Comments on
Diagnosis of a DSM 5 News Cycle

By John M. Grohol, Psy.D.

Diagnosis of a DSM 5 News CycleAs I was sitting around catching up on some mental health news on Saturday, I inadvertently stumbled upon another manufactured news cycle about the DSM 5. Considering no new significant research findings were released in the past week on the DSM-5 revision efforts, I was a little surprised.

This latest fake news cycle started on Thursday, apparently with the release of a Reuters news story from Kate Kelland. Kelland notes the newest concern comes from “Liverpool University’s Institute of Psychology at a briefing in London about widespread concerns over the manual.” There’s no link to the briefing. And I’m not sure what a “briefing” is — a press conference? (And since when is a press conference a news item? It’s not really equivalent to a new research study, is it?)

Kelland fails to note that Europe and the U.K. don’t actually use the DSM to diagnose mental disorders — it’s a U.S. reference manual for mental disorders diagnosis. So while it’s nice that some Europeans are expressing concern about this reference text, their concern isn’t exactly much relevant. Context is everything, and Reuters failed to provide any useful context in that article.

Sadly, Reuters is a brand name. And once you write an article under that brand name, it cascades down an entire news cycle. Let’s follow it for fun!

14 Comments to
Diagnosis of a DSM 5 News Cycle

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  1. Dr Grohol,
    Do you dispute the 4000% increase in BD diagnosis in America after DSM-IV came out, or the relation of DSM-IV’s criteria and definition changes to that increase?

  2. Hi Dave,

    Regardless of whether I dispute it or not, do you have any scientific research to trace the actual cause of the increase?

    Second, should we use as one gauge for whether we update diagnostic criteria or not the incidence of diagnosis of such criteria? We wouldn’t dream of doing this in medicine (e.g., look at the increase of cancer diagnoses in the 1970s and 1980s), so why would we believe it’s okay for mental disorders?

    • Dr. Grohol,

      Thank you for your thoughtful post and candid, balanced message about the DSM-5. The process of developing the DSM-5 has been transparent to an extreme, with robust opportunities for the public (including patients) and professionals to weigh in and be involved in the process. A main goal of revisions of diagnostic criteria is finding the appropriate balance between making sure those who need treatment get treatment, while not risking overdiagnosis in those who don’t actually have a disorder. The many, many people involved in developing the DSM-5 are basing all of their recommendations on vast wealths of research and field trials. I can’t imagine a more evidence-based process that truly puts the interests of patients first.

      Claudia Reardon, MD

  3. I heartily agree with Dr. Grohol’s assessment that the DSM-5 revisions are being falsely turned into a potential return to asylum era psychiatry. When in fact the expansion of certain diagnoses would allow for early intervention, making less invasive treatment like psychotherapy, not more medications, feasible more often. I am starting to wonder exactly in whose interests these protests actually are.

  4. Dr Grohol,
    I hope you will be forthright and include this follow-up to our first exchange, as unfortunately your response might misdirect readers.

    Firstly, you avoided my question by answering it with another question. I would like to resubmit that question to you: Do you agree or dispute a false bipolar epidemic was caused by DSM-IV?

    Meanwhile, let’s examine some points in your article objectively:

    “UK/EU physicians do not use DSM.”
    Nationality has no bearing whatsoever on anyone’s accuracy.

    “..not all .. are mental health professionals — only approximately 88 percent”
    Perhaps some petioning opinions should be disregarded; you don’t mention the opinions of the remaining many-thousands of mental health professionals in the 80%.

    “…miss mentioning how the current DSM-IV — overseen by the same Allen Frances — has done exactly the same thing…”
    A lack of mentioning DSM-IV does not negate a statement about DSM-V. If anything, the former leader of DSM, having watched its aftermath for 17 years, might have more insight than most.

    “…now that he’s out of the process, he suggests the APA shouldn’t be the one publishing the reference text. ”
    It took a decade for negative outcomes of DSM-IV’s methodology to become apparent. By that time Frances worked elsewhere. This is irrelevant, and again, does not negate the warnings.

