DSM5 in Distress

The DSM's impact on mental health practice and research

Defenses From DSM 5 Get 'Curiouser and Curiouser'

Trying to defend the indefensible

Elizabeth Lopatto has written an excellent piece in today's Bloomberg News summarizing concerns that DSM 5 will expand the boundaries of psychiatry, increase the already existing diagnostic inflation, and promote the excessive use of medications to treat life problems that don't really require them.

The Vice Chair of the DSM 5 Task Force tries to defend DSM 5 but with statements that have a strange Alice-in-Wonderland out-of-touch-with-reality quality.  

Quote 1: "The idea of medicalising normality comes from a perspective  
that there are no psychiatric disorders, and you need to avoid  
stigmatizing people by giving them one."

Response 1:  Wow. This argument implies that all of the criticism that has been specifically directed at DSM 5 must be really be based on a more general bias against psychiatry and against diagnosis. Where does this straw man come from and how can it possibly apply to me- a very concerned critic of DSM 5, but a determined defender of psychiatry when it is done well and with respect for the appropriate uses of psychiatric diagnosis and treatment. The DSM 5 proposals are criticized (by me and many others) because they are poorly conceived, poorly written, unsupported by convincing evidence, and likely to have dangerous unintended consequences. The point is that DSM 5 would expand psychiatry beyond its competence (treating clearcut, more severe psychiatric disorders) by focusing attention instead on milder conditions for which diagnosis and treatment will often do more harm than good- and waste much needed mental health resources. 

Quote 2: “Our intent is not to increase or decrease prevalence, but to make   
something that is more accurate and scientifically based.”

Response 2: This is a strange claim. The petition to reform DSM 5 (endorsed by 45 mental health organizations) was made necessary precisely because the science supporting the DSM 5 proposals is so very weak and incomplete. The future users of DSM 5 have made the completely reasonable request that there now be a more rigorous scientific review of its proposals, done independently from APA, and using the widely accepted methods of evidence based medicine. Moreover, it was a serious error of the DSM 5 field trials not even to attempt to measure the impact of its proposals on prevalence rates, when this will have such a dramatic effect on individual and public health (see my immediately preceding blogs).

Quote 3: "The revision should be 'a living document'... That’s so we can convene expert panels more frequently in the future.”

Response 3: A previous quote along the same lines was even more alarming- that DSM 5 is a admittedly a set of insufficiently tested  hypothesis, but can always be tested later after DSM 5 is published. No. No. No. DSM 5 is an official nomenclature that will affect people's lives now- not a document to set an agenda for future research. DSM 5 should be a public trust, not a public health experiment. Everything in it must be safe and scientifically sound. And given this experience, having APa convene expert panels doesn't seem like such a great idea. 

Bottom line- DSM 5 needs to drop its controversial proposals or have them subjected to a thorough and independent review; it needs to be much more carefully written; and it must be field tested again to determine if it can achieve adequate reliability and what will be its impact on prevalence.   
Anything less will lead to a careless and potentially quite harmful DSM 5. 

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

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