DSM5 in Distress

The DSM's impact on mental health practice and research

DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes

The ten worst suggestions that were recently approved for DSM-5 are summarized and the recommendation made that clinicians and the public not to use them at all or use them with great caution. Read More

Powerful conflicts of interest

You raise a good point re: financial conflicts of interest of the authors of the DSM-V when you say that "they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies", however I think that you overlook another important conflict of interest which ties the two together, which is the conflict of interest of power and influence.

In a nutshell, psychiatry is not viewed as a legitimate science and/or branch of medicine by many (and considering the actions of the DSM-V authors and APA why would it be?). Instead of actually testing their ideas and seeing if they hold true or not (which is admittedly hard to do when one is promoting unfalsifiable conjecture in the place of valid testable hypotheses), admitting failures when they occur and acknowledging the limitations of one's specialty (as the DSM-V authors/APA have repeatedly shown they have no interest in doing), one quick and possibly more direct way to acheive 'respectability' in this regard is to simply have colorful little pills to prescribe to people. By having such pills available to them (whether these colorful little pills work or not, a subject which is very much open to question when you consider the numerous problems which have been repeatedly documented on the subject of industry-sponsored 'research studies'), psychiatrists gain a semblence of legitimacy as to the fundamental worth and/or value of their profession. The more 'disorders' they have to 'treat' with their colorful little pills, the more 'legitimacy' they obtain as a result, with the relationship between the two growing in direct proportion to one another. This of course greatly benefits the pharmaceutical industry which makes vast sums of money as a result of selling these colorful little pills. The result of all this? DSM-V.

Although your cynicism

Although your cynicism towards our field is justified, I believe that your claims about the legitimacy of psychiatry, and the clinical research that backs it, they are purely misguided. I would somewhat agree on a profit-related incentive in the quasi psychopharmacology-corporate "conspiracy" (for the lack of a more appropriate term at the moment) that you speculate exists. Given that there might be skewed results presented by studies funded by the companies who make the drugs, drug efficacy and area of effect specificity has been on the rise and has been tested by non-interested third parties. Furthermore, most of the changes have been made in light of findings through neurobiological research that has been used more widely to provide a "more empirical" and "scientific way" of providing highly descriptive evidence for the etiology and course of illness of many psychiatric disorders, which in turn guides nosology, then treatment. The author's fear of a "slippery slope" for the creation of behavioral addiction category is also misguided since these addictions have proven to create similar neuroplasticity with people suffering with substance abuse, thus giving credence to their power. I agree with the sentiment behind his or her condemnation for BA's inclusion (a product of the [ironically] soritesean paradox of what is considered psychopathology, stigma, etc.), but one cannot question the existence (and the evidence for it) of most of the new classes of disorders that DSM V considers psychopathology nor the efficacy of the appropriate psychiatric medication used to alleviate the crippling acute symptoms of a disabling psychiatric illness. I could say more, but please please, practice prudence with informed reason

I agree

I agree, and am especially alarmed about Dr. Frances' title: "Ignore Its Ten Worst Changes." I could see "have caution" or "do some research and draw your own conclusions," but "ignore" is way too extreme (and irresponsible).

Vibrational Medicines

Beloveds,
the old is fading away and the New is already in Place.
In the new approach to all physical, mental and spiritual issues we use VIBRATIONAL MEDICINES. Those Vibrational Medicines have been tested in the Tribal- Shamanic- Tradition for thousands of years. Vibrational medicines include also new age techniques and highly advanced new technology.
All the solutions the pharmacological and medical establishment are offering right now will fade away, because the new methods will be much more effective than the old.
All the books who are considered bibles in the field are based on false asumptions that the body is a machine and that the spirit has nothing to do with the body/mind.
Ladies and Gentlemen we need to accept that also we are a part of the experiment: if you choose wisely which imput you give into creation the outcome will be beautiful for you and all the Universe and its creatures.
Blessings to all
George - centreoflight

Energy Medicine

Energy therapy - or vibrational medicine as George wrote - is the wave of the future. It provides an overview of a person and easily encompasses DSM distinctions, no matter what the vintage, without taking them as the end product of analysis. As Dr. Stolorow wrote elsewhere, one of the great shortcomings of any DSM approach is that it does not take into account the social field of the person, the interpersonal relationships and the social and political forces acting upon a person. Even more, the DSMs do not take into account the Soul, the Life Force, the Prana, of the person. Laugh if you like, but that is what heals -and shows respect for the client. Energy therapy can even include pharmacology, but does not rely on it, or any single intervention. Rather, the person's own energies are helped back into right relationship with themselves and their environment. What a pity that the small minded interests of the mental health guilds stigmatize even learning about energy medicine. Their refusal to look at something is hardly scientific, which is especially ironic since they pretentiously lay claim to being the only legitimate source of scientific knowledge.

