Chair’s Column January 2013

DSM-5: New but Not Improved

J. Lake

Commenting on the just-released DSM-V in an invited editorial published in the December, 2012 issue of Psychiatric Times, Allen Frances, M.D. former chair and now professor emeritus of the Department of Psychiatry at Duke remarked “This is the saddest moment in my 45-year career of studying, practicing, and teaching psychiatry.” Dr. Frances was reacting to the news that the Board of Trustees of the American Psychiatric Association had just given final approval for publication of the latest version of the Diagnostic and Statistical Manual—the widely acknowledged “bible” of psychiatric nomenclature and diagnosis. Dr. Frances remarked that many changes in the DSM-5 are “deeply flawed…clearly unsafe and scientifically unsound.” These words are not the rants of an anti-psychiatry cult they are the well-reasoned opinions of a highly respected academic psychiatrist. Dr. Frances remarks further “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.” Among these “ill-conceived and risky” proposals Dr. Frances includes the following: (comment on specifics).

Dr. Frances remarks in detail on several specific changes in the DSM that, in his words, are the result of “intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM-5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed.” He advises clinicians to simply ignore these changes or to follow them with “extreme caution and attention to their risks.” He also warns patients to be “skeptical…especially if the proposed changes are used to justify prescribing a medication.” Below (Psychiatric Times, 4 Dec, 2012) are specific changes in the new DSM that are widely regarded as problematic because they lack strong supporting evidence:
• A proposed new disorder called “Disruptive Mood Dysregulation Disorder” is based on the work of only one research group and may result in the diagnosis of temper tantrums in young children as a serious mental disorder. A consequence may be yet another rationale for the excessive and inappropriate use of medication in young children. Dr. Frances notes “During the past two decades, child psychiatry has already provoked 3 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 engage 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 vulnerable children.”
• According to Dr. Frances, the DSM-5 will invite an inappropriate and misleading diagnosis of major depressive disorder in individuals experiencing normal grief “thus medicalizing and trivializing our expectable and necessary 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 resiliency that comes with time and the acceptance of the limitations of life.”
• Non-pathological age-related declines in memory characteristic of old age will become Minor Neurocognitive Disorder in the DSM-5, “creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this “condition” the label provides absolutely no benefit (while creating great anxiety), even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.”
• Changes in DSM-5 criteria for ADHD will make it even easier to diagnose Adult ADHD, and “will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.”
• DSM-5 changes may also result in over-diagnosis of eating disorders. According to the new criteria excessive eating once every week for 3 months will qualify as Binge Eating Disorder.
• Changes in diagnostic criteria for substance abuse will blur the line between first-time substance abusers and hard-core addicts potentially resulting in inappropriate treatment of first-time abusers.
• Dr. Frances is concerned that he new diagnostic category of Behavioral Addictions may lead to over-diagnosis of internet and sex addiction and the “development of lucrative treatment programs to exploit these new markets.”
• Changes in criteria for Generalized Anxiety Disorder may invite misdiagnosis of individuals who have occasional anxiety symptoms with a serious psychiatric disorder legitimizing inappropriate prescribing of potent—often addictive—antianxiety medications.
• New DSM-5 criteria will make it easier to diagnose PTSD in forensic settings

Concerns over the new DSM-5 criteria are widely shared. In fact more than 50 mental health professional associations formally petitioned the American Psychiatric Association to invite an external review of the draft DSM-5 because of serious concerns over the rigor of its methodology and the soundness of its conclusions. To the detriment of both clinicians and patients the petitions were largely ignored by the APA. In an effort to re-coup the enormous investment that went into preparation of the DSM-5, Dr. Frances alleges, APA leadership chose to cancel crucial field tests to fast-track the DSM-5 toward lucrative publishing deals. In the absence of field test results many new changes in diagnostic criteria in the DSM-5 lack supporting evidence. Dr. Frances’ indictment continues, “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 people are placed on drugs—often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.”

