DSM 5 Finally Begins Its Belated and Necessary Retreat

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.

For the first time in its history, DSM 5 has shown some flexibility and capacity to correct itself. Hopefully, this is just the beginning of what will turn out to be a number of other necessary DSM 5 retreats. Today’s revisions should be just the first step in a systematic program of reform—a prelude to all the other changes needed before DSM 5 can become a safe and scientifically sound document.

The turnabout here can be attributed to the combination of: 1) extensive criticism from experts in the field; 2) public outrage; 3) uniformly negative press coverage; and, 4) the abysmal results in DSM 5 field testing. The same factors working together should deep six many of the other risky DSM 5 proposals. This is certainly no time for complacency. Much of the rest of DSM 5 is still a mess. The reliabilities achieved for many of the other disorders are apparently unbelievably low and the writing of the criteria sets is still unacceptably imprecise. The following specific issues need to be addressed.

1) Why introduce Disruptive Mood Dysregulation Disorder when it has been studied by only one research team for only six years and risks further encouraging the inappropriate use of antipsychotic drugs for kids with temper tantrums?

2) Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?

3) Why insist on removing the Bereavement exclusion—thus allowing the inappropriate diagnosis of Major Depressive Disorder in people who are experiencing normal grief?

4) Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder (by raising the allowed age of onset to 12)?

5) Why dramatically lower the threshold for Generalized Anxiety Disorder when this will confound mental disorder with the anxiety and sadness of everyday life?

6) Why combine substance abuse with substance dependence under the rubric of Addictive Disorders—when this confuses their different treatment needs and creates unnecessary stigma for many young people who will never go on to ‘addiction’?

7) Why include a category for Behavioral Addictions that will open the door to the mislabeling as mental disorder all sorts of normal interests and passions? The DSM 5 suggestion to include ‘internet addiction’ in the Appendix is an ominous first step.

8 ) Why include wording in the Pedophilia criteria set that will invite further forensic abuse of the already much misused Paraphilia section?

9) Why label as mental disorder the experience of indulging in one binge eating episode a week for three months?

10) Why introduce a system of personality diagnosis so complicated it will never be used and will give dimensional diagnosis an undeserved bad name?

11) Why not delay publication of DSM 5 to allow enough time to complete the previously planned and crucial second stage of field testing that was abruptly cancelled because of the constant administrative delays in completing the first stage? This is the only way to guarantee acceptable reliability. We should not accept ambiguously worded DSM 5 diagnoses whose reliability barely exceeds chance?

12) And most fundamental. Why not allow for an independent scientific review of all the remaining controversial DSM 5 changes. This has been proposed by fifty-one mental health organizations as the only way to guarantee a credible DSM 5?

The public has 6 weeks to comment on the current DSM 5 suggestions. Then there will be a round of final decisions- with everything probably sewn up by mid-fall. This opening chink in the previously impervious DSM 5 armor should spur renewed efforts to get the rest of DSM 5 right.

For more on the latest revisions of the DSM 5 criteria sets, see here.

Take this last opportunity to be heard.

Allen Frances is Professor Emeritus at Duke University and former Chair of its Department of Psychiatry. He was Chair of the DSM IV Task Force.

6 replies »


    The medical church of the ADHD is trying to fool us:

    “2) Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?”

    I am laughing…

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  3. Here’s the big question—–I have now been exposed to medical doctors diagnosing children as well as young adults and the elderly with anti-depressants, ADHD meds, anxiety meds, etc. Can someone tell me, where are the ethics in all of this medication being given out for mental diagnosis –
    is anyone even looking at the DSM? Yes – therapists, social workers, some psychologists, maybe a psychiatrist or two but I have now seen too many see a patient for 10 – 15 min and diagnose them and give a perscription.
    We are talking serious ramifications here for the client.

  4. Just to add a little perspective to the commentary the “financial windfall” from the DSM is about the same order of magnitude as the salaries of the CEOs of the top 4 or 5 health care corporations in the US. That’s right – the windfall is about the same as a one year salary of a business administrator who provides no health care services. There is a huge amount of unreimbursed work that goes in to each revision.

    The idea that the DSM is in “retreat” is largely because the DSM process has been demagogued in the media across many dimensions. That is also the reason for the “public outrage” cited by the author. The “public” does not know the difference between a psychiatrist and a psychologist. I really doubt that they are interested in the nuances of psychiatric diagnosis.

    I will be glad when the entire process is over. For DSM 6, I would propose that the entire process be done behind closed doors looking only at the science and not the politics. As far as “independent scientific review” by organizations goes they often have their own axe to grind with psychiatry. I have a better idea. Let them come up with their own diagnostic system. Johns Hopkins has come up with their own approach and many of the competing groups of health professionals surely have the resources available to them that a single department of psychiatry does. What about the Psychodynamic Diagnostic Manual (PDM) – a collaborative effort of the American Psychoanalytic Association and 5 other organizations. I have talked with psychoanalysts who use the PDM exclusively.

    There is no reason why nonpsychiatrists need to purchase a copy of the DSM much less be concerned about the psychiatric debate about the content. For the psychiatrists involved let’s keep that debate focused on science rather than political rhetoric.

  5. The revisions of the DSM are financial windfalls for those involved in making them due to the number of DSMs that will be sold. This publication has grown from a small, pocket size book for the original DSM to the large size it is now. I doubt seriously much more will be revised of the proposed changes, and that a DSM VI will be coming not too many years after the publishing of DSM V. This seems to point to what an inexact science we have in psychiatry necessitating so frequent updates and changes.

  6. Why ask why? At the end of the day, you think the hierarchy of the APA and much of psychiatric academia will stand down, when their are big bucks to lose?

    Irregardless of where and whom gets the profits, forever will it taint the health care process . Check out the guy running this online medical service Fox news spoke of yesterday between 1-2PM, where he starts out with “when the CUSTOMER comes to the site…” . Shameful, pathetic, and, perhaps illegal at least in some states?