A different feeling

Again, I hope the DSM-5 Committee will sign 1,000 copies or so,offering them for sale, To raise money for an agreed cause.

I'm very excited about its release, and I think they did a wonderful job.

Critique of DSM

This is an excellent, if sad, blog post, Dr. Frances. Here is my own, somewhat more radical, critique of the entire DSM enterprise:
http://www.psychologytoday.com/blog/feeling-relating-existing/201204/dec...

Minor Neurocognitive Disorder leading to misdiagnosis for IPV victims

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Minor Neurocognitive Disorder leading to misdiagnosis for IPV victims

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Minor Neurocognitive Disorder leading to misdiagnosis for IPV victims

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Minor Neurocognitive Disorder leading to misdiagnosis for IPV victims

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Minor Neurocognitive Disorder leading to misdiagnosis for IPV victims

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Minor Neurocognitive Disorder leading to misdiagnosis for IPV victims

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

DSM V

I wholeheartedly agree with your beautifully written portrayal of the erroneous 5th edition of the DSM!

Minor Neurocognitive Disorder leading to misdiagnosis for IPV victims

I am sorry that when I submitted this that it posted several times.

As I had mentioned that misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

In addition, similarly to victims of elder abuse. Such a misdiagnosis will further provide evidence to a victim that they need to be medicated.

Both research communities in IPV and elder abuse should take note of this issue leading to many false positives, over medication, and increasing victimization in IPV and elder abuse.

I don't mind your repost, but

I don't mind your repost, but I am very curious about the connection of IPV and Minor Neurocognitive Disorder. I've just never heard of this connection before. Could you explain the cause and effect here, or perhaps link to some literature on the subject? I'd appreciate it.

One link between IPV and

One link between IPV and Minor Neurocognitive Disorder: an uncertain but not insignificant proportion of victims/survivors of partner violence have (often undiagnosed) mild traumatic brain injury as a result of their abuse.

The OP's concern seems to be different: that abusive partners will convince doctors to misdiagnose 'normal' behaviour as psychological disorders, then force treat with medication (ie chemical restraint).

Another Worst Diagnosis: Somatic Disorders

Thanks for this great article. I agree that intellectual conflicts of interest are a serious problem and that failure to field test is also a failure in the production of this manual.

Another new diagnosis which deserves to be on this list is the Somatic Disorders diagnosis. Under this diagnosis, if a person has symptoms which are currently unexplained (whether because they do not have a diagnosis or whether because they have symptoms not listed in their diagnostic description), they can be given this label.

The treatment is CBT to correct the patients' anxieties which are giving rise to these 'extra' symptoms. Worse, to not conduct further testing to see if there is an alternate diagnosis which is a better fit or whether there is a comorbid condition.

This is bogus because all diseases have patients with symptoms not in the official definitions. And it's dangerous because many patients originally receive one or several incorrect diagnoses.

It also is biased towards a view that unexplained symptoms are necessarily psychosomatic. We should maybe have learned something from figuring out that multiple sclerosis, epilepsy, and so on are not psychosomatic.

Any patient is able to get additional conditions. It is very dangerous to put patients in a "do not test further" category.

Do Not Test Fruther

As a "psychosomatic" person with IBS issues and a clinician-in-training with several "do not test further" clients, I wholeheartedly agree with this comment.

behavioral addictions

Asinine. We've already got obsessive-compulsive. What do we need it for? To line the pockets of people running thirty-thou a month in-patient treatment facilities?

Follow the money.

Addiction is not OCD

I'm not in favor of any treatment programs, but a large body of brain research exist that points to all addictions causing the same fundamental brain changes and being triggered by the same molecular switches (deltaFosb & CREB).

Internet addiction alone has 25-30 recent brain studies confriming its existence.

Eating to obesity has countless animaland human brain studies all revealing the same brain changes as occur in drug addicts. The animal studies reveal all the same molecular mechanisms & specific brain changes.

