects of human suffering as well as the biological ones and spoke of the importance of the "Willingness to move and change paradigms." But despite the fact that the DSM by then had clearly proven to be feeding the overemphasis on allegedly biological factors, he did not propose any change of paradigms or indeed any alterations in the manual or in how the APA publicly represented it. This is particularly troubling in light of his mention as problematic the overfocusing on the DSM "inventory" that was leading psychiatrists to stop trying to understand the patient and of his call for "first consideration" to be "given to the patient, rather than to the demands of insurance companies," insurance companies already by then having become heavily dependent on the DSM.
1989: President Paul Fink expressed general concerns about the "ethical collapse facing the larger world"; described American psychiatrists' ethical dilemmas as a result of "this highly entrepreneurial, highly competitive, and fiscally driven world"; and raised the question "whether the psychiatrist is the advocate of the patient or of the company." He failed to articulate the applicability of this last question to the APA's maximizing of profits from its manuals at the cost of patients' welfare. This is the case despite his having underlined the importance of psychiatrists telling the truth and commitment to the "rights and best interests of patients." In his single mention of the DSM, he says that "through the development of DSM-III-R and DSM-IV," the APA had developed a model used internationally and that "The goal, to develop a universal, scientific, proven diagnostic scheme, is well on its way," though it was "not a perfect volume," and "we look forward to improvements that will incorporate new scientific evidence...." But he does not mention creating a mechanism for insuring that the science would be respected, that only high-quality science would be considered, or that anyone outside the DSM-IV's inner circle would see that true scientific rigor was maintained, and the results show that that the product was not scientifically grounded. Perhaps, given the status of the manual as a huge moneymaker for the APA and of the belief that the manual is scientific as contributing to psychiatrists' ability to command large sums of money, Dr. Fink's omissions are related somehow to what he said in his candidacy statement when running for APA president: "It is the task of APA to protect the earning power of psychiatrists."
1990: President Herbert Pardes described "humanistic values" as "at the very heart of our profession. The study of the mind, and the healing of the mental anguish that can rob people of the fulfillment of their humanity, is our life's work." But what was done to me as a result of being psychiatrically diagnosed was the opposite of the healing of mental anguish and the fulfillment of my humanity. Dr. Pardes went on to say that "First and foremost, we care about our patients. We are physicians, and we are the ones who chose to treat mental anguish." One would have thought that would be all the more reason to insure that the APA's diagnostic manual would not create mental anguish. President Pardes referred to what he called exciting research about "the refinement of diagnostic criteria" but did not mention the DSM by name, and like President Fink, at no point did he propose creating a mechanism to insure the scientific rigor of the manual or to gather information about harm the diagnoses had caused or to attempt to redress any of the harm.
President-elect Elissa Benedek spoke of the need to "understand current research and [be] able to translate it clinically, humanely, and ethically" and "all of us recognize that we must incorporate basic research findings into our clinical practice." Then speaking metaphorically, she said, "It is the researcher's job to send up the rockets, but it is the job of all of us to see that they come down in the right place, that the fruits of research are improved clinical practice and quality programs." But she does not apply this to the DSM. Her only mention of the DSM is to criticize III-R for devoting only 50 of its 500 pages to problems of infancy, childhood, and adolescence, with no mention of concern about the quality of the science or the harm.
1991: President Benedek in her lengthy presidential address made no suggestions related to the DSM. She urged "the rapid development of practice guidelines by the profession," failing to note that the APA's Practice Guidelines are based on, indeed begin with, DSM diagnostic categories which — not being scientifically grounded, reliable, or valid — cannot provide a sound foundation and framework for instructions about how to treat patients. In fact, she presented diagnosis as though it were scientifically grounded and also referred to "new and effective diagnostic procedures." She placed "importance on the continuing education of our members [about science], as well as...the need to reeducate those who have fallen behind," but she at no point suggested that that education and reeducation needed to include the truth about the DSM. Her omissions of recommendations to improve the knowledge of the public and professionals about the manual's limitations and risks are difficult to explain, in light of her repeated statements about the importance of including patients and families in decision making (How can they be included if they are misled into believing that the DSM is scientific, usually helpful, and safe?), her comment that "It is imperative that we retain the capacity to control the quality of care that we give all our patients" (which ought to include attention to the science behind and risks associated with diagnosis), and her extended disquisition on the importance of ethics in psychiatry: "...psychiatrists need ongoing interpretation and instruction in their code of ethics"; "...we have a responsibility to constantly review our ethical principles... We must participate in the establishment of ethical standards of practice, and we must also monitor our compliance and take appropriate action against those who do not adhere to the standards that have been set....we should see this as nothing more nor less than our obligation if we are worthy of being called professionals"; and "It is essential that we maintain the highest standards of practice and have the capability to eliminate from our midst those who are unwilling or unable to meet our high moral and ethical standards."
President-elect Lawrence Hartmann said that "Humane values should also lead us to special interest in the underdog and those who are different," and he did voice some criticisms of the DSM, but instead of proposing ways to safeguard patients from its unscientific nature and the harm it often causes, he said that "DSM-III and III-R and IV are part of the movement toward reliable categorization and measurement." It is not clear why he did not add that they were still far from reliable and why he did not propose ways to try to increase its scientific rigor and thus move toward real reliability.
1992: In his presidential address, Dr. Hartmann raised the question of what psychiatrists ought to know, what their "solid core of knowledge and experience" ought to be, but he did not suggest that thorough understanding of how to tell good research from bad, especially with regard to the DSM, should be part of that core. This is all the more perplexing in light of the concern he expressed about the movement of psychiatry toward "the purely physiological medical model" that is "inadequate." As he noted, quoting Dr. G.L. Engel, "The biomedical model is disease oriented" but "not patient oriented." He then suggested taking to heart Dr. Engel's concerns in light of "the relatively superficial and undynamic DSM-III and DSM-III-R" but again did nothing to try to educate the public or professionals about the problems of the edition then in use or of the DSM-IV that was then in preparation. This is surprising especially in light of his clear understanding of the vulnerability of people who are already suffering and of his statement that the DSM has emphasized reliability (this was an erroneous statement) but has sacrificed validity and the whole person.
President-elect Joseph English that year did not mention the DSM, despite the fact that his theme for the following year was to be "Patient Care for the Twenty-First Century: Asserting Professional Values Amidst Economic Constraints." Instead, he stated as his three major foci health policy, recruitment of young talent to psychiatry, and the public perception of psychiatry.
1993: President English claimed without evidence that "We have created diagnostic tools that portray the disorders in the brain," but he did not mention initiatives to ensure the ethical development of DSM-IV or the educating of the public and professionals about the unscientific, often unhelpful, and often harmful nature of the manual. He announced that his aims of recruiting young talent to the profession and of improving the public's perception of his profession had been met, including "most importantly" persuading Ann Landers to resume recommending psychiatric treatment to her readers. He also claimed that he had made an "energetic effort to promulgate and enforce our code of ethics" but did not connect this to the use, creation, or evaluation of the effects of any edition of the DSM, including the one that was to be published just one year later. He correctly pointed out that "The confidence of the public in a profession's ability to enforce its code of ethics takes years to develop" but did not address the APA's failure to apply its code of ethics to the creation of, full disclosure about, or failure to ensure reduce the harm from any DSM. He noted that "Physicians, including psychiatrists, possess special knowledge too complex for the average person to comprehend. Medicine 'professes' or pledges to use this knowledge in the patient's interest and to create mechanisms for policing itself" but did not apply this to the DSM, despite describing psychiatry as "a moral community accountable to a higher standard than the minimal requirements embedded in civil law." In fact, however, there is no indication that any APA authority has tried to ensure that the creation of, full disclosure about, or reduction of harm of the DSM would be monitored according to any ethical standard whatsoever. President Hartmann cited an ethics expert as describing two moral orders, one regarding ethical obligations to patients and the other regarding self-interest and the marketplace. It would have been important to ensure that all DSM-related work followed the former, and it is not too late to implement actions that would make that happen for the DSM-IV and any future editions.
In his response to the presidential address that year, President-elect John McIntyre mentioned the DSM only to describe it as having had "an enormously positive effect on our field." He neither specified what that positive effect might have been, nor, more importantly, did he raise the matter of what effects it had had on patients given diagnoses that came from it, and he did not suggest that gathering that information ought to be a priority for the APA. He referred to the APA's Practice Guidelines, each set of which is based on a DSM category. He surely knew or ought to have known — and this is the case for all APA officials who have served since the official Practice Guidelines were created — that treatment guidelines aimed at people given a label that has not been scientifically proven to represent a reliable and valid entity should carry no more weight than that which should require them to be labeled "Warning: These are not scientifically based and therefore cannot be said to be likely to be helpful or to be without risk of serious harm."
1994: President McIntyre named as APA's prime objectives "patient care, education, and research" and said that listening to "our patients and their families" is "the most basic lesson in psychiatry." He referred to the then-recently-initiated project of developing Practice Guidelines, one set for each of a number of diagnostic categories, saying, "The very existence of these guidelines gives testimony to the reality that we have specific, well-defined treatments for specific disorders" and further associated them with practices that are "scientifically based and clinically sound." He went so far as to say that "Mental illnesses are reliably diagnosed." It had been well-established by then that reliability for the DSM categories was actually poor, as documented earlier in this complaint, and President McIntyre knew or ought to have known that that was the case. The same is true for claiming that the Practice Guidelines were scientific because of being based on DSM categories that had been scientifically proven to be, as he wrongly asserted, "specific disorders." He neither stated that it would be important to ensure greater scientific rigor for the DSM-IV, which was published in that year of his tenure as president, nor proposed systematically to seek information about the effects on patients of getting DSM-IV labels, about harm that might be caused, or about ways to redress the harm.
President-elect Jerry Wiener said in his response to the presidential address that APA was "fortunate to have a veritable cornucopia of such data attesting to the reliability and accuracy of our diagnostic categories," a statement unsupported by the actual data. He announced a plan to "develop practice guidelines," and because those were to be based on DSM categories, which were not scientifically grounded, he was thereby planning to implement recommendations for treating actual human beings based on nothing like science. He did not acknowledge this, nor did he announce any plans for ensuring greater scientific rigor for the DSM-IV nor for systematically seeking information about the effects on patients of getting DSM-IV labels, about harm that might be caused, or about ways to redress the harm.
1995: President Wiener announced that APA's "attention, concerns, priorities, anxieties — and frustrations — have come to be focused on and dominated by managed care." Perhaps that is why he massaged the poor data about DSM reliability in order to make the claim that "Today's psychiatrist...is able to arrive at an accurate diagnosis with a reliability of up to 80%," despite the fact that reliability prior to DSM-IV was actually poor and despite the APA's failure even to have collected data about reliability for the DSM-IV, which was in use during President Wiener's tenure.
