By Thomas Insel, MD

In a few weeks, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This volume will tweak several current diagnostic categories, from autism spectrum disorders to mood disorders. While many of these changes have been contentious, the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published. Sometimes this research recommended new categories (e.g., mood dysregulation disorder) or that previous categories could be dropped (e.g., Asperger’s syndrome).¹

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better. Continue reading “Transforming Diagnosis”

By Allen Frances, MD

Many readers of my previous blog listing the 10 worst suggestions in DSM 5 were shocked that I failed to mention an 11th dangerous mistake — that DSM-5 will harm people who are medically ill by mislabeling their medical problems as mental disorder. They are absolutely right. I apologize for my previous failure to attend to this danger and hope it is not now too late to influence the process.

Adding to the woes of the medically ill could be one of the biggest problems caused by DSM-5. It will do this in two ways: 1) by encouraging a quick jump to the erroneous conclusion that someone’s physical symptoms are ‘all in the head’; and 2) by mislabeling as mental disorders what are really just the normal emotional reactions that people understandably have in response to a medical illness.

UK health advocate, Suzy Chapman, has closely monitored every step in the development of DSM-5. Her website is the best available resource for finding just about everything you need to know about DSM-5 and ICD-11. Ms Chapman sent me a troubling email that summarizes where DSM-5 has gone wrong and the many harmful consequences that will follow. More details are available at: ‘Somatic Symptom Disorder could capture millions more under mental health diagnosis’ (http://wp.me/pKrrB-29B )

Ms Chapman writes:

…The DSM-5 Somatic Symptom Disorders Work Group is planning to eliminate several little used DSM-IV Somatoform Disorders and replace them instead with an extremely broad new category that is likely to be wildly overused (‘Somatic Symptom Disorder’ — SSD).

Continue reading “Mislabeling Medical Illness”

By Allen Frances, MD

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry.

The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.

Just ignore the ten changes that make no sense.

Brief background. DSM 5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal- to produce a paradigm shift in psychiatry. Excessive ambition combined with disorganized execution led inevitably to many ill conceived and risky proposals.

These were vigorously opposed. More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

DSM 5 has neither been able to self correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis. Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably ‘psychosis risk’, mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, ‘hebephilia’, cumbersome personality ratings, and sharply lowered thresholds for many existing disorders). But APA stubbornly refused to sponsor any independent review and has given final approval to the ten reckless and untested ideas that are summarized below.

Continue reading “The Medicalization of Modern Life”

By Neuroskeptic

Last week, the proposed new DSM-5 revision of the American Psychiatric Association’s “Bible of Psychiatry” came under yet more criticism.

Aaron T. Beck, the father of currently-mega-popular cognitive behavioural therapy, started it off with an attack on the upcoming changes to one diagnosis, Generalized Anxiety Disorder; but many of the points also apply to the other DSM-5 proposals:

The lack of specific features, which is the primary issue for GAD, will not be addressed in DSM-5. The hallmark of the condition will remain pathological worry, although it also characterizes other disorders. Likewise, the proposed behavioral diagnostic criteria lack specificity for GAD, and it is not clear how these will be assessed. The proposed changes will lower the diagnostic threshold for GAD in DSM-5… many currently subthreshold cases will qualify for this diagnosis. The likely inclusion of many such “false-positives” will result in an artificial increase in the prevalence of GAD and will have further negative consequences.

Continue reading “DSM-5 Is Dead. Long Live DSM-5.”

By Allen Frances

The American Psychiatric Association just reported a surprisingly large yearly deficit of $350,000. This was caused by reduced publishing profits, poor attendance at its annual meeting, rapidly declining membership, and wasteful spending on DSM-5. APA reserves are now below ” the recommended amount for a non-profit (reserves equal to a year’s operating expenses).”

APA has already spent an astounding $25 million on DSM-5. I can’t imagine where all that money went. As I recall it, DSM-IV cost about $5 million and more than half of this came from outside research grants. Even if the DSM-5 product were made of gold instead of lead, $25 million would be wildly out of proportion. The rampant disorganization of DSM-5 must have caused colossal waste. One obvious example is the $3 million spent on the useless DSM-5 field trial—with its irrelevant question, poorly conceived design, and embarrassing results.

Because APA is left holding these huge IOU’s, it will be doubly desperate to begin recouping on its misguided investment. The bad financial report will ratchet up the pressure to publish DSM-5 in its current sorry state as scheduled next May—despite the fact that it has badly flunked its own field test and now still requires extensive editing and retesting before being anywhere near fit for use.

Continue reading “The Political Economy of DSM-5″

By Allen Frances

Sigh of relief. The DSM 5 website announced recently that two of its most controversial proposals have finally been dropped. We have dodged bullets on Psychosis Risk and Mixed Anxiety Depression. Both are now definitively rejected as official DSM 5 diagnoses and instead are being exiled to the appendix. And one other piece of good news-the criteria set for Attention Deficit/Hyperactivity Disorder has been tightened (not enough, but every little bit helps).

The world is a safer place now that ‘Psychosis Risk’ will not be in DSM 5. Its rejection saves our kids from the risk of unnecessary exposure to antipsychotic drugs (with their side effects of obesity, diabetes, cardiovascular problems, and shortened life expectancy). ‘Psychosis Risk’ was the single worst DSM 5 proposal—we should all be grateful that DSM 5 has finally come to its senses in dropping it.

