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Wednesday 29 February 2012

Why is no one satisfied with psychiatric diagnoses? Courtesy of MNT Website

Why No One Is Satisfied With Psychiatric Diagnoses
Main Category: Psychology / Psychiatry

 The Diagnostic and Statistical Manual of Mental Disorders is revised for the first time since 1994, controversy about psychiatric diagnosis is reaching a fever pitch.

Suggested changes to the definitions of autism spectrum disorders and depression, among others, are eliciting great concerns. However, there are larger concerns about the DSM as a whole.

"Almost no one likes the DSM, but no one knows what to do about it," said University of Michigan psychiatrist Randolph Nesse.

The current round of revisions is the fifth since the DSM was originally published by the American Psychiatric Association in 1952.

"A huge debate over when depression is abnormal seems likely to be resolved by removing the so-called 'grief exclusion,'" Nesse said. "At the moment, depression is not diagnosed in the two months after loss of a loved one.

"The result of this proposed change would be that people experiencing normal grief will receive a diagnosis of major depression. Doing this would increase consistency in diagnosing depression, but at the cost of common sense. It's clear that bereavement is not a mental disorder."

Nesse is the co-author with University of Cape Town psychiatrist Dan Stein of an article in the current issue of BMC Medicine titled "Towards a genuinely medical model for psychiatric nosology."

The article provides a diagnosis of the difficulty of categorizing mental disorders that the authors expect will displease many of their colleagues.

"The problem is not the DSM criteria," Nesse said. "The problem is that the untidy nature of mental disorders is at odds with our wish for a neat, clean classification system."

The proposed abolition of the grief exclusion in diagnosing major depression is just one example of a push to define psychiatric disorders according to their causes and brain pathology.

But Nesse and Stein point out that the rest of medicine recognizes many disorders that do not have specific causes.

"Conditions such as congestive heart failure can have many causes," Nesse said. "This doesn't bother physicians because they understand what the heart is for, and how it works to circulate blood."

Furthermore, he said, physicians recognize symptoms such as fever and pain as useful responses, not diseases.

"These symptoms can be pathological when they're expressed for no good reason, but before considering that possibility, physicians look carefully for some abnormality arousing such symptoms," Nesse said. "Likewise, the utility of anxiety is recognized, but its disorders are defined by the number and intensity of symptoms, irrespective of the cause.

"It's vital to recognize that emotions serve functions in the same way that pain, cough and fever do, and that strong negative emotions can be normal responses to challenging or anxiety-provoking situations."

So, as the DSM is revised once again, Nesse urges his colleagues and concerned members of the public to adopt realistic expectations.

"Instead of specific diseases with specific causes, many mental problems are somewhat heterogeneous overlapping syndromes that can have multiple causes," he said. "Most are not distinct species like birds or flowers. They are more like different plant communities, each with a typical collection of species. Distinguishing tundra from alpine meadow, arboreal forest and Sonoran desert is useful, even though the categories are not entirely homogenous and distinct."





New study: a safe, effective non-pharmaceutical treatment for ADD and ADHD

January 30, 2009 10:30 PM EST (Updated: January 31, 2009 12:57 PM EST)
views: 142 | comments: 14
New Study: Transcendental Meditation Technique Reduces ADHD Symptoms

JANUARY 30, 2009

Students practice the TM technique for 10 minutes twice a day
Student anxiety decreased 53 percent after 3 months
Attention and problem solving improved during the study
Sarina J. Grosswald, Ed.D, lead researcher of the study
Fred Travis, Ph.D., coauthor of the study
Transcendental Meditation Technique
Reduces ADHD Symptoms
The Transcendental Meditation® technique may be an effective and safe non-pharmaceutical aid for treating attention deficit hyperactivity disorder (ADHD) according to a promising new study published last month in the peer-reviewed online journal Current Issues in Education .
The study was conducted in a private K-12 school for children with language-based learning disabilities. Participation was restricted to 10 students, ages 11-14, who had pre-existing diagnoses of ADHD. About half of the students were on medication. The students practiced the TM technique at school in a group for 10 minutes, morning and afternoon.
After three months, researchers found over 50 percent reduction in stress and anxiety, and improvements in ADHD symptoms.
“The effect was much greater than we expected,” said Sarina J. Grosswald, Ed.D., a George Washington University-trained cognitive learning specialist, M.U.M. adjunct faculty, and lead researcher on the study. “The children also showed improvements in attention, working memory, organization, and behavior regulation.”
Dr. Grosswald said that after the in-school meditation routine began, “teachers said they were able to teach more, and students were able to learn more because they were less stressed and anxious.”
Other research shows ADHD children have slower brain development and a reduced ability to cope with stress. “This results in impaired executive functioning, causing difficulty with skills such as analyzing, problem solving, and focus,” said Dr. Grosswald. “By reducing stress through the practice of the TM technique, executive functioning improves – reducing the symptoms of ADHD.”
“The results were quite remarkable,” said Daryl Schoenbach, mother of one of the students. “The twice daily meditations smoothed things out, gave her perspective, and enabled her to be in greater control of her own life when things started falling apart. It took some time, but it gradually changed the way she handled crises and enabled her to feel confident that she could take on greater challenges.”
There is growing concern about the health risks and side effects associated with ADHD medications and the Transcendental Meditation technique can provide a safer alternative for parents and their children.
Dr. Fred Travis, Director of the Center for Brain, Consciousness and Cognition at M.U.M. also coauthored this study, which was funded by the Abramson Family Foundation and the Institute for Community Enrichment.
Click here to view an interview with participating students
Click here to view PBS Feature on the TM technique and ADHD

The Transcendental Meditation technique is easy to learn, enjoyable to practice, and enriches all areas of life. The Transcendental Meditation technique is a simple, natural, effortless procedure practiced 20 minutes twice a day, sitting comfortably with the eyes closed. This practical, proven meditation procedure requires no effort or concentration, no special skills, and no change of lifestyle.

The Transcendental Meditation technique must be learned personally from a certified teacher of the Transcendental Meditation program. The technique cannot be learned from a book, video or audio tape.
For more information on how to learn the Transcendental Meditation technique in the U.S. and Canada, call toll free: 1-888-LEARN TM (1-888-532-7686).

Friday 24 February 2012


DSM 5- 'Living Document' or 'Dead on Arrival'
untested 'scientific hypotheses' must be dropped
Published on November 11, 2011 by Allen J. Frances, M.D. in DSM5 in Distress

News flash From Medscape Medical News - 'APA Answers DSM-5 Critics,' a defense of DSM 5 offered by Darrel A. Regier, MD, vice-chair of the DSM-5 Task Force. Wonderful news that APA is attempting to address the fact that DSM 5 alarms many of its potential users- it is long past time for an open dialog. Unfortunately, however, Dr Regier dodges the concerns that must be addressed if DSM 5 is to become a safe and credible document. Five simple questions were previously posed to APA with a request for five straight answers:

1) Why is APA not willing to have an independent scientific review of
questionable DSM 5 proposals- especially since its own internal and
confidential review process has been so badly discredited?

2) Since the DSM 5 suggestions will all broaden the definition of mental
disorder, why should we not worry about diagnostic inflation and the massive mislabeling of normal people as mentally ill?

3) Won't this diagnostic inflation exacerbate the already rampant over
prescription of psychotropic medications (especially by primary care
doctors, especially antipsychotics, especially to kids)

4) Why should we not worry about the unintended forensic complications of a
sloppily written DSM 5 containing suggestions that are obvious targets for
forensic misuse?

5) Won't the many small, needless, and arbitrary changes in DSM 5 complicate future research efforts and make impossible the interpretation of data collected before vs after DSM 5?

None of the five questions gets anything approaching a real answer. Instead Dr Regier tells us that:

1) "We hear your concerns and are aware of those from others in the mental health field, and take them under serious consideration in our deliberations".

But if APA really heard our concerns, there would be an immediate independent scientific review to allay them. What possible excuse is there for not taking the one obvious step that will make DSM 5 credible?

2) Dr Regier assures us not to worry about the radical DSM 5 suggestions, promising "a rigorous test-retest design to assess the reliability and clinical utility of proposed criteria ... in 11 academic field trial centers." "The full range of disorders will be assessed in this field trial and the findings will contribute to the final decisions about the diagnoses."

