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Table Of Contents-Part 3
Critique of the DSM in General
The DSM has been criticized for giving the illusion that mental illness is a clearly identifiable disease. But the medical-mechanistic model (after identifying and naming the problem, treatment and cure follows) cannot simply be applied to psychology. Unlike medical diagnoses, psychiatric diagnoses are not precise, accurate, or objective. There are no blood tests, x-rays or brain imaging techniques to identify the presence of any of the diagnostic categories. (Zur & Nordmarken, 2007)
Different therapists are likely to come up with a different diagnosis for the same person. The differences reflect different theoretical orientations of therapists. Diagnosis, in psychotherapy, often depends on the eye of the beholder. Double blind studies cannot be executed because this subjectivity is involved in the diagnosis of the vast majority of cases. As a consequence, rigor in publication is very low in comparison with the more hard medicine and science. (Szenasi, 2013)
Szenasi sees a “huge problem with the psychiatric diagnostics. An illness is a malfunction of the body, not a behavior. When I talk about an illness, I presume the existence of a ‘chemical imbalance’ or some other sort of abnormalities in our biology. In my personal opinion, psychiatric diagnoses are not only scientifically invalid but they also have a high potential of doing harm. The distress we experience as human beings has a social and psychological cause too, to which psychiatrists tend to be blind.
When they give you a psychiatric diagnostic they also give you a stigma. Discrimination and social exclusion is happening all the time and, maybe more important than this, people diagnosed with a mental ‘disease’ tend to conform to the diagnostic. They might say: ‘Oh, poor me, I am depressive. I should act like a depressive. Let me see how to do that!’ People diagnosed with depression, for instance, will search on the Internet about the topic, read about its characteristic behaviors, conform to it, and act accordingly.” (Szenasi, 2013)
Shorter points out that “schizophrenia, bipolar disorder and major depression are the diagnoses at the heart of the DSM system, and none of the three correspond to the real illness that patients have in the real world:
Hickey goes even further saying that that the concept of mental illness is marchaic, pre-scientific nonsense, exactly on a par with the notion of witchcraft. He states that “arguing against DSM-5 without also challenging the concept of mental illness is analogous to saying that too many women are being persecuted for witchcraft, and that we need to concentrate instead on the ones who really are witches and who can be identified by the following signs: moles on the nose; odor of cabbage, etc., etc. … Getting away from the medical model, which incidentally most real doctors have already abandoned, involves a very radical shift of ideas, many of which are unspoken. For me, the fundamental concept is that the client is in charge. The client defines the presenting problem.” (Hickey, 2013 b) Hickey points out too, that diagnoses often dehumanize people (Hickey, 2013 a).
Peter Kinderman believes that “psychiatric diagnoses are not only scientifically invalid, they are harmful too. The language of illness implies that the roots of such emotional distress lie in abnormalities in our brain and biology, usually known as ‘chemical imbalances’. This leads us to be blind to the social and psychological causes of distress.” (Kinderman, 2013)
Controversies in Regards to the Changes in the DSM-5
A literary assault has emerged as several critical books were released – strategically timed – right before the publication of the DSM-5: The Book of Woe – The DSM and the Unmaking of Psychiatry (Greenberg, 2013 b), The Intelligent Clinician’s Guide to the DSM-5 (Paris, 2013), Saving Normal – An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (Frances, 2013 d), and Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5 (Frances, 2013 e). They appear to sell relatively well according to the Amazon.com ranking system.
Allen Frances, who chaired the DSM-IV revisions, quotes Patrick Landman, a prominent French psychiatrist, saying: “The people who oppose DSM-5 belong to many different schools of thought, but unite in the worry that it is not safe or scientifically sound. We are all deeply invested in psychiatry and cannot by any stretch of the imagination be seen as anti-psychiatry. Indeed, we are trying to save psychiatry from the errors of DSM-5.” (Frances, 2013 v)
This also means that many critics of the DSM-5 approve of psychiatric diagnosis in general. They believe that there is nothing inherently dehumanizing or stigmatizing about a psychiatric diagnosis. “Ironically, such inflammatory charges only worsen society’s animus and prejudice toward those with mental illness, by implying that having a psychiatric disorder is grounds for shame. Diagnoses in other medical specialties rarely provoke such a reaction.
Critics of psychiatric diagnosis in general typically reply that other medical specialties have ‘objective’ criteria for diagnosis of disease, whereas psychiatrists merely apply ‘labels’ to behaviors they (or society) find offensive.” (Pies, 2013) But – according to the opposing position – numerous medical and neurological diagnoses, such as migraine headache, are based on the same type of data that psychiatrists use: the patient’s history, symptoms and observed behaviors. Psychiatric diagnoses are castigated largely because society fears, misunderstands and often reviles mental illness. (Pies, 2013)
“‘Diagnosis’ means knowing the difference between one condition and another. For many patients, learning the name of their disorder may relieve years of anxious uncertainty. So long as diagnosis is carried out carefully and respectfully, it may be eminently humanizing. Indeed, diagnosis remains the gateway to psychiatry’s pre-eminent goal of relieving the patient’s suffering.” (Pies, 2013) Psychiatric diagnosis that is done well is therefore the essential prelude to an effective treatment.
“Done poorly, diagnosis can do more harm than good.” (Frances, 2013 k) Frances expressed concern about the scientific rigor of the review process and the content of changes in specific disorders. He believes that the manual defies clinical common sense and was prepared without adequate consideration of risk-benefit ratios and the economic cost of expanding the reach of psychiatry. He called the DSM-5 writing dense, clunky, and dreadfully obscure. “Therefore the manual has received bad press. There have been hundreds of articles in all the major newspapers of the world, dozens of editorials in major medical and psychiatric journals, and an internet blood bath.” (Frances, 2013 i)
Many opponents of the DSM-5 wonder whether “we really need a new DSM in the first place. There is little groundbreaking science that would redefine our diagnostic categories, and some of the changes appear to risk pathologizing everyday human misery.” (Friedman, 2013)
The controversy in regards to the revision of the DSM can be mostly found among clinicians who believe that psychiatric diagnosis in general is justified and useful. About a dozen different DSM-5 petitions and boycotts (for example Carney, 2013 a) were launched. The APA brushed them aside. (Frances, 2013 f) The question was even raised whether government intervention might be needed (Frances, 2012 e).
Several professional journals, the press, and the public vehemently objected to many changes that were made to the DSM (Bernard, 2012). The American Psychological Association, American Counseling Association, the American Mental Health Counselors Association, the British Psychological Society (The British Psychological Society, 2011), and others submitted critical responses to the APA’s call for commentary on the changes.
Although the DSM has no legal currency outside the U.S., European and Australian mental health professionals are very concerned about its revision because the effects of DSM-5 may spread beyond the boundaries of the United States. (Whitely, 2013) “The excessive diagnosis of ADD and Autism began in the U.S., but these false epidemics are catchy and have now become a world-wide phenomenon. For example, a team from Cambridge University is going to China to hunt for autism and that they anticipate placing the label on 14 million Chinese.” (Frances, 2013 o)
England’s Division of Clinical Psychology, which represents more than 10,000 practitioners, has criticized the DSM-5 for its categorizing of normal behaviors. (Kelly, 2013) A group based in Paris comprising (among others) prominent psychiatrists and psychoanalysts was disturbed by the power of the American Psychiatric Association and its “one-track” focus on biological psychiatry. (Lane, 2013) They are also worried that the revision of the DSM could potentially influence the revision of the ICD-10 and ICD-11, which over 100 countries use throughout the world. (“Psychologists to fight new list,” 2013).
International campaigns with petition drives in the United States, the United Kingdom (“Statement of Concern,” 2013 and “Is the DSM-5 Safe?” n. d.) and France were organized. One international boycott of the DSM-5 was launched by a committee of 40 prominent psychologists, psychiatrists, other professionals, and representatives of service users’ organizations from seven countries, including Australia and New Zealand.
They suggest that their concerns should be resolved through concerted, inter-professional, international dialogue and scientific research. “Until then, because there are safe and legal alternatives, clinicians, researchers, journal editors, healthcare planners, managers & commissioners, the pharmaceutical industry, and the media should avoid use of DSM-5 wherever possible.” (“International DSM-5 Response Committee,” n. d.) These reactions are perceived as “a wave of international anger” (Shorter, 2013).
