"Opening Pandora's Box: The 19 Worst Suggestions For DSM5" by Allen Frances, MD.
The author note states: "Dr Frances was the chair of the DSM-IV TaskForce and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke. "Here are some excerpts:
[begin excerpts]I have previously criticized the DSM5 process--for its unnecessary secretiveness, its risky ambitions, its disorganized methods, and its unrealistic deadlines. Now, it is finally time to evaluate the first draft ... Poor and inconsistent writing. Perhaps it should occasion no surprise that a flawed process should yield a flawed product. The most fundamental problem is the poor and inconsistent writing.
<snip>Higher rates of mental disorder In terms of content, most concerning are the many suggestions for DSM5 that would dramatically raise the rates of mental disorder.
<snip>DSM5 would create tens of millions of newly misidentified false positive "patients," thus greatly exacerbating the problems caused already by an overly inclusive DSM4. There would be massive overtreatment with medications that are unnecessary, expensive, and often quite harmful. DSM5 appears to be promoting what we have most feared--the inclusion of many normal variants under the rubric of mental illness, with the result that the core concept of "mental disorder" is greatly undermined. Unforeseen consequences: A third pervasive weakness in the DSM5 options is their insensitivity to possible misuse in forensic settings.
<snip>PROBLEMATIC NEW DIAGNOSES: The Psychosis Risk Syndrome is certainly the most worrisome of all thesuggestions made for DSM5. The false positive rate would be alarming--70% to 75% in the most careful studies and likely to be much higher once the diagnosis is official, in general use, and becomes a target for drug companies. Hundreds of thousands of teenagers and young adults (especially, it turns out, those on Medicaid) would receive the unnecessary prescription of atypical antipsychotic drugs. There is no proof that the atypical antipsychotics prevent psychotic episodes, but they do most certainly cause large and rapid weight gains (see the recent FDA warning) and are associated with reduced life expectancy--to say nothing about their high cost, other side effects, and stigma.
<snip>Mixed Anxiety Depressive Disorder taps nonspecific symptoms that are widely distributed in the general population and would therefore immediately become one of the most common of all the mental disorders in DSM5.
<snip>Minor Neurocognitive Disorder is defined by nonspecific symptoms of reduced cognitive performance that are very common (perhaps almost ubiquitous) in people over fifty. To protect against false positives, there is a criterion that requires objective cognitive assessment to confirm that the individual has decreased cognitive performance, but getting a meaningful reference point is impossible in most instances and the threshold has been set to include a whopping 13.5% of the population (ie, the percent of population within the first and second standard deviation). Moreover, the suggestion for objective testing will probably be widely ignored in the primary care settings where the bulk of diagnosing will be done.
<snip>Binge Eating Disorder will have a rate in the general population (estimated at 6%) and this will probably become much higher when the diagnosis becomes popular and is made in primary care settings.
<snip>Temper Dysfunctional Disorder with Dysphoria is one of the most dangerous and poorly conceived suggestions for DSM5--a misguided medicalization of temper outbursts.
<snip>The misapplication of this diagnosis would provide a blanket excuse for reduced personal responsibility and will lead to forensic nightmares. It is a nonstarter. Paraphilic Coercive Disorder would expand the pool of sex offenders who are eligible for indefinite civil commitment because they have a "mental disorder" to include cases of sexual coercion. Paraphilic Coercive Disorder was initially considered for inclusion in DSM-III-R (under the name Paraphilic Rapism) but was rejected because it was impossible to reliably and validly differentiate those rapists whose actions are the result of a paraphilia from the large majority of rapists who are motivated by other factors (such as power).
<snip>Hypersexuality Disorder would be a gift to false positive excuse seekers and potential forensic disaster. Another clear nonstarter. A Behavioral Addictions category would be included with the substance addictions section and would start life with one disorder, Pathological Gambling (transferred from Impulse Disorders section). Next in line might be a new category for Internet Addiction. This could provide a slippery slope leading to the back door inclusion of a variety of silly and potentially harmful diagnoses (ie,"addictions" to shopping, sex, work, credit card debt, videogames etc,etc, etc) under the broad rubric of "behavioral addictions not otherwise specified." The construct "Behavioral Addictions" represents a medicalization of life choices, provides a ready excuse for off loading personal responsibility, and would likely be misused in forensic settings.
