March 01, 2010|By Allen Frances
As chairman of the task force that created the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994, I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences.
Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics" -- attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many "patients" who might have been far better off never entering the mental health system.
The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
The manual, prepared by the American Psychiatric Assn., is psychiatry's only official way of deciding who has a "mental disorder" and who is "normal." The quotes are necessary because this distinction is very hard to make at the fuzzy boundary between the two. If requirements for diagnosing a mental disorder are too stringent, some who need help will be left out; but if they are too loose, normal people will receive unnecessary, expensive and sometimes quite harmful treatment.
Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status -- to say nothing of stigma and the individual's sense of personal control and responsibility.
What are some of the most egregious invasions of normality suggested for DSM-V? "Binge eating disorder" is defined as one eating binge per week for three months. (Full disclosure: I, along with more than 6% of the population, would qualify.) "Minor neurocognitive disorder" would capture many people with no more than the expected memory problems of aging. Grieving after the loss of a loved one could frequently be misread as "major depression." "Mixed anxiety depression" is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.
Diagnosing the ‘DSM-5’
Two Jews may, as the saying goes, have three opinions, but that appears to be a fairly modest ratio when compared with psychiatrists. It was inevitable that revisions to the Diagnostic and Statistical Manual of Mental Disorders would invite controversy—it’s the classic reference work for mental-health professionals, and a convenient field guide to understanding crazy exes for the rest of us—but even the American Psychiatric Association, which first appointed the work groups to update the text two years ago, couldn’t have predicted the squabbles now under way. Dr. Allen Frances, the man who chaired the task force that created the current edition (the DSM-IV), has today emerged as the most trenchant, and relentless, critic of the proposed revisions to the upcoming edition (the DSM-5; among the changes is a transition to Arabic numerals). Last Tuesday was the final day those revisions were open to public comment. “And hopefully,” Frances says, “most of them will drop out.”
Basically, Frances believes that the first draft of the DSM-5 is too promiscuous with its labels, both by loosening diagnostic criteria and by introducing a host of new and, to his mind, problematic maladies—like Binge Eating Disorder (more or less defined as gorging on massive amounts at least once a week for three months). By the estimate of one DSM-5 task-force member, Frances says, this disorder already afflicts 6 percent of the population. “And that,” he notes, “is before drug companies start marketing something for it.”
As Frances pointed out in a recent Los Angeles Times editorial, such taxonomic adjustments only seem to further shrink “the ever-shrinking domain of the normal.” Take another DSM-5 proposed addition: Temper Dysregulation Disorder With Dysphoria. Frances fears this may be deployed for kids who have typical temper problems. Or Major Depressive Episode: As it’s redefined, it could now be used to describe someone who’s spent two weeks grieving over a lost spouse, he contends. But the worst offender, in Frances’s view, is Psychosis Risk Syndrome, which attempts to identify and treat youngsters before they become psychotic. In his view, there isn’t any evidence that early intervention with medication helps, while there’s plenty to suggest that many teens could be misidentified. “And that I saw as a public-health danger,” he says, “because there are real drawbacks to being on antipsychotics.” Like weight gain and diabetes. “Those children are also disproportionately on Medicaid,” he adds.
One can, of course, sympathize with David Kupfer, the chairman of the DSM-5 task force (who said, via an assistant, he couldn’t speak before our deadline). The field has evolved since 1994, when the DSM-IV was first published, as have clinical practices. “Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients,” he and his colleagues wrote last summer in Psychiatric Times. “Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism.” And the current version of the DSM-5 is only a draft, after all (it won’t be out until May 2013). Even Frances is compassionate about his plight. “If you’re an expert in the field,” he says, “you really resent it when you can’t find a specific diagnosis for every patient. But you have to avoid the temptation to make changes that’d have disastrous unintended consequences.”
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