Speed Up & Sit Still

Dr Allen Frances, the lead author of DSMIV, and the British Psychological Association, lead the chorus of opposition to disease mongering proposals in DSM5

A decade in politics has taught me it is rare for prominent people to acknowledge mistakes and even rarer for them to do everything in their power to correct them. And taking responsibility for past errors is especially problematic for members of the American medical profession who work within a blame avoidance culture created by the ever-present threat of malpractice suits. Special praise is therefore due to Dr Allen Frances the psychiatrist who led the development of DSMIV for his efforts to ensure that the mistakes of DSMIV are not repeated in the development of DSM5.

In support of the criticisms of the proposed DSM5 changes to ADHD diagnostic criteria that I made in my in my last blog, Dr Frances wrote: ‘We are already in the midst of a false epidemic of ADD. Rates in kids that were 3-5% when DSM IV was published in 1994 have now jumped to 10%. In part this came from changes in DSM IV, but most of the inflation was caused by a marketing blitz to practitioners that accompanied new on-patent drugs amplified by new regulations that also allowed direct to consumer advertising to parents and teachers. In a sensible world, DSM 5 would now offer much tighter criteria for ADD and much clearer advice on the steps needed in its differential diagnosis……. The DSM 5 child and adolescent work group has perversely gone just the other way. It proposes to make an already far too easy diagnosis much looser. How puzzling and troubling.’ (Full blog by Dr Frances available at http://www.psychologytoday.com/blog/dsm5-in-distress/201108/dsm-5-will-further-inflate-the-add-bubble )

He had previously (February 2010) raised concerns about the DSM5 proposal for ADHD along with 18 other DSM5 proposals including; Psychosis Risk Syndrome, Mixed Anxiety Depressive Disorder, Minor Neurocognitive Disorder, Binge Eating Disorder, Temper Dysfunctional Disorder, Paraphilic Coercive Disorder, Hypersexuality Disorder, Behavioral Addiction Conditions, Addiction Disorder, Autism Spectrum Disorder, Pedohebephilia and medicalising normal grief. (see http://www.psychiatrictimes.com/dsm/content/article/10168/1522341 )

Dr Frances comments can’t be dismissed as the architect of the old edition protecting his work from revision. While criticising the proposals in DSM5, Dr Frances has identified that the DSMIV process he lead inadvertently helped ‘trigger three false epidemics. One for Autistic Disorder… another for the childhood diagnosis of Bi-Polar Disorder and the third for the wild over-diagnosis of Attention Deficit Disorder.’¹ Of course Dr Frances was not solely responsible for the development of the DSMIV diagnostic criteria for ADHD or for other disorders. They were developed by sub-committees of the American Psychiatric Association. However, as the overall leader of the DSMIV development process he has accepted his share of responsibility for the problems DSMIV helped create.

Dr Frances’ criticisms of the draft of DSM5 were recently mirrored by the British Psychological Societies (BPS).² The BPS responded to an invitation from the American Psychiatric Association to comment on the DSM5 proposals by concluding; ‘The putative diagnoses presented in DSM-V are clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements, with little confirmatory physical ‘signs’ or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity.’

The BPS and Dr Frances’ criticisms are not calls from the fringes. They are from the very heart of the psychiatric/psychological establishment. They must not be ignored.

The American Psychiatric Association’s DSM5 proposal for ADHD – Making lifelong patients of even more healthy people

The American Psychiatric Association (APA) has published its draft changes for the fifth edition of its internationally influential Diagnostic and Statistical Manual of Mental Disorders (DSM5), due for final release in May 2013.  Along with other worrying changes the APA seems determined to further loosen its already absurdly broad diagnostic criteria for ADHD.

Four more ways to display ADHD

The most obvious of the changes is the inclusion of four extra ways of exhibiting ADHD. For a diagnosis of the primarily hyperactive subtype instead of children having to display 6 of 9 (67%) impulsive/hyperactive diagnostic criteria, 6 of 13 (47%) would be sufficient. The four additional criteria are;

1- Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

2- Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

3- Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

4- Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).¹

(The full list of the proposed DSM5 behavioural criteria are listed at the end of this blog or from http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383)

All of the new DSM5 criteria are normal human behaviours. I for one never read instructions, am often impatient, frequently give into temptation, sometimes speed (and occasionally get angry with those who don’t and sit in the passing lane). I do these things because like the other 7 billion odd people on the planet I am far from perfect.

To anyone with a modicum of common sense or empathy the absurdity of these extra diagnostic criteria is self-evident. Although in fairness they are no more ridiculous than the current DSMIV criteria which include disliking homework and chores, losing toys, not listening, fidgeting, butting in, talking excessively or being easily distracted or forgetful.

In my experience the two most common reactions when people read the current DSMIV criteria for the first time is to say either “that’s me” or “that’s everybody”. (More detail about DSMIV is available at http://speedupsitstill.com/dodgy-diagnosis ) Arguably the changes proposed for DSM5 will make it harder not to meet the diagnostic criteria than to meet them.

Setting the bar even lower for Adult ADHD

For anyone 17 or older the ADHD bar will be lowered even further. It will be sufficient to meet as little as 4 (down from 6) of either the 9 inattentive or 4 of the expanded 13 impulsive/hyperactive criteria.² These changes continue the long term trend of lowering the bar for a diagnosis of ADHD.  DSMIII required six of nine inattentive behaviours and six of nine impulsive/hyperactive behaviours.  The bar was lowered significantly in DSM-IV when reduced to six of nine inattentive or six of nine hyperactive/impulsive behaviours.³ DSM5 lowers it even further.  Effectively an adult was required to display at least 12 of 18 (67%) behaviours in DSMIII, however for DSM-5 it proposed that as few as 4 of 22 (17%) will qualify for a diagnosis.

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Perth’s Dexamphetamine Hangover

Perth’s ADHD generation, those diagnosed and ‘medicated’ in the 1990’s and early 2000’s, are now young adults. They were prescribed ADHD amphetamines (primarily dexamphetamine) at three to four times the rate of their eastern states contemporaries¹ and old habits die hard. Many of Perth’s twenty to early thirty-somethings have grown to love their ‘dexies’, particularly with a drink or fifteen, on their weekend benders. With dexies on board they drink longer and harder, with the loss of inhibition and impaired judgement from alcohol but without the drowsiness. Some also use dexies as a substitute for sleep, to either get up for work after a hard night of partying, or to cram for exams or tight work deadlines.  

Part of the problem is that whilst methamphetamine is illegal in Australia and therefore understood to be harmful, it’s difficult to get Perth’s ‘dexie generation’ to realise that dexamphetamine is not a benign substance. It might help if we point out that methamphetamine (brand name Desoxyn) is a legally prescribed ADHD treatment in the US. Then again it might simply normalise the use of methamphetamine.

But as it stands many of Perth’s young adults love their dexamphetamine. Despite the fact that the ‘near amphetamine’² methylphenidate (Ritalin, Concerta) is the most commonly prescribed ADHD stimulant in Australia, (73% of all scripts)³, the vast majority of both new (82.5%) and continuing (86.6%) WA adult patients prescribed ADHD stimulants take dexamphetamine.⁴ Many get dexamphetamine rather than Ritalin, because they ask for it and they ask for it because dexies are the recreational prescription stimulant drug of choice amongst Perth’s hard partying young adults.

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