LOWERED THRESHOLDS: The greatest general impact would come from the suggestion to eliminate the "clinical significance" criterion required in DSM4 for each disorder that has a fuzzy boundary with normality (about two-thirds of them). These were included to ensure the presence of clinically significant distress or impairment when the symptoms of the disorder in mild form might be compatible with normality. Removing this requirement would reduce the role of clinical judgment as a gatekeeper in determining the presence or absence of mental disorders and thus would increase the already swollen rates of psychiatric diagnosis.
Attention Deficit/Hyperactivity Disorder. The DSM4 wording changes (along with extremely active drug company marketing) contributed to escalating rates of ADD - accompanied by the widespread misuse of stimulant medications for performance enhancement and the emergence of a large secondary illegal market. There are 4 suggestions for DSM5 that would make this existing overdiagnosis much worse.*The first change is to raise the required age of onset from 7 to 12. The second is to allow the diagnosis based only on the presence of symptoms, not requiring impairment. The third is to reduce by half the number of symptoms required for adults. These 3 changes greatly reduce the specificity of the ADD diagnosis in adolescents and adults and will result in a further flood of false positives and of resulting stimulus misuse for performance enhancement. The fourth change is to allow the diagnosis of ADD in the presence of autism. This might create the interaction of 2 false epidemics, encouraging increased stimulant use in an especially vulnerable population.
Addiction Disorder. DSM5 proposes to eliminate the distinction between substance abuse and substance dependence, lowering the threshold for diagnosing the new unified category-- "addiction"--that would be introduced to replace them both.
<snip>Autism Spectrum Disorder. Asperger's disorder would be collapsed into this new unified category. Although this consolidation appeals to some experts, it remains controversial and presents serious problems. Those with Asperger's (which is much less impairing) will be stigmatized by the association with classic autistic disorder. Moreover, in the average everyday practice conducted by non-experts, the spectrum concept will likely further fuel the "epidemic" of loosely defined autism that was already been triggered by the introduction of Asperger's in DSM4.
Medicalizing Normal Grief. DSM5 would reverse 30 years of diagnostic practice and allow the diagnosis of Major Depression to be made for individuals whose grief reaction symptomatically resembles a Major Depressive episode (eg, 2 weeks of depressed mood, loss of interest inactivities, insomnia, loss of appetite, and trouble concentrating immediately following the loss of a spouse would be a mental disorder.
<snip>Pedohebephilia is one of the most poorly written and unworkable of the suggested criteria sets.
<snip>Deleting the Multiaxial System. This would result in the loss of much valuable clinical information. Multi-axial diagnosis provides a disciplined approach to distinguishing between state and trait (Axis I versus Axis II) and to determining the contributions of medical conditions (Axis I II) and of stressors (Axis IV) to the diagnosis and treatment of psychiatric disorders. The GAF score (Axis V) provides the most convenient and familiar rating of overall functioning. No compelling rationale is offered for making so radical a change.
Various Small Changes. There are numerous small editorial changes meant to help clarify the existing criteria sets. Some of these appear to be improvements, many are trivial, and some are worse than their DSM4 counterparts. Any possible gain from wording changes has to be weighed against the risks that the new version will create its own set of unanticipated consequences.
<snip>Dimensional Assessments: Three dimensional assessments (for severity, co-morbid symptoms, and personality traits) are suggested for DSM5. Dimensions are most appropriate in describing continuously distributed phenomena that can be reduced to numbers. It has been widely accepted for several decades that adding dimensions would help to solve the categorical system's problem with fuzzy boundaries- thus improving the accuracy and precision of psychiatricdiagnosis. Unfortunately, however, the field has never achieved consensus on which dimensions to choose and how best to measure them. Moreover, and most crucial, clinicians find dimensional ratings far too unfamilar and cumbersome for use in everyday practice and all efforts to include even a few simple dimensional ratings into previous DSM's have been met by clinician resistance and neglect. The DSM5 dimensional proposals are especially problematic--ad hoc,unworkably complex, vague, untested, and premature.