    And your response to me:
    “Regardless of whether I dispute it or not, do you have any scientific research to trace the actual cause of the increase?”

    One does not need scientific research when one steps in dog poo to realize something went wrong, that it was related to the last step, and more importantly, to reconsider stepping there again.

    The exponential increase of BD disgnoses as soon as DSM-IV expanded BD categories and criteria is obvious proof that a checklist approach (especially one with incomplete characterizations such as “Bipolar Not Otherwise Specified”) can lead us all like lemmings off a cliff.
    http://tinypic.com/m/fd9fut/2

    We are systemically leading society (doctor and patient alike) down the path of inability to think outside the box. Or in this case, outside the DSM.

    It had some bad consequences before, so why would we believe there will be a different outcome this time?

    • Hi Dave,

      1. I disdain emotional-laden terminology when trying to have a discussion, such as the word “epidemic.” I believe all mental disorders have the potential to be misdiagnosed and over-diagnosed because most of their diagnosis is done by family physicians and primary care physicians — not mental health professionals. In that context, I believe that bipolar disorder can be “over” diagnosed — especially in children (which isn’t even recognized as a distinct disorder in DSM-IV — demonstrating that you don’t need a reference text in order to create an “epidemic” of overdiagnosis).

      2. I stand corrected on this point.

      3. When respected news agencies don’t bother fact-checking the data they report, they add to the misrepresentation of that data. For instance, putting the 11,000 number into some context would be invaluable. Is this 50 percent of mental health professionals?

      In the U.S., it’s less than 2 percent. Once you add in all the mental health professionals around the world, it’s far less than 1 percent.

      While I think it’s interesting that less than 1 percent of mental health professionals have signed the petition, it’s not really a number that suggests this is a major concern among most — or even many — professionals.

      4. & 5. I think the lack of a frank discussion of Allen Frances’ motivations in this matter is unfortunate. His opinion holds a lot of weight, yet he has apparently chosen to wield it in such a way that ensures it will result in little change.

      The DSM revision process is and always will be imperfect, upsetting some professionals in every edition because some are just against “change.” Given your suggestion that it took a decade after the DSM-IV to come out before we had sufficient data on it, it would seem to suggest we wait a decade until the data on the proposed criteria have been fully vetted in the research?

      6. And here’s what I expected — when asked for the data, one falls back on rhetoric.

      I would also kindly point out that virtually every major mental disorder in the DSM-IV has a “NOS” category. With your logic, we would’ve also expected to see an “epidemic” increase across the board in NOS diagnoses since the release of the DSM-IV — an epidemic of NOS, if you will.

      That, of course, has not occurred.

      John

  5. Dr Grohol writes:

    “Kelland fails to note that Europe and the U.K. don’t actually use the DSM to diagnose mental disorders — it’s a U.S. reference manual for mental disorders diagnosis. So while it’s nice that some Europeans are expressing concern about this reference text, their concern isn’t exactly much relevant.”

    From speaking to UK mental health professionals, my understanding is that both ICD-10 Chapter V and DSM-IV are used in England and Scotland.

    DSM-IV is also used in research in the UK and EU and both systems are used in legal proceedings in the UK. In addition to the US, DSM-IV is used in Canada, Australia, New Zealand, India and China.

    There are a number of UK and international members on the 13 DSM-5 Work Groups – there are, for example, two UK researcher clinicians informing the deliberations of the Somatic Symptom Disorders Work Group. A significant number of UK researchers and clinicians were invited to give presentations in the 13 2004-2008 APA/NIH/WHO DSM-5 Research Planning Symposia.

    International research and opinion has fed into the development of DSM-5 and the next edition of DSM will have international ramifications – clinically, for the research field and for forensics.

    Is it not a little arrogant to dismiss concerns for proposals coming from outside the US?

  6. i really feel like the whole dsm 5 thing has too many people in a tizzy. And to be honest i like some of their changes. The idea of lowering the symptoms needed for some of disorders is needed. I mean i have met a few people who i have felt were quit frankly on the cusp of having a mood disorder but they wee missing a few symptoms.