That same year, President-elect Mary Jane England claimed that "The validity of diagnosis has been enhanced by the completion and publication of DSM-IV," which she called "that really exceptional document" and "this masterful diagnostic compendium" that will "lay the groundwork for improving our value to our patients." This flies in the face of the then-known realities about DSM-IV, for without reliability, there can be no validity. Unsurprisingly in light of this, she proposed no mechanisms for improving the scientific basis for the manual, for making public its serious limitations, or for gathering information about or helping to redress the harm it had caused.
In 1995 in The American Journal of Psychiatry, which every president, trustee, and DSM-IV Task Force or Work Group member would be expected to read, a review of the DSM-IV appeared. The manual had been published the previous year, and the reviewer, Dr. Samuel Guze, made the bold and accurate statement that "DSM-IV is the natural outcome of what is essentially a process of discussion and debate within a sociopolitical context. In the absence of more powerful scientific foundations, this was and is inevitable." Dr. Guze described his proposal from 1970 for a more scientifically rigorous approach to creating the manual and noted, "Most thoughtful reviewers of DSM-IV would have to agree that very few of the hundreds of diagnostic categories have been satisfactorily validated according to these criteria."Those statements ought to have appeared in every advertisement and every other publication or statement that came out of the APA, and it is not too late to use that clear description as an important beginning in the move toward honest disclosure.
1996: President England this year claimed that "We have produced a new, valuable DSM-IV that is already of enormous help to many members of our profession around the world, as well as numerous other mental health caregivers." She further reified the unfounded and inappropriate notion that emotional suffering is "a type of medical illness," which is consistent with the unfounded claim that the DSM-IV is helpful in alleviating patients' suffering and that the suffering is caused medically. Despite stating that "we can be either leaders of reform or objects of reform," she proposed no mechanisms for improving the scientific basis for the manual, for making public its serious limitations, or for gathering information about or helping to redress the harm it had caused.
President-elect Harold Eist's response to the presidential address included the quotation from Chief Justice Earl Warren that, "The greatest menace to freedom is an inert people" and went on to say that the APA "must face up to our moral, ethical, and legal obligations to advocate in the political and social spheres for both the best patient care and excellent systems of care, and these systems must include high-quality education and research.... It is our duty to inform society of its needs for care and what we need to provide that care.... Remember, psychiatrists are experts at striking down false idols...." He ended his speech this way: "I remind you of Edmund Burke's words, 'All that is necessary for the triumph of evil is that good people do nothing.'" It is poignant that President-elect Eist's eloquent exhortations and descriptions of what APA ought to do provided the perfect framework for proposing mechanisms to improve the DSM's scientific basis, educating (Dr. Eist referred to the importance of education) the public and professionals about its serious limitations and ways to protect patients from the risks attendant on getting a diagnosis, and, in the spirit of providing "the best patient care," of actively initiating an information-gathering program to document harm that had been done thus far, and of creating mechanisms to use some of the APA's considerable profits from the DSM and associated products to redress at least some of the harm. He did not make any such suggestions.
1997: President Eist stated that APA's mission "is grounded in concern for the well-being of our patients, all our potential and future patients our educational and research institutions, and the public need for continued creative growth of our field, under our supervision, through clinical and scientific advances." He wrote that "the primary motivators of psychiatrists are altruism and heartfelt concern for those suffering from the ravages of the worst illnesses... [and] the doctor-patient relationship partakes of the divine ... and must be cherished...[and that] it is virtuous to defend and protect it at all costs." He said, "We must be the advocates the public needs. They depend on us, and we will not let them down. We will not relinquish and we have not relinquished this responsibility...." and further that "nothing will stop us in the pursuit of social justice." He might have pointed out that it is hard to imagine a group in greater need of social justice and cherishing than people who come to the mental health system because they are suffering, only to be misled by claims or implications that their treatment is scientifically grounded and likely to help, without being warned that the manual that is the basis of their diagnosis and thus of their treatment decisions is known often to result in serious harm. What appeared to be the focus of intense emotion for Dr. Eist was the wide publicity given an event he says APA convened that involved various mental health professionals and included "a heavily attended press conference at which we presented our Patient's Bill of Rights to the media. Our position advocating for full informed consent, freedom of choice, protection of confidentiality, and professional accountability made the front page of USA Today." How fitting it would have been to operationalize those rights by actively disclosing (so that fully informed consent would be possible) the truths about the DSM-IV and taking steps to be accountable by actively and systematically gathering evidence of harm and taking steps to redress the harm.
President-elect Herbert Sacks described what he called the previous "two decades of revolutionary scientific advances," as a result of which, "As never before, we have an integrated, sophisticated view of how to help our suffering patients." He pledged that APA would work to neutralize the adverse impact of managed care on "research, education, and, ultimately, recruitment to this exciting field," but he did not mention the detrimental effects of managed care on patients, which resulted from the pressures of managed care to make quick diagnoses, a problem all the more serious in light of the unscientific nature of the DSM and the harms caused by diagnosis, nor did he announce any initiatives to rectify any of these problems. This is even more perplexing in light of his statement of concern that "Drive-through psychiatry risks that our trainees, with the tacit support of attending psychiatrists, may make shallow diagnoses...." He worried about what individual psychiatrists might do but proposed no steps that the APA, as creator, publisher, and profitmaker from the DSM could take. These omissions are all the more puzzling in light of his closing of his speech with this quotation from poet Seamus Heaney: "History says, Don't hope/ On this side of the grave./ But then, once in a lifetime/ The longed-for tidal wave of justice can rise up." Dr. Sacks might have begun that tidal wave but did not.
1998: President Sacks said that "Comforting the sick is a core value of our calling. That value is part of our covenant with patients that must not be damaged in the marketplace by economic forces that have stricken 'caring' from their lexicon but not from their logos....Here in America our mission to repair the world will not be deterred by the dictates of those who profit from human suffering." Yet as leader of APA that year, he at no point so much as mentioned the DSM in his address, nor did he point out that, with the APA well on its way at that point to earning the $100 million of profit ("those who profit from human suffering") from the manual, his corporation was taking no steps toward full disclosure publicly or professionally of the truth about the manual and no steps toward documenting and redressing the harm it causes.
President-elect Rodrigo Munoz in his response to the presidential address pledged, "I will devote my efforts to the science of psychiatry" and noted that much of his professional career had been about "the social mission of psychiatry. This demands that we give the best to those who have the least." However, he said nothing about alterations sorely needed in the DSM, in how the APA misrepresented it publicly, the harm it caused, or redressing the harm. Especially poignant is that many of "those who have least" were suffering precisely because they had the least, and coming to mental health professionals for help, then suffering devastating changes in their lives as a result of getting DSM labels, ended up with even less.
Even if all of the APA Presidents up to 1998 had somehow managed to remain unaware of the many serious limitations of DSM-IV and the harm it had caused, surely they and the ones who came after them read in APA's own major journal, The American Journal of Psychiatry, Dr. Gary Tucker's 1998 editorial, "Putting DSM-IV in Perspective." Tucker accurately reports that "the new DSM diagnostic process has dominated the research, teaching, and contemporary practice of psychiatry. The DSM diagnosis has almost become a thing in itself — a certainty of 'concrete' dimensions. The DSM diagnosis has become the main goal of clinical practice. DSM-IV, as 'allegedly' being more data based, has even assumed the aura of allowing psychiatry to keep pace with the rest of medicine as a 'technological triumph'; but our current diagnostic process and zeal may also be ruining the essence of psychiatry. It is time to look at what we have wrought and make some midcourse corrections." He goes on to point out — no doubt responding to the frequency with which APA Presidents had focused their energies on health care reform — that psychiatrists need to acknowledge the problems caused by "the deal with which we and managed care have grasped the DSM process to our bosoms.... The current DSM process gives the image of precision and exactness, [although]... our diagnoses are nowhere near the precision of the diagnostic processes in the rest of medicine.... In psychiatry, no matter how scientifically and rigidly we use scales to estimate the patient's pathological symptoms, we are still doing pattern recognition." He goes on to bemoan that psychiatrists "have lost the patient and his or her story with this process; two, the diagnosis, not the patient, often gets treated; three, surprisingly, the study of psychopathology is almost nonexistent.... We are not looking at or studying the patient's phenomenology anymore but are looking for the symptoms needed to make a diagnosis." One consequence, he notes, is that "Many clinics and university programs have developed productivity standards based on a psychiatrist seeing four patients an hour for medication management."
1999: President Rodrigo Munoz did not mention diagnosis or the DSM and thus made no suggestions for improvement in its scientific basis, disclosure to anyone about its limitations, instructions to professionals and the public about ways to minimize harm from diagnosis, or ways the APA could collect information about the harm and attempt to redress it. Such suggestions would have followed well from his announcement in his presidential address, "My friends, we are at the doors of a promised land in which our patients make their own decisions, we build a new medical reality, and our patients can and do obtain the best attention and treatment."
President-elect Allan Tasman referred to the dramatic expansion of psychiatry's "knowledge base" and called for more research but failed to suggest any initiatives related to the DSM-IV or future editions of it.
2000: President Tasman critiqued DSM-IV on the grounds that it is not etiologically-based, but he described it as "the latest step in this tremendous record of advancement [in making "reliable and valid diagnoses"]." Thus, he, too, seriously misrepresented the degree to which the manual was and is scientifically reliable and valid, and given that he did that, it was not surprising that he, too, failed to propose fully disclosing the facts about the manual's limitations and did not suggest gathering evidence of harm or redressing the harm.
President-elect Daniel Borenstein in his response to the presidential address made no mention of the DSM.
2001: As President, Dr. Borenstein made no mention of the DSM in his address but instead announced that his presidential year began with a Board retreat focused on "our business relations initiative" and "patient privacy and the confidentiality of psychiatric records" and urged that the APA "commit more of its resources to legislative and public relations activities, including a new political action committee." The closest he came to the DSM was to announce that Darrel Regier — who later was to co-lead the DSM-5 Task Force — had as APA's executive director of research guided the APA to the obtaining research grants totaling $3.6 million for 2001. Not one penny was apparently earmarked to evaluated how DSM-IV or the then-brandnew DSM-IV-TR affect patients, to collect data about people harmed by being diagnosed with labels from the manuals, or to redress the harm.
President-elect Richard Harding in his response to the presidential address made some statements that might have led to action about the DSM but did not. These statements included: "We built this association on professional values and dedication to the welfare of our patients and members, and I intend to keep it that way"; [APA has] "scientific program excellence, unsurpassed in the medical community"; "We have learned what passivity does to our patients"; "Are we setting and living high professional standards?"; "Are we clear communicators with our patients and society?"; and "We are professionals, and professionals self-regulate."
