Sometimes you spot a serious problem and figure out a very well-intended solution, only to discover eventually that your solution created as much trouble as the original problem. The workers on DSM5 have spotted an enormously worrying problem-the wild overdiagnosis of childhood bipolar disorder (BD) which has led to a massive increase in the use of antipsychotic and mood stabilizing medications in children and teenagers.
DSM5 suggests 2 changes that would make it much easier for an adult to get a first time diagnosis of Attention Deficit Disorder (ADD): 1) reducing the number of symptoms required for adults from 6 to 3; and 2) relaxing the requirement that the onset of symptoms must have occurred before age 7 (by allowing the onset to be up to age 12).
The first drafts of DSM5 were posted 2 months ago, allowing the field and the public a first glimpse into what had previously been an inexplicably secretive process. Today is the last day for public comment on these drafts. This is a plea for continued openness and iterative interchange in the next steps in the preparation of DSM5.
DSM5 first went wrong because of excessive ambition; then stayed wrong because of its disorganized methods and its lack of caution. Its excessive and elusive ambition was to aim at a "paradigm shift.”
Mark Twain observed that "the past may not repeat itself, but it sure does rhyme." An unfortunate rhyme in psychiatric history is the recurrence of fad diagnoses. Childhood Bipolar Disorder is the most dangerous current bubble, with a remarkable forty-fold inflation in just one decade.
Avoid Surprises and Unintended Consequences
DSM-IV provides separate categories for Substance Abuse and Substance Dependence. The typical substance abuser is someone who gets into recurrent, but intermittent, trouble as a consequence of recreational binges. This is in contrast to the continuous and compulsive pattern of use that is typical of DSM-IV Substance Dependence.
There are 2 very different methods of describing people with a mental health problem. A typical psychiatrist will give the mental disorder a name. Many psychologists would prefer to give it a number on a rating scale. The first “categorical” approach is the simplest and most natural way people sort things. It is the method used throughout medicine (with just a few exceptions like hypertension). The second “dimensional” approach works best to describe phenomena that are continuous, lacking in clear boundaries, and reducible to numerical measurement.
The proposal for a "Psychosis Risk Syndrome" aims to solve a pressing problem in psychiatry-- the need for early identification and preventive treatment.
A major general problem in the preparation of DSM5 is that the various Work Groups have been given far too little guidance and support. This explains why: 1)most of the criteria sets are written so obscurely and inconsistently; 2) the rationales for change vary so widely in depth and quality across Work Groups,and; 3) so many suggestions that should have no chance at all have made it this far without being tossed.
The recently posted draft of DSM5 makes a seemingly small suggestion that would profoundly impact how grief is handled by psychiatry. It would allow the diagnosis of Major Depression even if the person is grieving immediately after the loss of a loved one. Many people now considered to be experiencing a variation of normal grief would instead get a mental disorder label.
Our country is in the midst of a 15-year "epidemic" of Attention Deficit Disorder (ADD). There are 6 potential causes for the skyrocketting rates of ADD-- but only 5 have been real contributors. The most obvious explanation is by far the least likely -- that the prevalence of attention deficit problems in the general population has actually increased in the last 15 years. Human nature is remarkably constant and slow to change, while diagnostic fads come and go with great rapidity. We don't have more attention deficit than ever before. . . we just label more attentional problems as mental disorder.
This commentary suggests how the research community can be instrumental in improving DSM-V and helping it avoid unintended consequences. According to several converging, anonymous (but I think quite reliable) sources to which I have had access, the draft options for DSM-V will finally be posted between mid-January and mid-February 2010. There will then be just 1 month (until mid-March) for collecting comments. The good news is that the products of a previously closed process will finally be available for wide review and correction. The bad news is that there will be only a brief period allotted for this absolutely crucial input from the field.
This commentary will suggest how the research community can be instrumental in improving DSM-V and helping it avoid unintended consequences. According to several converging, anonymous (but I think quite reliable) sources to which I have had access, the draft options for DSM-V will finally be posted between mid-January and mid-February of 2010.
I have elsewhere summarized the problems caused by the excessive and misdirected ambitions of the DSM-V effort.1 My purpose here is to suggest a different, more useful and attainable ambition for DSM-V-namely trying to integrate DSM-V and ICD-11 into one system. If successfully achieved, this would be by far the biggest accomplishment possible in this round of revision.
There is no magic moment when it becomes clear the world needs a new DSM. The publication dates of previous DSMs were determined by revision dates of the International Classification of Diseases (ICD). Thus, DSM-I appeared with ICD-6 in 1952; DSM-II with ICD-8 in 1968; DSM-III with ICD-9 in 1980; and DSM-IV with ICD-10 in 1994.
There is no magic moment when it becomes clear that the world needs a new edition of the DSM. With just one exception, the publication dates of all previous DSM’s were determined by the appearance of new revisions of the International Classification of Diseases (ICD). Thus, DSM-I appeared in conjunction with ICD-6 in 1952; DSM-II with ICD-8 in 1968; DSM-III with ICD-9 in 1980; and DSM-IV with ICD-10 in 1994. The lone exception was DSM-IIII-R, which appeared in 1987-out of cycle only because it was originally meant to be no more than a minor revision. The official publication date for DSM-V is May 2012. That date was picked to be consistent with an earlier, no longer correct, expectation that ICD-11 would be published in that same year.
I had intended not to reply to the silly suggestion made by the DSM-V leadership that I wrote my critique out of financial motivations. I had expected that we would be conducting a useful discourse on the concrete issues and was surprised by the unenlightening personal exchange. Unfortunately, the DSM-V leadership refuses to discuss any of the substantive questions I have raised and instead, I am told, persists in the shallow rationalization that whatever I say is about royalties.
I had intended not to reply to the silly suggestion made by the APA leadership that I wrote my critique of the DSM-V process out of financial motivations.
I have the highest respect and affection for Will Carpenter, MD, who wrote a recent response ("Criticism vs Fact: A Response To A Warning Sign on the Road to DSM-V by Allen Frances, MD," Psychiatric Times, July 7, 2009) to my earlier commentary, but we do differ sharply on the following points.
We have already gone past the midway point of the time allotted for the preparation of DSM-V. I realized that not enough has been accomplished and that most of what is being suggested is headed in a very wrong direction. Particularly troubling is the almost total lack of recognition that changes in an official manual of diagnosis can have devastating unintended consequences. Before it is too late, I feel a responsibility to help DSM-V avoid mistakes by sharing the lessons learned during the past 30 years working on the 3 previous revisions of the DSM. Perhaps my comments may help the DSM-V Task Force avoid some of the hidden landmines I think they are dancing around.
We should begin with full disclosure. As head of the DSM-IV Task Force, I established strict guidelines to ensure that changes from DSM-III-R to DSM-IV would be few and well supported by empirical data. Please keep this history in mind as you read my numerous criticisms of the current DSM-V process. It is reasonable for you to wonder whether I have an inherently conservative bias or am protecting my own DSM-IV baby. I feel sure that I am identifying grave problems in the DSM-V goals, methods, and products, but it is for the reader to judge my objectivity.
Since 1990, many states have instituted sexually violent predator (SVP) or sexually dangerous person (SDP) civil commitment statutes that seek to identify the small group of extremely dangerous incarcerated sexual offenders who would present a threat to public safety if released from custody.
Of all the misconceived DSM-5 suggestions, the one touching the rawest public nerve is the proposed medicalization of normal grief into a mental disorder. Fierce opposition has provoked two editorials in Lancet, a front page New York Times story, and incredulous articles in more than 100 journals around the world.
