The DSM-5 will likely lead patients down a road of over-diagnosis and over-medication.
February 8, 2013
After the American Psychiatric Association (APA) approved the latest version of its diagnostic bible, the DSM-5, psychiatrist Allen Frances, the former chair of the DSM-4 taskforce and currently professor emeritus at Duke, announced, “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry” (“A Tense Compromise on Defining Disorders”).
The DSM-5 (the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) will be released by the APA in spring 2013. However, Frances states, “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.”
For mental health professionals, this advice from the former chair of the DSM-4 taskforce is shocking—almost as if Colin Powell were to advise U.S. defense and state department employees not to blindly follow all administration orders. Particularly upsetting for Frances is the DSM-5’s pathologizing of normal human grief. On Jan. 7, 2013 in “Last Plea To DSM-5: Save Grief From the Drug Companies,” Frances wrote, “Making grief a mental disorder will be a bonanza for drug companies, but a disaster for grievers. The decision is also self-destructive for DSM-5 and further undermines the credibility of the APA. Psychiatry should not be mislabeling the normal.”
In the DSM-4, which Frances helped create, there had been a so-called “bereavement exclusion,” which stated that grieving the loss of a loved one, even when accompanied by symptoms of depression, should not be considered the psychiatric disorder of depression. Prior to the DSM-5, the APA had acknowledged that to have symptoms of depression while grieving the loss of a loved one is normal and not a disease. Come this spring, normal human grief accompanied by depression symptoms will be a mental disorder. Psychiatry’s official diagnostic battle is over. Mental illness gatekeepers such as Frances who are concerned about further undermining the credibility of the APA have lost, and mental illness expansionists —psychiatry’s “neocons”— have won.
Other New DSM-5 Mental Illnesses
The pathologizing of normal human grief is not the only DSM-5 embarrassment for Frances. (See his December 2012 blog: “DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes.”) Get ready to hear about a new mental illness diagnosis for kids: “disruptive mood dysregulation disorder” (DMDD). Frances concludes DMDD “will turn temper tantrums into a mental disorder.”
The APA, somewhat embarrassed by the huge increase of children diagnosed with “pediatric bipolar disorder” in the last two decades, wanted to give practitioners a less severe diagnostic option for moody kids. However, Frances’ fear is that DMDD “will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children....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.”
The DSM-5 also brings us “minor neurocognitive disorder”—the everyday forgetting characteristic of old age. For Frances, this will result in huge numbers of misdiagnosed people, a huge false positive population of people who are not at special risk for dementia. And he adds, “Since there is no effective treatment for this ‘condition’ (or for dementia), 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.”
“Binge eating disorder” has also now made it to the major leagues as an official DSM-5 mental illness (moving up from a non-official mental illness status in Appendix B in DSM-4). What constitutes binge eating disorder? Frances reports, “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 psychiatric illness called binge eating disorder.”
Frances’ “10 Worst Changes” in the DSM-5 also includes the following: “First-time substance abusers will be lumped in definitionally with hardcore addicts despite their very different treatment needs and prognosis and the stigma this will cause.” DSM-5 also introduces us to the concept of “behavioral addictions,” which Frances points out “eventually can spread to make a mental disorder of everything we like to do a lot.” Additionally, Frances reports that “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 contributing to the already large illegal secondary market in diverted prescription drugs.” And Frances adds that “DSM 5 obscures the already fuzzy boundary between generalized anxiety disorder and the worries of everyday life.”
Brief History of the DSM
The first DSM was published in 1952 and lists 106 disorders (initially called “reactions”). DSM-2 was published in 1968, and the number of disorders increased to 182.
Both the first DSM and DSM-2 included homosexuality as a mental illness. In the 1970s, coinciding with the heightened significance of the DSM was the rise of gay activism. Thus, the elimination of homosexuality as a mental illness became the most visible psychiatric-political issue. Gay activists staged protests at American Psychiatric Association conventions. The APA was fiercely divided on this issue, but homosexuality as psychopathology was ultimately abolished and then excluded from the DSM-3, published in 1980.
Though homosexuality was dropped from DSM-3, diagnostic categories were expanded in the DSM-3 to 265, with several child disorders added that would soon become popular, including “oppositional defiant disorder” (ODD).
DSM-4, published in 1994, has 297 disorders and over 400 specific mental illness diagnoses. L.J. Davis, in the February 1997 issue of Harper’s, wrote a book review of the DSM-4 titled “The Encyclopedia of Insanity: A Psychiatric Handbook Lists a Madness for Everyone,” wrote that the DSM-4 “is some 886 pages long and weighs (in paperback) slightly less than three pounds; if worn over the heart in battle, it would probably stop a .50-caliber machine-gun bullet at 1,700 yards.”
