What's Wrong With DSM-5?
Editor's Note:
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is scheduled for release in May 2013. As preliminary draft revisions to the current DSM diagnostic criteria have been made available for review, multiple prominent psychiatrists have spoken out against finalizing a revised edition at this time. The proposed updates were addressed at this year's American Psychiatric Association (APA) Annual Meeting, and recently it was revealed on DSM5.org that 2 controversial condition proposals -- attenuated psychosis syndrome and mixed anxiety depressive disorder -- will now be included in section III of the revised manual, meaning that more research is required before consideration as formal disorders. Dr. Allen J. Frances, MD, a professor emeritus at Duke University and chair of the DSM-IV Task Force, has been an outspoken dissenter against numerous proposed DSM-5 revisions. Medscape recently invited Dr. Stephen M. Strakowski, Chairman, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, to interview Dr. Frances about his views on revising psychiatry's principal diagnostic resource.
Dr. Strakowski: Dr. Frances, you have been fairly critical of the creation of the newest psychiatry diagnostic manual, the DSM-V. What is your background that allows you to comment? And what are your major concerns, particularly in light of the announcement this week that 2 of the more controversial proposals would be dropped?
Dr. Frances: My most relevant background was working on DSM-III, DSM-IIIR, and chairing the DSM-IV Task Force; conducting research on psychiatric diagnosis; and, perhaps equally important, having evaluated and treated many thousands of patients.
My great fear is that DSM-5 will inappropriately expand the boundaries of psychiatry and increase our already existing problem of diagnostic inflation. This will result in inappropriate medication use, unnecessary stigma, and the misallocation of scarce mental health resources. The DSM-5 proposal that got me started on this reluctant crusade was "psychosis risk" (since renamed "attenuated psychotic symptoms"). "Psychosis risk" is a well-intentioned research diagnosis aimed at preventing or reducing the burden of schizophrenia. However, it would have terrible, unintended consequences were it to become an official DSM-5 disorder and be widely applied in general clinical practice. Most of the leading researchers in the field are against its premature inclusion in DSM-5, and thankfully the DSM-5 Task Force just announced that they will drop the proposed change.
That the DSM-5 team finally backed down on its worst suggestion is a big plus -- thank goodness that psychosis risk is no longer in play. Also good is their rejection of mixed anxiety depression and the partial correction of what had been a ridiculously loose definition of attention-deficit/hyperactivity disorder (ADHD), allowing for onset as late as age 12, which would confound ADHD with other causes of hyperactivity, impulsivity, and distractibility. That said, there are many other radical and potentially dangerous ideas in DSM-5.
Dr. Strakowski: The pushback to not releasing a new edition might be that DSM-IV is old enough now and there have been sufficient advances that a new DSM is needed. Do you think that assumption is correct?
Dr. Frances: The exponential basic science advances in understanding how the normal brain works have not yet translated into any advances in how clinical psychiatry is practiced. Regrettably and surprisingly, there are still no biological tests for any of the mental disorders. We are years away from having an Alzheimer's battery and there is nothing very encouraging in the diagnostic pipeline for any of the other problems we treat. The brain has turned out to be elusively complex; the more we learn about it, the more we understand how little we know and how tough it will be to pin down pathogeneses. Each disorder in the DSM is probably just a final common presentation caused by hundreds of different and heterogeneous biological pathways. Clearly, it will take decades to make meaningful steps in understanding psychopathology -- a real slog with very small, very hard-won steps.
In the meantime, we are left with a descriptive psychiatry that has great limitations but enormous practical uses and influence. It makes no sense to change the system based on the arbitrary decisions of those in charge of the rewrite. Indeed, a strong case could be made that the world would be a better place were we all still using DSM-III. Each change in a DSM is an opportunity for clinical and forensic misuse, with unpredictable and harmful unintended consequences. Changes are also costly to psychiatric research in direct ways, such as the cost of changing instruments midstream, and even more importantly in indirect ways, such as the noncomparability of findings across time.
It might be worth the risks and costs of DSM-5 changes if there were compelling science supporting them, but there isn't. That is why I have been calling for an independent scientific review of the DSM-5 proposals and also why APA has refused. I would bet my house that none of the DSM-5 changes would ever make it through an impartial and rigorous scientific review.
Dr. Strakowski: But isn't the goal of the DSM to provide guidance to psychiatrists in order to better define patients ("cases") so as to better direct treatment? Wouldn't it be helpful, then, to expand and identify as many cases as possible, which might very well require new diagnoses and descriptions? What are the real risks to our patients or to psychiatry?
Dr. Frances: We want to identify the patients we can help and we want to avoid identifying the ones who don't need treatment or who may be harmed by it. Psychiatry does best with, and is most needed by, patients who are moderately to severely ill. Studies consistently show that they benefit with strong treatment effects. In contrast, studies of the mildly ill show equally consistently that they experience no significant benefit compared with placebo. We already have a perverse misallocation of resources, with two thirds of severely depressed people receiving no mental health care, while many on antidepressants are placebo responders who don't really need them.
DSM-5 will make this much worse by dramatically reducing thresholds for existing disorders and by introducing new and untested disorders with high prevalence rates. Literally tens of millions of new "patients" will be created overnight with no evidence that they can be accurately identified, no proven effective treatment, and every indication that the medication treatments offered can have very harmful side effects. This will lead to worse directed treatments, more harm than good for patients, and even greater distortions in the allocation of scarce resources.