A number of psychiatrists, including Robert Spitzer, who chaired the revisions of the DSM-III (Sandeen, 2008), and Allen Frances also submitted critical comments about the process and content of disorder changes. They assailed the DSM-5 task force in an open letter for its lack of transparency (Frances & Spitzer, 2009). Frances expressed his disapproval with statements like: “DSM-5 violates the most sacred tenet in medicine – First Do No Harm!” and “This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry.” (Frances, 2012 b)
What motivated Frances is the experience of having inadvertently contributed to fads and psycho-diagnoses that have resulted in over-diagnosis and over-treatment. “Some of this happened during DSM-IV, even though we were more conservative with that document than they’ve been with DSM-5, with its many changes that are unsupported and, in some cases, quite reckless.” (Gray, 2013)
Division 32, Society for Humanistic Psychology of the American Psychological Association, submitted an Open Letter outlining their concerns and asking for an independent review by scientists and scholars who had no associations with the DSM-5 Task Force or the American Psychiatric Association. (Gray, 2013) Over 50 professional, academic, and practical associations supported this Open Letter and it received over 14,500 signatures (Division 32, 2012).
This Open Letter fell on deaf ears. In their response, the Task Force and the American Psychiatric Association refused the request, stating “there was no outside group of scholars and scientists that was qualified to evaluate the DSM-5 proposals.” (Elkins, 2012) This prompted chairs of the DSM-5 Response Committee to write a Statement of Concern calling for Boycott of the DSM-5.
They called on practitioners, researchers, healthcare professionals and members of the pharmaceutical industry to avoid use of the DSM-5 until these concerns have been addressed. Further, the committee is entreating all professional counselors, nurses, academic professors, and administrators to rely on other means of diagnoses, education, and evidence as they feel that the methods used to support the changes in the DSM-5 are unethical and unreliable. (“Statement of Concern”, 2013)
In a bold and controversial decision, the National Institute for Mental Health (NIHM) announced that it would no longer use DSM diagnoses in its research projects. Some consider this announcement nothing short of a cataclysm in mental health. (Koven, 2013) The NIHM launched an initiative to create a replacement diagnostic system based exclusively on objectively measurable parameters. (Insel, 2013) Consequently, some believe that the identification and treatment of mental illness is about to leave the realm of psychiatry and enter the science of neurology. (Jaffe, 2013)
Critics of the DSM-5 have raised concern that it may be have been too early to create a new classification of psychiatric diseases. “The main question is whether there have been sufficient advances in the pathophysiologic, phenomenologic, and therapeutic understanding of mental illness to warrant a revised DSM.” (Stetka & Correll 2013)
The National Institute for Mental Health director, Thomas Insel, said that the dominance of the DSM system has hampered research, preventing scientists from pinpointing the real causes of psychological suffering. The NIHM director wants his institute to develop “vaccines, not iron lungs”. (Frances, 2012 t)
Insel also stated: “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century, as we have understood that symptoms alone rarely indicate the best choice of treatment. Patients with mental disorders deserve better.” (Insel, 2013)
Since the beginning of 2011, the NIMH has been working on a different categorization system to classify mental disorders, in order to help further its research efforts. It is called the Research Domain Criteria project (RDoC). “Because a diagnostic system has to be based on the emerging research data, not on the current symptom-based categories, the NIHM plans to incorporate genetics, imaging, cognitive science, and other levels of information to lay the foundation for this new classification system.” (Insel, 2013)
The NIHM assumes that mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, and behavior. “Therefore, future psychiatric research will focus on characterizing and treating diseases on the basis of their underlying biology, rather than the DSM’s symptomology.” (Insel, 2013) “Our concepts and language for describing mental illness depend far too much on observed symptoms, and are frequently also historical artefacts that have not been revised in light of more recent knowledge.” (Murphy, 2006)
In an interview with The New York Times, Insel said: “As long as the research community takes the DSM to be a bible, we’ll never make progress. People think that everything has to match DSM criteria, but you know what? Biology never read that book.” (Belluck & Carrey, 2013) The NIHM director believes that the DSM should be used solely as a dictionary, so that clinicians share the same descriptions of symptoms. (Fields, 2013) Whether even this can always be accomplished is doubtful, since new research has found that the chance of two doctors agreeing on a diagnosis of major depression is just 60 per cent. (“DSM5: Psychiatry guide”, 2013)
Subsequently, the chair of the DSM-5 issued an agreement, saying: “In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity.” (Kupfer, 2013)
The chairman of the DSM-IV Task Force, Allen Frances, remarked in response to this that “the potential for exciting neuroscience findings in the future should not distract us from taking much better care of our patients now. … NIMH was trumpeting its new research agenda to support its request to Congress for an expanded brain research budget.” (Frances, 2013 t) He refers to Isaac Newton who said almost 250 years ago: “I can calculate the motions of the heavens, but not the madness of men.” Figuring out how the universe works is simple compared to understanding what causes schizophrenia. (2013, m)
Frances also reminded us that the “DSM-5 hoped to include biological markers that might reflect past research and promote future research. This was a premature and unrealizable ambition: the science simply isn’t there now. And it has become increasingly clear that the DSM descriptive system may be a research dead end because its syndromes are too diverse and overlapping to be good research targets. So the NIMH has wisely chosen another approach that is more likely to bear fruit – picking simpler targets for study and bringing to bear all of its enormous resources to determine their causal mechanism. What we call schizophrenia does not present in one uniform way, and there will not be one cause – there probably are hundreds.” (Frances, 2013 p)
Cohen agreed, stating: “The DSM-5’s attempt to find some quasi scientific foothold inside the professional world is exactly its problem. … Short of mapping the entire universe, it might just be the best that we have for now, and that is good enough for me.” (Cohen, 2013)
Other opposing voices expressed the following thoughts: “Insel represents a crucial American school of thought – by far the dominant one in the United States today – – that equates the future of mental health with the brain, pure and simple. This school of thought is fundamentally wrong, has always been wrong, will always be wrong.” (Peele, S., 2013) Prescribing an appropriate treatment involves not checking symptoms, but requires hours of evaluation to determine who the patient is and what he or she has experienced and done. (Mchugh, 2013)
Frances emphasized that the flat out rejection of the DSM-5 by the NIHM is a sad moment for mental health and an unsafe one for patients. “The APA and NIMH are both letting us down. … The NIMH statement went very far overboard with its implied promise that it would soon find a better way of sorting, understanding, and treating mental disorders. … The new plan will further, and be furthered, by the big, new Obama investment in brain research. But the likely payoff is being wildly oversold. There is no easy solution to what is in fact an almost impossibly complex research problem. … If it has been so hard to figure out how simple breast tissue goes awry to become cancerous, imagine how many orders of magnitude more difficult will it be to eventually understand the hundreds or thousands of ways neurons can misconnect to cause what we now call schizophrenia.” (Frances, 2013 m)
According to the British Psychological Society, there is no scientific evidence that psychiatric diagnoses such as schizophrenia and bipolar disorder are valid or useful. Given this lack of evidence, it is time for a “paradigm shift” in how the issues of mental health are understood. The British Psychological Society calls for a conceptual system not based on a “disease” model. Their statement effectively casts doubt on psychiatry’s predominantly biomedical model of mental distress – the idea that people are suffering from illnesses that are treatable by doctors using drugs. “On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse.” (Doward, 2013)
Frances responded to this statement by claiming, “no details were offered and indeed no new model of psychosocial diagnosis actually exists”. (Frances, 2013 t) “A hundred years ago, Freud warned of this kind of reductionist view of human behavior. The NIMH biological reductionism finds its absurd reflection in the British Psychological Society psycho-social reductionism. Responsible leaders of powerful organizations should know better than to suggest that complicated mental illnesses can ever be reduced to simple and reductionistic answers. We need a model of mental illness that attends to the biological, to the psychological, and to the social. … Paradigm shifts emerge from new scientific findings – not from bloviating statements, however well intended.” (Frances, 2013 n)
Critics consider the DSM irrelevant to determining the cause and treatment of psychological problems for the following reasons:
“In light of its failures, one might reasonably ask: why a new DSM? In truth, this fifth edition is just moving a few deck chairs on a sinking ship. … Soon we’ll need to finish what the NIMH started – lower the lid, hammer it down, and bury the Diagnostic and Statistical Manual of Mental Disorders.” (McKay, 2013)
Researchers from Columbia and Rutgers Universities argue that the DSM-5 authors missed several issues in their most recent revision process, including:
These researchers propose an independent research review body to monitor diagnostic variations, recommend new avenues of research, and identify changes in mental health policy. (Hansen et al., 2013)
So that it can be readily updated to reflect the sometimes rapid and dramatic changes in neuroscience and pathophysiology, the new manual was created as a “living document,” typified in the change of edition number from the Roman numeral “V” to Arabic numeral “5” so that there can be mini updates (5.1, 5.2, and so on) before the DSM-6 comes out.
