This blog was originally Published on December 2, 2012 in DSM5 in Distress at http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association (APA) has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound.  My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.  Just ignore the ten changes that make no sense.

Brief background.  DSM 5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal- to produce a paradigm shift in psychiatry.  Excessive ambition combined with disorganized execution led inevitably to many ill-conceived and risky proposals.

These were vigorously opposed.  More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits.  Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

DSM 5 has neither been able to self-correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis.  Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably ‘psychosis risk’, mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, ‘hebephilia’, cumbersome personality ratings, and sharply lowered thresholds for many existing disorders).  But APA stubbornly refused to sponsor any independent review and has given final approval to the ten reckless and untested ideas that are summarized below.

The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good.  Yesterday’s APA approval makes it likely that DSM 5 will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society.

The motives of the people working on DSM 5 have often been questioned.  They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine.  But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies.  Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

The APA’s deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation.  There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as a best seller.  When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control.  The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only- so that DSM 5 publishing profits can fill the big hole in APA’s projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation.

This is no way to prepare or to approve a diagnostic system.  Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

So, here is my list of DSM 5’s ten most potentially harmful changes. I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, especially if the proposed diagnosis is being used as a rationale for prescribing medication for you or for your child; and that payers question whether some of these are suitable for reimbursement. My goal is to minimize the harm that may otherwise be done by unnecessary obedience to unwise and arbitrary DSM 5 decisions.

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot.  Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life.  Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment.  This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM’s teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be.  Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and ‘behavioral addictions’ will soon be mislabeled as psychiatrically sick and given inappropriate treatment.

People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM 5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill.

Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession.  But we have to know our limits and stay within them.

DSM 5 violates the most sacred (and most frequently ignored) tenet in medicine- First Do No Harm!  That is why this is such a sad moment.

Martin Whitely’s comment:  Professor Frances’ comments can’t be dismissed as the architect of the old edition protecting his work from revision. As the overall leader of the DSM-4 development process he has accepted his share of responsibility for the problems DSM-4 helped create.[1. See http://speedupsitstill.com/dr-allen-frances-lead-author-dsmiv-british-psychological-association-lead-chorus-opposition-disease-mongering-proposals-dsm5 ]  However, rather than learn the lessons of inappropriate medicalisation of behavior and over-prescription from DSM-4, the American Psychiatric Association is about to deliver much worse in DSM-5.  Surely now is the time for the Australian psychiatric profession to end its slavish devotion to the broken American model that sees more than one in five US adults on at least one mental health drug.[2. Report: 1 in 5 American Adults Takes Mental Health Drugs. Time Magazine Nov. 16, 2011
http://healthland.time.com/2011/11/16/report-whos-taking-mental-health-drugs-in-america/?hpt=he_c2 ]

Australia should hardly be using America as the ‘model’ for enhancing the welfare of children. However, the reliance of Australian psychiatric practice on imported American Psychiatric Association (APA) diagnostic criteria, over which the Australian medical profession has no control, leaves Australian consumers, particularly children, vulnerable to the same forces that make America the home of indiscriminate psychiatric drugging.

In 2008 it was revealed that more than half the psychiatrists that developed the Diagnostic and Statistical Manual of Mental Disorders DSM-IV received drug company funds.^[3] Thankfully there has been some recent recognition of the problem from the top level of the APA. In the same year, then APA President, Dr Steven S. Sharfstein, wrote a groundbreaking commentary piece on the relationship between psychiatry and the pharmaceutical industry entitled;

‘Big Pharma and American Psychiatry: the Good, the Bad, and the Ugly’

There is widespread concern of the over-medicalization of mental disorders and the overuse of medications. Financial incentives and managed care have contributed to the notion of a ‘quick fix’ by taking a pill and reducing the emphasis on psychotherapy and psychosocial treatments. There is much evidence that there is less psychotherapy provided by psychiatrists than 10 years ago. This is true despite the strong evidence base that many psychotherapies are effective used alone or in combination with medications…

 One of the charges against psychiatry that was discussed in the resultant media coverage (of anti-psychiatry remarks by Tom Cruise) is that many patients are being prescribed the wrong drugs or drugs they don’t need. These charges are true, but it is not psychiatry’s fault—it is the fault of the broken health care system that the United States appears to be willing to endure…In a time of economic constraint, a ‘pill and an appointment’ has dominated treatment. We must work hard to end this situation and get involved in advocacy to reform our health care system from the bottom up.