Unike the other 9 worst changes, or any of the other current DSM diagnosis, addiction is backed up by 30 years of research, and thousands of animal and human brain studies.

It's clear from his writings that Frances is woefully ignorant of the state of current addiction neuroscience. No wonder he wasn't involved this time around.

Well said Sir! I

Well said Sir! I whole-heartedly agree.

Agreed

Thank you for your comment. I agree with quite a bit of Dr. Frances' article, but he does not seem to have kept up with the literature on behavioral addiction and related brain science. The criteria for addiction should be whether people are suffering and having adverse consequences in their lives--not the specific substance or activity. After all, alcohol is an "everyday" thing just like the Internet or TV or sex. Why should it be given any special status?

Also agreed

As someone who has struggled with both 'behavioral addictions' and substance abuse (both of which nearly killed me), I wonder if Dr. Frances has any concept of the similarity between the two processes from the patient's perspective (in addition to the neurological basis). There is already enough stigma and difficulty getting medical professionals to recognize that 'behavioral addictions' are serious conditions; it is distressing to me that a physician at my own institution has written something that may be used to further deny the struggle of these patients. I am now happily in recovery from all addictive processes, but I certainly have compassion for those still suffering.

I agree that the DSM-V is far from perfect, and I understand that sometimes you have to be controversial to get attention on these blogs. However, I'm very concerned that the extreme and one-sided perspective of Dr. Frances will end up hurting the exact patient population he is trying to protect. Additionally, family members are much more likely to read a blog like this than a scientific journal, and I'm worried that they could now cite a Duke Physician as supporting them in their deny of their loved ones 'behavioral addiction.'

Clinicians: use your own judgement, not their's

Dr. Frances makes a good point, it is up to use, as "front-line" clinicians to exercise our own judgement when deciding on whether or not to use a particular diagnosis. There is absolutely no legal or ethical requirement for us to label any individual with a diagnosis, if doing so would be contrary to our clinical opinion. If you are upset about these upcoming changes, remember that we, as clinicians, are the last line of defense!!

DSM 5

Mr. Pratt:

I wholeheartedly agree. The DSM IV TR or 5 are just guides to know what type of treatment or counseling technique to use. We are studying the DSM IV TR in Psychopathology in a Clinical Perspective at Walden.

Do you know the main differences between the DSM IV TR and DSM 5?

Is there a site where I can view the DSM 5?

Thank you.

Regards,
Susan Hemann

Is autism/Asperger's overdiagnosed?

Dr. Frances,
Thank you for your insights into the DSM process, which I've always found enlightening.

I have the same question for you that I've put to other researchers and clinicians, including some of those engaged in the DSM-5 autism revisions (with no answer so far): why are you so sure that autism/Asperger's is overdiagnosed? Over the last year we've seen frequent references to this "overdiagnosis" problem, but no supporting data. The increasing prevalence does not in itself justify this conclusion. What does?

Interesting

Interesting thoughts. But I think what is needed is research findings actually showing what you fear. I think sadness could be change for interest. Maybe the results are better than the prognosis.

Gluttony

Gluttony is a judgment word, not a diagnosis or especially compassionate. I am doing an undergraduate study on obesity bias. Sir, your attitude towards binge eating is not helpful in treating or finding compassion for the stigmatized obese population.

Research shows that binge eating is very often connected to adverse childhood experiences (see the CDC's ACE Study), much in the way of many self-destructive behaviors. Yes, there is sensual pleasure in a gluttonous feast, but binge eaters have usually gone long past the point of pleasure in their eating and do it strictly to manage anxiety. Treat the anxiety and the binge eating tends to take care of itself. As it is currently, most insurance companies refuse treatment of eating disorders apart from anorexia and bulimia with purging.

I would ask you kindly to reconsider using stigmatizing language with any population, not just the obese.

Kimberly Mendoza

Binge-eating disorder

I agree with this comment. I am 20 years old, 5 feet tall, and 100 pounds, and I have binge-eating disorder. The state of public information about eating disorders frustrates me. Excessive eating as an expression of gluttony is not a psychological disorder, but when overeating becomes a coping mechanism for unresolved internal conflicts, binge-eating disorder can result. This article made very good points, but the undermining of a legitimate psychological addiction is an insensitive and ignorant shame.

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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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