Allen J Frances M.D.

DSM5 in Distress

DSM 5 Promotes Sixty Percent Jump In Rates Of Alcohol Use Disorders

High rates will trivialize psychiatric diagnosis

Posted Jan 13, 2011

A new study from Australia reported by Reuters found that DSM 5 would result in a sky-rocketing sixty percent increase in the rate of alcohol use disorders as compared to DSM IV. The study is neutral on the crucial question of whether the consequences of such a huge jump would be more positive or more negative. It was not designed to determine whether the newly diagnosed "problem drinkers" might more likely benefit from being caught in the much wider net caste by DSM 5 or whether they in fact lack clinically significant impairment and more likely would be harmed by misidentification and unnecessary stigma.

Some thoughts:

1) This kind of comparison between rates of diagnosis using DSM 5 versus DSM
IV needs to be done for every change suggested in DSM 5. Otherwise, we will
have no idea what will be the impact of DSM 5 on psychiatric diagnosis and
on the boundary between mental disorder and normality. Unaccountably (and
irresponsibly), the DSM 5 field trials have avoided asking this most crucial

2) If, as seems probable, many of the new DSM 5 proposals encourage similar
large jumps in diagnostic rates, the concept of psychiatric disorder will be
trivialized. We already have a diagnostic system whose low thresholds result
in a psychiatric diagnoses for more than forty five million Americans every
year. The further watering down of definitional standards will make
psychiatric diagnosis so ubiquitous as to be almost meaningless- and divert
scarce resources away from those who do need them.

3) The obvious next step is to determine more about the risks and benefits
of such a huge swing in diagnostic practice-both to the individuals who
would be newly labeled as mentally disordered by DSM 5 and to the nation's
health care policy.

4) Decisions with such huge import to people and policy should not be left
to a small group of experts. Experts are always biased to lower thresholds
so as to avoid false negative, missed diagnoses. They are consistently
insensitive to the risks of false positive over diagnosis. Two weeks ago, I
went into this in more detail.

5) Changes of this magnitude should not be made in a fast draw, shoot from
the hip manner, without sufficient study of their possibly profound

About the Author

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

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