2002: President Harding claimed that "our science and our clinical effectiveness are stronger than ever before"; that the APA has "an unmatched scientific knowledge base"; and that "our ethics are solid, we have a strong commitment to the individual's and the public's health, and we are in an ideal position to lead. However, being in an ideal position is of little value unless leaders step forward." He said nothing about stepping forward to lead in disseminating the truth about the DSM or about documenting, preventing, or redressing harm it causes.
President-elect Paul Applebaum in his response to the presidential address did not mention the DSM.
2003: President Appelbaum did not mention the DSM in his presidential address. He noted the creation of services for APA members, including FOCUS: The Journal of Lifelong Learning in Psychiatry, "free online continuing medical education," but he did not propose that that would be an ideal vehicle for disseminating the truth about the unscientific nature of the DSM, warnings of the harm it had caused, suggestions about how to minimize the harm, or discussions about ways to redress it.
President-elect Marcia Kraft Goin in her response to the presidential address did not mention the DSM.
2004: President Marcia Kraft Goin did not mention the DSM in her presidential address.
In her response to the presidential address, President-elect Michelle Riba did not mention the DSM. She noted the plan for APA to hold two major conferences, "one focused on medical student education, the other on residency training." Those would have been important conferences at which to make full disclosure about the limitations and risks of the DSM known.
2005: President Riba did not mention the DSM in her presidential address, despite announcing that "ultimately what we do is about how to best serve our patients."
President-elect Steven Sharfstein described a "crisis of credibility for American medicine and American psychiatry" and expressed concern that "How well we care for patients is rarely measured and even more rarely reimbursed." Since care for patients by all means should include monitoring the effects of one's corporation's major profitmaking product, the DSM, on patients' lives, protecting them from harm, and redressing harm that has been caused, he had a perfect opening for proposing that the APA undertake some measures as well as increasing the scientific rigor of the DSM and, until that is done, taking full responsibility for publicizing to professionals and the public its serious limitations. He did not do so. How perplexing are those omissions in light of these other statements from his response to the presidential address: "We do not ensure quality in our own ranks. Our system of self-discipline is erratic, inconsistent, and also not in the public interest. We allow an unacceptable rate of medical errors in our practice, even as we campaign for tort reform." "We have let the biopsychosocial model become the bio-bio-bio model." "We have allowed ourselves to be corrupted in this marketplace with lucrative consulting to industry, speaker panels, boards of directors, and visits from industry representatives." "We are seen, above all, as an interest group, a trade association, and too oftenwe have behaved like one." "Our second step toward credibility is to create and enforce ethical standards to make the rest of our nation take note." "Our third step is to defend our core professional values, including...scientific integrity." And he promised, "Above all, I will work tirelessly to enhance the credibility of our profession." These admirable aims were at no point in his address paired with any mention of fixing the problems with diagnosis, and that is all the more striking in light of the fact that diagnosis had by then come to promote heavily the "bio-bio-bio" model, in large measure because of APA's promotion of the DSM as scientifically grounded. APA has every step of the way woefully failed to live up to its ethical standards or professional values in the ways it has dealt with its astoundingly profitable DSM. It is worth noting that his admirable, generally-stated aims and the omission of any proposals to put them into action with regard to protecting patients in the realm of diagnosis appear in his address, which is titled "Advocacy for our patients and our profession." 
2006: President Sharfstein did not mention the DSM in his presidential address. He said that "psychiatry is part of a struggle between science and antiscience in America today. As physicians we search for the truth based on science, producing replicable results through research." He neglected to disclose that almost nothing in the DSM-IV was based on replicable research. He said further that "Our profession aims to provide the highest quality of psychiatric care to persons who suffer from mental illness" and specifically warns that "the thinnest of thin lines...separates...consultation from involvement in facilitating deception and cruel and degrading treatment." He was referring to interrogation of detainees, but the same principle applies to the deception of patients, whether leading them to believe or allowing them to assume mistakenly that their diagnosis is scientifically based and likely to lead to help, and to their cruel and degrading treatment both by professionals once they are diagnosed and by others because they been psychiatrically labeled.
President-elect Pedro Ruiz did not mention the DSM in his response to the presidential address.
2007: Dr. Ruiz in his presidential address described himself as having been "very industrious and addressed most of the problems that I observed and/or detected in our organization." With regard to the DSM, he described two initiatives, but neither had anything to do with the then-current (and still current) edition of the manual, with disclosing its unscientific nature, warning of harm, or redressing harm. Both initiatives were related to DSM-5, one of which was to make what he called the DSM-5 policy "the most transparent and ethically driven policy that one could humanly design," although that did not include anything about the kinds of disclosure, warning, or redressing just mentioned, not even with regard to the upcoming edition. His other initiative involved the "screening" of nominees for the DSM-5 Work Groups, screening now widely known to be deeply flawed (details not given here, since this complaint is about the two previous editions). What is telling is that he concluded: "I am very happy to report that to you that our DSM-V [sic] project is as protected as it can possibly be." Based on his own words, the focus was on protecting the public image of the project and the APA, not the welfare of the patients, a disturbing focus in light of his statement: "My fellow psychiatrists, it is our social responsibility as psychiatrists and citizens to ensure that humane care is not just a privilege for some but a right for all who live in the United States, as well as across the world." In fact, he repeated the claim about the need for "humane care" and "social responsibility," throughout his speech, even asking the dramatic rhetorical question, "My fellow psychiatrists, how much inhumane care do we have to observe in our daily practices and society at large before we say enough is enough?" despite proposing no way to protect patients from current or future DSM editions. Far from acting on "Enough is enough," he did nothing in this regard.
In her response to the presidential address, President-elect Carolyn Robinowitz urged, "We must be strong and effective advocates for our profession and for our patients"; asked her listeners to "join me in a commitment to advocacy...to educate, inform, and ensure that our patients...have access to appropriate care"; and asserted the APA's "moral responsibility to commit to our core professional values and protect our patients"; but she did not propose ways to make patient care less harmful as a result of the problems with the DSM. Indeed, she asserted without reservation, "...we can effectively diagnose...." and even said that "As professionals, we must ensure that new scientific knowledge becomes translated into clinical-based care," although to make that work to the patient's benefit, the scientific knowledge must be rigorously produced and interpreted, which of course was not done for the DSM-IV or DSM-IV-TR. She placed a great deal of emphasis on APA and psychiatrists as "resources to policy makers and the media, as well as the public" and said that "Gaining access to legislators allows us to educate and inform them on issues that no other organization will address." She would have well to include educating them fully about the limitations of the DSM or at the very least have begun to "address" issues about the manual, since no other organization is in a better position to address them, given that they produce and profit from it.
2008: President Robinowitz in her presidential address said that "Accuracy and consistency of diagnosis is key to clinical practice and appropriate treatment depends on the correct diagnosis. Preparation of the fifth edition of APA's Diagnostic and Statistical Manual is well under way under the superb leadership of David Kupfer," but she failed to acknowledge the serious lack of scientific rigor that has characterized all past editions, and she proposed no mechanism for ensuring that the next edition would be more scientifically sound, nor did she propose the active collection of evidence of harm, ways to redress the harm, or ways to inform the public and professionals comprehensively about the limitations and risks of either the DSM-IV-TR in use during her tenure or, likely, of the next edition.
President-elect Nada Stotland said in her response to the presidential address: "We are working on DSM-V. We bring to it the perspectives of scholars and clinicians.... DSM sets the standard for diagnosis in much of the world and we set a very high standard for DSM. Over a thousand experts will engage in nearly a decade of intensive literature review, field trials, and discussion. We will circulate drafts and make revisions." She failed to mention that, despite the very high standard that the APA ought to set, in light of the wide use of the manual, engaging in intensive literature review, field trials, and discussions, circulating drafts, and making revisions does not guarantee and had not guaranteed scientific rigor in any of those processes for DSM editions. Since President Stotland had spoken out forthrightly about these very kinds of problems with one of the categories first included in DSM-III-R and then retained for DSM-IV (which incidentally looks likely to be included also in DSM-5), and since she had objected to its inclusion in the manual, it is clear that she was aware that these kinds of problems plague the production of the manual. She is to be commended, however, for trying to reduce some of the harm from the DSM, albeit somewhat indirectly, by taking the courageous stand that APA should not accept drug company money for its convention.
2009: President Stotland announced that "Our field is blossoming with new science" but fails to point out the unscientific nature of the DSM or take steps to do anything about that or the harm in either the then-current (and still-current edition) or the one then in preparation. She stated that "The APA has been a leader in addressing conflicts of interest" but did not point out the magnitude of the conflict of interest for APA between profiting by $100 million from the sale of the DSM -- and much more from its DSM-associated products -- and allegedly standing for the care of suffering patients. She said, "We have to scrutinize research data and make independent judgments about whether the conclusions are warranted," but this was in relation to research produced by drug companies, and she did not apply that to research connected to diagnosis. In light of this failure, it is noteworthy that she asserted: "Our guiding principle is the welfare of our patients. Their welfare depends not only on the treatment we provide, but also on their trust that our recommendations are informed by unbiased scientific evidence. We are equally scrupulous as we develop the fifth edition of our diagnostic manual...." In the total absence of any unbiased and scientifically knowledgeable individual or group appointed by the APA to oversee the historically intensely biased and unscientific process of compiling any edition of the DSM, this statement is totally unwarranted.
President-elect Alan Schatzberg's response to the presidential address included a statement that APA's "zeal for social betterment perhaps also led to an overbroadening of syndrome criteria and to an oversimplification of psychiatric diagnosis." He said, however, with no evidentiary justification, that "DSM-III and subsequent editions were major steps forward in diagnosis and classification," and he suggested no oversight mechanism to rein in the overbroadening or rectify the oversimplification, nor did he propose any mechanism to ensure greater scientific rigor in the next edition, to educate the public and professionals about the unscientific basis of the current edition, or to gather evidence about harm the latter has caused or to find ways to redress that harm.
2010: It is hard not to wonder whether President Schatzberg's acknowledgement in his presidential address of David Kupfer as a friend and colleague for more than 25 years might have led to his unwittingly neglecting to implement measures for quality control of the DSM edition that Kupfer was in charge or preparing or of taking any steps to reveal the truth or redress the harm from the edition then in use. Indeed, rather than doing anything of that sort, he praised both the Practice Guidelines based on DSM categories and the DSM itself. He especially lauded the effective public relations work APA had achieved in connection with the DSM and Drs. Kupfer and Darrel Regier. It is inexcusable that, in light of all that was known in 2010 about the serious flaws and risks of the current and previous editions of the manual, he would refer to "the seriousness of the APA's efforts to provide the world a useful nomenclature that can unite us in our efforts to help those with mental illness...." Those whose lives have been damaged or eliminated because of the sequence of events that began with their getting a DSM diagnosis would not have considered the manual to be "useful" or helpful. Furthermore, President Schatzberg's assertion that the generation of 41 million hits and more than 8,700 comments on the DSM-5 website is "a great example of transparency" is absurd, given that outsiders looking at the site or leaving comments reveals nothing at all about whether transparency would characterize the way those comments would be dealt with. The claim that this reflects transparency is appalling in light of the history of successive DSM editors over the decades pronouncing their processes to be open and aboveboard while systematically ignoring any evidence or argument that failed to fit with their plans. His assertion indeed helps pull the wool over the eyes of professionals and the public, because it gives the impression of transparency when secrecy and politically-based decisions are the rule for this edition and for earlier ones. In fact, immediately after mentioning a concern or two about specific DSM-5 proposals, he explicitly made the deceptive claim that "we should be proud of what we have achieved in all the iterations of the DSM."