Critics call this an “absolutely ridiculous idea”:
Classifying certain constellations of symptoms as indicating the presence of a disorder works only when extreme symptoms are considered as indicative of mental illness. “The extreme symptoms of schizophrenia and bipolar – hallucinations, delusions, and cognitive impairments – are enough to tell us something is wrong, even if we don’t know what it is. But with each iteration of DSM, the APA has gathered less extreme symptoms together and decided they also indicate the presence of illness. The number of diagnoses exploded and normality – like having too much grief when someone dies – has now gained a label and a billing code.” (Jaffe, 2013)
Therefore, Allen Frances emphasizes that there has been an overdose of diagnosis and of medication in recent years. He also believes that the DSM-5 makes this worse by introducing new diagnosis that will have many millions of people qualifying for a mental disorder who – the night before it is published – would not have been considered to have a psychiatric illness. (Frances, 2013 e) There have been studies showing 50 per cent of the western population would now generate a DSM diagnosis. (“DSM5: Psychiatry guide”, 2013)
Except for autism, the DSM-5 is reducing many of the thresholds for existing disorders, which again increases diagnostic inflation and make it more likely that people get psychotropic medication that they do not need plus the stigma of having a diagnosed condition that they do not have. (Frances, 2013 e)
Frances explains in an interview: “It’s a lot easier to make a diagnosis than to get rid of one if it’s wrong. So, sometimes once it gets on the record, it takes on a life of its own … and will haunt you even if it is incorrect. … If somebody is put on a medication and they don’t really need it; what are the adverse side-effects, the iatrogenic effects of it? …
So these are some serious problems, but I wouldn’t underestimate the problems we already have before DSM-5. It may help to turn what is already a severe diagnostic inflation into something of a diagnostic hyper-inflation, but we already have the problem.” (Kall, 2013)
“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.” (Frances, 2012 b)
The following are the most relevant sentiments from a formal Statement of Concern of the Division 32, Society for Humanistic Psychology of the American Psychological Association:
(Division 32, 2012)
Frances calls this possible misallocation of resources a cruel paradox: “We are spending tens of billions of dollars plying the worried well with unnecessary and expensive drugs, while at the very same time ignoring the desperate needs of those who really could benefit from psychiatric diagnosis and treatment. Because of sharp cuts in state mental health budgets, more than one million mentally ill people are behind prison bars for nuisance crimes that could have been avoided if they had access to care and decent housing. This is inhumane and economically irrational.” (Frances, 2013 l)
The DSM-5 is established as the governing authority for determination of mental disorders under the Worker’s Compensation Act. Therefore, some employers are concerned that the revised manual could result in more people being classified as having conditions such as post-traumatic stress disorder, caffeine or cannabis withdrawal, and social (pragmatic) communication disorder. This might justify more sick leave, disability leave, use of medication as treatment, or increased disability insurance and drug plans. (Phillips, 2013)
This will drive up employer costs for the benefits plans commonly provided. “That sets these employers up for demands for ‘reasonable accommodation’ and potential lawsuits – an area that already has seen dramatic growth, with the number of lawsuits alleging disability discrimination nearly doubling in five years.” (Rosiak, 2013)
Possible Causes of the Problems
Some critics express concern that the APA – as a private guild with extensive ties to the drug industry – owns the naming rights to mental disorders. 69% of the DSM-5 task force have ties to the pharmaceutical industry. (Hickley, 2013, c) “That so significant a public trust is in private hands, and on such questionable grounds, is what we ought to worry about.” (Greenberg, 2013 a)
Frances explains the reasons that he sees behind the problems in the following way:
“Squeezed for time, DSM 5 was forced to cancel its planned quality control step and has put together the manual in a hectic, last minute rush. No doubt, the work group was pressured to go with the flow so that DSM 5 could be sent to the presses. This has been the DSM 5 story from start to finish: excessive ambition, disorganized method, closed process, tunnel vision, and publishing profit taking priority over public trust.” (Frances, 2013 b) “The $3 million DSM-5 Field Trials have been a pure disaster from start to finish.
It is sad that the American Journal of Psychiatry agreed to publish this sleight of hand interpretation of the remarkably poor DSM-5 field trial results. Clearly, AJP has been forced into the role of a cheerleading house organ, not an independent scientific journal. AJP is promoting APA product instead of critically evaluating it. Scientific journals all have some inherent conflicts of interest — but this is ridiculous.The DSM-5 field trial fiasco and its attempted cover-up is more proof (if any were needed) that APA has lost its competence and credibility as custodian for DSM. A diagnostic system that affects so many crucial decisions in our society cannot be left to a small professional association whose work is profit driven, lacking in scientific integrity, and insensitive to public weal.” (Frances, 2012 d)
Frances also demonstrates how field trials don’t always help with predictions when he reports from his experience with the DSM-IV: “Attention Deficit Disorder is a good illustration that what is written in the diagnostic manual doesn’t always determine how the diagnoses are actually made in real life. In DSM IV, we made some small changes in the definition of ADD to recognize the fact that girls are more likely to have problems with inattentiveness than with hyperactivity. Our field trials predicted an increase in rate of ADD of only 15 percent. Instead, ADD rates have tripled in the last 15 years because of factors we didn’t and couldn’t predict.” (Frances, 2013 l)
According to a 2005 study 46.4% of Americans have a diagnosable mental illness in their lifetimes, based on the previous manual. (Kessler et al., 2005) The chair of the DSM-IV Task Force takes partial responsibility for the diagnostic inflation following the revision of the two previous editions of the manual: “I have been involved in the preparation of DSM’s that set too low a threshold for diagnosing mental disorder. The decisions we made seemed appropriate at the time, but we never anticipated the awesome power of drug company advertising to sell psychiatric ills as a way of encouraging people to buy their over-priced and over-sold pills.” (Frances, 2013 l)
“They sold the idea that problems of everyday living are really mental disorders, caused by a chemical imbalance and cured with a pill. Meanwhile, we are neglecting the severely ill who can be accurately diagnosed and effectively treated. State budgets for mental health have been slashed, radically reducing access to care for the people who most need medicine and are likely to benefit from it.” (Frances, 2013 k)
He also states: “The people preparing DSM 5 are not doing this with the intention of helping the pharmaceutical industry. … They are making very bad decisions for the purest of reasons. The conflict of interest is not financial; it’s more intellectual, and there are two parts to it. One is, if you are an expert working in a field, you tend to develop a huge attachment to your field. You always worry about the fact that you may miss a patient that has a diagnosis in the area of interest that you have. So you worry very much about expanding the domain of your area of research and clinical interest. Experts never think about the impact of people who are mislabeled; they always worry about the people who are missed. And, they tend to overvalue their own research and their own area of interest.” (Kall, 2013)
Gray agrees with this view saying that the DSM-5, in many ways, reflects the politics of psychiatry. “Everybody has a kind of investment in certain diagnoses.” (Gray, 2013)
Shorter perceives three additional causes for the problems with the DSM-5:
These are all widely shared thoughts, and those who share them have no use for the whole DSM concept. I think we will not see a DSM-6.” (Shorter, 2013)
The following arguments are based on the concern that the DSM-5’s development lacked scientific consistency: The American Journal of Psychiatry (Freedman, et al., 2103) analyzed the outcomes of the field trials that were conducted by the DSM-5 Task Force, to determine the inter-rater reliability of the multiple diagnostic categories that comprise the DSM-5. Inter-rater reliability refers to the extent to which two clinicians agree on a diagnosis when presented with the same clinical picture. (Carney, 2013 b) “The end results are mixed, with both positive and disappointing findings.” (Freedman, et al., 2103)
A more cynical view has been expressed in the following way:
“The APA’s agenda is to widen the ‘diagnostic’ net to include as many people as possible. But they’re not complete fools. They know that there’s a good deal of anti-psychiatry feeling out there, so in my view, they floated some very contentious proposals, fully accepting that these would be withdrawn under pressure, thereby creating the perception that they are reasonable folk just trying to do what’s right. Meanwhile, other proposals go under the wire unscathed, and the ‘diagnostic’ net is widened. Mission accomplished.It has backfired somewhat, however, in that the sheer outrageousness of some of the original proposals has raised serious questions about the validity and destructiveness of the DSM system generally, and these criticisms aren’t going away.” (Hickey, 2013 a)
The DSM-5 has also been criticized for saying nothing about the biological underpinnings of mental disorders: “In the past, that shortcoming reflected the science. For most of the DSM’s history, investigators have not had a detailed understanding of what causes mental illness.