  7. @ dave the increase in Bd or adhd for that matter has nothing to do with dsm changes. Every doctor is prone to mistakes regardless.

  8. Dr G,
    Thanks for your response.

    I have met several families in person with children who were incorrectly diagnosed with BD– and who were later cured by very different diagnoses and treatment. And thus, my stance on DSM risks.

    You might find Dr Littel’s take on DSM methodology this interesting:
    http://www.madinamerica.com/2012/01/bipolar-everywhere/

    That’s an interesting point about Frances’ choice in communication methods. I rather suspect that he felt any other method would have less, if not zero impact. Nonetheless, it seems unfortunate you zinged him for non-disclosure. He started off with that disclosure in the Psychiatric Times 2 years ago. I suggest there isn’t a need to preface his every paragraph with it.
    http://www.psychiatrictimes.com/dsm-5/content/article/10168/1425378

    @ ‘anonymous Jen’, what you wrote is a sentiment not a fact, without supportive facts or data to back it up.

    • Hi Dave –

      There always has been and always will be misdiagnosis when it comes to any medical disease or mental disorder. A diagnostic manual or any diagnostic system will never be 100 percent perfect.

      The fact is, the diagnosis you’re complaining about — bipolar disorder in children — is not a recognized nor official DSM diagnosis. How can we complain that it’s a DSM problem when the diagnosis is not even in the DSM?

      To me, this seems more clearly a problem with the professionals who are making these diagnoses, based upon their reading of the research literature. Since all professionals are given wide latitude in their diagnostic judgment, none of this would be affected by whatever is done or not done in the DSM-5. In other words, even if the DSM-5 didn’t include a childhood bipolar disorder diagnosis, it will continue to be diagnosed.

      As for Allen Frances, here’s his short disclaimer from 2 1/2 years ago from the article you referenced:

      We should begin with full disclosure. As head of the DSM-IV Task Force, I established strict guidelines to ensure that changes from DSM-III-R to DSM-IV would be few and well supported by empirical data. Please keep this history in mind as you read my numerous criticisms of the current DSM-V process. It is reasonable for you to wonder whether I have an inherently conservative bias or am protecting my own DSM-IV baby. I feel sure that I am identifying grave problems in the DSM-V goals, methods, and products, but it is for the reader to judge my objectivity.

      The “trust me, this isn’t my own personal bias” has a name in psychology — confirmation bias or “myside bias” (which we previously wrote about here). All people — even experienced and thoughtful researchers — experience this bias.

      I’ve never disagreed and said there weren’t areas of improvement for the DSM-5. Any system is going to have such areas (even the DSM-IV), and some of the petitioners’ points are well-taken. But they are not new and there was no new news here.

      Last I point out — as I’ve done time and time again — that the developers of the DSM have noted they intend to keep the DSM-5 version updated more frequently to reflect our current knowledge and understanding. This is a stake in the ground for a process that will hopefully see updates every 4 or 5 years — instead of every 20 or 25.

      John

  9. Thank you Dr. Grohol, for all of your thoughts and comments. I couldn’t agree more!

    Bottom line is we have to go forward with thoughtful diagnosis of children and adults with psychiatric illness. DSM V is likely not to be perfect, but we should work with it, learn from it and use it to help our patients as best we can instead of criticizing and further stigmatizing our patients.

  10. Thank you for a very insightful and thoughtful commentary highlighting some of the “news manufacturing” that’s going on in the “controversy” over DSM-5. It’s nice to know that someone can cut through the spin once in a while.

  11. “Keep in mind, the use and adoption of the DSM is completely a market-driven, voluntary choice. Nobody is demanding professionals use the DSM to diagnose mental disorders in the U.S.”

    I wish I could have got here sooner, but that is just life. When you make the statement about the DSM being volunteer you are completely correct. But if I could ask, when the third parties get ready to cut a check, what is it they want to see? Exactly, the current DSM diagnosis.
    It does not have to be legally required, it is required for survival.
    Anyone that does not recognize an epidemic is not looking at the situation. Not one specific disorder, but over the entire spectrum.

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