Health News Review

Dr. Allen Frances writes that the American Psychiatric Association approval of the 5th edition of the Diagnostic and Statistical Manual this past weekend marks “a sad day for psychiatry.“  Frances, psychiatry professor emeritus at Duke, chaired the DSM-4 task force.

He lists the top ten changes that he says should be ignored:

“I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, 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.

1) Disruptive Mood Dysregulation Disorder: 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 diagnosis 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 twenty-times increase in Autistic Disorder, and a forty-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.

2) Normal grief will become Major Depressive Disorder, 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.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, 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’ (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.

4) 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.

5) 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.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% 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 understandably 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.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) 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 do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.”

Kaiser Health News rounded up stories that covered the weekend meeting of the American Psychiatric Association as the changes were approved.

USA Today: Psychiatrists Approve Vast Changes To Diagnosis Manual
Asperger’s is out, but binge eating and hoarding are in as official mental disorders in the latest version of the diagnostic bible published by the American Psychiatric Association, following a vote Saturday by that group’s board. The Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, is often called the “bible” because it’s used to identify and classify mental disorders.

The Associated Press: Asperger’s Dropped From Revised Diagnosis Manual
“Full details of all the revisions will come next May when the American Psychiatric Association’s new diagnostic manual is published, but the impact will be huge …The manual also is important for the insurance industry in deciding what treatment to pay for, and it helps schools decide how to allot special education. … The aim is not to expand the number of people diagnosed with mental illness, but to ensure that affected children and adults are more accurately diagnosed so they can get the most appropriate treatment, said Dr. David Kupfer. He chaired the task force in charge of revising the manual.”

Bloomberg Businessweek: Psychiatrists Redefine Disorders Including Autism After 7-Year Fight
“The move comes after a seven-year debate that has split the mental health community over whether the changes will spur over- diagnosis of some disorders, and limit treatment for others. The guide collapses several conditions into a broadened definition for autism. It also adds new maladies, including one called disruptive mood dysregulation disorder for children who have temper tantrums at least three times a week.”

The Wall Street Journal: Psychiatric Association’s Diagnosis Revisions Seen Upending Evaluations
“The changes—the first major revisions since 1994—could affect millions of adults and children and billions of health-care dollars, determining who qualifies for subsidized services, treatment programs and insurance reimbursements. An estimated 30% of Americans are diagnosed with at least one mental illness in their lifetimes, and several conditions face major revisions in the DMS-5.”

CNN: Psychiatric Association Approves Changes To Diagnostic Manual
“[T]hese incremental revisions raised concerns among some researchers and advocacy groups who feared the new criteria would result in many children losing their autism diagnosis and much-needed services. For example, in March, a study presented by Yale autism expert Dr. Fred Volkmar suggested only 60% of those meeting current criteria for autism would still be diagnosed with the disorder under the proposed criteria. … Kupfer agrees that some children might fall off the autism spectrum, but he believes maybe 5% to 10% of patients will no longer meet the criteria for autism.”

Under an extremely insensitive and inaccurate headline, “Redefining Crazy: Changes to the Bible of Psychiatric Disorders,” TIME.com reported:

“What will not be added to the DSM is hypersexual disorder—sex addiction—even though many APA members argued for its inclusion. According to one member of the APA’s Board of Trustees, “the evidence just wasn’t there.” Other mental-health professionals note that the DSM is subject to political influence. “This is a huge money-maker for the American Psychiatric Association,” says Marsha Linehan, a University of Washington professor and a leading expert on personality disorders. In short, the approval this weekend of DSM-5 ends years of editing but begins years of debate.”

 


Comments

Joe posted on December 3, 2012 at 11:46 am

All in the name of pharmaceutical marketing

Martha Burge posted on December 3, 2012 at 2:09 pm

As an ADHD coach and author I agree with Dr. Frances 100% that the new diagnostic criteria, particularly for adult ADHD, is capable of causing harm. This diagnosis, whether for adults or children, tends to miss the mark. With the expanded criteria for adult diagnosis the problem will only grow. The only solution is to understand the underlying condition and learn to mitigate the problems and build on the inherent strengths. Any other approach is only treating symptoms.

jcchighway posted on December 4, 2012 at 7:59 am

Temper tantrums at least three times a week? Wow! How about three times a day or more. Many, many children, as part of the learning process, seek to “push the envelope” when first identifying strategies that work vs. strategies that don’t work to get their needs met. My son had them frequently for a period of 3-4 months. It was exhausting and frustrating, but perfectly and a normal part of the human development curve. The treatment strategy – smart parenting. Now, less confident parents will turn to a pill instead of a parenting manual to help their kids. Good grief!

Denise posted on December 13, 2012 at 12:54 pm

Agreed with the Dx criteria for the disruptive mood disorder. I have a child who has a combo of issues and it was no three times a week thing. It was all day everyday and she was injuring herself- biting clawing etc. it was no normal childhood tantrum. It also presented along with other serious impulse control issues leaving her personal safety in question. I would call three times a week average based on my friends who have no disabled children. This is ridiculous indeed. Clinicians are going to have to become vigilant in using discretion.

Fort Worth Frank.. posted on December 15, 2012 at 5:42 pm

TIME actually got one right. It is saturated with political influence and Psychiatric professionals are burning there APA cards in droves.

Megan posted on December 16, 2012 at 10:18 pm

I think you are all forgetting that these behaviors cannot just be your everyday run of the mill behaviors, they are far beyond the normal spectrum. For example, classifying Binge Eating disorder separate from Eating Disorder-Not Otherwise Specified has many more points of criteria that must be met other than “Excessive eating 12 times in 3 months” it also states that the person must feel a significant lack of control while eating, also these people eat up to 2 days worth of food in one sitting. Is that normal? No. Then it needs to be classified as something so these people suffering can get help. This isn’t about just medicating people, it’s about treating people psychologically so they can learn the proper coping skills to deal with their given diagnoses. You might think it a “sad day for psychiatry” but these changes can help people who would have suffered under the criteria of the DSM-IV because they are only missing one or two points of criteria for diagnoses. Mental illness is a serious issue in this country and this post shows how un-serious even professionals in this field take it. A gross injustice in my eyes.

    Rich posted on December 26, 2012 at 4:46 pm

    Someone who eats 2 days of food in one sitting is called a gluttonous pig not mentally ill. They eat because they have an abundance of readiy available food and the means to obtain it. How many homeless without these means do you think will be diagnosed with such a disorder. My guess will be none. Reason being, most homeless people don’t weight over 140lbs. Are homeless people immune from such a disorder or does their financial means just limit the availability of food for them? What you subjectively determine as normal isn’t nessecarily normal. All old paintings typically depict large men and woman. Gluttonous people during times when most people were starving. Those same areas these paintings come from are typically filled with abundance or depict well off individuals. What about the concept of the natural state of man. When abundance is present, people consume. Scarcity forces conservation. This is entirely about medicating as many people as possible. Psychiatry is a business an it depends on public acceptance and pharmaceutical donations. People are more accepting when their is an excuse for their own personal bad behavior.

Lisa Woodward posted on December 27, 2012 at 3:21 pm

Is there an alternative to the DSM? I will not pay for the piece of trash they plan on marketing as a diagnostic tool. Who contributed to this? A bunch of liberal idiots who do not care about science or psychology. Grief as major depressive disorder? Who who diagnose a patient in that category? Transgender not a confused person at all??????? Wow! This is unfortunate!