DSM-IV Boss Presses Attack on New Revision
Published: May 17, 2013

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By John Gever , Deputy Managing Editor, MedPage Today

A new edition of psychiatry’s diagnostic guide “will probably lead to substantial false-positive rates and unnecessary treatment,” charged the man who led development of the last version.

To be released this weekend at the American Psychiatric Association’s annual meeting, the fifth edition of theDiagnostic and Statistical Manual of Mental Disorders, or DSM-5, “introduce[s] several high-prevalence diagnoses at the fuzzy boundary with normality,” according to Allen Frances, MD, who chaired the task force responsible for DSM-IV issued in 1994.

Frances, now an emeritus professor at Duke University, wrote online in Annals of Internal Medicine that changes from DSM-IV will apply disease labels to individuals who may be unhappy or offensive but still normal. Such individuals would include those experiencing “the forgetfulness of old age” as well as children with severe, chronic temper tantrums and individuals with physical symptoms with no medical explanation.

He also worried about new marketing pushes from the pharmaceutical industry seeking to exploit what he believes are “loose” diagnostic criteria in the new edition. “Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form,” he wrote.

The attack is the latest in a campaign against DSM-5 that Frances and others have waged since even before the first draft was released for public comment in 2010.

In open letters, blog posts, articles published in mental health journals and consumer media, and two books, Frances has repeatedly blasted his successors for missing deadlines, failing to conduct the types of research he believed were required, and shutting him and his allies out of the process. (APA officials have called the DSM-5 process more open than ever before, with comments on early drafts solicited twice from health professionals and the public.)

The original DSM-5 release date was set for May 2012, but delays in developing the initial draft for subsequent review and testing forced postponement to this year. The time window for conducting field trials of revised diagnostic criteria was cut short as well, although APA officials insisted that the process’s integrity had not been compromised.

In his Annals article, as before, Frances begged to differ. He argued that, in fact, the new criteria have not been adequately tested. In particular, he wrote, the process lacked “adequate consideration of risk–benefit ratios and the economic cost of expanding the reach of psychiatry.”

Frances pointed to dramatic increases in diagnoses of such conditions as autism and related disorders, attention deficit-hyperactivity disorder, and bipolar disorder over the past 20 years. These increases, he suggested, reflect “overdiagnosis” and serve as examples of what can go wrong when diagnostic criteria are drawn too loosely.

Ironically, DSM-5 has come under attack from the autism community for rewriting the autism spectrum classification in ways that autism advocates have feared will disqualify many children from receiving autism diagnoses — a controversy that Frances did not address.

Frances also did not admit that DSM-IV was flawed in any way, even though his examples of past overdiagnosis all arose during the DSM-IV era.

But he did suggest that the DSM in general has become too important after a very modest beginning in the 1950s.

“The DSM … has since acquired perhaps too much real-world influence as the arbiter of who gets what treatment and whether it will be reimbursed; who is eligible for disability benefits, Veterans Affairs benefits, and school and mental health services; and who qualifies to receive life insurance, adopt a child, fly an airplane, or buy a gun,” Frances observed.

He urged physicians to “use the DSM-5 cautiously, if at all,” and pointed out that physicians are free to rely instead on ICD-9 codes — which, as it happens, largely reflect the DSM-IV classifications.