<snip>Severity ratings tailored for each disorder. In fact, this approach was tried for 8 categories in DSM3R, but was dropped in DSM4 because the anchors of the severity ratings were not validated and the system was too cumbersome for routine clinical use.
<snip>Ratings on "crosscutting" symptoms that exist across a number ofdifferent diagnoses to supplement the primary categorical diagnosis. Such assessment might be useful in some settings, but is far too cumbersome for use in routine clinical practice.
Dimensional ratings for personality. These would, in theory, have clear advantages over the clumsy categorical approach to personality assessment. In practice, however, the multiple, complicated, confusing, and cumbersome systems suggested for DSM5 would be far too unfamiliar and time consuming to ever be used by clinicians. Another side effect would be deletion of five of the personality disorders (paranoid, narcissistic, histrionic, dependent, schizoid) from the manual.
CONCLUSIONS: It will likely be argued by the DSM5 leadership that I am unduly and prematurely alarmist, that they are still early in the DSM5 process, and that any problematic suggestions will eventually be weeded out in the field trials. This is putting the cart (ie field testing) before the horse (ie having usable criteria sets to test) and continues to miss the point that DSM5 has been and remains in serious trouble. I feel it is my responsibility to raise clear alarms now because the past performance of the DSM5 leadership does not inspire confidence in its future ability to avoid serious mistakes. What leads me to this pessimistic conclusion? Every step in the development of DSM5 has been secretive and disorganized. The leadership has established a consistent track record of proposing unrealistic plans and impossible to meet timetables--with predictably erratic course changes and repeatedly missed deadlines. It was, for example, announced last May at the APA annual meeting (and in the press) that the DSM5 field trials were about to begin in the summer of 2009. Then, it turned out that none of the necessary preparatory steps had been accomplished and the field trials had to be postponed for at least a year.
<snip>I wish to emphasize that the problems in this DSM5 draft are not at all the fault of the Work Group members who have labored hard under very unpromising conditions. The DSM5 options are poorly conceived and executed because of the interaction of 4 unfortunate decisions made by the DSM5 leadership:
1. Requiring unnecessary confidentiality agreements that insulated the Work Groups from the usual and necessary corrective interaction with the field
2. Tightly restricting Advisors to a small and highly selected group
3. Establishing the expectation that Work Groups be innovative rather than risk/benefit conscious
4. Providing the Work Groups with remarkably little guidance,consistency, and editorial assistance. Because of the secretive and closed nature of the DSM5 process, the expectable enthusiasms of the experts who comprise the Work Groups have not been balanced, as they must always be, with real world practical clinical wisdom and a careful risk/benefit analysis of the possible unintended consequences of every suggestion.
<snip>What needs to be done next? The responsibility (and opportunity) for rescuing DSM5 falls most heavily on the field at large and on the Oversight Committee. Now that the DSM5 drafts are finally open for wide review, it behooves the field to be active in identifying problems and providing the needed pressure to ensure they will be corrected. My recommendations for the Oversight Committee are:
1. Extend the period allotted for public review to 3 months.
2. Use this time to ensure the careful editing of each word of each item of every criteria set to provide the clarity and consistency that is nowsorely lacking and is absolutely necessary before any meaningful field testing can begin.
3. Post field trial methods for public review.
4. Appoint 3 subcommittees reporting to the Oversight Committee(responsible, respectively, for monitoring forensic review, risk benefit analysis, and field trials.
5. Post the literature reviews and plans for ICD-11 harmonization. Every future step in the preparation of DSM5 should involve active interaction with the field and with the Oversight Committee and its subcommittees. Unnecessary secrecy has caused the current problems and only full transparency and openness to outside input will solve them. I have had the space and expertise to identify only the DSM5 troublespots that are most obvious to me. The rest is up to you. Please take the time to review the DSM5 options (at least in your areasof interest) and supply your input. They can be found at www.dsm5.org.
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The article is online at:<http://bit.ly/9DHv6L> |