That excuse is no longer valid. Neuroscientists now understand some of the ways that brain circuits for memory, emotion and attention malfunction in various mental disorders. Since 2009 clinical psychologist Bruce Cuthbert and his team at the National Institute of Mental Health have been constructing a classification system based on recent research, which is revealing how the structure and activity of a mentally ill brain differs from that of a healthy one.” (Jabr, 2013 a)
The DSM-IV had the first official recognition of the role of culture in diagnosing mental illness in its Appendix I, which contained a Glossary of Cultural Bound Syndromes and an Outline of Cultural Formulation. The appendix provided a method of categorizing and normatively defining culturally bound disorders that parallel, but did not precisely fit defined disorders. In the DSM-5, the cultural formulation is being replaced with the Cultural Formulation Interview (CFI), which is a 14 itemed, structured clinical interview to be administered during a patient’s initial assessment. The CFI is designed to make cultural formulation quicker and easier.
Critics have questioned the use of the CFI without collateral information from family members and associates of the patient. Also, concern has been expressed about whether the CFI differentiates content for specific cultures. (Munson, 2013)
Concerns about Specific Diagnoses
Frances states: “DSM-5 will
In their Open Letter, the Division 32 of the American Psychological Association emphasized that the lowering of diagnostic thresholds, which may result in various iatrogenic hazards, such as inappropriate treatment and stigmatization of normative life processes, apply especially to
The association is also concerned about the development of novel scales (e.g., severity scales) with little psychometric testing rather than utilizing established standards. (Elkins, 2012)
Critics are glad that some of the revisions’ “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).” (Frances, 2012 b)
There has been a heated controversy about the DSM-5’s definition of autism. Combining the previous multiple definitions of autism into a single category makes some healthcare providers worry that the new definition could mistakenly lead to misdiagnoses of individuals who do not actually have autism spectrum disorder. (Scrowley, 2013)
“People with a previous diagnosis of Asperger’s disorder may be stigmatized with an autism diagnosis, which might likely be termed mild autism.” (Halter et al., 2013) “Some people in the Asperger’s community maintain that Asperger’s is different enough from autistic disorder to merit its own category, worrying that they will lose an important part of their identity; others in the community applaud the change, embracing the idea of a continuum.” (Jabr, 2013 b)
The DSM-5 work group claims these changes will have minimal impact: only 10% less children will be assessed for autism spectrum disorder (ASD). The revision will not affect education services for those who are currently diagnosed with Asperger’s disorder, because it is incorporated under this umbrella diagnosis, which covers the full range of autism symptoms. Anyone who met the criteria for Asperger’s in the old manual would be included in the new diagnosis. (Frances, 2012 a).
Scientific studies tell a radically different story. (Weissman, 2013) Several critics of the DSM-5 point out that the new definition of autism will result in a much lower rate: Mattila found only 46% of those given a DSM-IV diagnosis met criteria for DSM-5 ASD (Mattila, et al., 2011). Taheri and Perry found only 63% of DSM-IV patients met DSM-5 criteria (Taheri & Perry, 2012). McPartland, Reichow, and Volkmar found only 60% diagnosed with ASD under DSM-IV would get a DSM-5 ASD diagnosis (McPartland, Reichow &Volkmar, 2012).
In a 2012 study on the potential fallout from the DSM changes, an analysis of symptoms in nearly 1,000 individuals were evaluated for autism in a field trial. They found that about 25 percent of those diagnosed with classic autism – and 75 percent of those with Asperger’s Syndrome or PDD-NOS – would not meet the new criteria for autism. The study also suggests that higher-functioning individuals may be less likely to meet the new criteria than individuals with intellectual disabilities. (Greenfield, 2013)
Another study presented in Iceland in 2012 notes that under the new DSM-5 autism spectrum disorder criteria, only 45 percent of individuals previously diagnosed with Asperger’s syndrome or PDD-NOS will retain their diagnosis. (Scrowley, 2013)
Other researchers investigated how DSM-5 criteria will fare in a diagnostic clinic for adults with minimal intellectual disability. “Compared to ICD-10R and DSM-IV-TR, DSM-5 specificity was good but sensitivity was poor: 44% of adults who met ICD-10R ASD criteria and 22% who met DSM-IV-TR criteria for Asperger syndrome or autistic disorder would not qualify for a DSM-5 ASD diagnosis.” (Wilson, C. E., et al., 2013)
Therefore advocacy groups who identify with the Asperger’s community are concerned about the DSM changes. (Hill, 2013)
Others are concerned because children with autism versus Asperger’s disorder have different motor patterns. In particular, children with autism are more bouncy, they have more difficulty walking on a straight line. This irregular gait has not been observed in children with Asperger’s disorder. “So that tells us that there are probably differences in the area of the brain between these two groups.” (Malcom, 2013)
Temple Grandin commented on the change in the following way: “Previously, if you had speech delay as a kid, as I did, then you fell on the autistic side of the diagnostic divide (assuming you met the other necessary criteria, of course). If you didn’t, then you fell on the Asperger’s side. Now some of the former Aspies will get an ASD diagnosis, just by virtue of meeting all the criteria for that diagnosis but not having speech delay. … Those who previously would have been diagnosed with Asperger’s might learn that they don’t belong in the neurodevelopmental-disorders category at all, at least not officially. … To me, the DSM-5 sounds like diagnosis by committee. It’s a bunch of doctors sitting around a conference table arguing about insurance codes. Thanks to label-locked thinking, we now have a cornucopia of diagnoses – and there simply aren’t en
ough brain systems for all these names.” (Grandin, 2013)All the above-mentioned studies suggest that, contrary to the assertion of the DSM-5 work group, the revised manual will likely have a radical impact on autism diagnosis and qualification for school and mental health services, health insurance, and Medicaid coverage. (Frances, 2012 a) A higher functioning subset of affected children could lose funding for services due to the tighter diagnostic criteria (Willingham, 2012). For example, “there are disparities in services offered to affected individuals by diagnosis; a diagnosis of autism is eligible for speech, occupational, physical, and behavioral therapies, whereas funding for other diagnoses within the Neurodevelopmental Disorders category is significantly less.” (Halter et al., 2013)
Considering the varying symptoms and signs that children diagnosed with different forms of autism can display, many parents and doctors have also expressed concerns that the new definition of autism spectrum disorder could overlook those in need of professional treatment. (Scrowley, 2013)
A peer-review of the above-mentioned Iceland study revealed in March 2012 that while the DSM-5 rules out a large portion of previously diagnosed cases, it is effective at eliminating those who are not actually autistic. (Scrowley, 2013) “Unfortunately, the DSM-5 group has chosen to simply ignore data that don’t conform with its beliefs. … The DSM-5 autism group has been blinded by an intellectual conflict of interest. Eager to introduce its concept of an autism spectrum, the group somehow lost sight of a crucial and obvious fact – its proposed criteria set is written so exclusively that it must inevitably reduce the diagnosis of autism.” (Frances, 2012 a)
1 in 50 school-aged children are reported to have autism. (Falco, 2013) Frances believes that autism has been over-diagnosed because it is too closely coupled to school services. But he does not think the needed reduction of rates should come from a mistake in DSM-5 criteria writing or the over valuation of one study that has been conducted by the person who is most responsible for recommending the change. (Frances, 2012 a)
“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.” (Frances, 2012 b)
In response to these concerns, the Autism Spectrum Disorder Work Group of the APA asserted that the new criteria are more inclusionary, rather than exclusionary, for the following reasons:
Frances also refers to two fatal technical flaws in the DSM-5 definition of autism, explaining: “DSM-5 turns the current confusion into a complete Babel. The impossibly vague and confusing DSM-5 definition of Autism Spectrum Disorder is essentially useless for clinical or research purposes and is not a trustworthy guide for determining school services. … These egregious mistakes require immediate correction. Too much rides on the diagnosis of autism to let it ride on each clinician’s random preferences.” (Frances, 2013 u)
Attention-Deficit/Hyperactivity Disorder
The prevalence of ADHD in school-age children has doubled between 2000 and 2009. (Hickey, 2013 c) The NY Times reported that nearly one in five high-school-age boys in the United States and 11 percent of school-age children over all have received a medical diagnosis of attention deficit hyperactivity disorder, according to data (data collection: February 2011 through June 2012) from the federal Centers for Disease Control and Prevention. (Schwarz & Cohen, 2013) Critics of the DSM don’t believe that this diagnostic expansion is the result of more cases being recognized but that the criteria in the DSM are so vague and so ubiquitous that they can be stretched to embrace almost any child. (Hickey, 2013 c)
The DSM-IV required that the symptoms were present before age 7 and cause significant impairment in activities. The DSM-5 raised this threshold to 12 and requires only that the symptoms impact daily activities. The revision made it easier for adults to receive this diagnosis by reducing the adult threshold from 6 to 5 items – although adult distractibility can be caused by any number of psychiatric problems. “The diagnosis of ADHD needs to be tightened, not loosened.” (Frances, 2013 e) Therefore the revised definition of ADHD in the DSM-5 has been perceived as is a step in the wrong direction.