President-elect Carol Bernstein in her response to the presidential address praised the DSM and unwarrantedly described it as "advancing our research agenda and in helping us move toward integrating discovery with the clinical care of patients." Like some of her predecessors, she cited the numbers of people on the Task Force and the amount of "input" provided, without so much as mentioning the need for scientific rigor and minimizing of harm.
2011: President Bernstein in a "from the President" column in Psychiatric News falsely asserted that the DSM-III was "a pioneering scientific achievement" that "addressed the pressing problem of interrater reliability in psychiatric diagnosis." (She later described the DSM as having sacrificed validity in the search for reliability, and of course validity is essential, because it is what has the potential to make diagnoses helpful.) The latter part is true only if by "addressed" she meant "addressed but failed to increase reliability," as shown earlier in this complaint. Remarkably, given the vast amount of scientific research produced since DSM-III appeared, she wrote that "The DSM-III-R and DSM-IV remained close to the DSM-III approach, in part because of the dearth of new scientific information." She concluded that, "As a result, diagnoses in the DSM-III, DSM-III-R, and DSM-IV are best understood as useful placeholders, based on careful description, but not on deeper understandings." Aside from the obvious problem of her switch from praising edition III to describing it as a placeholder, the faint praise with which she damned all three editions failed to lead her to propose the much-needed (in light of her justified reservations), massive professional and public education about the lack of usefulness and scientific rigor, as well as the risks of harm. Her failure was all the more inexplicable in light of her justified concern that DSM categories have unfortunately come mistakenly to be assumed to represent real entities. Furthermore, had the categories been at least reliable (which they are not) as she asserted early in the article, then she might have been justified in stating that clinicians need DSM diagnoses to talk with each other and with patients and to receive reimbursement; but in the absence of good reliability, the statement of such need is unwarranted and misleading. She showed that she understood the pervasive influence and power of the manual when she stated that "DSM diagnostic entities continue to dominate research," but she did not propose notifying all funders and potential funders of research that these categories are (as she writes) not real entities and thus ought not to be bases of research. This omission was all the more troubling in light of her statement that DSM categories "fail to map onto clinical populations." Then what, one might ask her, is anyone doing using them, and why have patients, the wider public, and professionals not been notified of this? Why is APA not taking the lead in doing so?
In her presidential address, President Bernstein proposed no measures to disclose the limitations or dangers of the DSM-IV-TR, which had a full two years to be in use before being superseded by DSM-5. She announced that for DSM-5 she had directed the Board of Trustees to appoint a Scientific Review Committee to "evaluate the science that has informed the new proposals." That sounds good as far as it goes, but the statement is characterized by two glaring omissions: (1) She made no attempt to explain why a Scientific Review Committee would be necessary, given the plethora of claims from the APA itself and from many earlier presidents and DSM editors from various editions about the allegedly solid scientific study that went into their respective editions, and given that the Task Forces and Work Groups had allegedly studied the science for past editions and were allegedly in the process of studying the science for the future edition — that that was indeed said to be their primary task; and (2) She proposed no initiatives for education the public and professionals about the edition they were currently using and would use for two more years, and, related to this, she proposed no initiatives for reducing harm or redressing the harm that had been done. In light of this it is relevant that she called "patient-centered care...the watchword of 21st-century healthcare delivery" and advocated for psychiatrists to maintain their "ethical and humanitarian values." Dr. Bernstein also made the same claims made by other APA presidents about previous, current, and upcoming editions of the manual, claims that increase the aura of unwarranted scientific precision about them; that is, she reported impressive-sounding numbers of field trials in progress without commenting on their serious methodological shortcoming, and she claimed that the act of allowing the public to post comments about DSM-5 proposals on a website and some completely undefined "efforts to incorporate" such comments constituted evidence of "an open and transparent way." These statements are nearly identical to those made by earlier presidents despite the major methodological problems with field trials and the total power of the respective Task Force heads simply to ignore any critiques or suggestions they did not wish to incorporate and use only those that supported what they wanted to do. She did state accurately that the DSM is primarily a nosological text, but in the ways described, she nevertheless gave the apparently contradictory impression that it is solidly scientific. And to make her further claim that the DSM would be helpful to researchers who are trying to develop effective treatments, she had to ignore the vast literature showing that the manual's categories have neither reliability nor validity, which makes them virtually useless in trying to examine what treatments are helpful.
President-elect Oldham did not mention the DSM, despite the fact that three of his four stated priorities were very much related to it. These are patients' right to "quality treatment"; the fact that "fragmented care is not quality care," though he did not say that psychiatric diagnosis tends to promote fragmented care; and "research and education provide the best blueprint for our future," though he did not propose that good research and the education of all mental health trainees and continuing education for licensed professionals ought to include the facts about the DSM. He went so far as to say that psychiatrists need to be "eloquent ambassadors" who bring the truth to "our patients and their families, to our medical colleagues, to third-party payers, and to our legislators and policymakers," but he suggested no initiative for including anything about the DSM in those ambassadorial duties. When he wrote about patients' rights to be treated with dignity and respect, the ethical requirement to inform them fully about the limitations and risks of diagnosis ought to have come to his mind, but he did not name them. This is all the more troubling in light of what he presented as the poignant story of a time in his early career when "What I...had trouble seeing at the time was the person behind the psychosis, though he was there watching me and wanting to connect with me all the time." Dr. Oldham realized that he himself allowed diagnosis to get in the way of seeing what a patient needed, yet he failed to implement measures to warn other professionals, patients, managed care companies, legislators, and policymakers about how an unscientific, often unhelpful, and often harmful diagnostic system does exactly that. If all were educated about those facts, some of that harm could be prevented.
2012: President Oldham spoke in his presidential address of "our goal to achieve high quality, evidence-based, patient-centered integrated care" but proposed no initiatives to disclose to professionals or the public the serious limitations of the DSM still in use or to redress the harm that had been done. That is perplexing in light of the lack of evidence from good studies as the basis for the DSM-IV or DSM-IV-TR or of the DSM-5 in preparation, and it is perplexing in light of the demonstrated tendency for the use of the manual to result in fragmented care. In fact, he contributed to the erroneous impression that the manual is solidly based in good scientific research by quoting former APA President Harding's description of psychiatry as having "an unmatched scientific knowledge base." In fact, he did not mention the DSM. Shortly before delivering his presidential address, he wrote a letter to the Washington Post editor in which he without foundation portrayed psychiatric diagnosis as scientifically grounded and ignored the harm it caused, which was the subject of the Post article to which his letter was intended to be a response.
3.4.2 Reports from the Trustees to the APA Membership Show the Same Pattern of Total Neglect
The documents titled "Annual Reports to the Membership" during the years in question follow the same pattern as those in the above section, powerfully adding to the evidence of a total failure of the APA as an entity and its Presidents and Trustees to take the kinds of action needed with regard to the diagnostic manual that would bring them into conformity with the APA's own ethical standards and Purposes and Objectives. This section is brief because of the total failure by the Trustees from 1988 to the present to create any policy that (1) would have led to the full (or even partial) disclosure of the facts about the DSM's unscientific basis or its often unhelpful and often harmful nature or (2) would have initiated a process of seeking information about harm resulting from the manuals or a process of finding ways to redress both financial and nonfinancial forms of the harm. The actions taken by the Trustees from 1988 to the present appear in a document called "APA Position Statements," that includes the statement that "Policy documents are approved by the APA Assembly and Board of Trustees... These are...position statements that define APA official policy on specific subjects" with the notation that this quotation comes from the APA Operations Manual. The document listing these actions, which range annually from 2 to 22 in number, can be found at http://www.psychiatry.org/advocacy--newsroom/position-statements/apa-position-statements, where the total absence of actions related to the APA's diagnostic manuals is stark.
What the APA as an entity did do in relation to the DSM, however, was to order a single individual who had started a nonprofit website where she criticized the DSM to cease and desist, allegedly because she was using the manual's trademarked initials in the URL. There is no record of the APA's having used its attorneys to order anyone using the manual's name and saying positive things about it to cease and desist and certainly not to protect patients or the wider public. Thus, the only publicly known action taken by the APA itself with regard to the DSM other than creating, promoting, profiting from it, and falsely advertising it, was to apply its considerable weight and resources, its corporate power, to the punishing of one woman while failing to use it to disseminate the truth about the manual or to redress the harm it has caused.
3.4.3 Official Advertising of the Manual and Associated Products
On full-page advertisements for the DSM-IV-TR and associated other, expensive publications, the false claims include that the manual is "important...for treatment planning," as though its diagnoses had been shown to be reliable and valid and therefore to have predictive value associated with improved treatment planning. They also include the unsupported and actually false claims that the DSM-IV-TR promotes "effective diagnosis, treatment, and quality of care" and that it benefits "from new research." As noted earlier, the APA advertises the massive, multi-volume DSM-IV Sourcebook as the compilation of the empirical evidence for that edition of the manual, giving the impression of a solid scientific foundation. As noted, the APA's advertising flyer and order form for the DSM-IV began with the following statement from John McIntyre, APA president the year that edition was published: "Perhaps no other work in APA history has been the subject of such rigorous review as has DSM-IV."
Drs. Pincus and First, as well as the presidents and trustees of APA at every point at which such advertisements have been published and the APA itself, are responsible for violations of the ethical standards involving false and fraudulent claims about the related science and about the principles of concern for the patient's welfare, which at the very least begins with honesty and full disclosure about the extent to which the manuals are scientifically based, shown to be reliable and valid and have predictive value, shown to be helpful, and shown to carry risks of harm.
4. Actions Requested to Redress the Harm and Prevent Further Harm
[Include in this section ONLY those of the following that actually apply to losses you suffered, although so far, each complainant has included the ones that here below are numbered 4.10 through 4.17. Feel free to change the order of the items in this section. IF the APA takes any action on anyone’s complaint, we have no way of knowing what it might assert to be limits on the kinds of actions they can take. It is possible that they will say that they are only empowered to make findings of whether or not there were failures to meet ethical standards. But as a matter of record, it can be important for you to ask for any actions that you consider to be appropriate.]