But, simply stated, the field trials are completely useless for DSM 5 decision making. They failed to ask and therefore cannot begin to answer the only really important question- what will be the effect of DSM 5 on the rates of mental disorder? Will DSM 5 mislabel as mentally ill millions of people who have problems that are just part of the human condition. And experience teaches us that results generated in academic centers often have nothing at all to do with how DSM is actually used (and often misused) in the real world.

3) Dr. Regier goes on to admit the obvious- that the new DSM 5 proposals are not based on anything resembling adequate research: "However, a lot of this has not been tested as well as we would like." "Some of these fixes are not as well studied as others and we recognize that. But we can't move forward without some of these put into practice. So we think this is a much more testable set of scientific hypotheses." "And that's what the DSM is - a set of scientific hypotheses that are intended to be tested and disproved if the evidence isn't found to support them."

There could not possibly be any more eloquent testimony to exactly where DSM 5 has gone badly and dangerously off the tracks. DSM 5 most definitely should not harbor the ambition of providing a set of 'scientific hypotheses' created by and for researchers to encourage further testing of their pet ideas. DSM 5 is not at all meant to be a program setting forth 'scientific hypotheses' to guide future research. Instead, DSM 5 is a guide to current clinical practice that will have a crucial impact on the lives of the people misdiagnosed- they will often be hurt, sometimes badly hurt, by receiving unnecessary medicine and unnecessary stigma. Recent experience proves that children will be particularly vulnerable to the mislabeling that will follow this exercise in DSM 5 'hypotheses testing.' To say nothing of the misallocation of resources away from the truly ill (who desperately need them) and toward the worried well (who often will be more harmed than helped). There is no conceivable excuse for conducting what amounts to an uncontrolled public health experiment just so the DSM 5 researchers can further the testing of their pet ideas.

4) Dr Regier is fond of calling DSM 5 a "living document that can be revised regularly." "We're thinking of having a DSM-5.1, DSM-5.2, etc". The implication of this 'living document' concept is chillingly out of touch with the perils of clinical reality. Although he doesn't come right out and say it, Dr Regier seems to be reassuring us with something like- Don't you worry if our untested hypotheses get it wrong now, we can always fix it up later. This blithely ignores the needless and sometimes dangerous medication side effects and stigma to be endured by those who are mislabeled by the premature and untested DSM 5 'scientific hypotheses'. The makers of DSM 5 have forgotten the most important injunction in medicine - the Hippocratic First Do No Harm.

What needs to be done? In the short term, APA has only two choices- submit DSM 5 to external review or drop the most dangerous suggestions. Otherwise DSM 5 risks not being trusted and not being used by mental health clinicians.

For the future, the lesson couldn't be clearer- never again allow researchers the freedom to turn DSM into a plaything for their pet 'scientific hypotheses'. The DSM's are not meant to be a casually undertaken experiment. They have become far too important an influence on clinical practice and public health policy. DSM 5's radical ambitions have failed- it attempted to fly too high and now must come back to earth.

If you agree we me that the APA defense of DSM 5 is much more troubling than reassuring, consider signing the petition requesting reform at:


Is DSM 5 A Public Trust Or An APA Cash Cow?
Commercialism And Censorship Trump Concern For Quality
Published on January 3, 2012 by Allen J. Frances, M.D. in DSM5 in Distress




DSM 5 will have a big impact on how millions of lives are led and how scarce mental health resources are spent. Getting the right diagnosis and treatment can be life enhancing, even life saving. Incorrect diagnosis can lead to the prescription of unnecessary and potentially harmful medication and to the diversion of services away from those who really need them and toward those who are better left alone. Preparing DSM 5 should be a public trust of the highest order.

But DSM 5 is also an enormously profitable commercial venture. DSMs are perpetual best sellers (at least one hundred thousand copies sold every year) netting the American Psychiatric Association yearly profits exceeding five million dollars.

From the very start of work on DSM 5, APA took unprecedented steps to protect its commercial interest- but in the process betrayed its obligation to the public trust. Work group members were recruited only on condition that they first sign confidentiality agreements - thereby squelching the free flow of ideas that is absolutely necessary to produce a quality diagnostic manual. 'Intellectual property' has been the priority - a safe, scientifically sound DSM 5 has been the victim.

DSM 5 commercialism and heavy handed censorship have recently assumed a new and troubling form. APA is exercising its 'DSM 5' trademark to unfairly stifle an extremely valuable source of information. Suzy Chapman, a patient advocate from England, runs a highly respected and authoritative site providing the best available information on the preparation of both DSM and ICD. Her writings can always be relied upon for fairness, accuracy, timeliness, and clarity. The site has gained a grateful following with over 40,000 views in its first two years.

Ms Chapman recently sent me the following email describing her David vs Goliath struggle with the APA and its disturbing mplications both for DSM 5 and for internet freedom:

"Until last week, my website published under the domain name
http://dsm5watch.wordpress.com/ .
On December 22, I was stunned to receive two emails from the Licensing and Permissions department of American Psychiatric Publishing, claiming that the domain name my site operates under was infringing upon the DSM 5 trademark in violation of United States Trademark Law and that my unauthorized actions may subject me to contributory infringement liability including increased damages for willful infringement. I was told to cease and desist immediately all use of the DSM 5 mark and to provide documentation within ten days confirming I had done so."

"Given my limited resources compared with APA's deep pockets, I had no choice but to comply and was forced to change my site's domain name to
http://dxrevisionwatch.wordpress.com. Hits to the new site have plummeted dramatically and it will take months for traffic to recover - just at the time when crucial DSM 5 decisions are being made."

"Was APA justified in seeking to exercise its trademark rights in this situation? Or do APA's actions fly in the face of accepted internet trademark practice, common sense, and good public relations? I am not a lawyer, but I have made a careful study of
'U.S. Trademark Law, Rules of Practice & Federal Statutes, U.S. Patent & Trademark Office, November 8, 2011' and of many other available sources. My conclusion is that APA is making excessive and unwarranted claims for its DSM 5 trademark. Courts have found that using a trademark in a domain or subdomain name is 'fair use' if the purpose is non commercial, where there is no intent to mislead, where use of the mark is pertinent to the subject of discussion, and where it is clear that the user is not implying endorsement by, or affiliation with, the holder of the mark."

"The home page of my site clearly defines its purpose - 'DSM-5 and ICD-11 Watch - Monitoring the development of DSM-5, ICD-11, ICD-10-CM' and carries this disclaimer,
'This site has no connection with and is not endorsed by the American Psychiatric Association (APA), American Psychiatric Publishing Inc., World Health Organization (WHO) or any other organization, institution, corporation or company. This site has no affiliations with any commercial or not-for-profit organization...This site does not accept advertising, sponsorship, funding or donations and has no commercial links with any organization, institution, corporation, company or individual.'"

"It puzzles and worries me that APA would seek to suppress my clearly non commercial resource created only to provide information and commentary on the revision process of two internationally used classifications. My only purpose is to inform interested stakeholders and those patient groups whose medical and social care may potentially be impacted by proposals for changes to diagnostic categories and criteria."

"There is a paradox here. The APA has promoted its commitment to transparency of process, but has rarely demonstrated it. Much has been made of the posting of drafts for public review and soliciting feedback. But to usefully participate in this process, patients, patient groups, and advocacy organizations need to know about proposed changes and when and by what means they can input comment during public review periods. Now, because of APA's arbitrary actions, it will be harder for them to find the information they need- just when they most need it."

I am surprised and saddened by APA's ill-conceived attempt to restrict Suzy Chapman's free expression on DSM 5. It can only be in the service of the equally unworthy goals of censorship and/or commercialism. I simply can't imagine that anything should ever be kept secret in the preparation of a diagnostic manual and wonder what in Suzy Chapman's web site could possibly be so frightening to APA.

Using a trademark to suppress comment is a violation of APA's public trust to produce the best possible DSM 5. This is another indication that DSM has become too important for public health and for public policy for its revisions to be left under the exclusive control of one professional organization - particularly when that organization's own financial future is at stake. This basic conflict of interest can be cured only by creating a new institutional framework to supervise the future DSM revisions. Censorship and commercial motivations must not warp the development of a safe and scientifically sound diagnostic manual.