Frances fears that this will result in inflation of children diagnosed with this disorder. The easier-to-gain adult diagnosis can increase the potential for psycho-stimulant drug abuse for performance enhancement and recreation. This might contribute to the already large illegal secondary market in diverted prescription drugs. (Frances, 2012 b)
Rejecting the DSM’s definition of an onset for this disorder as late as age 12, Frances suggests expecting strong signs of it to appear by age 7 or earlier. “Allowing later onset further confuses ADHD with the many other psychiatric causes of hyperactivity, impulsivity, and distractibility. Kids with clearly diagnosable ADHD are pretty much born with the problems and show them early. Later onsets are likely to have other causes. (Frances, 2013 e)
Hickey points out that there are no objective tests for ADHD, and no established organic pathology. “The ‘diagnosis’ is based entirely on subjective reports from parents and teachers. … The APA created the ‘illness,’ and pharma created the drugs.” (Hickey, 2013 c)
Disruptive Mood Dysregulation Disorder
This disorder is added in DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. Mental health care providers and the public alike have criticized disruptive mood dysregulation disorder for its medicalization of temper tantrums. The new diagnosis may result in attributing pathology where it is not appropriate. (Halter et al., 2013 a)
Critics worry that psychiatrists will continue what they see as a trend of over-diagnosis and over-medication. (Jabr, 2013) Frances believes that the new diagnosis is a result of a misguided hope to reduce over-diagnosis. He believes that there is a better way to solve this problem: “It should have been confronted directly in DSM-5 with bold warnings in the bipolar disorder section and through conferences to re-educate clinicians and counter drug company marketing.” (Frances, 2013 e)
Frances also remarks: “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 vulnerable 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.” (Frances, 2012 b)
Axelson et a. put disruptive mood dysregulation criteria to the test using several years’ worth of data collected from 706 children. He concluded that the new disorder was not very useful. It confusingly overlapped with – and was often difficult to distinguish from – two established diagnoses: oppositional defiant disorder and conduct disorder. He also argues that a diagnosis of disruptive mood dysregulation in childhood was not a good predictor of future mental health issues, specifically depression and anxiety. (Axelson, et al., 2012)
The DSM-IV made provisions for bereavement. The manual prevented individuals with depressive symptoms from being diagnosed with major depression if their symptoms occurred within 2 months of losing a loved one, understanding that many of these symptoms are normal and appropriate responses to a significant loss.
The criteria for major depressive disorder in the DSM-5 supports its diagnosis after 2 weeks of sadness and loss of interest in life events – along with reduced appetite, sleep, energy, etc. – following the loss of a loved one. This means that the new manual is essentially requiring providers to diagnose a grieving individual as mentally ill.
Therefore, many people formerly considered to be experiencing a variation of normal grief now get a mental disorder label. Critics believe that this revision could cause confusion or harm because it is setting up the idea that some forms of grief are normal and some forms of grief are indicative of a mental disorder. (“Grief is agony,” 2013)
Frances notes that this is helpful for some people who would receive much needed treatment earlier than would otherwise be the case. “But for many others, an inaccurate and unnecessary psychiatric diagnosis could have many harmful effects. Medicalizing normal grief stigmatizes and reduces the normalcy of the pain, short circuits the expected existential processing of the loss, reduces reliance on the many well established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment.” (Frances, 2010)
Frances added later that this change might lead to trivializing our expectable and necessary emotional reactions to the loss of a loved one and the resiliency that comes with time and the acceptance of the limitations of life. (Frances, 2012 b) A view that minimizes normal grief may impair the dignified process of grief and may discourage the appropriate use of religion and the comfort of family and friends. (Kleinman, 2012).
Noel emphasized, “the world looks to the field of psychology to understand normal versus abnormal behavior, and the field of psychology uses the DSM as its guide for drawing the often fine line between what is normal and abnormal. This is a responsibility that should not be taken lightly. Labeling someone as mentally ill has significant implications. … In cases where a perfectly healthy person is labeled as mentally ill, the implications can be devastating – just ask the gay man who was considered mentally ill in the early 1970s before homosexuality was removed from the DSM. To be labeled as sick, to be pathologized, for being who you are, or for being appropriately devastated by the loss of a loved one, serves no purpose and may be quite harmful.” (Noel, 2013)
Gup explains that the latest iteration of the DSM, like those before, is not merely a window on the profession but on the culture it serves, both reflecting and shaping societal norms. “Ours is an age in which the airwaves and media are one large drug emporium that claims to fix everything from sleep to sex. I fear that being human is itself fast becoming a condition. It’s as if we are trying to contain grief, and the absolute pain of a loss. We have become increasingly disassociated and estranged from the patterns of life and death, uncomfortable with the messiness of our own humanity, aging and, ultimately, mortality.
Challenge and hardship have become pathologized and monetized. Instead of enhancing our coping skills, we undermine them and seek shortcuts where there are none, eroding the resilience upon which each of us, at some point in our lives, must rely. Diagnosing grief as a part of depression runs the very real risk of delegitimizing that which is most human – the bonds of our love and attachment to one another.” (Gup, 2013)
Other critics argue that there are major differences between grief and clinical depression: Grieving people usually do not have the same problems of self-esteem as the depressed, and the recurrence rate of major depression in the bereaved is no greater than in the general population. The bereaved are also less likely to have impaired role functioning or comorbid disorders. Another distinction is that clinical depression lacks the stages – from initial shock and numbness through to yearning, anger, guilt and eventual resolution – which are integral to grief. There are also huge differences in treatment response. (“Grief over DSM-5”, 2013)
Major depressive disorder is an illness that can wax and wane across the lifespan. People with this disease may suddenly find themselves in a depressed mood with negative self talk, lack of ability to derive pleasure in life, low energy, and decreased functioning. Although these random depressive episodes frequently have no stressor in origin, they can also be triggered by stressful life events, like the loss of a loved one. The experience of bereavement can mimic the symptoms associated with major depressive disorder but they don’t necessarily have the chronic flavor of major depression. (Line, 2013)
“Rather than try to shoehorn grief into the domain of clinical depression, it might be better to go the other way and consider whether many reactive depressive conditions would fit more comfortably within a grief paradigm. … By pathologising and medicalising grief and indirectly encouraging doctors to prescribe antidepressants for it, psychiatrists run the risk of losing a lot of credibility.” (“Grief over DSM-5”, 2013)
The reduction of symptom duration from 6 to 3 months and the reduction of the number of symptoms from 3 to 1 have been opposed by Aaron Beck, the father of cognitive-behavioral therapy. He asserts that reducing the symptom threshold for anxiety will result in false positives. (Starcevic, Portman, & Beck, 2012) The new definition is far too loose and therefore obscures the already fuzzy boundary been generalized anxiety disorder and the worries of everyday life. Increased diagnoses might expand the widespread practice of inappropriately prescribing, and the overuse of, addictive anti-anxiety medications. (Frances, 2012 b)
Frances believes that instead, this diagnosis should be reserved for people whose worries are extensive, pervasive, beyond the ordinary, disabling, enduring (for at least six months or more), and not better accounted for by another diagnosis. (Frances, 2012 e)
Allen Frances is concerned that the DSM-5 has diluted the “stressor gatekeeper”: The only definitional hurdle that protects against the inappropriate forensic diagnosis of posttraumatic stress disorder (PTSD) is the requirement that the patient had intense contact with an unusually severe stressor. “The DSM-5 lowered this threshold considerably by allowing the diagnosis of PTSD in people who have had no direct exposure, but merely learned about a violent traumatic event that was experienced by a close relative or friend.