4.1 I request that the respondents individually and collectively send a letter to me to say that [fill in here the label(s) you were given, and correct the words in the rest of the paragraph if necessary] ______________ is/are not scientifically validated, that is, has/have not been shown to be real entities, and that use of the labels has been shown to be often highly subjective and damaging, partly but not solely because they mask the real causes of people’s emotional suffering; that it is inappropriate and risky ever to use these labels; and that those labels should be removed from my charts.
4.2 I request that the respondents individually and collectively assist me in obtaining the pay I would have earned if I had not stopped working because of being diagnosed with [insert label(s) you were given].
4.3 I request that the respondents individually and collectively assist me in obtaining the $________ [be sure you have given the amount and described what it is for in Section 2. My Story] lost to my family and me because of the consequences of being psychiatrically diagnosed.
4.4 I request that the respondents individually and collectively assist me in getting back the home, belongings, savings, and health insurance that I lost because of being psychiatrically diagnosed, and my health.
4.5 I request that the respondents individually and collectively send a letter like the one described in 4.1 to every medical, mental health, and other professional who is credentialed to assign psychiatric diagnoses and to all training programs, professional associations, and licensing bodies, as well as all government entities that use psychiatric diagnosis (including but not limited to Medicare, Medicaid, the military, and the Department of Veterans Affairs) for psychotherapists and counselors in all disciplines, and to chaplains’ training programs. This letter should also warn that the [fill in here the label(s) you were given]____________ label(s) should never be used, because there is no scientific reliability or validity attached to it and therefore no predictable benefit to using it, and it causes a great deal of harm. This letter should also warn that these labels should never be used, because there is no scientific reliability or validity attached to them and therefore no predictable benefit to using they, and they cause a great deal of harm.
4.6 I request that the respondents individually and collectively help me to find paid employment, which has been especially difficult to obtain because it is now part of my record that I “have” [insert the label(s) you were given]______________.
4.7 I request that the respondents individually and collectively reimburse my family and me for the economic costs I have incurred as a result of being diagnosed with categories from their manual. [fill in here the label(s) given to you , fill in “is” or “are” as appropriate to your situation, and then check the wording from here through the last of the requested actions to make sure the right forms of verbs and nouns are used]
4.8 I request that the respondents individually and collectively send a letter to me, to say that the way I was psychiatrically labeled has no bearing on my ability to be a good parent.
4.9 I request that the respondents individually and collectively send me a letter of apology for their failure to publicize the truth about the poor scientific basis of their manual, the low probability that application of its labels is helpful to the patient, and the likelihood that receiving a label from it can cause a wide array of kinds of harm.
4.10 I request that a significant portion of the enormous monetary profits from the DSM-IV and DSM-IV-TR should be set aside for APA-funded programs aimed to undo harm that has been done through use of the manuals and programs aimed to prevent future harm. The APA as an entity, as well as the current president and trustees, should take active steps (as, for instance, auto manufacturers have done) to collect information as comprehensively as possible about who has been harmed by being labeled with one or more DSM-IV or DSM-IV-TR labels, the nature and variety of those kinds of harm, and the extent of such harm, and then to develop ways to redress that harm.
4.11 I request that the respondents individually and collectively and/or others designated by the APA should disseminate widely warnings such as the following:
… our diagnostic classification is the result of historical accretion and at times even accident without a sufficient underlying system or scientific necessity. The rules for entry have varied over time and have rarely been very rigorous. Our mental disorders are no more than fallible (if undeniably very useful) social constructs…. There is no scientifically proven, single right way to diagnose any mental disorder—and don't let any expert tell you that there is.
The [belief] that mental disorders are real things existing ‘out there’ that will soon reveal their secrets through scientific study…was the predominant view among biological psychiatrists until about ten years ago, but it is now widely recognized to be a misleading and reductionistic simplification….
4.12 I request that the APA and its officers take responsibility to include Black Box warnings on every DSM and DSM-related product and in advertisements of every kind related to the manual both currently and in the future, these warnings to include the statement that the products are not grounded in high-quality science, are not reliable or valid and thus have no predictive validity, and can be hazardous to the health and well-being of the persons to whom diagnostic labels from them are applied. This might include the following description of the process by which the manual is compiled:
The DSM-IV experience with the personality disorders was a rude and disheartening awakening. I very much hoped to include a (at least optional) dimensional personality rating scale. We were able to gather together in one room the proponents of all the competing dimensional systems to attempt the selection of one or some compromise among them. It didn't work – we could not forge a consensus because each participant remained wedded to his own scale (however minimally different it was from its near neighbors).
4.13 I request that every advertisement for any edition of the DSM current and future, as well as any other publication or statement issued by the APA in relation to the DSM include the following statements quoted earlier from Dr. Samuel Guze (these appeared in The American Journal of Psychiatry): "DSM-IV is the natural outcome of what is essentially a process of discussion and debate within a sociopolitical context. In the absence of more powerful scientific foundations, this was and is inevitable... very few of the hundreds of diagnostic categories have been satisfactorily validated according to these criteria."
4.14 I request that the respondents collectively or in any combination develop other ways to make widely known to the public and to professionals the serious limitations of the DSM's scientific basis, including the poor reliability and lack of predictive and other kinds of validity, and the risks of harm that getting a DSM diagnosis can carry.
4.15 I request that the respondents collectively or in any combination compile and distribute at no cost within the U.S. and internationally curriculum materials for use in teaching psychiatrists, residents, interns, and others in the mental health field the kinds of steps they can take to minimize the harm to their patients, including but not limited to stating in the chart and in a letter to the patient that whatever diagnoses they were given are not scientifically grounded and cannot legitimately be assumed to shed light on the patient's ability to be a good employee or parent or to make decisions about their medical and legal affairs.
4.16 I request that the American Psychiatric Association convene public hearings within six months of today’s date, these hearings to be about the subject of harm that those given DSM-IV and DSM-IV-TR diagnoses have experienced as a result of receiving those labels.
4.17 I request that at the American Psychiatric Association’s 2013 convention, those who have been harmed as a result of being given DSM-IV and DSM-IV-TR labels be impaneled as speakers in a series of presentations about the topic of these kinds of harm. This would allow us to be heard in open dialogue and would establish the APA as an active creator and supporter of public discussion of this neglected topic.
5. Procedural Requests
5.1 The published guidelines for filing complaints make it clear that a complaint may be handled by the national level's Ethics Department or by a district branch. This complaint absolutely must be dealt with at the national level, because nothing in it applies to the conduct or practice of any of the respondents within the districts in which they have their licenses or local APA branch affiliations. All of the unethical conduct described herein relates to the production, promotion, and public representation of the commercial product known as the DSM, which takes place not only at the national but even at the international level; this renders it irrelevant and diversionary if this complaint were to be routed to one or more district branches. This is a course to be avoided, given the seriousness of the matters described herein, which makes my right to a fair and speedy resolution particularly important.
5.2 I request that the APA's Ethics Department avoid conflicts of interest or even the appearance of conflicts of interest in handling this complaint by bringing in impartial third parties who are not APA members to review and issue a decision about it. This is in the interests of not only me as a complainant but also of the APA itself.
5.3 Following principles of fundamental fairness, I request that you send me all of the information that you receive in response to my complaint. I request to see what you do with the information we are filing now, and I want an opportunity to respond to it.
5.4 I request that the Ethics Committee convene a hearing about this complaint and that I be allowed the opportunity to cross-examine witnesses called by any of the respondents and to present witnesses on my behalf.
5.5 I request that I be sent a full description of the standard procedures of the Ethics Committee, including the time periods and deadlines for the filing of responses to the complaint and then of my responses to their responses, as well as to the rendering of a decision or decisions by the Ethics Committee. I also request that I be sent a full description of procedures of appeal that are available to me if I wish to appeal the Ethics Committee’s decision.
[print your name, snailmail address, and email address here. We advise you NOT to add your phone number. We further advise that you never given them your phone number, and if they should phone you, say politely and immediately that you will need to have all communications from them by email or snailmail and then say that you have to end the call. That is to ensure that you will always be protected to the extent of having a full record of all communications and so that they will not try to influence or pressure you at a time when you may be alone or feel especially vulnerable and not have time to consider fully what they are asking.]
Schedule A: Excerpts Concerning Problems of Scientific Rigor and Validity
1. Andreassen, N. C. (2007). The DSM and the death of phenomenology in America. Schizophrenia Bulletin 33(1): 108-112.
“…validity has been sacrificed to achieve reliability. DSM diagnoses have given researchers a common nomenclature – but probably the wrong one. Although creating standardized diagnoses that would facilitate research was a major goal, DSM diagnoses are not useful for research because of their lack of validity.”
2. Cuthbert, B., & Insel, T. (2010). Classification issues in women’s mental health: Clinical utility and etiological mechanisms. Archive of Women’s Mental Health 13: 57-59
“Questions such as these arise from the fact that current psychiatric nosologies were developed approximately 30 years ago and necessarily based upon consensus regarding clinical symptom constellations given the lack of knowledge about the structure and functioning of the brain. The classic formulation of Robbins and Guze (1970) and subsequent refinements were developed primarily with the aim of increasing reliability in diagnosis, with the assumption that future developments such as laboratory tests and family histories would validate the categories. However, these assumptions have increasingly proved problematic.”
3. Hyman, S. (2010). “The Diagnosis of Mental Disorders: The Problem of Reification”; Annual Review of Clinical Psychology 6: 155-79.
“The substantial need for NOS criteria, excessive comorbidity, the mismatch between real-world populations and “pure” clinical trial samples, arbitrary and rigid diagnostic thresholds, and the gulf between DSM-IV disorders and emerging results of genetic studies all point to significant failures inherent in the current DSM-IV classification.” (171)
4. Insel, T. (2010). Director’s Blog: Looking Forward in 2010 (Jan. 8). http://www.nimh.nih.gov/about/director/2010/looking-forward-in-2010.shtml
“Diagnosis has been a chronic challenge for both research and treatment of mental illness. It has become increasingly clear that most of our diagnostic categories are heterogeneous, and most of our patients have “co-morbid” conditions. The Diagnostic and Statistical Manual of Mental Disorders, or DSM, has yielded improved reliability, but validity will require an approach based on pathophysiology, not clinical consensus.”
5. Insel, T., & Cuthbert, B. (2009). Endophenotypes: Bridging genomic complexity and disorder heterogeneity. Biological Psychiatry 66: 988-989.