DSM-5: How Reliable Is Reliable Enough?

Published on January 18, 2012 by Allen J. Frances, M.D. in DSM5 in Distress

This is the title of a disturbing commentary written by the leaders of the DSM 5 Task Force and published in this month's American Journal of Psychiatry. The contents suggest that we must lower our expectations and be satisfied with levels of unreliability in DSM 5 that historically have been clearly unacceptable. Two approaches are possible when the DSM 5 field trials reveal low reliability for a given suggestion: 1) admit that the suggestion was a bad idea or that it is written so ambiguously as to be unusable in clinical practice, research, and forensics; Or, 2) declare by arbitrary fiat that the low reliability is indeed now to be relabeled 'acceptable'.

In the past, 'acceptable' meant kappas of 0.6 or above. When the personality disorders in DSM III came in at 0.54, they were roundly derided and given only a reluctant bye. For DSM 5, 'acceptable' reliability has been reduced to a startling 0.2-0.4. This barely exceeds the level of agreement you might expect to get by pure chance.

Previously in its development, DSM 5 has placed great store in its field trials. This quote is from the Chair of the DSM 5 Task Force: "There's a myth that all the decisions have been made, when in fact, all the decisions haven't been made. Just because things have been proposed doesn't necessarily mean they'll end up in the DSM-5. If they don't achieve a level of reliability, clinician acceptability, and utility, it's unlikely they'll go forward."

And this quote is from a 2010 interview given to a science writer by the head of the DSM 5 Oversight Committee: "It's going to be based on the work of the field trials- based on the assessment and analysis of them. I don't think anyone is going to say we've got to go forward if we get crappy results."

The DSM 5 tune has now changed dramatically. The commentary written for AJP by the leadership of DSM 5 Task Force appears to be suggesting that they will, in fact, "go forward," and with sub par reliabilities of 0.2-0.4. Now consider that the original field trial plan was to have a second phase to permit fixing those diagnostic criteria that were found to have unacceptable reliability in the first phase. These would go back to the workgroups who could then rewrite the offending criteria and retest the new version in the second phase of the field trial. But poor planning and administrative foul-ups kept pushing back the field trials so that they are now at least 18 months late in completion. As time was running out, DSM 5 leadership quietly dropped the second phase of the field trials, removing any reference to it from the timeline posted on the DSM-5 website. Their Plan B substitute for adequate field testing appears in AJP- To wit: a drastic lowering of the bar for what is 'acceptable' reliability.

Can 'accepting' unacceptably poor agreement uphold the integrity of psychiatric diagnosis? Poor reliability degrades our ability to communicate with one another clinically, and prohibits meaningful research. 'Accepting' as reliable kappas of 0.2-0.4 is to go backwards more than thirty years to the days of DSM II. Before DSM III, Bob Spitzer and Mel Sabshin saw the need to develop a criterion based system that could achieve reasonable diagnostic agreement. This is the very minimum condition necessary for current clinical work and future progress in psychiatry.



Special Report

Psychiatric Times.

DSM5 Temper Dysregulation—Good Intentions, Bad Solution
by Allen Frances, MD | 21 April 2010


Sometimes you spot a serious problem and figure out a very well-intended solution, only to discover eventually that your solution created as much trouble as the original problem. The workers on DSM5 have spotted an enormously worrying problem—the wild overdiagnosis of childhood bipolar disorder (BD) which has led to a massive increase in the use of antipsychotic and mood stabilizing medications in children and teenagers.

Something clearly needs to be done to correct this. The proposed DSM fix—a new diagnosis called "Temper Dysregulation with Dysphoria"—is meant to provide a less risky diagnostic home for the kids currently misdiagnosed as bipolar. Unfortunately, "temper dysregulation" is just the kind of unhappy solution that you later come to greatly regret. It is a makeshift proposal, with considerable risks, and a disqualifying conceptual problem.

How is it makeshift? As the DSM5 Work Group candidly admits, the research evidence on this new diagnosis is remarkably thin, based on the very recent work of just one research group. Virtually nothing is known about its likely prevalence in the general population; whether it can be distinguished reliably from normal developmental or situational irritability; its relation to other disorders that present with temper outbursts; its course; its preferred treatments; and the tradeoff between treatment response and adverse complications.

The criteria set for "temper dysregulation" require: 1) severe recurrent temper outbursts in response to common stressors; 2) occurring at least three times a week; 3) for at least a year; 4) in someone who is persistently irritable.

The definition was created largely ad hoc with no systematic testing (outside that one research program) of the performance characteristics of the items to determine how they would play if in wide general use. It is loosely written and in fact contains no exclusion for use in adults (which I assume is an oversight).

Why is such a makeshift solution being given any serious consideration? The Work Group freely admits that the scientific rationale is completely inadequate. Their proposal rests exclusively on 2 real and pressing clinical needs: 1) to reduce the overdiagnosis and over treatment of BD; and, 2) to do something to help the considerable suffering that these temper outbursts cause the children themselves, their parents and teachers, and society at large.

But is this attempted fix itself highly risky and likely to set off its own cascade of unfortunate unintended consequences? The biggest problem with the proposal is that it is not nearly restrictive enough. While trying to rescue kids who are now misdiagnosed as bipolar, it will undoubtedly open the door to the misdiagnosis of normal kids who happen to be temperamental or in difficult family circumstances. Every effort must be made to distinguish "mental disorder" level temper problems (that cause clinically significant distress and impairment) from those that are within the limits of a normal, but difficult, temperament experiencing the aches and pains of growing up.

This is hard to do. First off, there is enormous variability in what are considered appropriate expressions of temper across kids, across developmental periods, across families, and across subcultures. The definition of "severe" will likely vary greatly depending on the tolerance of the clinician, family, school, and peer group. "Stressors" that trigger the episodes may be minimal in some cases, remarkably provoking of readily understandable temper reactions in others. Family fights that are based in interpersonal problems will be translated into individual psychopathology. Finally, in the heat of battle, it will be forgotten that kids often do outgrow a developmentally or situationally triggered temperamental period in their lives.

In expert hands, it is conceivable that the diagnosis might be contained to achieve just its intended goal of reducing the diagnosis of BD; but in the real world many diagnoses are made by primary care clinicians who have limited expertise in psychiatry and little time with each patient, are dealing with harried family members who want a quick solution to a pressing problem; and are influenced by drug company salespeople. My experience tells me that this makeshift diagnosis may well become very popular and will spread to normal kids who would do a lot better without treatment.

"Temper Dysregulation" also shares very difficult-to-define boundaries with about a dozen other mental disorders. It would be excluded in the differential diagnosis with major depressive, dysthymic, bipolar, schizophrenic, autistic, separation anxiety, and posttraumatic stress disorders. It would be allowed to coexist with oppositional, conduct, attention deficit, and substance use, creating an artificial comorbidity with them and raising the risk of unnecessary and inappropriate treatment. For example, many drug-abusing teenagers will meet the criteria for Temper Dysregulation. Most often, the preferred intervention should be dealing with the substance problem, not adding a medication.

This brings us to the risks of treatment for this prematurely concocted diagnosis. Unfortunately, it is inevitable that this will often consist of atypical antipsychotic drugs because these are heavily marketed and may be helpful in reducing some forms of explosive temper outbursts. But their beneficial effects in some must be balanced against their very great dangers when widely used for the many. These medications often cause enormous and rapid weight gain, increasing the risk of diabetes, medical complications, and reduced life span. Their use in severely disturbed kids raises its own set of serious clinical and ethical questions, but it can be justified in extremely exigent circumstances. Their use in kids who are having disturbing (but essentially "normal") developmental or situational storms or are irritable for other reasons (e.g. substance use, ADD) would be disastrous—but it will happen and probably often.

What is the conceptual problem? "Temper Dysregulation" describes a single symptom, not a complete syndrome. It is at the same level of abstraction as fever or suicide—it can occur as part of the presentation of any number of disorders, but is not a separate disorder in and of itself. In the distant past, psychiatry used to classify by symptoms but found this to be cumbersome and much less satisfying than our current serviceable, if limited, syndromal approach.