This may make good clinical sense, but inadvertently creates a forensic disaster. Every one of the victim’s relatives and friends can now claim damages based on their second hand, contact PTSD.” (Frances, 2013 e) Therefore, the DSM-5 might have opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings. (Frances, 2012 b)
Frances points out that the history of psychiatry has been filled with recurring fads of dissociative disorder like multiple personality disorder or conversion disorder. Fads in psychiatric diagnosis start with an exciting idea. A group of charismatic and gullible therapists promote it, and a growing army of suggestible and theatrical patients dramatize and spread it. (Frances, 2013 e)
Dissociation has often provided the exciting idea – that something has been split off and repressed deep within the patient’s psyche and that she can be healed once it is returned to consciousness. The problem is that allegedly “repressed” material can take fantastic forms shaped by the joint creative imaginations of the therapist and patient. What emerges from their efforts often bears little or no relation to either psychic reality or real reality. (Frances, 2013 e)
Somatoform disorders in the DSM-IV was confusing and flawed. (Dimsdale, 2011) They were rarely used in clinical practice. Primary care physicians did not understand the terms, and patients found them demeaning and offensive. (Levenson, 2011)
Instead of dispensing altogether with a clutch of disliked, dysfunctionalcategories, and despite the vehement opposition of many in the health care field, the American Psychiatric Association decided to include somatic symptom disorder in the DSM-5. In the revised manual, somatic symptom disorder (SSD) appears in a new section, among somatic symptoms and related disorders, which replaces the somatoform disorders section found in DSM-IV. Den Broeder brings the new definition of somatic symptom disorder to a point, saying: “DSM-4: ‘If we can’t understand it, it must be mental.’ DSM-5: ‘If we can understand it, surely it must be mental as well.'” (Den Broeder, 2013)
The Somatoform Disorders Work Group rebranded these disorders and assign new criteria that captures patients with diverse illnesses, expanding application of psychiatric services, antidepressants, and behavioral therapies. (Chapman, 2012) The new category extends the scope of mental disorder classification by eliminating the requirement that somatic symptoms must be “medically unexplained.”
In the DSM-5, the focus shifts to “excessive” responses, to distressing, chronic, somatic symptoms with associated dysfunctional thoughts, feelings, or behaviors. (Frances, 2013 h) Somatic symptom disorder is now based on subjective and difficult to measure cognitions that enable a “bolt-on” diagnosis of mental disorder to be applied to all medical conditions, irrespective of cause. (Frances, 2013 a)
“The relation between psychiatry and the rest of medicine has been difficult to manage both for mental health practitioners and for primary care doctors, and this is even more problematic for patients caught in between. The boundary has never been clear-cut or static but has shifted back and forth depending on new findings and fashions. The realm of psychiatry would shrink, and that of medicine would expand, whenever advancing science discovered a cause for a previously poorly understood presentation. … This fuzzy boundary between psychiatry and general medicine is about to experience a seismic shift” (Frances, 2013 h).
UK health advocate Suzy Chapman provided a devastating and compelling critique. She stated that there is no research to support this change, which opens the gates to widespread diagnosis and treatment of people who would have been previously just considered “worrywarts”. (Chapman, 2012)
“To meet requirements for Somatization Disorder (300.81) in DSM-IV, a considerably more rigorous criteria set needed to be fulfilled: a history of many medically unexplained symptoms before the age of thirty, resulting in treatment sought or psychosocial impairment. The diagnostic threshold was set high – a total of eight or more medically unexplained symptoms from four, specified symptom groups, with at least four pain and two gastrointestinal symptoms. In DSM-5, the requirement for eight symptoms is dropped to just one. …
While media and professional attention has been focused on the implications for introducing new disorders into the DSM and lowering diagnostic thresholds for existing categories, the Somatic Symptom Disorders Work Group has been quietly redefining DSM’s somatoform disorders with radical proposals that could bring millions more patients under a mental health diagnosis. …
This will license the application of a mental health diagnosis for all illnesses – whether ‘established general medical conditions or disorders’ like diabetes, heart disease and cancer or conditions presenting with ‘somatic symptoms of unclear etiology’ – if the clinician considers the patient is devoting too much time to their symptoms and that their life has become ‘subsumed’ by health concerns and preoccupations, or their response to distressing somatic symptoms is ‘excessive” or ‘disproportionate,’ or their coping strategies ‘maladaptive’. …
At the APA’s 2012 Annual Meeting, Work Group Chair, Joel Dimsdale, MD, admitted his committee has struggled from the outset with the ‘SSD’ criteria set. But rather than revising in favor of less inclusive requirements or subjecting the entire section to independent, external scientific review, the Work Group’s puzzling response has been to lower the threshold even further. …
The refusal of the APA to even broaden the criteria for Somatic Symptom Disorder is not just a bitter disappointment, but a potentially dangerous mistake.” (Bernard, 2013) “Unfortunately, the DSM-5 invitation for comments from the field turned out to be no more than an empty public relations show.” (Chapman, 2012)
“Adding to the woes of the medically ill could be one of the biggest problems caused by DSM-5. … The emotional distress some people have in reaction to real or feared illness does sometimes get out of all proportion enough to require psychiatric attention. But there are serious risks attached to over-psychologizing somatic symptoms and mislabeling the normal reactions to being sick.” (Frances, 2012 c)
“For reasons that I can’t begin to fathom, DSM 5-has decided to proceed on its mindless and irresponsible course.” (Frances, 2013 a) The sad result will be the mislabeling of potentially millions of people with a fake mental disorder that is unsupported by science and flies in the face of common sense because they are just the normal emotional reactions that people understandably have in response to a medical illness.
For example, one in four people with chronic pain will be mislabeled. “In a field trial study to check for somatic symptom disorder, the results included 15% of patients with cancer or heart disease and 26% with irritable bowel syndrome or fibromyalgia. The rate of psychiatric disorder among medically ill patients is unknown, but these rates seem high.” (Frances, 2012 c)
Bernhard remarks: “Some health insurance companies won’t cover mental health treatments (from therapy to psychotropic drugs) unless the patient has a diagnosis from the DSM. So if you wished to seek therapy or try these medications to help you adjust to the drastic life changes brought about by chronic pain or illness, it’s possible that this expanded definition of somatic disorders will allow you to get these services paid for by your insurance company.
But the downsides of including Somatic Symptom Disorder in the DSM-5 far outweigh the benefits:
I thought the rule of thumb in medicine was to rule out physical causes before settling on psychological ones.” (Bernard, 2012)
Chapman describes additional potential far-reaching implications for all patient populations:
Frances adds to this list:
Phillips adds to these arguments: The authors of the guidelines for making major changes in the DSM say that SSD should require a very high level of empirical support. “It’s not evident where and what such support is for SSD. … In not following its own guidelines, the DSM-5 Task Force does seem vulnerable to the criticism of diagnostic expansion.” (Phillips, 2013)
Steven A. King, the Chair of the DSM-IV and DSMIV-R Pain Disorders Committees, believes that at least as regards to how it handles pain, the new diagnosis is a step in the wrong direction and the rationale for making the proposed changes are incorrect. “I don’t know how any one could determine what are “excessive thoughts, feelings and behaviors” required for this diagnosis for example for a patient with cancer pain or one who has been disabled by chronic pain as we have absolutely no idea as to what would be a normal or expected response to these problems. From my experience such thoughts, feelings and behaviors would probably be more a reflection of the mismanagement of pain experienced by many patients rather than psychological issues of the patients themselves. Furthermore, its indication that this diagnosis fits on a continuum with conversion and factitious disorders strongly suggests the pain involved isn’t “real.” In fact, pain that is secondary to the mental disorders (and pain is one of the most common presenting symptoms of both depressive and anxiety disorders) is just as real to patients as that related to medical disorders. … Unlike Dr. Frances who fears the new diagnosis may be overused, I believe it will be rarely if ever used.” (King, 2013)
“During the second public review, the Somatic Symptom Disorders proposals attracted more responses than almost any other category. The SSD Work Group is aware that patients, caregivers and patient advocacy organizations have considerable concerns.” (Chapman, 2012)
For example, Frances proposed a possible solution to the problems he has identified: “Somatic Symptom Disorder should be removed from the main body of DSM-5 that is meant to describe the various mental disorders. Instead, unexplained physical symptoms or problematic responses to illness should be covered in the V Code section of the manual that includes Other Conditions That May Be A Focus Of Clinical Attention. This would remove the stigma and risks of mislabeling somatic concerns as mental disorders, while still providing clinicians with a code to describe the presentation. Second best solution – tighten the wording of the criteria set to make it less wildly over inclusive.” (Frances, 2012 c)
Subsequently, Frances pointed out: “The DSM 5 work group did discuss my suggestions, but rejected them, and is moving ahead with their loose definition. … Why is APA prepared to abrogate its duty of care as a professional body and expose its membership, physicians and the allied health professional end-users of its manual to the risk of potential law suits?” (Frances, 2013 b)
He assumes three possible explanations for the failure of DSM 5 to correct this problem:
Members of the DSM Somatic Symptoms Workgroup respond to this criticism saying that …
Another response to the critique stated: “If 15% of patients with cancer or heart disease and 26% with irritable bowel syndrome or fibromyalgia could benefit from a psychiatric intervention then should we not offer it? On the other hand, if they wouldn’t benefit, then it would seem inappropriate to include them in this diagnosis. Improving the value of the diagnostic criteria then becomes a matter of increasing the number of people offered an appropriate intervention and reducing the number offered an inappropriate one. Combating the stigma associated with psychiatric diagnoses will be slow and difficult, but the solution cannot be simply to deny people have psychiatric symptoms, thereby denying them any access to treatment for them.” (Pritchard, 2013)
Chapman and Frances are concerned that the new definition of SSD will also be reflected in ICD-11. “ICD-11 is field testing a new category – ‘Bodily Distress Disorder’ – proposed to replace six or seven existing ICD-10 somatoform disorders, which, according to working group reports on emerging proposals, mirrors the DSM-5 somatic symptom disorder definition.” (Gross, 2013)
Psychological Factors Affecting Medical Condition
The DSM-5 has moved the psychological factors affecting medical condition (PFAMC) from the back of the book (where it is not a mental disorder) to front and center in the chapter on Somatic Symptom Disorders (where it is now a mental disorder).
