Experts React to DSM-5 Approval

Deborah Brauser

December 03, 2012

Experts and organizations are weighing in on this weekend's decision by the American Psychiatric Association (APA) Board of Trustees to approve the final diagnostic criteria for the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

As reported by Medscape Medical News, the APA's Board approved the sometimes controversial and widely debated proposed criteria on December 1. The manual is on track to be published and released in the spring of 2013.

"We have sought to be very conservative in our approach to revising DSM-5," said David J. Kupfer, MD, chair of the DSM-5 Task Force, in a release.

However, Allen Frances, MD, chair of the DSM-IV Task Force and one of the DSM-5's most vocal critics, disagrees.

Dr. Allen Frances

"DSM-5 opens up the possibility that millions and millions of people currently considered normal will be diagnosed as having a mental disorder and will receive medication and stigma that they don't need," Dr. Frances, professor emeritus from the Department of Psychiatry at Duke University School of Medicine in Durham, North Carolina, told Medscape Medical News.

"This is the saddest moment in my 45-year career of studying, practicing, and teaching psychiatry. [The] approval makes it likely that DSM-5 will start a...dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society," he wrote in his online blog for Psychology Times the day after the approval.

Dr. Geraldine Dawson

Nevertheless, Geraldine Dawson, PhD, chief science officer of Autism Speak, writes on the organization's Web site that after careful consideration, she is "cautiously optimistic" about the APA's move.

"We are reassured that the DSM-5 committee has stated that all individuals who currently have a diagnosis on the autism spectrum, including those with Asperger syndrome, will be able to retain an ASD diagnosis," writes Dr. Dawson.

"This means that no one...should 'lose' their diagnosis because of the changes in diagnostic criteria," she added.

Key Changes

Key changes to the manual will include removal of the multiaxial system used in the DSM-IV; the inclusion of binge eating, hoarding, and excoriation (skin-picking) disorders in Section 2 for "categorical diagnoses"; and the addition of attenuated psychosis syndrome, nonsuicidal self-injury, and Internet use gaming disorder in Section 3, for those conditions deemed to require further research.

Hypersexual disorder and parental alienation syndrome were not accepted into either Section 2 or 3.

For the diagnosis of autism, the DSM-5 collapses Asperger syndrome and autistic disorder, which were included in the DSM-4, into the overall heading of ASD.

"Going forward, it will be crucial to study how the new criteria function in real-world community settings," Dr. Dawson noted.

She reported that Autism Speaks is currently funding, along with the Centers for Disease Control and Prevention, a study that will compare criteria in the DSM-IV to those found in the DSM-5 "in a large ethnically diverse community-based sample of children in south California."

Dr. Dawson also noted that the organization had been in close contact with DSM-5 committees during the past year.

"Throughout the year, we've communicated directly with the revision committee, conveying our concerns — indeed, our insistence — that the DSM-5 not result in the denial of autism-related services to any who need them."

In a statement to Medscape Medical News, Dr. Dawson added that although the DSM-5 field trials, which were concluded earlier this year, were "somewhat reassuring," they were based on a relatively small number of children.

"We still have very little information about the impact of the DSM-5 on diagnosis of autism spectrum disorder in young children and adults," she said.

Ten Revisions That "Make No Sense"

Dr. Frances, on the other hand, is frustrated with many of the manual's overall changes.

"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," he writes on his blog.

Dr. Frances advised that clinicians ignore 10 diagnostic revisions "that make no sense." These include the following:

  • the inclusion of disruptive mood dysregulation;

  • taking out the bereavement exclusion;

  • creating "a slippery slope" by introducing the concept of behavioral addictions;

  • introducing adult attention deficit disorder, which could lead to the misuse of stimulants;

  • obscuring "the already fuzzy boundary" between generalized anxiety disorder and worries from everyday living.

"Except for autism, all the DSM-5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation," he writes.

Dr. Frances told Medscape Medical News that one of his biggest concerns is that "real psychiatric problems" are already shortchanged and are not given enough attention and resources. The newly added, and he says unneeded, diagnoses in the DSM-5 will end up diverting away these precious resources.

Serious Disappointment

Last year, divisions of the the American Psychological Association created an "open letter" online petition addressing serious reservations about the DSM-5. It garnered more than 14,000 signatures from mental health professionals, societies, and students.

The organization's Division 32 (Society for Humanistic Psychology) was a key sponsor of the petition. The president-elect of this division told Medscape Medical News that the newly approved criteria are a serious disappointment.

Dr. Brent Dean Robbins

"The final document, from what we understand, has not nearly addressed the major flaws we identified in our petition," said Brent Dean Robbins, PhD, who is also director of the psychology program at Point Park University in Pittsburgh, Pennsylvania.

"In addition, we are very concerned that the field trials exposed extremely poor reliability for most of the major diagnostic categories. As a result, we believe strongly that the DSM-5 will not provide clinicians with the confidence that they are using a scientifically reliable and valid tool to assess the mental health of patients," said Dr. Robbins.

He also noted concerns over the inclusion of disruptive mood dysregulation disorder, which may "lead to a pathologizing of normal children," and the removal of the bereavement exclusion, which he says will blend together normal grief and clinical depression.

"The line between these 2 states of mind have been completely blurred by the DSM-5. As a result, in our opinion, the DSM-5 Task Force has demonstrated abject failure to recognize the difference between normative human experiences...and abnormality. This failure undermines the validity of the entire DSM-5 project."

Real-World Implications

Dr. Frances said that, contrary to accusations that have been brought up throughout the DSM-5 approval process, he does not believe that the task force had any significant financial conflicts.

"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. Theirs is an intellectual, not financial, conflict of interest," he wrote on his blog.

When asked by Medscape Medical News whether it might be more important to better diagnose people who would otherwise "fall through the cracks" than to be so concerned about overdiagnosing in those who do not really need it, Dr. Frances said this is a faulty argument.

"Only one third of people with severe depression see a mental health clinician in the previous year. And there have been substantial cutbacks to treat people with severe psychiatric illness," he reported.

"So as a country, we are devoting fewer and fewer resources to those people who are most clearly diagnosed."

He added that the DSM-5 Task Force is composed of experts who worry most about the missed patient and not about the mislabeled one.

"All the effort has been to not miss a single person. But doing that will misidentify lots of people who are better off without us, including many who are just over the boundary of normal. It is more important to catch those who are severely ill," said Dr. Frances.

"There is a tremendous misallocation of resources. And this will make it worse. I think the DSM-5 people were well meaning. They just don't see the implications of these suggestions once applied in the larger world."

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