“It has become increasingly recognized that the current nosological framework represented by the DSM-IV and ICD-10, originally developed to promote reliability in making diagnoses, exhibits serious shortcomings with respect to validity. These include extensive comorbidity among diagnoses, overspecification of categories, and “Not Otherwise Specified” diagnoses that for some areas (such as eating disorders) represent the modal diagnosis. Further troubling is that the categories, created over a generation ago when brain science was in its infancy, do not represent current knowledge about genetics, neural circuits and neurotransmitters, and behavior.”
6. Insel, T., & Cuthbert, B. (2010> “Research Domain Criteria (RDoC): Toward a new classification framework for research on mental disorders. American Journal of Psychiatry167 (7): 748-750.
“Current versions of the DSM and ICD have facilitated reliable clinical diagnosis and research. However, problems have increasingly been documented over the past several years, both in clinical and research arenas. Diagnostic categories based on clinical consensus fail to align with findings emerging from clinical neuroscience and genetics. The boundaries of these categories have not been predictive of treatment response. And, perhaps most important, these categories, based upon presenting signs and symptoms, may not capture fundamental underlying mechanisms of dysfunction.”
7. Kendell, R., & Jablensky, A. (2003). Validity and utility of psychiatric diagnoses. American Journal of Psychiatry 160 (1); 4-12.
“Psychiatry is in the position –that most of medicine was in 200 years ago- of still having to define most of its disorders by their syndromes. Because of the consequent need to distinguish one disorder from another by differences between syndromes, the validity of diagnostic concepts remains an important issue in psychiatry.”
“The consequence of defining diagnostic validity in the way we are proposing is, of course, that most contemporary psychiatric disorders, even those such as schizophrenia that have a pedigree stretching back to the 19th century, cannot yet be described as valid disease categories.”
8. Poland, J.S. (2001). Review of DSM-IV SOURCEBOOK, Volume 1. Metapsychology: Online Reviews 5(14). April 7. http://metapsychology.mentalhelp.net/poc/view_doc.php?&id=557&cn=392
“Indeed, the deepest problem with DSM categories in general is their lack of demonstrated construct and predictive validity. Volume 1 of the Sourcebook provides little evidence that such issues were seriously addressed, let alone the issue of whether an adequate research base exists to validate the categories. It is simply not the case, for example, that systematic reviews of treatment efficacy research were conducted for each of the disorders, nor were systematic studies of construct validity conducted for each DSM-IV category. For the most part, categories in DSM-III-R, which were included in that edition without adequate evidence of validity or clinical utility, were largely retained in DSM-IV without any new or satisfactory evidence vindicating their original inclusion in the official diagnostic classificatory system. Although there are some discussions of validity issues in Volume 1 of the Sourcebook, these discussions are neither systematic nor deep. The inertial forces operating within the DSM development process are quite powerful and they all but guarantee the retention of categories of mental disorder that were not introduced on the basis of demonstrated validity and have not been vindicated in this regard by subsequent research.”
“It is somewhat puzzling that a process of development, widely advertised as bringing to bear scientific research on the classification of mental disorder, would give so little attention to the central research issues for any system of classification, and hence utilize so few pertinent empirical constraints on the development of the DSM system. (p.7)”
“… the bottom line is that DSM-IV categories, at least those studied in Volume 1 of the Sourcebook, have not been validated by scientific research. And yet they continue to inform, not only current and future scientific research, but also numerous cultural practices (e.g., clinical, legal, educational, health care).”
“…the quality of the research base is questionable: the studies considered often date back decades, the methodological quality of the studies is too frequently not addressed, the comparability of the studies is in doubt (e.g., due to different conceptualizations of the disorders), and the relevance of the studies to the questions addressed is not always clear. Second, the poverty of the research base becomes evident when it is seen that numerous issues cannot be meaningfully addressed at all, let alone resolved, because of insufficient evidence (this is frequently acknowledged by the contributors to the Sourcebook). Third, empirical evidence is not used in many decisions; rather, loosely constrained speculations regarding concepts, coherence with other systems, face validity, and consensus of the field are taken to suffice for making a decision. Fourth, even when empirical evidence is employed, it is often not clearly relevant, or, even when relevant, the decisions are only loosely connected to the evidence cited. Finally, it should be noted that, given the lack of demonstrated construct validity of the categories, many of the issues discussed are potentially quite meaningless (e.g., deliberations about accuracy of diagnosis).”
“Thus, as evidenced by Volume 1, the process of DSM-IV development very imperfectly lives up to the ideals, aspirations, and claims made by the developers, and it neither seriously addresses nor allays the concerns of the critics of the DSM approach to classification. As a consequence, the idea that the process exhibited in this volume places the development of the DSM classification system on a solid empirical basis cannot be seriously entertained. The real and very significant value of the sourcebook is that it provides us with a good look at how decisions about the DSM-IV were made. Unfortunately, far from establishing the scientific credibility of the DSM, it helps us to see more accurately just how far we have to go before a credible system will be achieved”
9. Poland, J.S. (2002). Review of DSM-IV Sourcebook, Volume 2. Metapsychology: Online Reviews 6(9). February 25. http://metapsychology.mentalhelp.net/poc/view_doc.php?&id=996&cn=394
[Poland found that this volume – which includes the research about Mood Disorders, Anxiety Disorders, Personality Disorders, Psychiatric System Interface Disorders, Sexual Disorders -- shares all the problems of Volume 1].
“…the development process did not live up to its own standards and has not achieved some of its most important stated objectives. To begin, it does not seem likely that the DSM development process, as reflected in Volume 2 of the Sourcebook, has succeeded in effectively breaking with the long tradition (re-affirmed in both DSM-III and DSM-III-R) of basing decisions regarding the existence and nature of diagnostic categories on consensus among practitioners rather than on sound science, either in the form of carefully collected empirical data or well tested theories. There are at least three reasons for thinking this. First, throughout the volume there are repeated affirmations of the lack of relevant empirical research findings bearing on issues concerning the construct and predictive validity of the categories (i.e., their scientific meaningfulness.) Most of these issues could not be so much as seriously raised, let alone resolved during the DSM-IV development process. Second, as a consequence of the conservative approach to change (viz., to make changes only when there is a “solid basis” for doing so) and the lack of relevant empirical research, the inertia supplied by past editions of the DSM dominated this most recent effort. Since it is generally agreed that DSM-III and DSM-III-R were developed on the basis of a politically derived consensus (sometimes not even among “experts”; cf., p. 647) and without being informed by any serious research bearing on the validity of the categories, it can only be concluded that DSM-IV consists largely of categories which have been introduced and retained, not on the basis of science, but on the basis of political consensus unconstrained by empirical research.”
“… Throughout this volume, the widespread lack of relevant and good quality research made the process quite vulnerable to loose, sometimes rambling and barely coherent, speculation. A frequent refrain throughout the volume involved vague appeals to “ease of use” and “clinical utility” without any clarification or justification. More serious problems perhaps are the imposition of dubious ideas onto the reasoning process… and pursuit of lines of reasoning which are barely relevant to an issue under discussion or barely coherent…. It is one thing to call for changes for which a solid basis exists, it is quite another to have and adhere to a serious standard of what counts as a solid basis.”
“… Two specific sorts of change recommended for introduction into DSM-IV are especially noteworthy in both their significance and their lack of a solid basis. The first concerns the widespread introduction of a criterion of clinical significance@ (e.g., clinically significant distress or impairment in social, occupational or other important area of functioning) for most if not all categories. None of the work groups identified any relevant data to support such an introduction as improving the construct or predictive validity of the categories they considered.”
“… it is pointed out by the developers that the DSM development process involves many stages with ample opportunity for critical review and discussion of evidence, options, deliberations, and recommendations by the substantial number of consultants and the psychiatric community at large (e.g., by circulation of interim drafts, presentations at conferences, publications). In this way, the ideals of peer review and open critical discussion in the relevant scientific community are supposed to be realized. But, there is reason to be skeptical about just how open the process was.”
“… Controversy may be permitted, but only within rigid assumptions to which many participants may well be blind and only subject to politically influenced procedural practices.”
“… There was frequent confusion about the nature of the entities being included in or excluded from the taxonomy (e.g., Are they empirically defined syndromes?, Are they disorders involving a core dysfunction?), and hence there was lack of clarity regarding the sorts of considerations relevant to making key decisions (e.g., p 5.) Further, discussions regarding the distinction between disorder and no disorder (normality and abnormality) were marred by a lack of understanding of and attention to conceptual issues raised by such questions. Hence, there was again an evident lack of clear understanding of what needs to be shown in order to effectively address important questions (e.g., p. 955-6 .) And, as noted above, the broad incorporation of a clinical significance criterion was made without any serious attention to the issues raised by the problems of categorical heterogeneity, inflated prevalence rates, and false positives. The somewhat dismaying conclusion of the discussion was that, even though there is a broad consensus that the categorical approach needs to be replaced because it is riddled with problems and is not promoting either clinical or research purposes very effectively, the categorical approach will be retained in DSM-IV because it is the standard for research and clinical purposes and because changes would be too confusing and disruptive (cf., p. 647-650.) The deep problems with changing the DSM come into full view here: even when a solid basis for change exists, change proves impossible because of the powerful inertia of the interests and the tradition that supports the current form of the classification system. Never was there a more patent need for clarity about the foundations of a discipline than is evident here; and yet, the DSM development process, to date, has given no serious attention to such issues.”
“Second, the evident lack of empirical research bearing on the most critical issues concerning the development of a categorical system of classification, viz., the validity of the categories, meant that these issues could not so much as be meaningfully framed, let alone addressed by the Work Groups represented in Volume 2. As a consequence of both this lack of evidence and the conservative approach of the development process, the discussions represented in Volume 2 (as in Volume 1) displayed a very powerful bias to retention of categories (the vast majority of categories) which had been introduced in DSM-III and retained in DSM-III-R on the basis of no sound scientific evidence of validity. As a consequence, beginning in 1994 (the publication date of DSM-IV), we have had eight more years (and counting) of powerful influence on clinical and research practice of a system of classification containing categories with no demonstrated validity. Critics of the DSM approach to classification have contended for two decades that this approach (as initiated in DSM-III) is not a sound way to develop a system of classification which exhibits appropriate levels of validity, and the deliberations in Volume 2 of the Sourcebook provide nothing to encourage a more optimistic view.”
“Finally, since the deliberations and recommendations made in Volume 2 were rarely based on sound scientific considerations, they were inevitably made on the basis of considerations that tend to corrupt future scientific research.”
“… The result of laying bare the nature of the scientific evidence and the deliberations supporting the decisions leading to the publication of DSM-IV is to bring into sharper relief just how deep the problems with the DSM system of classification go.”
