
- Psychiatric Times Vol 25 No 4
- Volume 25
- Issue 4
DSM5: Pandora Replies to Dr Frances
In his recent David Letterman-like Top-19 list of DSM5 issues, Dr Allen Frances targeted a proposed revision of the DSM-IV diagnosis of Pedophilia, and 2 proposed new diagnoses: Hypersexual Disorder and Paraphilic Coercive Disorder.
In his recent David Letterman-like
If Dr Frances were a thoughtful critic of the DSM5, he could at least have studied the detailed literature reviews and the stated rationales for the changes-easily accessible along with the proposed diagnostic criteria in the
I also doubt that he has read Dr Blanchard’s3 lengthy report on the serious problems with the DSM-IV-TR diagnostic criteria for Pedophilia, which were detailed in his published report to the DSM5 Paraphilias Subworkgroup, a report that can be downloaded for free at
It is ironic that Dr Frances criticizes the wording of the proposed diagnostic criteria for the paraphilias, when the criteria prepared under his supervision contained such logical absurdities. He has often and ominously warned of future, possible “unintended consequences” of the wording details of the diagnostic criteria, but he has been strangely silent about clear errors in diagnostic criteria that should have been obvious in the DSM-IV. In order to correct this problem, the Paraphilias Subworkgroup has introduced the proposed distinction between ascertaining a Paraphilia versus diagnosing a Paraphilic Disorder. In my view, this is an extremely creative distinction that might do well in distinguishing people who have paraphilic behavior from those who have a paraphilic disorder. He had his kick at the paraphilic can and missed it.
Regarding the proposed new diagnoses of Hypersexual Disorder (HD) and Paraphilic Coercive Disorder, Dr Frances ignores the detailed literature review by Kafka4 regarding the former and the advisor reports on the latter.5-7 Regarding HD, all he can muster is an oversimplified morality lecture: “[HD] would be a gift to false positive excuse seekers...” For thoughtful readers of Psychiatric Times, the Paraphilias Subworkgroup welcomes detailed feedback on its proposed diagnoses and diagnostic revisions. That is, after all, the purpose of the
-Kenneth J. Zucker, PhD, CPsych
DR FRANCES RESPONDS
I thank Dr Zucker for accurately stating
The behaviors captured by “paraphilic coercion” and “hypersexuality” are anything but private or harmless-but that does not make them mental disorders. There is no infallible definition guiding what should, and what should not, be included in the official manual of mental disorders.
Many decisions can be tough calls. But it seems abundantly clear that these proposals from the Sexual Disorders Work Group have no place in DSM5. They offer little gain and would create significant problems. The construct “paraphilic coercion” has already contributed significantly to a grave misuse of psychiatry by the legal system in the handling of sexually violent predators-a misuse much opposed by the
Both constructs also medicalize undesirable sexual behavior and thereby provide a psychiatric excuse helpful to those who are attempting to evade personal responsibility. Such obviously risky proposals would deserve serious consideration only if they fill an important need; are supported by a wide, deep, and high quality base of scientific evidence; and would have containable blowback.
None of these conditions is met here. These proposals do not belong anywhere in DSM5-not even as Not Otherwise Specified examples.
Dr Zucker will no doubt respond that he is the expert on sexual disorders and that I don’t know what I am talking about. This would miss the point that the official diagnostic system is too important to be left exclusively in the hands of the experts. Experts in any given area often have pet diagnoses that may have some value in their own hands but can cause unintended societal disasters when taken out of context and put to general use. Experts also tend to overvalue the quality and relevance of the scientific literature in their own field.
Every new diagnosis suggested for DSM5 requires (but has not yet received) a searching risk/benefit analysis and a thorough forensic review. I am confident that none of the suggestions for new diagnoses made by the Sexual Disorders Work Group would stand up to such scrutiny.
-Allen Frances, MD
References:
References
1. Frances A. Opening Pandora’s box: The 19 worst suggestions for DSM5. http://www.psychiatrictimes.com/dsm-v/content/article/10168/1522341. Accessed February 22, 2010.
2. Zucker KJ. Reports from the DSM-V work group on sexual and gender identity disorders: an introduction [editorial]. Arch Sex Behav. 2009, doi: 10.1007/s10508-009-9548-9.
3. Blanchard R. The DSM diagnostic criteria for pedophilia. Arch Sex Behav. 2009, doi: 10.1007/s10508-009-9536-0.
4. Kafka MP. Hypersexual disorder: a proposed diagnosis for DSM-V. Arch Sex Behav. 2009, doi: 10.1007/s10508-009-9574-7.
5. Quinsey VL. Coercive paraphilic disorder. Arch Sex Behav. 2009, doi: 10.1007/s10508-009-9547-x.
6. Thornton D. Evidence regarding the need for a diagnostic category for a coercive paraphilia. Arch Sex Behav. 2009, doi: 10.1007/s10508-009-9538-6.
7. Knight RA. Is a diagnostic category for paraphilic coercive disorder defensible? Arch Sex Behav. 2009, doi: 10.1007/s10508-009-9571-x.
Articles in this issue
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Sleep Disorders in the Elderlyover 17 years ago
Intimate Partner Violence Among Women With Severe Mental Illnessover 17 years ago
Accountable but Not Responsibleover 17 years ago
Task Force Proposes New Bipolar Guidelinesover 17 years ago
Study Faults Selective Publication of Antidepressant Trialsover 17 years ago
New Findings in Early-Onset Schizophreniaover 17 years ago
Adult Experiences, Genetic Activity, and Maturationover 17 years ago
Psychiatric Testimony and the Insanity Defenseover 17 years ago
Mental Health Services for Survivors of Mass Violenceover 17 years ago
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