What is the solution? Severe, recurring, and persistent temper outbursts are a crucially important clinical and societal problem and deserve special attention. But given the limited state of current knowledge, it is premature to regard Temper Dysregulation as an independent coherent syndrome that would solve more problems than it would cure. There are two far better ways for DSM5 to attempt to address this problem.

DSM5 could add a specifier, "With Explosive Outbursts,” whenever this is a prominent part of the presentation of all of the dozen or so conditions in the differential diagnoses. Or it could add the specifier just to Oppositional Defiant Disorder and attempt to use this as a default away from BD. Or "temper problems" could be one of the cross cutting dimensions, if these make it into DSM5. Each of these possible conventions would make the point that temper outbursts are (again like fever or suicidal thoughts) nonspecific symptoms of many disorders, not a specific and separate disease.

The criteria and text of DSM5 should be as commendably clear as are the drafts that there are serious problems caused by the current practice of overdiagnosis of childhood BD. Specific guidelines should be recommended that would attempt to preempt the loose noncriteria based diagnostic habits that have recently gained such unwarranted purchase.

These steps alone will, of course, not solve the dangerous "epidemic" of childhood BD. There are limits to what DSM5 can do in this regard. The NIMH and FDA may have to step up their involvement. There is a pressing need for an educational campaign to professionals and to the public to highlight the risks of overuse of atypical antipsychotics and to recommend caution in diagnosis and treatment of kids with temper outbursts. Much more research funding should be directed to this area. Funding for the study of explosive behavior has been inadequate in the past because it is an inherently difficult research topic, but the huge public health significance of widespread antipsychotic use should now give it a priority for national debate.

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The Ideal and the Real: How Does
Escape The DSM-5

Ronald Pies MD
SUNY Upstate Medical University; and Tufts University School of 

        What is your aim in philosophy? To show the fly the way out of the fly-bottle.
                                            ...Ludwig Wittgenstein (Philosophical Investigations)


    We all have our fantasies, and I confess that one of mine is a tad grandiose: I imagine being charged with creating a new system of psychiatric diagnosis, starting from scratch. My strong belief is that American psychiatry has become trapped, much like Wittgenstein’s famous fly, in a kind of conceptual fly-bottle, embodied in the DSM framework. Getting psychiatry out of that trap is the impetus behind my fantasy, and motivates part one (“The Ideal”) of this essay. On the other hand, I am realistic enough to know that we are likely to be saddled with some version of the present DSM framework for many years to come. With that in mind, I offer some specific comments on the DSM-5 framework, and on some of its prominent critics, in part two of this piece.

The Ideal
    So what’s my first move in creating a new diagnostic framework?  I would drop the “DSM” designation—where were all those “statistics” anyway?—and call my magnum opus the Manual of Brain-Mediated Disease, or MBMD.  I choose the term “brain-mediated disease” because I assume there is relatively little controversy in the claim that those conditions of greatest interest to psychiatrists are “mediated” by the brain. The concept of “mediation” gets me out of the fruitless Cartesian conundrum of “mind” versus “brain”, “mental” versus “physical” or somatic conditions, psychological vs. biological theories of disease, etc. My supposition is that—whatever the ultimate, ontological nature of what are now called “mental disorders”—the organ chiefly responsible for their manifestation is the brain, and not, say, the gallbladder.
    Technically speaking, the particular conditions listed in the MBMD would be considered “instantiations of disease”, rather than as “disease entities” or discrete “diseases.” I avoid the term “diseases” because this term carries with it the connotation of reified entities in the physical world, with the same ontological status as stones, trees, or sodium atoms.  I don’t believe disease entities sit in the same ontological category as these objects; rather, disease entities are essentially pragmatic constructs for making sense of human suffering.  In this regard, my view is closely related to that of Kendell and Jablensky, who wrote in 2003 that “…the mere fact that a diagnostic concept is listed in an official nomenclature and provided with a precise, complex definition tends to encourage this insidious reification.” [1]
    To be clear: my position does not deny that specific pathoanatomic lesions or pathophysiological dysfunctions may underlie many common instantiations of disease. But my position entails that such lesions or dysfunctions are not disease itself. The latter—derived from our subjective awareness of “dis-ease”—is a pre-scientific construct, available to men and women long before there were physicians, X-rays, or MRIs. (The English language once had the term “diseasy” to describe how people feel when experiencing dis-ease). The distinction I draw is one based on Virchow’s apparent distinction between Krankheiten (diseases) and die Krankheit (disease in general) [2]. I also draw on the important claim put forth by Kendell; namely, that “disease” is properly predicated of persons (“people”)—not of minds, brains, or bodies [3]. 
    My next move would be to separate clinical descriptions of disease —embodied in what I call “prototypes” [see below]--from research-oriented criteria aimed at fostering inter-rater reliability and uniform selection of research subjects. These research criteria would be relegated to one of the MBMD appendices, and would not be of primary interest to clinicians. The research-oriented criteria would be quite similar to those now used in the DSMs, and would consist of symptom checklists that “define” a particular condition, for research purposes. These criteria sets would indeed be “conservative”, as Dr. Frances would have it, to this extent: criteria would be altered from the previous DSM only if convincing scientific data supported the change—an issue to be determined by experts in research methodology, not just by experts in a particular area of study. By separating clinical from research-based descriptions, I try, in a rudimentary way, to deal with the important distinction Dr. James Phillips makes; i.e., “…the distinction between utility in practice and utility in research.” [4]. As Dr. Phillips rightly asks of the present DSM diagnostic criteria, “Who uses them?”
    The MBMD would be built upon six foundational principles, which I call the 6 “Ps”: privilege, prototypes, parsimony, pragmatism, pluralism, and phenomenology.  Roughly, these are defined as follows:    
    1. “Privilege” refers to strict limitations on what conditions are permitted into the diagnostic schema. If psychiatric nosology is conceived as a house with many rooms, only certain kinds of conditions would get through the front door; namely, only conditions that entail substantial and enduring suffering and incapacity. (To signal forward a bit, I believe my position is compatible with similar views advanced by Dr. Allen Frances). Furthermore, the “suffering” would need to be intrinsic to the condition, at least in part—not merely the result of societal disapproval, punishment, or “bad stuff” ensuing from a particular behavior [5].  In the Judaic tradition, the rabbis speak of tiruf hada’at—“mental anguish”. This is not a bad phenomenological starting point for the kinds of conditions we ought to let through our diagnostic “door” to disease. Accordingly, conditions like ego-syntonic “hypersexuality” or sociopathy—both presumably lacking intrinsic suffering—would not be admitted as instantiations of disease. This is not to say that such conditions should never be the focus of therapeutic intervention, or of social and legal regulation —but those thorny issues would take us far afield.
    2. “Prototypes” refers to the use of idealized models or archetypes of disease, rather than of “categorical” or “dimensional” methods of classification. These prototypes are similar to what Nassir Ghaemi has called “ideal types”, described as “…simplified version[s] of reality”[6]. The use of disease prototypes is one way to navigate around the Scylla of “nominalism” and the Charybdis of “realism” [7]. In a sense, prototypes are the diagnostic equivalent of “fuzzy logic”, and would make up the core of the new diagnostic descriptions. Each prototype would consist of a richly-detailed, generic, clinical case history, illustrating a particular clinical condition. The prototypes would be compatible with, but not identical to, the research-oriented criteria. Essentially, the research criteria would constitute a subset of features within the surrounding “fuzzy” construct of the prototype.  
    3. “Pragmatism” refers to the instrumental nature of the diagnostic schema; specifically, psychiatric diagnosis is seen fundamentally as a means to an ethical and humanitarian end—namely, the effective relief of certain kinds of human suffering and incapacity (“dis-ease”). Thus, my diagnostic categories would strive for “utility” in roughly the sense described by Kendell and Jablensky [1] . Specifically:  if the net amount of psychic misery in the world were reduced more by using prototype A than prototype B, prototype A gets priority, all other factors being equal. I do not use the term “pragmatic” in the debased sense that Nassir Ghaemi MD rightly castigates; i.e., as a hodge-podge of “…the beliefs of clinicians, the wishes of patients, our general ignorance about many scientific facts, the limitations of our treatments, [and] the needs of insurance reimbursement.” [8]
    4. “Parsimony” refers to the goal usually expressed in terms of Occam’s Razor; i.e., “entities should not be multiplied beyond what is necessary". Ideally, this principle would reduce the total number of psychiatric diagnoses, but without eliminating essential categories. However, I would not prejudice the scientific enterprise by aiming for a particular number of diagnostic categories, or even for the goal of increasing or decreasing the total number of such categories. 
    5.  “Pluralism” refers to the use of multiple types of evidence and levels of understanding, in answering Prof. Tim Thornton’s question; i.e., “What is it…for something to be a mental disorder?” [9] Or, in my terms, “What ought to count as an instantiation of brain-mediated (“psychiatric”) disease?” Pluralism allows for, but does not require, biologically-based criteria for specific instantiations of brain-mediated disease. Data on biological factors related to a particular condition would be appended to the basic prototype, as “Supporting Data.” Phenomenological data (see #6) would also “count” in identifying instantiations of brain-based disease.
    6. “Phenomenology” –i.e., the contents and structure of the patient’s felt experience—would be an important part of the prototypical descriptions in the MBMD, following the work of Husserl, Karl Jaspers, and various “existential” philosophers. Exemplary in this regard are Arieti’s classic descriptions of the inner world of patients with schizophrenia [10].

