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.

Other subtle but nonetheless significant changes include:

1- The relaxation of the DSMIV expectation that teachers independently provide evidence.4

2- Replacing hyperactive actions in the wording of criteria to feelings or perceptions of ‘restlessness’.5

3- The medicalisation, of the normal phenomena that ADHD behaviours are ‘typically more marked during times when the person is studying or working’ than ‘during vacation’. 6

4- The inclusion of adult relevant examples in most of the diagnostic criteria which had previously been primarily orientated to children in a school setting. 7

5- The change in the requirement that signs of the behaviour should be displayed before age seven to age twelve.8

$ The Bottom Line $

All the DSM5 proposed changes if implemented are likely to increase ADHD patient numbers and pharmaceutical company profits. Too often regulators like the FDA and TGA treat big pharmaceutical companies as if them as if they are benevolent enterprises. In reality they are morally neutral profit maximisers, superb marketers and completely indifferent as to whether their products help or harm humanity. They know how to promote ‘experts’ who, however well intentioned, advocate their products and they thrive in the current largely self-regulated environment.9 It is time for policy makers to understand how much it is economics rather than science that is behind the explosion in ADHD prescribing.

The history of ADHD is a classic example of how to create and then expand a previously non-existent market. It was initially sold as a boy’s disorder requiring both hyperactivity and inattention. Then passive ADD (without the H for Hyperactivity) was marketed as a gender equity issue with the argument that ‘quiet girls’ were believed to be missing out as their ‘disability’ was ‘under-recognised’.10 The changes proposed for DSM5 will protect and enhance the child market and create continuity of the pharmaceutical company’s customer base into adulthood and likely replicate the massive explosion in psychotropic drug prescribing rates that occurred when DSMIV replaced DSMIII in 1994.11

With the benefit of hindsight, Dr Allen Frances, who was the chief of psychiatry at the Duke University Medical Centre and led the effort to update DSM-IV, regretted broadening the diagnostic criteria and warned of problems with the drafting of the next edition, DSM-V, due for final release in 2012. Frances believes: ‘We learned some very, very, painful lessons in doing DSM IV…we thought we were being really careful about everything we did and we wanted to discourage changes. But inadvertently, I think we helped to 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.’ 12

Whilst it is heartening that Dr Frances has learned the lessons of DSMIV it is clear from the draft of DSM5 the American Psychiatric Association (APA) have not. Given the APA’s long history of close ties to Big Pharma13 and recent revelations about undisclosed drug company payments to the world’s most frequently cited ‘ADHD expert’ Harvard Professor Joseph Biederman, it is easy to assume the ‘experts’ guiding the DSM5 changes are motivated by money. (see http://speedupsitstill.com/world-leading-adhd-%e2%80%98expert%e2%80%99-harvard-professor-joseph-biederman-sanctioned-hidden-drug-company-money-allegations )

However, the APA have made some effort recently to restrict their reliance on pharmaceutical company funding and I believe most ADHD enthusiasts are not corrupt. Rather they are fervent believers in the ‘disorder’ and it’s hypothesised ‘biological roots’. It is likely money is not the primary motivation of those developing the DSM5 criteria for ADHD. Instead they are probably suffering from the one ‘disorder’ that is both very common and destructive but yet to be officially recognised, CSDD (Common Sense Deficit Disorder).

Either way being disorganised impatient, inattentive, impulsive, or failing to resist temptation isn’t disease, its humanity. And giving children amphetamines for basically being immature, annoying, inconvenient or embarrassing isn’t a medical treatment, its child abuse. Too many young Australians have suffered from our country’s blind acceptance of the American Psychiatric Association’s approach to mental health. This doesn’t just apply to ADHD. As I will outline in coming blogs the APA’s DSM5 proposals for other disorders are just as troubling.

The Australian response to DSM5 must be unequivocal. It is time to go it alone and abandon our slavish devotion to the American Psychiatric Association’s model because although DSMIV contained more than its fair share of crap, DSM5 smells far worse.

Appendix – The American Psychiatric Associations proposed new DSM5 diagnostic criteria fo ADHD are listed below.

A.   Either (1) and/or (2).

1.  Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: for older adolescents and adults (ages 17 and older), only 4 symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.

(a)  Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (for example, overlooks or misses details, work is inaccurate). 

(b)  Often has difficulty sustaining attention in tasks or play activities (for example, has difficulty remaining focused during lectures, conversations, or reading lengthy writings).

(c)  Often does not seem to listen when spoken to directly (mind seems elsewhere, even in the absence of any obvious distraction).

