DSM5 in Distress

The DSM's impact on mental health practice and research

Should Temper Tantrums Be Made Into a DSM 5 Diagnosis?

Don't medicalize temper tantrums.

 

A recent front page story by Shari Roan in the Los Angeles Times explores the heated controversy over the DSM 5 proposal to include a Disruptive Mood Dysregulation Disorder (DMDD) in DSM 5. I very much oppose the inclusion of this new 'disorder'- fearing that DMDD would medicalize temper tantrums in children and run the risk of exacerbating the already shameful overuse of antipsychotics.

When it comes to DMDD, everyone agrees on one thing only- that it is based on the thinnest possible research support; studies by one lone group for a mere six years. DMDD was largely dreamed up by the DSM 5 work group. They are trying to deal with a real problem- the massive overdiagnosis of childhood bipolar disorder and its attendant stigma and overprescription of potentially dangerous medication. But the proposed solution will create its own set of unintended consequences with the likely increase overprescription of medication for the new and inviting target of temper tantrums. And we are talking about lots of kids- estimated at 3% now and likely to grow to many more once the diagnosis is official and drug companies get their hands on it.

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The right solution to the childhood bipolar fad is so much simpler and safer. DSM 5 should include a warning black box in its definition of Bipolar Disorder alerting clinicians to the dangers of overdiagnosis and overtreatment in children. My advice to child psychiatrists- tame the fad you have already created and please don't create another fad of a new 'disorder' that can so easily be misused. No one denies that irritable children are a problem, but let's not prematurely and blindly invent essentially meaningless, but potentially very dangerous labels for them.

The truly incredible thing about child psychiatrists is their inability to learn from their past experience of fad creation. These are the people who brought us the three main fads of the past fifteen years- childhood bipolar, attention deficit disorder, and autism. And now they recklessly suggest a potential fourth in DMDD. DSM 5 clearly needs some adult supervision with this thought in mind- beware nosologists bearing new and untested child diagnoses.

This brings us to the most dispiriting chapter in this sad story. The DSM 5 'scientific review group' has proven not to be scientific and seems incapable of careful reviewing. Most remarkably, it has approved DMDD on tissue thin evidence and with no consideration of risk. A porous filter indeed. This highlights the obvious necessity for independent and evidence based reviews (say by the Cochrane group) to ensure the scientific integrity and safety of DSM 5 suggestions.

 

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

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