The uproar over the DSM-5 points to the unsettled debate surrounding the validity of current practices in psychiatric nosology and diagnosis. At the heart of the debate is a fundamental dispute over what symptoms mean and their patterns of occurrence. In the DSM and ICD models of psychiatric nosology complex symptom patterns associated with cognitive, emotional and behavioral problems are interpreted as indicators of distress or dysfunction and diagnosed as discrete “disorders.” This approach is an artifact of the conceptual framework of biomedicine in which a particular symptom of physical illness is ‘reduced’ (ie ‘rendered equivalent’) to a discrete identified or inferred underlying “cause” in terms of pathological changes presumed to manifest as a discrete symptom or symptom pattern (ie, ‘disorder’). This conceptual approach is valid and practically useful when classifying or diagnosing many physical illnesses however discrete or easily identified causes of emotional distress, cognitive dysfunction or behavioral disregulation seldom occur. Further, with some exceptions, most psychiatric ‘disorders’ are multi-factorial in origin and it is extremely difficult to discern how genetic, biological, environmental and socio-cultural factors influence the pathogenesis of mental illness. To make things even more complicated, emotional, cognitive and behavioral symptoms seldom occur in a predictable manner in the same individual or population ‘diagnosed’ with a particular psychiatric ‘disorder.’ (Shanfield 2004). In the ‘phenomenologically’ messy world of human emotions and suffering mental illness consists of symptoms frequently change both in quality and severity in relationship to complex biological, psychological and environmental factors—which also undergo change over time. The finding that similar cognitive and affective symptom patterns are reported by individuals diagnosed with different DSM diagnostic labels and normal healthy individuals suggests that the orthodox methodology of conceptualizing mental illness as a series of discrete disorders lacks validity.

The core phenomenology of mental illness is a world that is in constant flux in which symptom patterns that are labeled “psychiatric disorders” seldom persist more than several weeks in the same individual, and seldom recur as aggregates of discrete symptoms in populations carrying the same diagnosis. The fiction of contemporary psychiatric classification is perpetuated by academic discourse in which the definition of “disorder” is based on “expert consensus” within DSM Committees led by academic psychiatrists who have deeply vested interests in the fortunes of the pharmaceutical manufacturing industry. Newly revised diagnostic criteria for disorders in all DSM-5 diagnostic categories confirm an alarming trend in American psychiatry of correlating ‘disorder’ with continuously lowered symptom threshold values. So-called “expert” consensus reached in DSM Committees rests on judgments about the clinical significance of symptoms in relationship to threshold values of symptom severity and associated functional impairment below which there is no “disorder,” and above which it can be claimed that a “disorder” is present (Zimmerman 2004). Since its inception iterations of the DSM have incorporated different models of threshold values however these changes are seldom made explicit and often reflect biases—and funding sources—of the academic psychiatrists who form DSM Committees. Psychiatric classification and diagnosis become even more problematic in cases when “expert” consensus on a particular ‘disorder’ is based on shared ‘expert’ opinions in the absence of compelling evidence from field trials—the issue at the center of the contentious debate over the validity of new changes in the DSM.

A recently proposed alternative to the fixed criteria sets in DSM methodology categorizes symptoms along a continuum from “normal” to “disturbed” obviating classification of symptoms into discrete disorders that often lack construct validity (Shanfield 2004). The continuum model is consistent with findings from studies showing that specific genes regulate activity in brain circuits associated with specific psychiatric symptoms—not disorders—and that the neurobiological or genetic basis of a particular cognitive or affective symptom does not vary across different DSM disorders in which the same symptom is present (Stahl 2003a and b). The continuum model more adequately explains the complex nature and causes of mental illness, avoids inherent problems of construct validity in DSM descriptive classification of symptoms into ‘disorders,’ and is supported by research evidence showing that the same drug (and presumably the same neuropharmacological mechanism) is often an effective treatment of similar symptoms that occur in different “disorders.”