To Frances, “it is definitely not mental illness to feel stress or to disagree with treatment or to be high strung or to be a couch potato or to be promiscuous. We all do things that are unhealthy – that doesn’t mean we are all mentally ill. … This makes no sense and will further pathologize the medically ill (including children) by giving them yet another opportunity to be stigmatized with an inaccurate and unnecessary diagnosis of mental disorder.” (Frances, 2013 c)
He explains that he can think of only two possible explanations for the otherwise unaccountable inclusion of PFAMC within the ranks of the mental disorders. “Either:
Like the somatic symptom disorder, a diagnosis of PFAMC might mislabel as mentally ill many people who are just physically ill. “It is burden enough having a medical illness. By piling on a fake psychiatric diagnoses, DSM 5 just adds insult to injury.” (Frances, 2013 c)
Binge eating disorder (BED) was created to diagnose people who have recurring eating binges, without the compensatory activities like vomiting and laxative use seen in bulimia nervosa. Critics point out that excessive eating 12 times in 3 months is no longer just a commonplace of human experience as well as a manifestation of gluttony and the easy availability of good-tasting food. DSM-5 has instead turned it into a mental disorder. (Frances, 2012 b)
Frances believes that this diagnosis could easily become the most common in psychiatry despite the fact that there has been very little research on how it should be defined and assessed, on its implications for treatment, and on the risks and benefits of applying it to a given patient.
Other opponents of the inclusion of this disorder note that while overeating is not healthy or good behavior, it should not be used to label a common eating behavior in the DSM. (Halter et al., 2013 a)
In response to these concerns the following perspective has been expressed: “There is a marked difference between someone with an eating disorder and a person who eats to excess on occasion. … It’s the quality associated with the sense you can’t control what, when and where you’re eating that discriminates BED from simple overeating.” (Hanlon, 2013)
Avoidant/Restrictive Food Intake Disorder
Allen Frances sees two disqualifying problems with the diagnosis of avoidant/restrictive food intake disorder. This diagnosis resembles normal individual differences and preferences (e.g., fussy eaters) and it has received far too little study to be qualified as an official diagnosis of mental disorder. (Frances, 2013 e)
Female Sexual Interest/Arousal Disorder
Frances states: “If anything in the DSM can possibly be misused, it will be misused. Whenever a profit is to be made by twisting the DSM, it will be twisted. The drug companies’ aggressive marketing of sexual dysfunctions is a great case in point. The DSM-5 will give drug companies running room to continue their disease mongering of female sexual disorders (FSD), hyping this DSM diagnosis as a means of pushing pills. … “female sexual disorder” section is likely to be hyped and misused. …
Certainly there are some women who would like to have more sexual interest and easier orgasms, and diagnosis and treatment may sometimes be useful for them. But the disease-mongering pitch attempts to stretch this small market into a giant one by implying that sexual dysfunction is a fairly ubiquitous part of being female, and this is simply nonsense.” (Frances, 2013 g)
The DSM-5 eliminated the term gender identity disorder (GID) and introduced gender dysphoria for the distress occurring over a marked incongruence between one’s experienced gender and assigned gender. This change speaks to the mental state that accompanies being transgender within this society. “The removal of GID is compared to the organization’s declassification of homosexuality as a mental disorder. … Rather than indicating that a person needs to be fixed, the diagnosis indicates that the issues that need to be addressed lie outside the individual. … But the fact remains that trans and especially transsexual folks needing hormonal or surgical transition care are still classified as mentally disordered.” (Johnson, 2013)
Substance-Related and Addictive Disorders
Supporters believe that in this new one overarching disorder, the criteria have not only been combined, but also strengthened. With the rationale that addictions exist on a continuum, severity of diagnoses in this category is rated as mild, moderate, or severe, based on standardized rating scales. (Halter et al., 2013 a)
Frances, on the other hand, is concerned that first time or temporary substance abusers (e.g., many college students who binge drink) are lumped in definitionally with hard-core addicts, despite their very different treatment needs and prognosis, and the stigma this causes. (Frances, 2012 b)
In the DSM-5, cannabis abuse and dependence symptoms are combined into one disorder. When this factor is considered, researchers at the University of New South Wales in Australia found thousands previously categorized as having a cannabis disorder fell below the diagnostic threshold. Some are concerned that people who abuse this substance are now even less likely to seek help for the problems associated with the abuse because this research does not consider them as having a problem. (Davey, M. 2013)
For the first time, the new manual includes gambling disorder in the same chapter as substance use disorders. “Research indicates that gambling and substance-related and addictive disorders share a common reward-system neurocircuitry and behavioral patterns.” (Moran, 2013) Previous editions of the DSM classified “pathological gambling” as an impulse control disorder. Whether one can be addicted to a behavior like gambling the same way one can be addicted to a drug remains highly controversial. (Jabr, 2013 b)
Another behavioral addiction, Internet use gaming disorder, appears in section III, which is reserved for conditions that require further research before they are considered formal disorders. (Jabr, 2013 b) This concerns Frances who believes that Internet addiction is now particularly likely to become a new fad. (Frances, 2013 e)
Frances fears that introducing the concept of behavioral addictions might eventually make a mental disorder of everything we like to do a lot. This development indicates a “slippery slope” because our interests and passions are turned into addictions. (Frances, 2013 l) There is a risk that addictions to the Internet, sex, shopping, sun worship, exercise, or working, or video games, etc., become loosely applied as mental disorders. (Frances, 2013 e) This can lead to the development of lucrative treatment programs to exploit these new markets. (Frances, 2012 b)
The APA responded to these concerns saying that there was no intent to include a “catchall category” for other behaviors. “This has never been recommended by the work group. The only behavioral disorder (non substance diagnosis) proposed is gambling disorder. Gambling disorder has been included in previous editions of the DSM as pathological gambling.” (American Psychiatric Association, 2012 e)
The APA also does not see any problems with including Internet use disorder in Section III. “The work group was very conservative with their proposals, even though there was pressure from clinicians to add this and other behavioral addictions.” (American Psychiatric Association, 2012 e)
Opponents of this revised diagnosis are concerned that the everyday characteristic of forgetting in old age might be misdiagnosed as mild neurocognitive disorder and therefore pathologized: With aging, people naturally begin to lose cognitive skills just as they gradually lose physical skills. There is no line separating what should be labeled illness vs. what is the expectable wear and tear of life – particularly given the vast individual differences in previous baseline functioning, in self-expectations, and in the cognitive challenges that have to be faced. There will be an alarming and unacceptably high false positive rate – surely exceeding 50 percent – suggesting serious impairments of cognition. (Frances, 2013 e)
The DSM-5 definition of mild neurocognitive disorder provides absolutely no benefit even for those at true risk for later developing dementia. There is currently no effective treatment for mild neurocognitive disorder and none is obvious on the near horizon. Almost certainly, we will have accurate biological tests far before we will have an effective treatment. (Frances, 2013 e) Although it provides no useful call to action, the new label can create great anxiety when only limited, non-curative, non-reversing treatments exist for dementia. It will cause far more harm than good. (Frances, 2012 b)
“Accurate diagnosis of mild neurocognitive disorder will most certainly require biological tests. And these are now well within reach – within the next few years, we will have objective laboratory methods to identify the prodrome [early symptoms] of Alzheimer’s. Much remains to be done in standardizing these tests, determining their appropriate set points and patterns of results, and negotiating the difficult transition from research to general clinical practice – but the goal is within sight. The rapidly advancing science makes obvious how premature it is now to attempt to diagnose mild neurocognitive disorder on vague and untested clinical criteria. No purpose can possibly be served by rushing ahead with a second rate clinical method of prodrome diagnosis when more accurate biological testing will so soon be available.” (Frances, 2013 e)