Continue reading “DSM 5 Finally Begins Its Belated and Necessary Retreat”

By BENJAMIN NUGENT

For a brief, heady period in the history of autism spectrum diagnosis, in the late ’90s, I had Asperger syndrome.

There’s an educational video from that time, called “Understanding Asperger’s,” in which I appear. I am the affected 20-year-old in the wannabe-hipster vintage polo shirt talking about how keen his understanding of literature is and how misunderstood he was in fifth grade. The film was a research project directed by my mother, a psychology professor and Asperger specialist, and another expert in her department. It presents me as a young man living a full, meaningful life, despite his mental abnormality.

“Understanding Asperger’s” was no act of fraud. Both my mother and her colleague believed I met the diagnostic criteria laid out in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The manual, still the authoritative text for American therapists, hospitals and insurers, listed the symptoms exhibited by people with Asperger disorder, and, when I was 17, I was judged to fit the bill.

I exhibited a “qualified impairment in social interaction,” specifically “failure to develop peer relationships appropriate to developmental level” (I had few friends) and a “lack of spontaneous seeking to share enjoyment, interests, or achievements with other people” (I spent a lot of time by myself in my room reading novels and listening to music, and when I did hang out with other kids I often tried to speak like an E. M. Forster narrator, annoying them). I exhibited an “encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus” (I memorized poems and spent a lot of time playing the guitar and writing terrible poems and novels).

Continue reading “I Had Asperger Syndrome. Briefly.”

By Allen Frances, MD

DSM 5 has suddenly become a star press attraction. In just the last three weeks, more than 100 news stories featuring DSM 5 appeared in major media outlets located in more than a dozen countries. (For a representative sample see Suzy Chapman’s post on Dx Revision Watch.) The explosion of interest started with a flurry when The New York Times published two long DSM 5 articles and three DSM-5-related op-ed pieces, all within a few days. An unrelated press conference in London then generated a widely distributed Reuters story and also many independent pieces. Several other reporters had also been working on their own DSM 5 stories that just happened to arrive at the same time.

The intense press scrutiny of DSM 5 is really just beginning. I know of at least 10 additional reporters who are preparing their work now for publication in the near future. And many of the journalists whose articles appeared during these last few weeks intend to stay on this story for the duration — at least until DSM 5 is published, and probably beyond. They understand that DSM 5 is a document of great individual and societal consequence — and that its impact and risks need a thorough public airing.

The press coverage has been almost uniformly and devastatingly negative. The two most common themes are 1) DSM 5 will radically expand the boundaries of psychiatry, medicalising normality and leading to unneeded and harmful treatment; and 2) DSM 5 decisions are being made arbitrarily, based on narrow input and lacking sufficient scientific support. The DSM 5 proposals that have elicited the most concern are changes in the definition of autism and the expansion of major depressive disorder to capture much of normal grief.

The articles sometimes contain small inaccuracies and sometimes emphasize peripheral issues. And the most dangerous DSM 5 proposals get far too little mention. I will discuss in later blogs how DSM 5 will worsen the over-diagnosis of attention-deficit disorder and the over-prescription of antipsychotic mediation. But the press has gotten the main points just right and somehow manages to see the risks of DSM 5 much more clearly than do the people working on it.

Continue reading “Can the Press Save DSM 5 from Itself?”

By Anne Dachel

Reports of autism cases per 1,000 children grew dramatically in the US from 1996 to 2007. Source: Wikipedia.

It’s hard to imagine more chaos in the world of autism than what we see happening right now.  Autism is more and more in the public spotlight.  The numbers are huge and no one can explain them.  Since 2009 we’ve been told that one percent of children have autism.  Among boys alone, it’s almost two percent.  Mainstream medicine can’t explain the stunning increase in a once rare disorder.  For years health officials gave doctors credit for all the autism everywhere.  They said it was the result of “greater awareness” and “better diagnosing.”  Children who were mislabeled as something else were now correctly called autistic.  The criteria for diagnosing autism was laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and a child with symptoms would be placed somewhere on the autism spectrum, as it came to be known.  This included very high functioning autism and Asperger’s syndrome all the way over to the other end of the spectrum to those with severe intellectual impairment and all the signs of classic autism. Continue reading “DSM-5: You’re Still Autistic. You’re Just Weird. You We’re Not Sure About. Call Us Tomorrow.”

By GAYNELL PAYNE

Finally a proposition to stop the epidemic of ASD (Autism Spectrum Disorder). But is it valid? An expert panel at the American Psychiatric Association is proposing to do just that. The D.S.M., Diagnostic and Statistical Manual of Mental Disorders is undergoing the most dramatic revision in 17 years. The D.S.M. is the standard used to diagnose mental disorders.

By new definitions, most of those now diagnosed with high functioning Aspergers will lose their diagnosis. Experts believe that this will stem the rising tide of numbers of those diagnosed with ASD, numbers which now are reaching “epidemic proportions.”

“We would nip [the rising Autism rate] in the bud,”  said Dr. Fred R. Volkmar, director of the Child Study Center at the Yale School of Medicine and an author of the new analysis of the proposal.

There has been an argument raging for years with one faction claiming that the numbers are merely the results of better diagnoses, while many experts still hold that that still doesn’t account for the fact that one child in a hundred is now diagnosed with ASD.

Continue reading “Stopping an Epidemic By Redefining It”