The Real: DSM-5 and its
Discontents: Areas of Agreement with Dr. Allen Frances

    I find many areas of agreement with Dr. Allen Frances’s positions, regarding the DSM-5.  For example, I agree with Dr. Frances that there is no “paradigm shift” involved in the ideas underlying the DSM-5. As several commentators in the AAPP Bulletin have already pointed out, Kuhn’s construct of the paradigm shift is in no way commensurate with the tactical tinkering proposed for the DSM-5, including the possible use of “dimensional” approaches to diagnosis.
     I also agree with Dr. Frances that there is a “threshold” problem with several of the diagnostic categories proposed for DSM-5; i.e., too many conditions that do not reach the level of “suffering and incapacity” seem to be getting through the door. Specifically, I agree with Dr. Frances that “… the difficulties people have in meeting society's expectations should not all be labeled as mental disorders…” [11], absent convincing evidence of intrinsic suffering and substantial incapacity; that is, the presence of dis-ease [5]. If society were suddenly to demand that we all function at the cognitive level of Steven Hawking, and began to label as “mentally disordered” those who couldn’t meet that expectation, something clearly would be amiss.  On the other hand, it is pragmatically necessary to specify certain (relatively) culture-neutral, rudimenatry abilities as defining the lower limits of functional capacity; e.g., the ability to get out of bed, feed oneself, maintain basic self-care, and perform certain essential cognitive tasks, such as remembering to turn off the stove. 

Consequentialism in the DSM-5

    As Dr. Alan Stone has noted (personal communication 12/24/09), medical ethics partakes of both deontological (duty-based) and consequentialist (outcome-based) elements.  Dr. Frances espouses a largely “consequentialist” ethos, in his urging that psychiatrists consider the possible adverse effects that may flow from changes in the diagnostic schema.  Thus, in a recent blog, he writes: “Much has been written about the "validators" of psychiatric diagnosis and how they should influence DSM...To my mind, by far the most important validator is how will any decision help or harm patient care, given the forseeable circumstances under which it will be used.” (italics added) [12]
     Indeed, on a purely ethical level, I agree with Dr. Frances’s position. By way of analogy: in the Talmud, the principle of pikuach nefesh (“danger to life”) overrides all religious laws except those involving murder, idolatry, and prohibited sexual unions. [13]. In psychiatric nosology, I would argue that demonstrable “danger to life” (e.g., “harm to patients”) should also override virtually all other concerns, if there is strong empirical evidence of such a danger.  For example,  if we had  well-founded, empirical evidence—say, from actual clinical experience in Europe—that criteria set A  for diagnosing ADHD inevitably leads to substantial harm to patients, whereas criteria set B does not, the latter ought to be favored, all other things being equal—even if criteria set A were directly linked with specific biomarkers, endophenotypes, etc.
    But it is a different matter when—despite persuasive scientific evidence to the contrary—we preemptively manipulate our diagnostic categories, in order to head off some anticipated form of substandard medical care.  In my view, this amounts to well-intentioned but misguided nosological gerrymandering. Thus, the fear that criteria set A will harm patients, based solely on hypothetical scenarios of slipshod medical practice, should not be sufficient to overcome criteria set A’s scientific superiority to criteria set B.   
    For this reason, I am very uneasy with Dr. Frances’s speculation that certain proposed changes in the DSM-IV criteria will lead to excessive prescribing of stimulants [11] or antidepressants [14].  In this regard, both Dr. Sidney Zisook and I differ with Dr. Frances on the issue of the “bereavement exclusion” for major depressive disorder, which now appears likely to be eliminated in DSM-5 [14, 15]. Zisook and I believe that concerns regarding overzealous prescribing practices are best addressed thorough careful drug labeling information; and especially, through intensive continuing medical education aimed at improving prescribing practices.  Indeed,  I am not aware of any medical specialty that routinely determines if condition X is, or is not, a “disease”;  or whether symptom X ought or ought not to be part of the criteria for a disease, based on anticipated problems with physicians’ prescribing habits or the marketing strategies of pharmaceutical companies.

What is Harm Avoidance?

Similarly, the issue of harm avoidance—often expressed by the maxim, “First, do no harm”—also needs careful analysis. As Dr. Ghaemi has noted in his discussion of the Hippocratic philosophy, the complete quote attributed to Hippocrates is, “As to diseases, make a habit of two things —to help, or at least to do no harm." [16]  (italics added). Note that the first Hippocratic principle entails actively helping the patient. Ghaemi goes on to observe that, for Hippocrates, “ethics grows out of science”, which for Hippocrates meant knowledge of disease. “The ethical principle, standing by itself, is not at all what Hippocrates taught.” [16] 
    Thus, Hippocratic “harm-avoidance” begins with good science: i.e., deciding whether or not the patient is actually suffering from disease; if so, determining what kind of disease; and then offering the appropriate treatment. Hippocratic harm-avoidance is not a solicitation to “gaming the system” by pre-arranging our disease criteria so as to avoid certain feared socioeconomic or behavioral outcomes.
    To be sure, Dr. Frances rightly calls attention to the risk of overmedication that might very well accompany “over-diagnosis” [11, 14]. But this is merely one element of an overall, clinical risk-assessment. The inherent morbidity and mortality of a disorder must also be weighed in the balance. For example:  Dr. Frances maintains that reducing the number of days required for the diagnosis of hypomania (from the current 4 to 2 days) will result in over-diagnosis of bipolar disorder; over-prescription of atypical antipsychotic drugs; and adverse medical outcomes, such as metabolic syndrome[17]. This putative pathway to “harm” might or might not come to pass. But assuming, as Dr. Ghaemi argues, that the 2-day hypomania criterion is scientifically well-founded, its use could lead to robust societal “goods” that may well overcome the putative harm envisioned by Dr. Frances. 
    For example, the suicide rate in bipolar disorder is roughly 15-20 times that of the general population [18]. It is quite possible that by reducing the hypomania criteria from 4 to 2 days, we would vastly increase bipolar patients’ access to lithium, which appears to reduce suicide risk substantially in bipolar populations [19].   To be sure, this is a pharmaco-epidemiological prediction that depends in part on the behavior—and proper education—of physicians.  We would need several careful, medical-epidemiological studies, analyzing, say, the risk of antipsychotic-induced metabolic syndrome compared with the risk of missed bipolar disorder and subsequent suicide. My point is that merely positing iatrogenic harm to patients should not, by itself, overcome the scientific merits of refining our criteria for hypomania.  Only well-documented, demonstrable harm to the public interest should “trump” scientific data showing that a change in criteria is justified. As Drs. Waterman and Curley persuasively argue, we must consider “…the negative consequences of leaving largely unchanged a taxonomy we know to be inadequate at best and simply wrong at worst.” [20]
    As a very crude mathematical representation of these complex calculations, we can write:
J=    S1B
    Where J is the justification for changing a specific criterion; S1 is the scientific evidence supporting the change; B is the known benefits of diagnosing and optimally treating the condition (e.g., reduced suicide rates, disability, etc.); S2 is the scientific evidence arguing against the change, and R is the known risk of over-diagnosis and excessive or inappropriate treatment.  Obviously, this theoretical calculation would be exceedingly difficult in practice. But it is equally evident that retaining a dubious DSM-IV diagnostic criterion requires much more justification than a mere prediction of iatrogenic harm to patients.