“The developers of DSM-IV appear to have been massively uninformed by sound scientific research and to have been deeply confused about a number of important foundational issues. Both of these shortcomings impact upon the coherence and credibility of the process, as well as upon its capacity to clarify and effectively cope with important problems as they arise. The result is that powerful inertial forces direct the development process and lead to retention of categories that have never had a scientific justification. These problems are compounded by concerns about the objectivity and scientific integrity of the DSM development process and about the potential for future research based upon DSM categories to be productive. Volume 2 of the Sourcebook has done nothing to allay such concerns, and has provided additional grounds for thinking it is time for some profound changes in how we conceptualize, investigate, and respond to mental illness, and in how a highly influential system of classification gets developed.”
Prepare a cover letter that says:
To the American Psychiatric Association's Ethics Department:
Attached, please find my complaint that I request that you consider.
The published guidelines for filing complaints make it clear that a complaint may be handled by the national level's Ethics Department or by a district branch. This complaint absolutely must be dealt with at the national level, because nothing in it applies to the conduct or practice of any of the respondents within the districts in which they have their licenses or local APA branch affiliations. All of the unethical conduct described herein relates to the production, promotion, and public representation of the commercial product known as the DSM, which takes place not only at the national but even at the international level; this renders it irrelevant and diversionary if this complaint were to be routed to one or more district branches. This is a course to be avoided, given the seriousness of the matters described herein, which makes my right to a fair and speedy resolution particularly important.
I request that the APA's Ethics Department avoid conflicts of interest or even the appearance of conflicts of interest in handling this complaint by bringing in impartial third parties who are not APA members to review and issue a decision about it. This is in the interests of not only me as a complainant but also of the APA itself.
Please email me to acknowledge receipt of this complaint as soon as it reaches you, and let me know what the next steps and sequence of steps will be from now through the end of the complaints process, since much of this is not clear from the APA's published information.
Print out the entire complaint, sign it where indicated, and then scan it in as a Word or pdf file that has your name and “APA Ethics Complaint” on it. Send it to
In the Subject Line, write: Ethics Department or Complaint to Ethics Department
Please send us a note through the contact form at www.psychdiagnosis.weebly.com to say (with or without your name or contact information) to say simply that you have filed a complaint, so that we can keep track of how many complaints have been filed…and, if you wish, anything else you want to tell us. This could include the respondents you listed and/or the actions you requested. And we hope that in any case you will keep us posted through the contact form about whether or when you hear from the APA that they have received your complaint and anything else you learn about whether they move forward with it.]
IF AND ONLY IF you ALSO want to send it by snailmail (please send it for sure by email), then mail the original version that you signed (KEEP A COPY OF THE SIGNED VERSION FOR YOURSELF) to:
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Arlington, VA 22209
If you send a snailmail version, PLEASE send it return receipt requested.
IF YOU HAVE ANY FURTHER QUESTIONS OR CONCERNS, please send them to the contact form at ww.psychdiagnosis.weebly.com or get in touch with the person who initially told you about this process. Chances are they can answer your questions or respond to your concerns or know how to find a person who can.
Congratulations! Now you are ready to send in your complaint. You are helping to make history just by filing your complaint.
Operations Manual of the Board of Trustees and Assembly of the American Psychiatric Association. (2011), p.110.
 The Opinions of the Ethics Committee on The Principles of Medical Ethics found at http://psychiatry.org/practice/ethics/resources-standards/ethics-resources-and-standards
 Dr. Gary Tucker is purposely not named as a respondent, because despite his membership on a DSM Work Group, he publicly and strongly wrote an extensive critique that is cited later in this complaint.
 James Phillips, Allen Frances, Michael A Cerullo, John Chardavoyne, Hannah S Decker, Michael B First, Nassir Ghaemi, Gary Greenberg, Andrew C Hinderliter, Warren A Kinghorn, Steven G LoBello, Elliott B Martin, Aaron L Mishara, Joel Paris, Joseph M Pierre, Ronald W Pies, Harold A Pincus, Douglas Porter,Claire Pouncey, Michael A Schwartz, Thomas Szasz, Jerome C Wakefield, G Scott Waterman, Owen Whooley, and Peter Zachar. (2012). The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis. Philosophy, Ethics, and Humanities in Medicine 7, January 13, 3. (This reference is to part 1 of a three-part series with this title. Other quotations in this complaint come variously from parts 1, 2, or 3.)
 Phillips, James. (2012). Conclusion [of Part 1]. In Phillips et al. (2012).
 Pincus, Harold. (2012). Commentary. In Phillips et al. (2012), and First, Michael. (2012). Commentary: The National Institute of Mental Health Research Domain Criteria (RDoC) Project: Moving towards an etiologically-informed diagnostic classification in psychiatry. In Phillips et al. (2012).
 Frances, Allen. (2012). There is a time and place for every umpire. In Phillips et al. (2012). An entire chapter about this very point had appeared in Caplan, P.J. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. Reading, MA: Addison Wesley, under the title "Whose normality is it anyway?" (pp. 33-59) and had also by then been addressed at length by Kirk, S., & Kutchins, H. (1992). The selling of DSM. NY: Aldine DeGruyter and was subsequently addressed by many other authors whose work is cited in this complaint.
13 Caplan, P.J. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. Reading, MA: Addison Wesley, p.27.
 Jacobs, D. H., and Cohen, D. (2010). The make-believe world of antidepressant randomized controlled trials---An afterword to Cohen and Jacobs (2010). The Journal of Mind and Behavior 31, 25-36; Horwitz, A.V., & Wakefield, J.C. (2007). The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press; as well as Caplan (1995).
 American Psychiatric Association. (1993). Fact sheet: Psychiatric diagnosis and the diagnostic and statistical manual of mental disorders (fourth edition), DSM-IV. Washington, D.C.: American Psychiatric Association. August.
 Caplan (1995). See Chapter 7, pp. 185-225, "How Gatekeeping Replaces Scientific Precision," including a list of 25 gatekeeping techniques on pp. 222-25 that illustrate how the DSM-IV heads achieved what they called consensus by actually excluding or ignoring the input of those who disagreed with them.
 Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2002).
 Jacobs, D. H., and Cohen, D. (2010). The make-believe world of antidepressant randomized controlled trials---An afterword to Cohen and Jacobs (2010). The Journal of Mind and Behavior 31, 25-36; Horwitz, A.V., & Wakefield, J.C. (2007). The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press; as well as, e.g., Caplan (1995); Widiger et al. (1996); Poland (2002).
 Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2002), and Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2001) and Poland (2002).
 Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2002), and Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2001) and Poland (2002).
 Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2002), and Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2001) and Poland (2002).
 Widiger, T.A., Frances, A.J., Pincus, H.A., First, M.B., Ross, R., & Davis, W. (eds). (1994). DSM-IV Sourcebook: Volume 1. Washington, DC: American Psychiatric Association; and Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2002).
 Widiger, T.A., Frances, A.J., Pincus, H.A., Ross, R., First, M.B, & Davis, W.W. (eds). (1996). DSM-IV Sourcebook: Volume 2. Washington, DC: American Psychiatric Association. See also Poland (2001) and Poland (2002).
 Jacobs, D. H., and Cohen, D. (2010). The make-believe world of antidepressant randomized controlled trials---An afterword to Cohen and Jacobs (2010). The Journal of Mind and Behavior 31, 25-36; Horwitz, A.V., & Wakefield, J.C. (2007). The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press; as well as, e.g., Caplan (1995); Widiger et al. (1996); Poland (2002).
 Poland, J. (2001), op.cit.; Poland (2002), op.cit.; Caplan (1995), op.cit.; and Kutchins & Kirk (1997), op.cit., among many others.
 This is documented, by, e.g., Poland, J. (2001, 2002), and Caplan, P.J. (1995), pp. 111, 187-92, 220, but there are many others available on request, some of which are cited later in this complaint.
 e.g., Poland, J. (2001, 2002) and Caplan, P.J. (1995), op.cit., pp. 115, 118, 119, 128, 131, and many others are cited later in this complaint.
 e.g., Poland (2001, 2002) and Caplan (1995), op.cit., e.g., pp. 184, 209 and many others are cited later in this complaint.
. Kirk & Kutchins (1994). The myth of the reliability of DSM. Journal of Mind and Behaviour 15(1&2), 71-86.
 Paris, Joel. (2012). Commentary. In Phillips (2012), Part 2.
 Frances, Allen. (2012). Alternate universes must prove themselves. In Phillips et al. (2012), part 3.
 Frances, A., Sreenivasan, S., and Weinberger, L. E. (2008). Defining mental disorder when it really counts: DSM-IV-TR and SVP/SDP statutes. Journal of the American Academy of Psychiatry and the Law, 36, 375-384, p. 380.
 For instance, Janacek,B., & Caplan,P.J. (2006). Does Borderline Personality Disorder exist? What the data show. Harvard University (unpublished paper); Becker, D. (1997). Through the looking glass: Women and borderline personality disorder. Boulder: Westview Press; Becker, D., & Lamb, S. (1994). Sex bias in the diagnosis of borderline personality disorder and posttraumatic stress disorder. Professional Psychology: Research and Practice, 25, 55-61; and Fish, V. (2004). Some gender biases in diagnosing traumatized women. In P.J. Caplan & L. Cosgrove (2004). Bias in psychiatric diagnosis.
 American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders-IV. Washington, DC: APA and American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders-IV-TR. Washington, DC.
 American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders-IV-TR. Washington, DC, p. 8.
 Frances, A., Sreenivasan, S., and Weinberger, L. E. (2008). Defining mental disorder when it really counts: DSM-IV-TR and SVP/SDP statutes. Journal of the American Academy of Psychiatry and the Law, 36, 375-384, p. 380. See also Jacobs, David H. 2011. Is the DSM formulation of mental disorder a scientific-technical term? The Journal of Mind and Behavior 32, 63-80; Jacobs, David H. 2010. Is there really mental disorder?The Humanistic Psychologist 38, 355-374; and Jacobs, David H. 2009. Is a correct psychiatric diagnosis possible?Ethical Human Psychology and Psychiatry 11, 83-96.
 American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders-IV-TR. Washington, D.C, pp. 27, 37.
 Poland, J.; Von Eckardt, B.; & Spaulding, W. (1994). Problems with the DSM approach to classifying psychopathology. In G. Graham & L. Stephens (Eds.), Philosophical Psychology. Cambridge, MA: MIT Press.
 Jacobs, D. H., and Cohen, D. (2010). The make-believe world of antidepressant randomized controlled trials---An afterword to Cohen and Jacobs (2010). The Journal of Mind and Behavior 31, 25-36.
 Phillips, James. (2012). Conclusion. In Phillips et al. (2012), part 2.
