Well, the Board of Trustees of the American Psychiatric Association has done it – they’ve signed off on a DSM-5 containing changes that are fraught with flaws, replete with overkill and scientifically weak. My advice to clinicians is this: If you have any intention of attending a DSM-5 workshop (or maybe you already have), you should challenge the presenter to address the changes that make absolutely no sense and that will likely lead to considerable over-diagnosis and indiscriminate medication use.
To distinguish itself from its DSM predecessors, DSM-5 attempted to turn psychiatry on its ear, that is, to make a splash by adopting a “more is more” approach. This overzealousness – together with a disorganized game plan that had us wondering if this edition would ever be released – has led to excessive riskiness that can potentially violate the most sacred tenet of medicine – Do No Harm!
This tact did not go unchallenged. Numerous mental health associations called for an independent review process to assess the benefits vs. the risks of the most controversial changes. Respected publications, the media and even the public got involved to some extent – all with the expressed purpose of challenging inclusion decisions that seemed to lack scientific credibility and defied common sense. The APA refused to endorse any independent review challenges and as such, we are where we are.
Here’s my take on DSM-5’s most potentially egregious changes and the ones I endorse you ignoring:
- Disruptive Mood Dysregulation Disorder (DMDD). This diagnosis morphed out of the over-diagnosis of Bipolar Disorder in youth, and will serve as a diagnostic dumping ground for children that all too often are having no more than temper tantrums. Don’t we already have Oppositional Defiance to cover for this? And what’s the chance that a clinician who is intolerant of unruly behavior will be quick to diagnosis this – and get paid by an insurance company? This is a mess waiting to happen, is untested and opens another door for medicating kids inappropriately and excessively.
- Childhood Bipolar Disorder. The diagnosis of this disorder in youth increased 40X in just a decade! And it’s because of this rampant over-diagnosis that DMDD made it to the drawing board in the first place. A 40-fold diagnostic rate is preposterous and serves as a horrible representation of child psychiatry’s ability to assess for this appropriately. We don’t need another fad, and that just what this has become, following in the footsteps of the tripling of ADD. And to add insult to injury, Autistic Disorder is at a 20X increase. Yet another door opens to medicate vulnerable children. I’m wondering how many doors there are now, or more accurately trap doors.
- Minor Neurocognitive Disorder. The certainty with which we can differentiate a symptomatic or performance profile which represents a true prodrome from occasional variability in cognitive performance is problematic. Thus, forgetfulness associated with the aging process will now be at risk for a diagnosis of Minor Neurocognitive Disorder. It’s true that some of these people may be at risk for dementia, but it also could create a pool of false positives for those not at risk for dementia – creating unnecessary anxiety for these people. Also, there is NO effective treatment for MND, so why not wait for the more accurate biological markers for dementia – particularly the Alzheimer’s type – to emerge. I’ll bet that they’ll be available within five years.
- Binge Eating Disorder. This is defined as excessive eating at least once a week over a period of three months (12 times in three months). In the city of New Orleans, where I’m from, and where there is an abundance of great food on practically every street corner, I suppose that many of us qualify for this one. Leave it to DSM-5 to turn overeating into something deserving of diagnostic criteria. I suppose the word gluttony has lost its cache. And how a clinician will be able to obtain an accurate picture of what’s going on here is beyond me. Are we to trust client self-report as a measure? I think not.
- Generalized Anxiety Disorder. This disorder has had shady boundaries since it was first included in the DSM. Now that the duration of symptoms has been reduced from six months to three months it will be harder to distinguish what is truly a chronic disorder from the concerns of everyday life. This will create a sizable new subset of “anxious” people who will be unnecessarily treated with antianxiety medications when all they’re experiencing are the ups and downs of living life on life’s terms.
I’ve been saying for years now that it’s just a matter of time before we all qualify for a mental health disorder of some sort. The cultural bar for diagnostic systems has been lowered and people with bonafide psychiatric Illness are already badly shortchanged from a treatment perspective due to our severely fractured mental health system. DSM-5 will make this worse by directing scare resources away from the very ill and instead toward people mislabeled as mentally ill. The mental health profession and those we serve deserve better.
To be fair: The DSM has served as a viable diagnostic guide for decades now, and its use as a teaching tool for graduate students and novice clinicians for understanding the process steps pursuant to diagnosis has proven to be most valuable. That said, we at the clinic level working in the trenches with mental illness every day, deserve a book that has been adequately field tested and subjected to outside scrutiny to confirm its credibility. This didn’t happen so my enthusiasm to embrace this manual is markedly tempered.