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Will DSM-5 Make Us Worry More?

Mental Health Problems: Under-diagnosis or Over-diagnosis – which is best?

Will DSM-5 make us worry more? That is one question being asked about the forthcoming published changes to mental health diagnostic criteria. The Diagnostic & Statistical Manual (DSM) developed by the American Psychiatric Association is the principal tool used by practitioners and medics to diagnose mental health problems, and the 5 th edition of this enormous (and expensive ) tome is due to be published in two months time.

There have been many critical evaluations of the changes to diagnostic criteria in this latest edition – many posted on Psychology Today. One of the major criticisms is to do with the potential for over-diagnosis. Changes will probably lead to (1) more people being diagnosed with particular primary mental health problems, and (2) the ‘medicalization’ of some everyday experiences that many people would feel are distressing, but normal.

For example, Generalized Anxiety Disorder (GAD) is the DSM category for which pathological and uncontrollable worry is the cardinal diagnostic feature. Yet the number of criteria necessary to establish a diagnosis of GAD have been reduced in DSM-5. The same is true of Major Depression. Taken together, GAD and Major Depression represent the bulk of common mental health problems experienced by people, and so are likely to be diagnosed more often under DSM-5 than they were before. DSM-5 has also removed what is known as the “bereavement exclusion” from the diagnosis of Major Depression. Previously, low mood resulting from a recent bereavement was excluded from the diagnostic criteria because it was considered to be a normal and adaptive emotion. Now, in DSM-5, it can be included in diagnosis – with the risk of labeling perfectly normal emotional experiences as dysfunctional.

With each successive revision of the DSM, we are likely to include more and more new diagnostic mental health disorders – not because we are discovering new disorders, but because those people who’s job it is to develop DSM are more worried about false negatives (i.e. the missed diagnosis or patient who doesn’t fit neatly into the existing categorizations), and this leads to either more inclusive diagnostic criteria or even more diagnostic categories. Unfortunately, experts are relatively indifferent to false positives – patients who receive unnecessary diagnosis, treatment, and stigma – and so are less likely to be concerned about over-diagnosis. Allen Frances has eloquently argued that this is likely to create “false-positive” epidemics – the diagnosis and consequent treatment of individuals who by many criteria are neither ill nor experiencing distress at levels beyond that experienced during normal everyday living.

There are, of course, those who will benefit from over-diagnosis or a ‘false-positive’ epidemic. The pharmaceutical industry is one, and the medicalization of grief following a bereavement, or worry following a stressful life event provides just two new markets for palliative drugs – especially if GPs and physicians are over willing to prescribe them.

This still leaves unanswered the major question. Which, on balance, is better – to have a diagnostic system that labels more and more people as ‘mentally ill’ or a diagnostic system that labels fewer people as ‘mentally ill’? Currently, the British Medical Journal is running a campaign in medicine called “ Preventing Overdiagnosis ” arguing that over-diagnosis in general medicine is “actively harmful”. The bottom line is that in medicine many people are getting a diagnosis they don’t need – is that also happening in mental health provision? Also in medicine, there is a rapidly growing tendency to medicalize risk factors for illness by indicating these too need to be treated – obvious examples include risk factors for heart disease and diabetes. And this is a process that both medicalizes and labels conditions that are often quite common and quite normal (e.g. many forms of hypertension). Yet DSM-5 itself had begun to identify prodromal states for diagnosis. Mild Neurocognitive Disorder (which would diagnose cognitive decline in the elderly) and Attenuated Psychosis Syndrome (seen as a potential precursor to psychotic episodes) are just two that were discussed during the development of DSM-5.

But I can hear you saying to yourself that mental health is not the same as medicine! Yet in the last month, those responsible for the development of DSM-5 released a statement including the following quote “Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine…”! Oh dear – make way for over-diagnosis. Perhaps someone, somewhere needs to sit down and carefully think through the consequences of over-diagnosis and the consequences of under-diagnosis in mental health provision in a balanced way.

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