ADD5107: Week 10 Discussion 2: DSM-5 Criticism: A Follow-Up

Allen J Frances M.D.

DSM5 in Distress

PSYCHIATRY

DSM 5 Is Guide Not Bible —Ignore Its Ten Worst Changes APA approval of DSM-5 is a sad day for psychiatry.

Posted December 2, 2012

Reviewed by Ekua Hagan

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This is the saddest moment in my 45-year career of studying,

practicing, and teaching psychiatry. The Board of Trustees of

the American Psychiatric Association has given its final ap‐

proval to a deeply flawed DSM 5 containing many changes

that seem clearly unsafe and scientifically unsound.

My best advice to clinicians, to the press, and to the general

public — be skeptical and don't follow DSM 5 blindly down a

road likely to lead to massive over-diagnosis and harmful

over-medication. Just ignore the 10 changes that make no

sense.

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Brief background. DSM 5 got off to a bad start and was never

able to establish sure footing. Its leaders initially articulated a

premature and unrealizable goal: to produce a paradigm shift

in psychiatry. Excessive ambition combined with disorganized

execution led inevitably to many ill-conceived and risky

proposals.

These were vigorously opposed. More than fifty mental

health professional associations petitioned for an outside re‐

view of DSM 5 to provide an independent judgment of its

supporting evidence and to evaluate the balance between its

risks and benefits. Professional journals, the press, and the

public also weighed in, expressing widespread astonishment

about decisions that sometimes seemed not only to lack sci‐

entific support but also to defy common sense.

DSM 5 has neither been able to self correct nor willing to

heed the advice of outsiders. It has instead created a mostly

closed shop, circling the wagons and deaf to the repeated

and widespread warnings that it would lead to massive

misdiagnosis.

Fortunately, some of its most egregiously risky and unsup‐

portable proposals were eventually dropped under great ex‐

ternal pressure (most notably "psychosis risk," mixed

anxiety/depression, internet and sex addiction, rape as a

mental disorder, "hebephilia," cumbersome personality rat‐

ings, and sharply lowered thresholds for many existing disor‐

ders). But APA stubbornly refused to sponsor any indepen‐

dent review and has given final approval to the ten reckless

and untested ideas that are summarized below.

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The history of psychiatry is littered with fad diagnoses that in

retrospect did far more harm than good. Yesterday's APA ap‐

proval makes it likely that DSM 5 will start a half or dozen or

more new fads which will be detrimental to the misdiagnosed

individuals and costly to our society.

The motives of the people working on DSM 5 have often

been questioned. They have been accused of having a finan‐

cial conflict of interest because some have (minimal) drug

company ties and also because so many of the DSM 5

changes will enhance Pharma profits by adding to our al‐

ready existing societal overdose of carelessly prescribed psy‐

chiatric medicine.

But I know the people working on DSM 5 and know this

charge to be both unfair and untrue. Indeed, they have made

some very bad decisions, but they did so with pure hearts

and not because they wanted to help the drug companies.

Their's is an intellectual, not financial, conflict of interest that

results from the natural tendency of highly specialized ex‐

perts to overvalue their pet ideas, to want to expand their

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own areas of research interest, and to be oblivious to the dis‐

tortions that occur in translating DSM 5 to real-life clinical

practice (particularly in primary care where 80% of psychiatric

drugs are prescribed).

The APA's deep dependence on the publishing profits gener‐

ated by the DSM 5 business enterprise creates a far less pure

motivation. There is an inherent and influential conflict of in‐

terest between the DSM 5 public trust and DSM 5 as a best

seller. When its deadlines were consistently missed due to

poor planning and disorganized implementation, APA chose

quietly to cancel the DSM 5 field testing step that was meant

to provide it with a badly needed opportunity for quality con‐

trol. The current draft has been approved and is now being

rushed prematurely to press with incomplete field testing for

one reason only — so that DSM 5 publishing profits can fill

the big hole in APA's projected budget and return dividends

on the exorbitant cost of 25 million dollars that has been

charged to DSM 5 preparation.

This is no way to prepare or to approve a diagnostic system.

Psychiatric diagnosis has become too important in selecting

treatments, determining eligibility for benefits and services,

allocating resources, guiding legal judgments, creating

stigma, and influencing personal expectations to be left in the

hands of an APA that has proven itself incapable of producing

a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new

drugs because they influence whether or not millions of peo‐

ple are placed on drugs — often by primary care doctors after

brief visits. Before their introduction, new diagnoses deserve

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the same level of attention to safety that we devote to new

drugs. APA is not competent to do this.

So, here is my list of the DSM 5's 10 most potentially harmful

changes. I would suggest that clinicians not follow these at all

(or, at the very least, use them with extreme caution and at‐

tention to their risks); that potential patients be deeply skepti‐

cal, especially if the proposed diagnosis is being used as a

rationale for prescribing medication for you or for your child;

and that payers question whether some of these are suitable

for reimbursement. My goal is to minimize the harm that may

otherwise be done by unnecessary obedience to unwise and

arbitrary DSM 5 decisions.