What is a “False Positive” in

    I also find Dr. Frances’s use of the term “false positive” [14] in the psychiatric context deeply problematic. Indeed, some psychiatrists have appropriated this term from the fields of pathology or infectious disease, without thinking through its epistemological meaning in psychiatry.  For example, when an infectious disease expert says, “False positive FTA-ABS tests [for syphilis] can occur in Lyme borreliosis,”[21]  the expert is invoking a very different epistemological “deep structure” than that invoked, implicitly, by Dr. Frances. Thus, when Dr. Frances expresses concern that eliminating the bereavement exclusion will increase the rate of “false positive” diagnoses of MDD [14], it is unclear to what veridical standard he is appealing. What is our laboratory “test” for a true positive in MDD? Until we have a widely agreed-upon criteria set for MDD, for which a specific biomarker or endophenotype has been identified, the term “false positive” is, at best, a wishful metaphor; and at worst, a kind of Rylean “category mistake.” The term misappropriates, from the epistemic structure of the physical sciences, a term that has little if any “physical” meaning in psychiatry—at least, in the sense that an infectious disease expert would use the term “false positive.” One hopes, of course, that this situation will change as neurobiological knowledge advances [22]. 
    That said, the term “false positive” can have a coherent conceptual meaning in psychiatry, when, for example, it describes a problem with the application of specific diagnostic criteria.  For example, the statement, “Failure to recognize cocaine intoxication can lead to a false positive diagnosis of DSM-IV-defined mania” is at least conceptually sound, since we can point to cocaine as a confounding factor in applying our present criteria for the diagnosis of mania. 
    Finally, it is fallacious to assume, following a change in condition X’s diagnostic criteria, that an increase in the total number of cases of X necessarily indicates an increase in “false positives” for X.  To assert this is merely to beg the question of what constitutes a false positive; indeed, absent a veridical biomarker for condition X, the increase in cases may simply reflect a legitimate increase in the identification of the illness. Thus, if elimination of the “bereavement exclusion” leads to an increase in the total number of diagnosed cases of major depressive disorder, this does not necessarily point to an increase in “false positives”[15].


    I have tried to look at the problems of DSM-5 from the standpoints of the “ideal” and the “real”. Ideally, in my view, the field of psychiatry would scrap the basic “categorical” structure of the DSMs, and start from scratch. A new diagnostic system, in my view, would be guided by the six basic principles enumerated earlier:  privilege, prototypes, parsimony, pragmatism, pluralism, and phenomenology.  The foundational principle of this idealized system is that only those conditions that entail substantial, intrinsic suffering and incapacity “count” as instantiations of disease. Disease descriptions would consist of “ideal types” (prototypes)—not symptom check-lists specifying necessary and sufficient conditions or “essential definitions.”
    In reality, we are probably stuck with tinkering around the edges of our present, seriously flawed diagnostic system. Even so, our tinkering should at least be guided by the best available science. Absent convincing empirical evidence that a change in criteria will harm those we treat, our diagnostic criteria should follow the principle, “Go where the best science leads you.” That direction just might lead psychiatry out of the diagnostic fly-bottle!


    1. Kendell RE, Jablensky A: Distinguishing Between the Validity and Utility of Psychiatric Diagnoses. Am J Psychiatry 2003; 160:4-12
    2. Pies R: On myths and countermyths: more on Szaszian fallacies. Arch Gen Psychiatry 1979; 36:139-144.
    3. Kendell RE :The myth of mental illness. In: Szasz Under Fire. Edited by JA Schaler. Chicago, Open Court, 2004, pp. 29-48
    4. Phillips J: The muddle that is DSM-V. AAPP Bulletin, 2010; 17:10-12.
    5. Pies R: What should count as a mental disorder in DSM-V? Psychiatric Times. April 14, 2009. Accessed at: www.searchmedica.com.
    6. Ghaemi SN: The Concepts of Psychiatry. Baltimore, Johns Hopkins, 2003, p. 179.
    7. Coppleston FC: Medieval Philosophy. New York, Harper Torchbooks, 1970.
    8. Ghaemi SN: The secret of DSM-IV: The danger for DSM-5 .How DSM-IV attitudes could harm DSM 5. Psychology Today blog, published on April 28, 2010 Accessed at:
    9. Thornton T: On wishing for a paradigm shift. AAPP Bulletin, 2010; 17: 17-19
    10. Arieti S: Interpretation of Schizophrenia. New York, Basic Books, 1974
    11. Frances A: DSM5 Plans To Loosen Criteria For Adult ADD. Psychiatric Times, April 20, 2010. Accessed at: http://www.psychiatrictimes.com/depression/content/article/10168/1556462
    12. Frances A: Should Practical Consequences Influence DSM5 Decisions?  Yes, of course. Psychology Today blog, April 27, 2010, Accessed at: http://www.psychologytoday.com/blog/dsm5-in-distress/201004/should-practical-consequences-influence-dsm5-decisions.
    13. Kottek S: The practice of medicine in the Bible and Talmud. In: Pioneers in Jewish Medical Ethics. Edited by F. Rosner. Northvale NJ, Jason Aronson, 1997, pp. 7-2
    14. Frances A:  How To Avoid Medicalizing Normal Grief In DSM5.  Psychiatric Times March 16, 2010. Accessed at:www.searchmedica.com.
    15. Pies R, Zisook S: Disentangling Grief and Depression: Rejoinder to Dr Frances. Psychiatric Times, March 16, 2010.  Accessed at: www.searchmedica.com
    16. Ghaemi S: First Do No Harm and DSM - Part I: An empty slogan? What does First Do No Harm mean?  Psychology Today blog, May 6, 2010. Accessed at: http://www.psychologytoday.com/blog/mood-swings/201005/first-do-no-harm-and-dsm-part-i-empty-slogan
    17. Frances A: Bipolar II Revisited-Always Take The Experts With A Grain Of Salt. Psychology Today blog, April 26, 2010. Accessed at: http://www.psychologytoday.com/blog/dsm5-in-distress/201004/bipolar-ii-revisited-always-take-the-experts-grain-salt
    18.  Pompili M, Rihmer Z, Innamorati M et al: Assessment and treatment of suicide risk in bipolar disorders. Expert Review of Neurotherapeutics  2009;  9: 109-136
    19. Tondo L, Baldessarini RJ.Long-term lithium treatment in the prevention of  suicidal behavior in bipolar disorder patients. Epidemiol Psichiatr  Soc. 2009;8:179-83.
    20. Waterman GS, Curley DP: Doing no harm: the case against conservatism. AAPP Bulletin, 2010; 17:19-20
    21. Smith JL, Crumpton BC, Hummer J.  The Bascom Palmer Eye Institute Lyme/syphilis survey. J Clin Neuroophthalmol. 1990 Dec;10(4):255-60.
    22. Maletic V, Raison CL Neurobiology of depression, fibromyalgia and neuropathic pain. Front Biosci. 2009; 14:5291-338.

Thursday 23 February 2012




Open Letter to the DSM5 TASK FORCE

To the DSM-5 Task Force and the American Psychiatric Association:

As you are aware, the DSM is a central component of the research, education, and practice of most licensed psychologists in the United States. Psychologists are not only consumers and utilizers of the manual, but we are also producers of seminal research on DSM-defined disorder categories and their empirical correlates. Practicing psychologists in both private and public service utilize the DSM to conceptualize, communicate, and support their clinical work.

For these reasons, we believe that the development and revision of DSM diagnoses should include the contribution of psychologists, not only as select individuals on a committee, but as a professional community. We have therefore decided to offer the below response to DSM-5 development. This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues.


