I constantly struggle with the backlash against the DSM 5 — the latest revision of the diagnostic and statistical manual of mental disorders. Every medical text is revised decade after decade with little significant argument.
But when it comes to mental disorders, apparently there’s a different standard for them — one that is neither equal nor fair when compared to their medical brethren.
The latest article on the controversy comes from Rob Waters writing his hyperbole earlier this week over at Salon.com (ridiculous sample: “As the task force producing it has posted drafts on its website, an undercurrent of dissatisfaction has exploded into a full-scale revolt by members of U.S. and British psychological and counseling organization.” [emphasis added]). Repeating many tired phrases like “bible of mental health” in reporting on this story, it’s not exactly clear there’s any objectiveness. Instead, it’s heavily slanted toward the opponents of the revision of the manual.
The proponents are led, ironically, by the former head of the last revision process, creating the DSM-IV, Allen Frances, who gleefully blogs about all the problems he sees in the DSM-5 revision process over at Psychology Today.
It gets even more ironic when you look at the criticisms leveled at the DSM-5 — criticisms that began a long time ago, in a revision we’re all familiar with called… yes, you guessed it, the DSM-IV.
Even the Reporting on the DSM-5 is Flawed
Criticizing new stuff is part and parcel of any profession, I suppose. Especially when that new stuff impacts your daily practice. In this case, hundreds of thousands of mental health professionals around the country will have to learn the diagnostic criteria for the handful of new disorders that make it into this revision, and understand the changes made to existing disorder criteria.
But what I don’t get is the first criticism Rob Waters note is about attention deficit hyperactivity disorder (ADHD/ADD):
For many critics, Exhibit A is childhood ADD. As the disorder describing fidgety, easily distracted kids morphed from “hyperkinetic reaction of childhood” to the current “attention deficit hyperactivity disorder,” the number of children given the diagnosis exploded, fueling, by one account, a 700 percent increase in the use of Ritalin and other stimulants in the 1990s. Diagnosis requires checking six of nine boxes from a list of symptoms that include “often does not seem to listen when spoken to directly” and “often fidgets with hands or feet or squirms in seat.” Sound familiar, parents?
Yet there are absolutely no changes being proposed for childhood ADHD or ADD diagnostic criteria. Doh!
The change that is being proposed is to lower the number of symptoms required from 6 to 4 if the person is an older teenager (17 or older) or an adult. Why the change? Because in reviewing the research, the working group found that while ADHD and ADD can persist into adulthood, adults often exhibit a few less symptoms than children do.
The opponents of this change appear not to argue from empirical data or research. According to Waters and the online petition, the concern is about “over-diagnosis” of this disorder. From the online petition:
The reduction in the number of criteria necessary for the diagnosis of Attention Deficit Disorder, a diagnosis that is already subject to epidemiological inflation. [Ed. – there is no research reference for this term, ‘epidemiological inflation’]
So, despite research demonstrating this change might more accurately categorize people who are adults with ADD or ADHD, opponents are arguing we shouldn’t do it because then more people might be diagnosed with the disorder. That’s convoluted, circular logic if I’ve ever heard it.
In that case, we should never, ever propose the addition of any new disorders, despite any research findings, because a new disorder would result in new diagnoses of people, classifying them as “mentally ill” when previously they were not so classified.
But honestly, if you want to look at the problem with attention deficit disorder, don’t blame a diagnostic manual that hasn’t even been published yet. If you believe the problem is with “over diagnosis” of ADHD, then the actual problem should be able to be traced back to the current ADHD diagnostic criteria (from, yes, the flawless DSM-IV).
Where’s the outcry over the flawed process that created such criteria in the first place? If the DSM-IV process was so reliable and good, how could it have created this current “epidemic” of “over diagnosis” of ADHD?
The DSM Has Always Created New Disorders
As for the other new disorders proposed, I haven’t reviewed the literature like the working groups have, so I have to trust that there must’ve been something in the research that suggested these are potential disorders to consider including.
We should keep in mind that the DSM has always been criticized from two points of view. From the positivist paradigm, criticisms have focused on the “reliability and validity of the conclusions used to justify inclusion and exclusion of particular criteria for a diagnosis,” (Duffy et al., 2002) or indeed, whether a diagnosis should be included at all.
The other criticism comes from a social constructivist standpoint — that the DSM simply reflects the belief system of a socially dominant group that has selectively chosen which knowledge to utilize in order to better understand the world. From this sort of criticism, you can never argue objectively from either side, because both sides of the argument merely change (or redefine) what they consider relevant and valid knowledge of the world. This criticism also worries that the dominance of the DSM model drowns out alternative understandings and categorizations of human dysfunctional behavior and mood (Duffy et al., 2002).
Every new DSM creates new disorders, and there’s usually a resulting outcry about their creation. The DSM-IV brought us one such notable classic — premenstrual dysphoric disorder. At the time, critics (such as Caplan, 1995) argued the PMDD had no solid evidence to support its inclusion in the section of “Criteria sets and axes provided for further study.” There was, in fact, a lot of hand-wringing and outcry over the inclusion of this disorder in the DSM-IV. However, further study proved critics wrong in this instance.