Mental illness expansionism in the DSM-5 is no laughing matter for Allen Frances who reminds us: “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.” Though the APA claims that DSM-5 will not significantly add to the DSM-4 total of mental illnesses, by one DSM-5 declaration alone—eliminating the bereavement exclusion to depression—they will have created millions more mentally ill people.
DSM: Dogma or Science?
How exactly do certain human behaviors become a mental illness? It comes down to the opinion of a board of trustees of the American Psychiatric Association. Davis writes in Harper’s, “First, and primarily, the DSM-4 is a book of dogma, though as theology it is pretty pedestrian stuff.”
Is the DSM dogma or, as establishment psychiatry would claim, science?
Two important aspects of a scientific instrument are validityand reliability. DSM scientific validity would mean that behaviors labeled as disorders and illnesses are in fact disorders and illnesses. And DSM reliability would mean that clinicians trained in DSM criteria agree on a diagnosis.
One historical example, a century before the first DSM, of a clearly invalid mental illness is drapetomania. Louisiana physician Samuel A. Cartwright was certain he had discovered a new mental disease. After studying runaway slaves who had been caught and returned to their owners, Cartwright concluded in an 1851 report to the New Orleans Medical and Surgical Journal that these slaves suffered from drapetomania, a disease causing them to flee.
While virtually all psychiatrists today rightfully mock the idea that fleeing slavery could be considered a valid mental illness, it was not until the 1970s that cultural upheaval and political protests persuaded the APA of the invalidity of homosexuality as a mental illness.
And while homosexuality was dropped from the 1980 DSM-3, oppositional defiant disorder (ODD) was added, and ODD is now a popular child and adolescent diagnosis. The symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules” and “often argues with adults.” Is it any more valid to label teenage rebellion and anti-authoritarianism as a mental illness than it is to label runaway slaves as mentally ill?
Even if you believe that oppositional defiant disorder and all the other DSM disorders are in fact valid mental illnesses, for them to be considered scientific, they have to be able to be reliably diagnosed.
In a landmark 1973 study reported in Science, David Rosenhan sought to discover if psychiatry could distinguish between “normals” and those so “psychotic” they needed to be hospitalized. Eight pseudopatients were sent to 12 hospitals, all pretending to have this complaint: hearing empty and hollow voices with no clear content. All pseudopatients were able to fool staff and get hospitalized. More troubling, immediately after admission, the pseudopatients stated the voices had disappeared and they behaved as they normally would but none were immediately released. The length of their hospitalizations ranged from seven to 52 days, with an average of 19 days, each finally discharged diagnosed with “schizophrenia in remission.”
Psychiatry was embarrassed by Rosenhan and other critics and knew if the DSM wasn't fixed, they would continue to be mocked as a science. The 1980 DSM-3 was dramatically altered to have concrete behavioral checklists and formal decision-making rules, which psychiatry hoped would solve its diagnostic reliability problem. But did it?
Herb Kutchins and Stuart A. Kirk are coauthors of two books investigating this claim of “new and improved” reliability of the DSM-3 and DSM-4: The Selling of DSM: Rhetoric of Science in Psychiatry (1992), and Making Us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders(1997).
Kutchins and Kirk detail a major 1992 study done to examine the reliability of the supposedly new and improved DSM-3. This reliability study was conducted at six sites in the United States and one in Germany. Experienced mental health professionals were given extensive training in how to make accurate DSM diagnoses. Following this training, pairs of clinicians interviewed nearly 600 prospective patients. Because of the extensive training, Kutchins and Kirk note, “We would expect that diagnostic agreement would be considerably lower in normal clinical settings.” The results showed that the reliability of the DSM-3—even with this special training—was not superior to the earlier unreliable editions of DSM, and in some cases it was worse. Kutchins and Kirk summarize:
What this study demonstrated was that even when experienced clinicians with special training and supervision are asked to use DSM and make a diagnosis, they frequently disagree, even though the standards for defining agreement are very generous....[For example,] if one of the two therapists....made a diagnosis of Schizoid Personality Disorder and the other therapist selected Avoidant Personality Disorder, the therapists were judged to be in complete agreement of the diagnosis because they both found a personality disorder—even though they disagreed completely on which one!...Mental health clinicians independently interviewing the same person in the community are as likely to agree as disagree that the person has a mental disorder and are as likely to agree as disagree on which of the...DSM disorders is present.
Kutchins and Kirk report there is not a single major study showing high reliability in any version of the DSM, including the DSM-4.
Is there any good news about the DSM-5? The APA just announced that its price for the DSM-5 will be $199 a copy, and this is good news for Allen Frances who reacted: “People are not likely to rush out to buy a ridiculously expensive DSM-5 that has already been discredited as unsafe and scientifically unsound...The good news is that its lowered sales and lost credibility will limit the damage that can be done by DSM-5.”
By: Bruce E. Levine
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