DSM5 in Distress

The DSM's impact on mental health practice and research

DSM 5 Will Expand the 'Epidemic' of ADD

The 'epidemic' of Attention Deficit Disorder

Our country is in the midst of a fifteen year "epidemic" of Attention Deficit Disorder (ADD). There are six potential causes for the skyrocketting rates of ADD- but only five have been real contributors. The most obvious explanation is by far the least likely - that the prevalence of attention deficit problems in the general population has actually increased in the last 15 years. Human nature is remarkably constant and slow to change, while diagnostic fads come and go with great rapidity. We don't have more attention deficit than ever before-we just label more attentional problems as mental disorder.

The "epidemic" can be traced to a complex interaction among five other contributors: 1-wording changes in DSM4(published in 1994); 2- heavy drug company marketing to doctors and advertising to the general public; 3- extensive media coverage; 4-pressure from parents and schools to control unruly children;and 5-the use of stimulants for performance enhancement.

There is controversy on whether the resulting increased prevalence of ADD should be the cause of celebration or concern or perhaps both. Some believe that the higher rates mostly reflect the useful identification of ADD in patients who were previously missed. No doubt increased diagnosis has been helpful for many people who otherwise would not have received appropriate treatment with stimulus medication.

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This gain has to be offset against the serious costs to many others. Some of the increased prevalence of ADD ( no one can tell for sure what proportion) results from the "false positive" misidentification of people who would be better off never receiving a diagnosis. The rapid expansion of stimulant use has undoubtedly led to unnecessary treatment with medications that sometimes cause harmful side effects and complications. There is also a large problem with stimulant misuse for purposes of performance enhancement and abuse for purposes of intoxication- both leading to the development of a large, illegal secondary market for stimulant drugs.

DSM5 will become the official manual for psychiatric diagnosis when it is published in 2013. The recently posted first draft contains a number of suggestions that would make it even easier to get a diagnosis of ADD: 1)raising the requirement that onset of symptoms occur before age 7 to age 12; 2) dramatically reducing the symptom threshold for adult ADD; 3) removing the requirement that there be accompanying clinically significant distress or impairment; and, 4) allowing the diagnosis of ADD in those who also have the diagnosis of autism.

In developing DSM4, we hoped to be careful and conservative. We believed that the diagnostic system should remain stable unless there was compelling evidence that change would be more helpful than harmful. We performed an extensive field trial that predicted (it turned out incorrectly) that our wording clarifications would not change the rates of ADD. Our experience proved that even small changes in the diagnostic criteria can have large unintended, and often unfortunate, consequences- (particularly if the drug companies find a way to amplify their effects).

The changes suggested for DSM5 are radical and could add fuel to the fire of the already raging "epidemic" of excessive diagnosis and treatment of ADD. I would suggest there be a careful risk/benefit analysis (that includes input from the public and consideration of public policy implications) before any of these changes are made official.

Problems with attention and hyperactivity are very common in the general population. There is no clear boundary to determine when these can be considered as no more than normal variation and when they are best labeled and treated as mental disorder. There are also many, many causes for distractability other than ADD. These include mood and anxiety problems, substance use, insomnia, stress, overextended scheduling, and many, many more. If the requirements for diagnosing ADD are too stringent, true cases will be missed. If they are too loose, innocent bystanders will be captured. Right now, I believe the criteria are, if anything, too loose and fear the results if DSM5 makes them far looser.

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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