But still, we have to think of the children and the epidemic the publication of the DSM-5 will bring:
Two other newly proposed disorders singled out as problematic in the petition are “mild neurocognitive disorder” in the elderly and “disruptive mood dysregulation disorder” in children and adolescents. Both lack a solid basis in research and may fuel the use of powerful antipsychotic medications, which cause weight gain, diabetes and a host of other metabolic problems, the petition says.
“We are gravely concerned that if this is published as is in 2013, it will create false epidemics where hundreds of thousands of children and the elderly who really are normal will be diagnosed with a mental disorder and given powerful psychiatric medications that have dangerous side effects,” Elkins says. “That is not tolerable.”
Scientists usually argue their differing opinions of what the research does and does not demonstrate in scholarly papers and meta-analytic reviews, not hyperbole spilled out into an online magazine and online petitions. Is popular vote by the masses really the best way to resolve scientific questions?
The DSM-IV Process (and Result) Was Flawed and Biased Too
Lest anyone think that the last time the DSM underwent a major revision, it went without a hitch, all one need do is review the research literature to see otherwise. We often have such short memories when it comes to history. The last revision was led by Allen Frances, M.D., who is now a critic of the same book that has his name on it.
For instance, one criticism of the DSM-IV working groups was it was hardly representative of people who actually treat and research mental disorders every day (Duffy et al., 2002). Only 22 of the 125 people on the DSM-IV working groups didn’t hold an M.D. degree — a general medical degree which has no specialized training in either research or mental disorders (without specific specialization in psychiatry). An M.D. without a Ph.D. is someone who has no particular scientific research training.
The DSM-5 working groups are composed of 143 people by my count, 49 of which hold only a Ph.D., and only 90 of which hold an M.D. (16 of which also hold a Ph.D.). That’s a significantly more diverse representation of the psychological and psychiatric fields than we saw last time around.
Livesley (1995) devotes a whole chapter on the inadequacies and shortcomings of the DSM-IV personality disorders category, which makes for illuminating reading lest anyone complain about the DSM-5’s attempt to reorganize the current mess of personality disorders. Boggs et al. (2005) found gender bias in the symptom criteria for borderline personality disorder — of little surprise to anyone who tries to read the DSM-IV criteria and think of a man.
And among the dozens of other published criticisms and critiques of the DSM-IV over the decades, it apparently suffered from cultural bias to boot (Dana, 2001). In a culturally diverse nation as the U.S., it’s odd that such a reference manual describing supposedly unbiased, scientific phenomenon should suffer from such a bias.
The DSM-5 is the result of 14 years worth of preparation and work by hundreds of professionals and researchers. And it is so easy to disparage such work from afar, when you’re not a part of the process.
But disparagement is hardly helpful from a scientific standpoint. The “Open Letter” petition was created, in private, by a three-member ad-hoc committee of a division of a competitive professional association, the American Psychological Association. And while I agree with some of the points raised in the petition, I have no reason to put my faith in these three people’s reading of the scientific literature over that of the 143 people in the working groups of the other APA.
And I can’t help but think there’s some sour grapes here, when the person who is predicting the failure of the DSM-5 is also the one person who claims he has a plan to save it:
The user revolt against the DSM-5 has emerged as a major challenge to the document, Frances says, and its future is looking unclear. He and Elkins are proposing that an independent committee of experts review the proposed draft and make recommendations.
Given all the flaws with the DSM-IV, why should I or any other mental health professional trust Frances over the current group of people overseeing the DSM-5 revision process?
The answer is simple, but not one anyone wants to hear — there is no “perfect” process, and there’s no process that isn’t going to be flawed or criticized by others. I’ve argued time and time again how the DSM process should always be more transparent — as it should have been back when the DSM-IV was being updated as well.
It’s far too late to “fix” the DSM 5 now (and I don’t believe it needs much fixing in the first place). But the APA has always said and will likely publish far more timely updates to the manual in the future. So we can wait and see.
Meanwhile, 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.
Read the full article: Therapists revolt against psychiatry’s bible
Boggs, Christina D.; Morey, Leslie C.; Skodol, Andrew E.; Shea, M. Tracie; Sanislow, Charles A.; Grilo, Carlos M.; McGlashan, Thomas H.; Zanarini, Mary C.; Gunderson, John G. (2005). Differential impairment as an indicator of sex bias in DSM-IV criteria for four personality disorders. Psychological Assessment, 17, 492-496.
Caplan, P. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. Reading, MA: Addison-Wesley.
Dana, R.H. (2001). Clinical diagnosis of multicultural populations in the United States. In: Handbook of multicultural assessment: Clinical, psychological, and educational applications (2nd ed.). Suzuki, Lisa A. (Ed.); Ponterotto, Joseph G. (Ed.); Meller, Paul J. (Ed.); San Francisco, CA, US: Jossey-Bass.
Duffy, M., Gillig, S.E., Tureen, R.M., Ybarra, M.A. (2002). A critical look at the DSM-IV. The Journal of Individual Psychology, 58, 363-373.
Livesley, W.J. (1995). The DSM-IV personality disorders. New York, NY, US: Guilford Press.