(d)  Frequently does not follow through on instructions (starts tasks but quickly loses focus and is easily sidetracked, fails to finish schoolwork, household chores, or tasks in the workplace).

(e)  Often has difficulty organizing tasks and activities. (Has difficulty managing sequential tasks and keeping materials and belongings in order. Work is messy and disorganized. Has poor time management and tends to fail to meet deadlines.)

(f)   Characteristically avoids, seems to dislike, and is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework or, for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers).

(g)  Frequently loses objects necessary for tasks or activities (e.g., school assignments, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones).

(h)  Is often easily distracted by extraneous stimuli. (for older adolescents and adults may include  unrelated thoughts.).

(i)   Is often forgetful in daily activities, chores, and running errands (for older adolescents and adults, returning calls, paying bills, and keeping appointments).

2.  Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: for older adolescents and adults (ages 17 and older), only 4 symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.

(a)  Often fidgets or taps hands or feet or squirms in seat.

(b)  Is often restless during activities when others are seated (may leave his or her place in the classroom, office or other workplace, or in other situations that require remaining seated).

(c)  Often runs about or climbs on furniture and moves excessively in inappropriate situations. In adolescents or adults, may be limited to feeling restless or confined.

(d)  Is often excessively loud or noisy during play, leisure, or social activities.

(e)  Is often “on the go,” acting as if “driven by a motor.” Is uncomfortable being still for an extended time, as in restaurants, meetings, etc. Seen by others as being restless and difficult to keep up with.

(f)   Often talks excessively.

(g)  Often blurts out an answer before a question has been completed. Older adolescents or adults may complete people’s sentences and “jump the gun” in conversations.

(h)  Has difficulty waiting his or her turn or waiting in line.

(i)   Often interrupts or intrudes on others (frequently butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing).

(j)   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.

(k)   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.

(l)   Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

(m) 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. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 
  2. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 
  3. For a full description of the history of how ADHD has evolved see Martin Whitely, Speed Up & Sit Still: The Controversies of ADHD Diagnosis and Treatment, Perth, UWA Publishing (2010): p.16
  4. DSMIV states:  ‘The clinician should therefore gather information from multiple sources (e.g. parents, teachers) and inquire about the individual’s behavior in a variety of situations within each setting. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition, Text Revision, Washington DC, American Psychiatric Association (2000): p.87 The wording proposed for DSM5 is: ‘In children and young adolescents, the diagnosis should be based on information obtained from parents and teachers. When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child’s behavior and performance at school.’ American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383
  5. One of the hyperactive/impulsive diagnostic criteria in DSMIV states: ‘often leaves seat in classroom or in other situations in which remaining seated is expected.’ American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition, Text Revision, Washington DC, American Psychiatric Association (2000): p.92. The wording proposed to replace this in DSM5 is: often restless during activities when others are seated (may leave his or her place in the classroom, office or other workplace, or in other situations that require remaining seated). American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder. http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383
  6. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383
  7. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383
  8. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383
  9. For more detail on how the TGA and FDA have allowed the ADHD drug manufacturer’s to largely self-regulate refer to Chapters 4 & 5 in Martin Whitely, Speed Up & Sit Still: The Controversies of ADHD Diagnosis and Treatment, Perth, UWA Publishing (2010)
  10. For more detail on the history of the expansion of ADHD symptoms and behaviours, see Martin Whitely, Speed Up & Sit Still: The Controversies of ADHD Diagnosis and Treatment,  UWA Publishing, Perth (2010): pp.14-21
  11. In 1991 in Australia, less than 10,000 prescriptions were dispensed for dexamphetamine sulphate.  In 1998, nearly 250,000 prescriptions were dispensed for the same drug, an increase of 2400 per cent.  Paul Mackey and Andrew Kopras, Medication for Attention Deficit Hyperactivity Disorder (ADHD): An Analysis by Federal Electorate, Parliament of Australia, Canberra (2001): p.4
  12. 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).
  13. In 2006, around 30 percent of the AMAs $62.5 million in financing came from pharmaceutical companies.  Around half of this amount was used for ‘drug advertisements in psychiatric journals and exhibits at the annual meeting, and the other half to sponsor fellowships, conferences and industry symposiums at the annual meeting.’ Benedict Carey and Gardiner Harris, ‘Psychiatric Group Faces Scrutiny over Drug Industry Ties’,  New York Times, 12 July 2008.  Available http://www.nytimes.com/2008/07/12/washington/12psych.html?ref=americanpsychiatricassn

Tags: American Psychiatric Association DSM5 and ADHD

  1. Just when you thought it could not get any more ridiculous! With these new “emotional wellness” checks for three year olds starting next year everyone has an illness until “proven” otherwise.