 From Frances, A. (2009b). Issues for DSM-V: The limitations of field trials: A lesson from DSM-IV.Am J Psychiatry; 166:1322: “A lesson from DSM-IV is that field testing cannot always predict the rates of mental disorders once a diagnostic system enters general use. The most difficult but also most consequential purpose of field trials is to determine how new criteria sets will affect definitions of caseness and rates of diagnosis. Ironically, clearer wording may make diagnoses easier to use but also make them susceptible to overuse—especially in primary care and by patients, families, and teachers. This potential can be amplified by drug company marketing—not just to psychiatrists, but especially to pediatricians, primary care physicians, and now the general public. The risk of an artifactual increase in diagnoses is particularly high for disorders at the boundary of normality, such as mood and anxiety disorders. ‘Not otherwise specified’ categories and dimensional ratings, in which there is no threshold for diagnosis but rather a continuous scale, are at particularly high risk for increased identification of symptoms in otherwise normal people.”
 Frances, A. (2010a). Opening Pandora’s Box: The 19 worst suggestions for DSM5.Psychiatric Times, February 11. http://www.psychiatrictimes.com/dsm/content/article/10168/1522341?pageNumber=1
 Frances, A. (2010c). The DSM-5 subthreshold disorders: Not ready for prime time. April 15. http://www.psychologytoday.com/blog/dsm5-in-distress/201004/the-dsm5-subthreshold-disorders-not-ready-prime-time
 Greenberg (2010). In this connection, see also Jacobs, D. and Cohen, D. (1999). What is really known about psychological alterations produced by psychiatric drugs.International Journal of Risk & Safety in Medicine 12, 37-47, who note that what are presented as therapeutic effects of psychiatric drugs (which are assumed to be needed to correct allegedly scientifically proven brain disorders or chemical imbalances that allegedly underlie “mental disorders”) are actually often adverse effects. These adverse effects are often ignored when patients report them, not the least of the reasons they are ignored being that patients are assumed to be mentally ill, to need the drugs to fix the mental illness, and to be incapable of accurately assessing how the drugs affect them (David H. Jacobs, personal communication, 2012).Greenberg, G. (2010). Inside the battle to define mental illness. Wired Magazine, December 27. http://www.wired.com/magazine/2010/12/ff_dsmv/all/1. In this connection, see also Jacobs, D. and Cohen, D. (1999). What is really known about psychological alterations produced by psychiatric drugs.International Journal of Risk & Safety in Medicine 12, 37-47, who note that what are presented as therapeutic effects of psychiatric drugs (which are assumed to be needed to correct allegedly scientifically proven brain disorders or chemical imbalances that allegedly underlie “mental disorders”) are actually often adverse effects. These adverse effects are often ignored when patients report them, not the least of the reasons they are ignored being that patients are assumed to be mentally ill, to need the drugs to fix the mental illness, and to be incapable of accurately assessing how the drugs affect them (David H. Jacobs, personal communication, 2012).
 Frances, A.F. (2012). My third letter to the APA trustees. Psychiatric Times, March 1.
 Waterman, G. Scott. (2012). Commentary: Psychiatric nosology: What are the stakes? In Phillips (2012).
 Caplan, P.J., & Cosgrove, L. (2004). Is this really necessary? In P.J. Caplan & L. Cosgrove (Eds.), Bias in Psychiatric Diagnosis. Lanham, MD: Rowman and Littlefield.
 See Schedule A here below for documentation, as well as Caplan (1995), op.cit; Linder, M. (2004). The construction of illness. In P.J. Caplan & L. Cosgrove (eds.), Bias in Psychiatric Diagnosis. Lanham, MD: Rowman and Littlefield, pp.3-7; Poland, J., & Caplan, P. (2004). The deep structure of bias in psychiatric diagnosis. In Caplan & Cosgrove (eds.), op. cit., pp.9-23.
 Caplan, P.J. (1995), gatekeeping chapter, "How Gatekeeping Replaces Scientific Precision," on pp. 185-225, as well as Larkin, June, & Caplan, Paula J. ( The gatekeeping process of the DSM. Canadian Journal of Community Mental Health/Revue canadienne de santé mentale communautaire. 11, 17-28.
 Frances, A.; Widiger, T.; First, M.B.; Pincus, H.A.; Tilly, S..; Miele, G.M.; & Davis W. W. (1991). DSM-IV: Toward a more empirical diagnostic system. Canadian Psychology 32(2).
 Many citations that are relevant here have been listed above. These include, as just two examples, Kirk and Kutchins (1992) and Caplan (1995).
 Caplan, P.J. (2011). Letter from DSM-5 Task Force leaves major concerns unanswered. Part 2. Psychology Today. June 18. http://www.psychologytoday.com/blog/science-isnt-golden/201106/letter-dsm-5-task-force-head-leaves-major-concerns-unanswered-part-2
 Pollock, George. (1988). Presidential address: Landfalls, journeys, and departures. The American Journal of Psychiatry 145(9), 1055-60.
 Fink, Paul. (1988). Response to the presidential address: Is "biopsychosocial" the psychiatric shibboleth? The American Journal of Psychiatry 145(9), 1061-67.
 Fink, Paul. (1989). Presidential address: On being ethical in an unethical world. The American Journal of Psychiatry 146(9), 1097-1104.
 Fink, Paul. (1986). Position statement.Psychiatric News, December 19, p.16.
 Pardes, Herbert. (1990). Presidential address: Defending humanistic values. The American Journal of Psychiatry 147(9), 1113-19.
 Benedek, Elissa. (1990). Response to the presidential address: Our children: Our future. The American Journal of Psychiatry 147(9), 1120-25.
 Benedek, Elissa. (1991). Presidential address: Looking ahead: New psychiatry, old values. The American Journal of Psychiatry 148(9), 1123-29.
 Hartmann, Lawrence. (1991). Response to the presidential address: Humane values and biopsychosocial integration. The American Journal of Psychiatry 148(9), 1130-34.
 Hartmann, Lawrence. (1992). Presidential address: Reflections on humane values and biopsychosocial integration. The American Journal of Psychiatry 149(9), 1135-41.
 English, Joseph. (1992). Response to the presidential address: Patient care for the twenty-first century. The American Journal of Psychiatry 149(9), 1142-4.
 English, Joseph. (1993). Presidential address: Patient care for the twenty-first century: Asserting professional values within economic restraints. The American Journal of Psychiatry 150(9), 1293-97.
 McIntyre, John. (1993). Response to the presidential address: The time is now. The American Journal of Psychiatry 150(9), 1298-1301.
 McIntyre, John (1994). Presidential address: Our heritage, our future. The American Journal of Psychiatry 151(9), 1257-61.
 Wiener, Jerry. (1994). Response to the presidential address: Roots, diversity, and professional identity. The American Journal of Psychiatry 151(9), 1262-64.
 Wiener, Jerry. (1995). Presidential address: Encompassing diversity and demanding equity. The American Journal of Psychiatry 152(9), 1249-51.
 England, Mary Jane. (1995) Response to the presidential address: One system of equal health care for all. The American Journal of Psychiatry 152(9),1252.
 Guze, Samuel. (1995). Review of DSM-IV. The American Journal of Psychiatry 152.
 England, Mary Jane. (1996). Presidential address: Leaders of reform: Equity, quality, outcomes, and partnerships. The American Journal of Psychiatry 153(9), 1119-22.
 Eist, Harold. (1996). Response to the presidential address: Why we must prevail. The American Journal of Psychiatry 153(9), 1123-25.
 Eist, Harold. (1997). Presidential address: Strengthening psychiatry's dedication and commitment to compassionate care, educational excellence, and creative research. The American Journal of Psychiatry 154(9), 1343-49.
 Sacks, Herbert. (1997). Response to the presidential address: New challenges for proven values. The American Journal of Psychiatry 154(10), 1350-53.
 Sacks, Herbert. (1998). Presidential address: New challenges for proven values. The American Journal of Psychiatry 155(9), 1479-82.
 Munoz, Rodrgio. (1998). Response to the presidential address: Toward the APA of the next century. The American Journal of Psychiatry 155(11), 1483.
 Tucker, Gary. (1998). Putting DSM-IV in perspective. The American Journal of Psychiatry 155(2), 159-61.
 Munoz, Rodrigo. (1999). Presidential address: A new APA for a new century. The American Journal of Psychiatry 156(10), 1487-88.
 Tasman, Allan. (1999). Response to the presidential address: Opportunities and challenges for psychiatry. The American Journal of Psychiatry 156(9), 1489-92.
 Tasman, Allan. (2000). Presidential address: The doctor-patient relationship. The American Journal of Psychiatry 157(11), 1763-68.
 Borenstein, Daniel. (2000). Response to the presidential address: APA enters the twenty-first century. The American Journal of Psychiatry 157(11), 1769-70.
 Borenstein, Daniel. (2001). Presidential address: Bridging the milennia: Mind meets brain. The American Journal of Psychiatry 158(10), 1597-1600.
 Harding, Richard. (2001). Response to the presidential address: 21st-century psychiatrist. The American Journal of Psychiatry 158(10), 1601-02.
 Harding, Richard. (2002). Presidential address. The American Journal of Psychiatry 159(10), 1635-37.
 Appelbaum, Paul. (2002). Response to the presidential address — The systematic defunding of psychiatry care: A crisis at our doorstep. The American Journal of Psychiatry 159(10), 1638-40.
 Appelbaum, Paul. (2003). Presidential address: Re-envisioning a mental health system for the United States. The American Journal of Psychiatry 160(10), 1759-62.
 Goin, Marcia Kraft. (2003). Response to the presidential address. The American Journal of Psychiatry 160(10), 1763-65.
 Goin, Marcia Kraft. (2004). Presidential address. The American Journal of Psychiatry 161(10), 1769-71.
 Riba, Michelle. (2004). Response to the presidential address. The American Journal of Psychiatry 161(10), 1772-74.
 Riba, Michelle. (2005). Presidential address. The American Journal of Psychiatry 162(11), 2041-44.
 Sharfstein, Steven. (2005). Response to the presidential address: Advocacy for our patients and our profession. The American Journal of Psychiatry 162(11), 2045-47.
 Sharfstein, Steven. (2006). Presidential address: Advocacy as leadership. The American Journal of Psychiatry 163(10), 1712-15.
 Ruiz, Pedro. (2006). Response to the presidential address. The American Journal of Psychiatry 163(10), 1716-18.
 This claim has proven to be unfounded, given the lack of transparency and ethics connected with DSM-5.
 Ruiz, Pedro. (2007). Presidential address: Assessing patient needs: Access, parity, and humane care. The American Journal of Psychiatry 164(10),1506-09.
 Robinowitz, Carolyn. (2007). Response to the presidential address. The American Journal of Psychiatry 164(10),1510-13.
 Robinowitz, Carolyn. (2008). Presidential address: Our voice in action: Advancing science, care, and our profession. The American Journal of Psychiatry 165(10), 1263-67.
 Stotland, Nada. (2008). Response to the presidential address. The American Journal of Psychiatry 165(10), 1268-70.