Though we admire various efforts of the DSM-5 Task Force, especially efforts to update the manual according to new empirical research, we have substantial reservations about a number of the proposed changes that are presented on www.dsm5.org.  As we will detail below, we are concerned about the lowering of diagnostic thresholds for multiple disorder categories, about the introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations, and about specific proposals that appear to lack empirical grounding. In addition, we question proposed changes to the definition(s) of mental disorder that deemphasize sociocultural variation while placing more emphasis on biological theory. In light of the growing empirical evidence that neurobiology does not fully account for the emergence of mental distress, as well as new longitudinal studies revealing long-term hazards of standard neurobiological (psychotropic) treatment, we believe that these changes pose substantial risks to patients/clients, practitioners, and the mental health professions in general.

Given the changes currently taking place in the profession and science of psychiatry, as well as the developing empirical landscape from which psychiatric knowledge is drawn, we believe that it is important to make our opinions known at this particular historical moment. As stated at the conclusion of this letter, we believe that it is time for psychiatry and psychology collaboratively to explore the possibility of developing an alternative approach to the conceptualization of emotional distress. We believe that the risks posed by DSM-5, as outlined below, only highlight the need for a descriptive and empirical approach that is unencumbered by previous deductive and theoretical models.

In more detail, our response to DSM-5 is as follows:

Advances Made by the DSM-5 Task Force

We applaud certain efforts of the DSM-5 Task Force, most notably efforts to resolve the widening gap between the current manual and the growing body of scientific knowledge on psychological distress. In particular, we appreciate the efforts of the Task Force to address limitations to the validity of the current categorical system, including the high rates of comorbidity and Not Otherwise Specified (NOS) diagnoses, as well as the taxonomic failure to establish ‘zones of rarity’ between purported disorder entities (Kendell & Jablensky, 2003). We agree with the APA/DSM-5 Task Force statement that, from a systemic perspective,

"The DSM-III categorical diagnoses with operational criteria were a major advance for our field, but they are now holding us back because the system has not kept up with current thinking. Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism." (Schatzberg, Scully, Kupfer, & Regier, 2009)

As researchers and clinicians, we appreciate the attempt to address these problems. However, we have serious reservations about the proposed means for doing so. Again, we are concerned about the potential consequences of the new manual for patients and consumers; for psychiatrists, psychologists, and other practitioners; and for forensics, health insurance practice, and public policy. Our specific reservations are as follows:

Lowering of Diagnostic Thresholds

The proposal to lower diagnostic thresholds is scientifically premature and holds numerous risks. Diagnostic sensitivity is particularly important given the established limitations and side-effects of popular antipsychotic medications. Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress. As suggested by the Chair of DSM-IV Task Force Allen Frances (2010), among others, the lowering of diagnostic thresholds poses the epidemiological risk of triggering false-positive epidemics.

We are particularly concerned about:

·         “Attenuated Psychosis Syndrome,”[1] which describes experiences common in the general population, and which was developed from a “risk” concept with strikingly low predictive validity for conversion to full psychosis.

·         The proposed removal of Major Depressive Disorder’s[2] bereavement exclusion, which currently prevents the pathologization of grief, a normal life process.

·         The reduction in the number of criteria necessary for the diagnosis of Attention Deficit Disorder,[3] a diagnosis that is already subject to epidemiological inflation.

·         The reduction in symptomatic duration and the number of necessary criteria for the diagnosis of Generalized Anxiety Disorder.[4]

Though we also have faith in the perspicacity of clinicians, we believe that expertise in clinical decision-making is not ubiquitous amongst practitioners and, more importantly, cannot prevent epidemiological trends that arise from societal and institutional processes. We believe that the protection of society, including the prevention of false epidemics, should be prioritized above nomenclatural exploration.

Vulnerable Populations

We are also gravely concerned about the introduction of disorder categories that risk misuse in particularly vulnerable populations. For example, Mild Neurocognitive Disorder[5] might be diagnosed in elderly with expected cognitive decline, especially in memory functions. Additionally, children and adolescents will be particularly susceptible to receiving a diagnosis of Disruptive Mood Dysregulation Disorder[6] or Attenuated Psychosis Syndrome. Neither of these newly proposed disorders have a solid basis in the clinical research literature, and both may result in treatment with neuroleptics, which, as growing evidence suggests, have particularly dangerous side-effects (see below)—as well as a history of inappropriate prescriptions to vulnerable populations, such as children and the elderly

Sociocultural Variation

The DSM-5 has proposed to change the Definition of a Mental Disorder such that DSM-IV’s Feature E: “Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual,”[7] will instead read “[A mental disorder is a behavioral or psychological syndrome or pattern] [t]hat is not primarily a result of social deviance or conflicts with society.”[8] The latter version fails to explicitly state that deviant behavior and primary conflicts between the individual and society are not mental disorders. Instead, the new proposal focuses on whether mental disorder is a “result” of deviance/social conflicts. Taken literally, DSM-5’s version suggests that mental disorder may be the result of these factors so long as they are not “primarily” the cause. In other words, this change will require the clinician to draw on subjective etiological theory to make a judgment about the cause of presenting problems. It will further require the clinician to make a hierarchical decision about the primacy of these causal factors, which will then (partially) determine whether mental disorder is said to be present. Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder.

Revisions to Existing Disorder Groupings
Several new proposals with little empirical basis also warrant hesitation:

·         As mentioned above, Attenuated Psychosis Syndrome[9] and Disruptive Mood Dysregulation Disorder (DMDD)[10] have questionable diagnostic validity, and the research on these purported disorders is relatively recent and sparse.

·         The proposed overhaul of the Personality Disorders[11] is perplexing. It appears to be a complex and idiosyncratic combined categorical-dimensional system that is only loosely based on extant scientific research. It is particularly concerning that a member of the Personality Disorders Workgroup has publicly described the proposals as “a disappointing and confusing mixture of innovation and preservation of the status quo that is inconsistent, lacks coherence, is impractical, and, in places, is incompatible with empirical facts” (Livesley, 2010), and that, similarly, Chair of DSM-III Task Force Robert Spitzer has stated that, of all of the problematic proposals, “Probably the most problematic is the revision of personality disorders, where they’ve made major changes; and the changes are not all supported by any empirical basis.”[12]

·         The Conditions Proposed by Outside Sources[13] that are under consideration for DSM-5 contain several unsubstantiated and questionable disorder categories. For example, “Apathy Syndrome,” “Internet Addiction Disorder,” and “Parental Alienation Syndrome” have virtually no basis in the empirical literature.

New Emphasis on Medico-Physiological Theory

Advances in neuroscience, genetics, and psychophysiology have greatly enhanced our understanding of psychological distress. The neurobiological revolution has been incredibly useful in conceptualizing the conditions with which we work. Yet, even after “the decade of the brain,” not one biological marker (“biomarker”) can reliably substantiate a DSM diagnostic category. In addition, empirical studies of etiology are often inconclusive, at best pointing to a diathesis-stress model with multiple (and multifactorial) determinants and correlates. Despite this fact, proposed changes to certain DSM-5 disorder categories and to the general definition of mental disorder subtly accentuate biological theory. In the absence of compelling evidence, we are concerned that these reconceptualizations of mental disorder as primarily medical phenomena may have scientific, socioeconomic, and forensic consequences. New emphasis on biological theory can be found in the following DSM-5 proposals:

·         The first of DSM-5’s proposed revisions to the Definition of a Mental Disorder transforms DSM-IV’s versatile Criterion D: “A manifestation of a behavioral, psychological, or biological dysfunction in the individual”[14] into a newly collapsed Criterion B: [A behavioral or psychological syndrome] “That reflects an underlying psychobiological dysfunction.”[15] The new definition states that all mental disorders represent underlying biological dysfunction. We believe that there is insufficient empirical evidence for this claim.

·         The change in Criterion H under “Other Considerations” for the Definition of a Mental Disorder adds a comparison between medical disorders and mental disorders with no discussion of the differences between the two. Specifically, the qualifying phrase “No definition adequately specifies precise boundaries for the concept of ‘mental disorder’”[16] was changed to “No definition perfectly specifies precise boundaries for the concept of either ’medical disorder’ or ‘mental/psychiatric disorder’.”[17][18] This effectively transforms a statement meant to clarify the conceptual limitations of mental disorder into a statement equating medical and mental phenomena.