There are examples of the ‘ugly’ practices that undermine the credibility of our profession. Drug company representatives will be the first to say that it is the doctors who request the fancy dinners, cruises, tickets to athletic events, and so on. But can we really be surprised that several states have passed laws to force disclosure of these gifts? So-called ‘preceptorships’ are another example of the ‘ugly’; that is, drug companies who pay physicians to allow company reps to sit in on patient sessions allegedly to learn more about care for patients and then advise the doctor on appropriate prescribing. Drug company representatives bearing gifts are frequent visitors to psychiatrists’ offices and consulting rooms. We should have the wisdom and distance to call these gifts what they are—kickbacks and bribes.^[4]

Despite Dr Sharfstien’s refreshing honesty, if we continue to blindly follow the lead of the American Psychiatric Association we can be confident that more trouble will follow. The psychiatrist who led the effort to update DSM-IV (in 1994), Dr Allen Frances, now regrets broadening the diagnostic criteria for a range of childhood disorders including autism; juvenile bipolar disorder, and ADHD. Dr Frances has warned of similar problems when DSM-V replaces DSM-IV in 2013. After reviewing the early draft of DSMV he predicted further ‘false epidemics’ and ‘unnecessary, expensive and often horrible treatments for conditions that really are made up by the people doing the manual (DSM-V)’.^[5]

The good news is we can avoid many of these problems. There is absolutely no need for Australia to continue to slavishly follow the lead of the APA as there is a better, although far from perfect, alternative. Chapter five of the International Clarification of Diseases 10 (ICD-10) is the criterion for mental health disorders published by the World Health Organization and used predominantly in Europe. It is largely overlooked in Australia.

The eighteen diagnostic criteria for hyperkinetic disorder outlined in ICD-10 are virtually identical to those for ADHD in DSM-IV. There are, however, two subtle but important distinctions. First, for a diagnosis of hyperkinetic disorder, an individual is required to display at least six of nine of the inattentive and three of five of the hyperactive and one of four of the impulsive behaviours. For a DSM-IV diagnosis of ADHD, six of nine of the inattentive or six of nine of the hyperactive/impulsive are sufficient. Second, unlike ADHD, hyperkinetic disorder is not diagnosed if another condition that may explain the behaviour is diagnosed.

While many of the criticisms of subjectivity of assessment of behaviours are common to both the DSM-IV and ICD-10, in practice far fewer children are diagnosed using ICD-10. Despite the fact that Australia is a member of the World Health Organization and obviously not the American Psychiatric Association, DSM-IV is the predominant criteria used in Australia. As a consequence, the rate of psychostimulant use per head in the US and Western Australia (using DSM-IV) between 1994 and 2000 was approximately ten times the UK rate (predominantly using ICD-10).^[6]

This is not only true for ADHD, DSM-IV generally contains looser, less rigorous diagnostic criteria than ICD-10. A 2005 study compared diagnosis rates for a range of childhood psychiatric disorders using the diagnostic criteria in DSM-IV and the equivalent disorder in ICD-10. For the majority of disorders, including ADHD, rates of diagnosis were higher using DSM-IV.^[7]

That is not to say that the ICD10 should be our final destination or that many of the same corrupting commercial influences don’t have an effect on the World Health Organisation’s ICD development processes. But it is an easily obtainable improvement and at least Australia is a member of the World Health Organisation with some capacity to influence its processes.

Perhaps Australia Day is an opportunity to reflect on whether we should continue to cede sovereignty of the mental health and wellbeing of our children to American Psychiatric Association and therefore indirectly to the pharmaceutical industry.