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. Dr Allen Frances, ‘Psychiatrists Propose Revisions to Diagnosis Manual’, PBS Newshour, 10 February 2010. Available at http://www.pbs.org/newshour/bb/health/jan-june10/mentalillness_02-10.html (accessed 26 February 2010).] 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).[3. The British Psychological Society, ‘Response to the American Psychiatric Association: DSM-5 Development’, June 2011. Available at http://psychrights.org/2011/110630BritishPsychologicalAssnResponse2DSM-5.pdf (accessed 15 August 2011)] 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.