·         We are puzzled by the proposals to “De-emphasize medically unexplained symptoms” in Somatic Symptom Disorders (SSDs) and to reclassify Factitious Disorder as an SSD. The SSD Workgroup explains: “…because of the implicit mind-body dualism and the unreliability of assessments of ‘medically unexplained symptoms,’ these symptoms are no longer emphasized as core features of many of these disorders.”[19] We do not agree that hypothesizing a medical explanation for these symptoms will resolve the philosophical problem of Cartesian dualism inherent in the concept of “mental illness.” Further, merging the medico-physical with the psychological eradicates the conceptual and historical basis for somatoform phenomena, which are by definition somatic symptoms that are not traceable to known medical conditions. Though such a redefinition may appear to lend these symptoms a solid medico-physiological foundation, we believe that the lack of empirical evidence for this foundation may lead to practitioner confusion, as might the stated comparison between these disorders and research on cancer, cardiovascular, and respiratory diseases.[20]

·         The proposed reclassification of Attention Deficit/Hyperactivity Disorder (ADHD) from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence to the new grouping “Neurodevelopmental Disorders” seems to suggests that that ADHD has a definitive neurological basis. This change, in combination with the proposal to lower the diagnostic threshold for this category as described above, poses high risk of exacerbating the extant over-medicalization and over-diagnosis of this disorder category.

·         A recent publication by the Task Force, The Conceptual Evolution of DSM-5 (Regier, Narrow, Kuhl, & Kupfer, 2011), states that the primary goal of DSM-5 is “to produce diagnostic criteria and disorder categories that keep pace with advances in neuroscience.”[21] We believe that the primary goal of DSM-5 should be to keep pace with advances in all types of empirical knowledge (e.g., psychological, social, cultural, etc.).

Taken together, these proposed changes seem to depart from DSM’s 30-year “atheoretical” stance in favor of a pathophysiological model. This move appears to overlook growing disenchantment with strict neurobiological theories of mental disorder (e.g., “chemical imbalance” theories such as the dopamine theory of schizophrenia and the serotonin theory of depression), as well as the general failure of the neo-Kraepelinian[22] model for validating psychiatric illness. Or in the words of the Task Force:

“…epidemiological, neurobiological, cross-cultural, and basic behavioral research conducted since DSM-IV has suggested that demonstrating construct validity for many of these strict diagnostic categories  (as envisioned most notably by Robins and Guze) will remain an elusive goal” (Kendler, Kupfer, Narrow, Phillips, & Fawcett, 2009, p. 1).

We thus believe that a move towards biological theory directly contradicts evidence that psychopathology, unlike medical pathology, cannot be reduced to pathognomonic physiological signs or even multiple biomarkers. Further, growing evidence suggests that though psychotropic medications do not necessarily correct putative chemical imbalances, they do pose substantial iatrogenic hazards. For example, the increasingly popular neuroleptic (antipsychotic) medications, though helpful for many people in the short term, pose the long-term risks of obesity, diabetes, movement disorders, cognitive decline, worsening of psychotic symptoms, reduction in brain volume, and shortened lifespan (Ho, Andreasen, Ziebell, Pierson, & Magnotta, 2011; Whitaker, 2002, 2010). Indeed, though neurobiology may not fully explain the etiology of DSM-defined disorders, mounting longitudinal evidence suggests that the brain is dramatically altered over the course of psychiatric treatment.


In sum, we have serious reservations about the proposed content of the future DSM-5, as we believe that the new proposals pose the risk of exacerbating longstanding problems with the current system. Many of our reservations, including some of the problems described above, have already been articulated in the formal response to DSM-5 issued by the British Psychological Society (BPS, 2011) and in the email communication of the American Counseling Association (ACA) to Allen Frances (Frances, 2011b).

In light of the above-listed reservations concerning DSM-5’s proposed changes, we hereby voice agreement with BPS that:

•       “…clients and the general public are negatively affected by the continued and continuous medicalization of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.”

•         “The putative diagnoses presented in DSM-V are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgments, with little confirmatory physical 'signs' or evidence of biological causation.  The criteria are not value-free, but rather reflect current normative social expectations.”

•          “… [taxonomic] systems such as this are based on identifying problems as located within individuals. This misses the relational context of problems and the undeniable social causation of many such problems.”

•  There is a need for “a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience” and the fact that strongly evidenced causal factors include “psychosocial factors such as poverty, unemployment and trauma.”

• An ideal empirical system for classification would not be based on past theory but rather would “ begin from the bottom up – starting with specific experiences, problems or ‘symptoms’ or ‘complaints’.”

The present DSM-5 development period may provide a unique opportunity to address these dilemmas, especially given the Task Force’s willingness to reconceptualize the general architecture of psychiatric taxonomy. However, we believe that the proposals presented on www.dsm5.org are more likely to exacerbate rather than mitigate these longstanding problems. We share BPS’s hopes for a more inductive, descriptive approach in the future, and we join BPS in offering participation and guidance in the revision process.


American Psychiatric Association (2011). DSM-5 Development. Retrieved from http://www.dsm5.org/Pages/Default.aspx

British Psychological Society. (2011) Response to the American Psychiatric Association: DSM-5 development. Retrieved from http://apps.bps.org.uk/_publicationfiles/consultationresponses/DSM-5%202011%20-%20BPS%20response.pdf

Compton, M. T. (2008). Advances in the early detection and prevention of schizophrenia. Medscape Psychiatry & Mental Health. Retrieved from http://www.medscape.org/viewarticle/575910

Frances, A. (2010). The first draft of DSM-V. BMJ. Retrieved from http://www.bmj.com/content/340/bmj.c1168.full

Frances, A. (2011a). DSM-5 approves new fad diagnosis for child psychiatry: Antipsychotic use likely to rise. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/display/article/10168/1912195

Frances, A. (2011b). Who needs DSM-5? A strong warning comes from professional counselors [Web log message]. Psychology Today. Retrieved from http://www.psychologytoday.com/blog/dsm5-in-distress/201106/who-needs-dsm-5

Hanssen, M., Bak, M., Bijl, R., Vollebergh, W., & van Os, J. (2005). The incidence and outcome of subclinical psychotic experiences in the general population. British Journal of Clinical Psychology, 44, 181-191.

Ho, B-C., Andreasen, N. C., Ziebell, S., Pierson, R., & Magnotta, V. (2011). Long-term antipsychotic treatment and brain volumes. Archives of General Psychiatry, 68, 128-137.

Johns, L. C., & van Os, J. (2001). The continuity of psychotic experiences in the general population. Clinical Psychology Review, 21, 1125-1141.

Kendell, R., & Jablensky, A. (2003). Distinguishing between the validity and utility of psychiatric diagnoses. The American Journal of Psychiatry, 160, 4-11.

Kendler, K., Kupfer, D., Narrow, W., Phillips, K., & Fawcett, J. (2009, October 21). Guidelines for making changes to DSM-V. Retrieved August 30, 2011, from http://www.dsm5.org/ProgressReports/Documents/Guidelines-for-Making-Changes-to-DSM_1.pdf

Livesley, W. J. (2010). Confusion and incoherence in the classification of Personality Disorder: Commentary on the preliminary proposals for DSM-5. Psychological Injury and Law, 3, 304-313.

Moran, M. (2009). DSM-V developers weigh adding psychosis risk. Psychiatric News Online. Retrieved from http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=112801

Regier, D. A., Narrow, W. E., Kuhl, E. A., & Kupfer, D. J. (2011). The conceptual evolution of DSM-5. Arlington, VA: American Psychiatric Publishing.

Schatzberg, A. F., Scully, J. H., Kupfer, D. J., & Regier, D. A. (2009). Setting the record straight: A response to Frances commentary on DSM-V. Psychiatric Times, 26. Retrieved from http://www.psychiatrictimes.com/dsm/content/article/10168/1425806

Whitaker, R. (2002). Mad in America. Cambridge, MA: Basic Books. Also see http://www.madinamerica.com/madinamerica.com/Schizophrenia.html

Whitaker, R. (2010). Anatomy of an epidemic. New York, NY: Random House.

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