In summary, the DSM-5 definition of mild neurocognitive disorder is a mistake because it is based exclusively on extremely fallible and unreliable clinical criteria. “This is a research idea, created by researchers, that is far out of touch with current clinical reality and is simply not ready for general use.” (Frances, 2013 e)
The DSM-IV defined “unusual” sexual stimulation as paraphilias. Paraphilic disorders are still included in the DSM-5 if the individual feels personal distress about their interest. Keenan refers to sexual masochism disorder, fetishistic disorder, transvestic disorder, and so on saying, “happy kinksters don’t have a mental disorder. But unhappy kinksters do.” (Keenan, 2013)
Although some sexual minorities have applauded this diagnostic compromise as a step forward, others consider it “just the same routine that the psychiatric community dragged homosexuality through decades ago, and adult, consensual (in other words, noncriminal) expressions of atypical sexuality should be removed from the DSM entirely for many of the same reasons that homosexuality was.” (Keenan, 2013) For example, the Trans community complains about the inclusion of Transvestic Disorder, which is defined as “excessive sexual or erotic interest in cross-dressing.” (Gray, E. 2013)
Feminist Julia Serano expressed her frustration, saying that the inclusion of paraphilic disorders in the DSM reinforces the cultural belief that young, thin, able-bodied cisgender women and men are the only legitimate objects of sexual desire. Individuals must be mentally disordered in some way if they are attracted to someone who falls outside of this ideal. “It’s bad enough that such cultural norms exist in the first place, but to codify them in the DSM is a truly terrifying prospect.” (Serano, 2009)
Keenan states that people who are stigmatized and misunderstood, such as sexual minorities, might be unhappy – but the unhappiness itself is the problem that should be treated, not the person’s sexual identity or practice. “A person who feels persistent personal distress about the shape of her nose, for example, can access psychiatric treatment despite the fact that “nose perception disorder” is not listed in the DSM. … Isolating specific paraphilias as potential “disorders” is redundant. Worse, that specificity suggests that there is something unique to people with certain atypical sexual urges that makes us more likely to be mentally disordered than anyone else.” (Keenan, 2013)
She also emphasizes, “the fundamental tenet of medicine is, ‘First, do no harm.’ … DSM-based diagnoses do have real-life consequences for all sexual minorities. They have influenced employment decisions, child custody proceedings, security clearances, and health insurance coverage.” (Keenan, 2013)
Almost every day, Keenan receives emails from kinky men and women around the world who tell her about their incredible loneliness and shame. Many of them cite the psychiatric understanding of paraphilias – a de facto endorsement of social stigma – as a partial source of their isolation. (Keenan, 2013)
It is hard to separate value judgments from what’s considered “sick”. As long as mental illness remains tangled in cultural ideas about morality and right and wrong, handling sensitive subjects such as sexual desire will remain complicated. “As long as we don’t have a good definition of a mental disorder, we won’t have a good classification of mental disorders.” (Pappas, 2013)
Allen Frances wrote in an email: “Don’t see much purpose to including paraphilias in DSM and their misdiagnosis has caused much mischief in sexually violent predator hearings.”
After the National Institute for Mental Health (NIHM) announced that it would no longer use the DSM diagnoses in its research projects, many responses appeared in defense of the DSM:
“Scientists have been searching for decades for the neural basis of mental disorders – the holy grail of psychiatry – but the goal has proved frustratingly elusive.” (Friedman, 2013)
David Kupfer, the chair of the DSM-5 task force, responded: “Efforts like the National Institute of Mental Health’s Research Domain Criteria (RDoC) are vital to the continued progress of our collective understanding of mental disorders. But they cannot serve us in the here and now, and they cannot supplant DSM-5. RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field. In the meantime, should we merely hand patients another promissory note that something may happen sometime? Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.” (Kupfer, 2013)
Without abandoning his basic position, the top government official, Insel, who had criticized the DSM-5, took a step back. In a joint statement, the leaders of the American Psychiatric Association and the National Institute of Mental Health expressed the “shared interest” of both organizations in “improving and advancing mental disorder diagnostics for the future”: “DSM-5 and RDoC represent complementary, not competing, frameworks for this goal. … As research findings begin to emerge from the RDoC effort, these findings may be incorporated into future DSM revisions and clinical practice guidelines. It will take years to fulfill the promise that this research effort represents for transforming the diagnosis and treatment of mental disorders.” (Insel & Lieberman, 2013)
Koplewicz stated, “the DSM is a clinical tool more than a scientific one, designed to compensate for the often unknown ‘etiology’ or cause of psychiatric illness. Lacking objective diagnostic tests – for now – the manual creates a set of clinical categories so that doctors are on the same page, and so that research into treatments could be effectively compared.” (Koplewicz, 2013) The RDoC “will be driving the NIMH research agenda, but it is unlikely to impact clinical practice anytime soon.” (Doub, 2013).
Frances quotes to Barney Carroll, “one of the great pioneers of biological psychiatry and perhaps the world’s leading expert on the role of biological testing in psychiatry”, who says:
(Frances, 2013 t)
In a PBS television interview, Judy Woodruff asked two supporters of the DSM-5, Michael First and Steven Hyman, whether the DSM could be harmful. They responded saying: “It’s not to be used as a cookbook. Clinical judgment – people go and learn how to be mental health professionals and spend years in practice gaining a skill. … If somebody were to open up the book and just read the words and just apply them without using any clinical judgment, that could be very, very harmful. …
People who are insurance claims adjustors and educators and people in courts of law are not trained as clinicians and tend to read the book quite literally. I think it’s important that, with the revision, there be appropriate educational efforts again to make sure that nobody who really is in need of services is denied services or the book is taken to be too literal. … The people who should take it least literally are scientists, because you can get yourself into the fix that if you recognize that the book is imperfect, but you force yourself to follow every dictate quite literally, then you find yourself unable to make the very necessary progress that psychiatry needs.” (“What DSM-5, Updated Mental Health ‘Bible,’ Means”, 2013).
Since the APA is counting on having a captive audience that feels forced into using the DSM-5, Frances suggested that a successful boycott would free that audience: “Don’t buy it. Don’t use it. Don’t teach it.” (Frances, 2013 l) The International DSM-5 Response Committee calls on clinicians, consumers, scientists and other relevant parties to avoid use of the DSM-5 wherever possible and to actively seek out alternative diagnostic approaches. (International DSM-5 Response Committee, n. d.)
John Grohol, the creator of the website Psych Central, responded in the following way: “There is no “perfect” process, and there’s no process that isn’t going to be flawed or criticized by others. … I’ll hold the hyperbole while we hold our breaths that no ‘epidemic’ of mental disorder diagnoses will occur while we wait. There’s no ‘war,” there’s no ‘revolt,’ and professionals will go on using the DSM-5 just as they use the DSM-IV, because insurance companies and those paying the bills will leave them little choice.” (Grohol, 2013 a)
Frances disagrees, stating that there is no need to buy the DSM-5 to code their patients for billing purposes. The only official codes are the ones provided by the ICD. Therefore, the codes used for insurance purposes are not DSM codes at all – they are ICD codes that are freely available on the Internet (http://www.cdc.gov/nchs/icd/icd9cm.htm).
“The editors of DSMs simply pick the ICD codes they feel most resemble the DSM categories. Their choices are based solely on their own opinions, not through any officially sanctioned mechanism and they carry no special weight. There is nothing sacred about the DSM-5 choices – I know because I am the one who made the final choices for DSM-IV.” (Frances, 2013 l)
One of the biggest health insurance companies, Optum (UBH: United Behavioral Health), emphasizes in a note to providers: “Because the ICD and DSM codes have such a high level of overlap, many behavioral health clinicians may not be aware that claim platforms in the United States rely on ICD-9-CM. The DSM code you enter on a claim is the same as the ICD code. … DSM-IV-TR codes are closely aligned to the ICD-9-CM codes which will continue to be used through September 30, 2014 for all claim submissions.” (“DSM-5 & ICD-10”, 2013) This means in effect that UBH ignores the revision of the DSM.
For Extended Bibliography and References, click here.