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  2. I agree with you, this is so absurd on its surface that it’s hard to believe it’s real. Yet it is, and thus the absurd begins to look sinister. Who benefits from this sort of reckless labeling? Not the kids, that’s for sure . . .

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  3. I could not agree more with what you are saying here and the saddest part to me is that many of them do honestly believe that they are doing a good thing?!!

    I remember when I was studying an Arts Degree in the late 90’s and majoring in Psychology I did a major assigment about ADHD and its increase. There was one study that I examined that has remained with me firmly in my memory ever since. They did a study of all the children in one large school district in the US who were “medicated” for ADHD. Only 47% who were on medication had EVER met the diagnostic criteria for ADHD in the DSM IV. But they also compared them to the DSM IIIR criteria and only 29% met the criteria for that. And then against the DSM III criteria and only 14% met the criteria for that. So while they had expanded the criteria to include ever more numbers of children, it did not mean that those on medication would actually meet the criteria before being medicated.

    And Dr Jo you are so so so correct, from next year the rate of mental illness will no longer be 45% as the simple fact is I am yet to know of ANY three year old who can sit still and concrentrate at the best of times. No longer will they need a parent to actually ask for assistance and say I don’t know how to handle this child, no now parents who consider their child to be perfectly “normal” will be told that they are not normal!!

    And of course they are lessing the amounts of sessions with a psychologist and so all of these kids will just be medicated unless the parents acually have the courage to do otherwise. Given that GP’s are more than happy to hand out antidepressents as Candi to teenagers at present against all TGA guidelines it won’t be long before they start the same thing with younger children. And the fact is we are encouraging and activily promoting GP’s doing this stuff. And then they will wonder WHY the community is falling apart.

    The fact is common sense says that what we are currently doing is not working. The vast majority of applications for disability pensions in Australia now are for mental illness, exactly as in the US. And yet the solution is always to just encourage more and more medication. If the medication was working then people would not be disabled!!

    The other reality is that even if you did believe that you could make medications to help these conditions, the fact is you cannot do that without first knowing what the conditions are. ANd we do not know what any of these conditions are. We cannot put psychosis, or depression or ADHD in a test tube and find ways of killing it with medicaton. They are all just human emotions, behaviours and feelings and while they are incredibly real feelings in some cases they are not real diseases as you cannot test them!!

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  4. I really like your call to our society to not medicate our kids unnecessary. I fully agree with that.
    There are two points I would like to make:
    1) You seem to assume: DSM diagnosis equals medication…
    This is an incorrect assumption. The DSM classifies mental/behavioural symptoms. It doesn’t prescribe or suggest specific treatments. So it could very well be that a psychiatrist after speaking with a patient and noting a DSM-diagnosis suggests to do a training, read a book, talk to you parents, suggests psychotherapy, gives tips in how to deal with you employers or very importantly suggest to do nothing with/about it. You get my point? Off course I know that in some countries, in some professions it is common or even standard to think f.i. ADD=ritalin and I agree fully with you when you chalenge this practice but I think you shouldn’t blame the DSM. Blaming the DSM is like blaming a mobile telephone company for the stupidity of te average conversation by mobile phone from there customers…
    2) In my own environment I often come across people who feel uncomfortable with the suggestion that “mental madness” is not neatly seperated from “healthy” that there might be a contiuum in which people apparantly move in (and out!) while to me this seems very realistic and fitting in with my own live and observation of others. I think developing a language ( like f.i. DSM ) is a good thing and a prerequisite to deal with it in the most humane way.

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  5. “The other reality is that even if you did believe that you could make medications to help these conditions, the fact is you cannot do that without first knowing what the conditions are. ANd we do not know what any of these conditions are (oh, yes we do!). We cannot put psychosis, or depression or ADHD in a test tube and find ways of killing it with medicaton. They are all just human emotions, behaviours and feelings and while they are incredibly real feelings in some cases they are not real diseases as you cannot test them!!”

    Do you take medicine for headaches or joint pain or diarrhea or constipation? Do you first find out why you have this problem before you take an aspirin? The brain is an organ like any other and like any other it has it own diseases. Because it is the seat of emotion and thought it may seem very mysterious but it is all just biochemistry. And the genetics of “mental illness” is becoming more and more clear. Depression, psychosis, ADD are not out there in the ether somewhere, they reside in the brain and can be demonstrated in brain scans and can be effected by medications. This does not mean that everyone is correctly diagnosed but there are treatable brain diseases that are well understood and really exist. Feeling fine on marijuama is an emotion, too, and getting “high” is also all about altering brain chemistry just like medicine but not in a good way.

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