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DSM 5 will turn temper tantrums into a mental disorder — a

puzzling decision based on the work of only one research

group. We have no idea whatever how this untested new di‐

agnosis will play out in real-life practice settings, but my fear

is that it will exacerbate, not relieve, the already excessive

and inappropriate use of medication in young children.

During the past two decades, child psychiatry has already

provoked three fads- a tripling of Attention Deficit Disorder, a

more than 20-times increase in Autistic Disorder, and a 40-

times increase in childhood Bipolar Disorder. The field should

have felt chastened by this sorry track record and should en‐

gage itself now in the crucial task of educating practitioners

and the public about the difficulty of accurately diagnosing

children and the risks of over- medicating them. DSM 5

should not be adding a new disorder likely to result in a new

fad and even more inappropriate medication use in vulnera‐

ble children.

1. Normal grief will become Major Depressive Disorder, thus

medicalizing and trivializing our expectable and neces‐

sary emotional reactions to the loss of a loved one and

substituting pills and superficial medical rituals for the

deep consolations of family, friends, religion, and the re‐

siliency that comes with time and the acceptance of the

limitations of life.

2. The everyday forgetting characteristic of old age will now

be misdiagnosed as Minor Neurocognitive Disorder, cre‐

ating a huge false positive population of people who are

not at special risk for dementia. Since there is no effective

treatment for this 'condition' (or for dementia), the label

provides absolutely no benefit (while creating great anxi‐

ety) even for those at true risk for later developing de‐

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mentia. It is a dead loss for the many who will be

mislabeled.

3. DSM 5 will likely trigger a fad of Adult Attention Deficit

Disorder leading to widespread misuse of stimulant drugs

for performance enhancement and recreation and con‐

tributing to the already large illegal secondary market in

diverted prescription drugs.

4. Excessive eating 12 times in 3 months is no longer just a

manifestation of gluttony and the easy availability of really

great tasting food. DSM 5 has instead turned it into a psy‐

chiatric illness called Binge Eating Disorder.

5. The changes in the DSM 5 definition of Autism will result

in lowered rates — 10 percent according to estimates by

the DSM 5 work group, perhaps 50 percent according to

outside research groups. This reduction can be seen as

beneficial in the sense that the diagnosis of Autism will be

more accurate and specific- but advocates understand‐

ably fear a disruption in needed school services. Here the

DSM 5 problem is not so much a bad decision, but the

misleading promises that it will have no impact on rates of

disorder or of service delivery. School services should be

tied more to educational need, less to a controversial

psychiatric diagnosis created for clinical (not educational)

purposes and whose rate is so sensitive to small changes

in definition and assessment.

6. First-time substance abusers will be lumped in definition‐

ally in with hardcore addicts despite their very different

treatment needs and prognosis and the stigma this will

cause.

7. DSM 5 has created a slippery slope by introducing the

concept of Behavioral Addictions that eventually can

spread to make a mental disorder of everything we like to

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do a lot. Watch out for careless overdiagnosis of internet

and sex addiction and the development of lucrative treat‐

ment programs to exploit these new markets.

8. DSM 5 obscures the already fuzzy boundary been

Generalized Anxiety Disorder and the worries of every‐

day life. Small changes in definition can create millions of

anxious new "patients" and expand the already wide‐

spread practice of inappropriately prescribing addicting

anti-anxiety medications.

9. DSM 5 has opened the gate even further to the already

existing problem of misdiagnosis of PTSD in forensic

settings.

DSM 5 has dropped its pretension to being a paradigm shift

in psychiatric diagnosis and instead (in a dramatic 180-degree

turn) now makes the equally misleading claim that it is a con‐

servative document that will have minimal impact on the rates

of psychiatric diagnosis and in the consequent provision of

inappropriate treatment. This is an untenable claim that DSM

5 cannot possibly support because, for completely unfath‐

omable reasons, it never took the simple and inexpensive

step of actually studying the impact of DSM on rates in real-

world settings.

Except for autism, all the DSM 5 changes loosen diagnosis

and threaten to turn our current diagnostic inflation into diag‐

nostic hyperinflation. Painful experience with previous DSMs

teaches that if anything in the diagnostic system can be mis‐

used and turned into a fad, it will be. Many millions of people

with normal grief, gluttony, distractibility, worries, reactions to

stress, the temper tantrums of childhood, the forgetting of old

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age, and "behavioral addictions" will soon be mislabeled as

psychiatrically sick and given inappropriate treatment.

People with real psychiatric problems that can be reliably di‐

agnosed and effectively treated are already badly short‐

changed. DSM 5 will make this worse by diverting attention

and scarce resources away from the truly ill and toward peo‐

ple with the everyday problems of life who will be harmed,

not helped, when they are mislabeled as mentally ill.

Our patients deserve better, society deserves better, and the

mental health professions deserve better. Caring for the men‐

tally ill is a noble and effective profession. But we have to

know our limits and stay within them.

DSM 5 violates the most sacred (and most frequently ig‐

nored) tenet in medicine: First Do No Harm! That's why this is

such a sad moment.

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About the Author

Allen Frances, M.D., was the chair of the

DSM-IV Task Force and is currently a

professor emeritus at Duke.

Online: Twitter, Twitter

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