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Clinician's Digest - Page 2

DSM-5 and its Critics

Despite delays, the American Psychiatric Association (APA) is now firmly committed to bringing out psychology's revised bible, DSM-5, by 2013. Nonetheless, an unprecedented outcry from past DSM lead editors and members of DSM-5 work groups has been highly critical of the compilation process, of several proposed new diagnoses, and of a major new diagnostic procedure. They say that the work groups are too quickly making decisions that aren't supported by the research. Not mincing words, Allen Frances, lead editor of DSM-IV, fears the 2013 deadline is becoming "a rush to produce an inferior product."

The increasing impact of the DSM can't be underestimated. Originally intended primarily to create a more coherent taxonomy of mental disorders, it now helps shape insurance coverage, lawsuits, criminal prosecutions, and even how we think of ourselves and others. When homosexuality moved from a disorder to a normal expression of sexuality, for example, the attitudes of many gay and straight people shifted, which then influenced social legislation and cultural norms. Its inclusion of PTSD led to a wide range of groundbreaking research and opened the door to millions of dollars in lawsuits and disability payments. From an economic standpoint, its diagnostic categories have led to the increasing use of psychotropic medications, making it a treasure trove for the pharmaceutical industry.

Like earlier editions, DSM-5 will be a blend of hard science, political compromises, educated guesses, and research biases. Frances knows firsthand what this combination can create. Although the editors attempt to classify every disorder, there are always people who don't fit neatly into any existing category, sometimes resulting in the designation of new disorders, despite insufficient research. In spearheading DSM-IV, Frances wrestled with creating bipolar II disorder to describe people who seemed to fit somewhere between depression and the old bipolar diagnosis. "We included it as bipolar II disorder," he says, "because of what seemed to be compelling enough research evidence that it sorted better with bipolar than with unipolar mood disorders." Although he feared that some unipolar patients might be mislabeled and prescribed more powerful mood stabilizers and antipsychotics instead of antidepressants, he decided that the greater risk would be to treat bipolar people with antidepressants. Subsequently, the pharmaceutical industry poured money into advertising and investigating the new diagnostic category. This resulted in a dramatic increase in bipolar II diagnoses and in the use of mood stabilizers and antipsychotics.

Worse yet, according to Frances, bipolar II led to the new diagnosis of childhood bipolar disorder, which caused thousands of children to be mislabeled and heavily medicated. He estimates that if some proposed new disorders, such as attenuated psychotic symptoms syndrome, which attempts to identify adolescents in a pre-psychotic state, make it into DSM-5, 20 to 30 million more people may be diagnosed with mental disorders and medicated.

Frances and Columbia University psychiatrist Michael First also worry about the proposed new shift toward using dimensional scales. Such scales are intended to improve upon the symptoms checklists that encourage a yes or no diagnosis, which many have considered a major flaw of the DSM. But, insists First, there's no good evidence to indicate that these scales will be of any use to clinicians. It'll take years to accumulate outcome data, and he worries that, in the meantime, administrators, insurance carriers, and other restrictors of care might use them to deny coverage to some people, such as those with subclinical or mild mood disorders.

Frances, First, and other insiders are quite familiar with the unintended consequences of rushed deadlines that force decision-making ahead of good science and, however well-intentioned, subvert the fundamental medical principle of doing no harm. "We used to say proudly that DSM was never on the leading edge, but always on the following edge," says First. As DSM-5 rushes toward its 2013 deadline, critics are trying to ensure that, if they can't slow it down, they can at least help make the final decision-making more conservative.

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