Editor's Note:
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is scheduled for release in May 2013. As preliminary draft revisions to the current DSM diagnostic criteria have been made available for review, multiple prominent psychiatrists have spoken out against finalizing a revised edition at this time. The proposed updates were addressed at this year's American Psychiatric Association (APA) Annual Meeting, and recently it was revealed on DSM5.org that 2 controversial condition proposals -- attenuated psychosis syndrome and mixed anxiety depressive disorder -- will now be included in section III of the revised manual, meaning that more research is required before consideration as formal disorders. Dr. Allen J. Frances, MD, a professor emeritus at Duke University and chair of the DSM-IV Task Force, has been an outspoken dissenter against numerous proposed DSM-5 revisions. Medscape recently invited Dr. Stephen M. Strakowski, Chairman, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, to interview Dr. Frances about his views on revising psychiatry's principal diagnostic resource.
Introduction
Dr. Strakowski: Dr. Frances, you have been fairly critical of the creation of the newest psychiatry diagnostic manual, the DSM-V. What is your background that allows you to comment? And what are your major concerns, particularly in light of the announcement this week that 2 of the more controversial proposals would be dropped?
Dr. Frances: My most relevant background was working on DSM-III, DSM-IIIR, and chairing the DSM-IV Task Force; conducting research on psychiatric diagnosis; and, perhaps equally important, having evaluated and treated many thousands of patients.
My great fear is that DSM-5 will inappropriately expand the boundaries of psychiatry and increase our already existing problem of diagnostic inflation. This will result in inappropriate medication use, unnecessary stigma, and the misallocation of scarce mental health resources. The DSM-5 proposal that got me started on this reluctant crusade was "psychosis risk" (since renamed "attenuated psychotic symptoms"). "Psychosis risk" is a well-intentioned research diagnosis aimed at preventing or reducing the burden of schizophrenia. However, it would have terrible, unintended consequences were it to become an official DSM-5 disorder and be widely applied in general clinical practice. Most of the leading researchers in the field are against its premature inclusion in DSM-5, and thankfully the DSM-5 Task Force just announced that they will drop the proposed change.
That the DSM-5 team finally backed down on its worst suggestion is a big plus -- thank goodness that psychosis risk is no longer in play. Also good is their rejection of mixed anxiety depression and the partial correction of what had been a ridiculously loose definition of attention-deficit/hyperactivity disorder (ADHD), allowing for onset as late as age 12, which would confound ADHD with other causes of hyperactivity, impulsivity, and distractibility. That said, there are many other radical and potentially dangerous ideas in DSM-5.
Dr. Strakowski: The pushback to not releasing a new edition might be that DSM-IV is old enough now and there have been sufficient advances that a new DSM is needed. Do you think that assumption is correct?
Dr. Frances: The exponential basic science advances in understanding how the normal brain works have not yet translated into any advances in how clinical psychiatry is practiced. Regrettably and surprisingly, there are still no biological tests for any of the mental disorders. We are years away from having an Alzheimer's battery and there is nothing very encouraging in the diagnostic pipeline for any of the other problems we treat. The brain has turned out to be elusively complex; the more we learn about it, the more we understand how little we know and how tough it will be to pin down pathogeneses. Each disorder in the DSM is probably just a final common presentation caused by hundreds of different and heterogeneous biological pathways. Clearly, it will take decades to make meaningful steps in understanding psychopathology -- a real slog with very small, very hard-won steps.
In the meantime, we are left with a descriptive psychiatry that has great limitations but enormous practical uses and influence. It makes no sense to change the system based on the arbitrary decisions of those in charge of the rewrite. Indeed, a strong case could be made that the world would be a better place were we all still using DSM-III. Each change in a DSM is an opportunity for clinical and forensic misuse, with unpredictable and harmful unintended consequences. Changes are also costly to psychiatric research in direct ways, such as the cost of changing instruments midstream, and even more importantly in indirect ways, such as the noncomparability of findings across time.
It might be worth the risks and costs of DSM-5 changes if there were compelling science supporting them, but there isn't. That is why I have been calling for an independent scientific review of the DSM-5 proposals and also why APA has refused. I would bet my house that none of the DSM-5 changes would ever make it through an impartial and rigorous scientific review.
Dr. Strakowski: But isn't the goal of the DSM to provide guidance to psychiatrists in order to better define patients ("cases") so as to better direct treatment? Wouldn't it be helpful, then, to expand and identify as many cases as possible, which might very well require new diagnoses and descriptions? What are the real risks to our patients or to psychiatry?
Dr. Frances: We want to identify the patients we can help and we want to avoid identifying the ones who don't need treatment or who may be harmed by it. Psychiatry does best with, and is most needed by, patients who are moderately to severely ill. Studies consistently show that they benefit with strong treatment effects. In contrast, studies of the mildly ill show equally consistently that they experience no significant benefit compared with placebo. We already have a perverse misallocation of resources, with two thirds of severely depressed people receiving no mental health care, while many on antidepressants are placebo responders who don't really need them.
DSM-5 will make this much worse by dramatically reducing thresholds for existing disorders and by introducing new and untested disorders with high prevalence rates. Literally tens of millions of new "patients" will be created overnight with no evidence that they can be accurately identified, no proven effective treatment, and every indication that the medication treatments offered can have very harmful side effects. This will lead to worse directed treatments, more harm than good for patients, and even greater distortions in the allocation of scarce resources.