It won't be published until May, but the American Psychiatric Association's Diagnostic Statistical Manual, Fifth Edition, or DSM-5—an updating of the field's highly influential and pleasingly profitable handbook—is already in deep trouble. Every decade or so, DSM publishes a major edition, and often the changes stir controversy. But the alterations the APA announced for DSM-5 this week sparked unusually ferocious attacks from critics, many of them highly prominent psychiatrists. They say the manual fails to check a clear trend toward overdiagnosis and overmedication—and that a few new or expanded diagnoses defy both common sense and empirical evidence. This medicine is not going down well.
Nothing burns the critics worse than "Disruptive Mood Dysregulation Disorder," a new diagnosis for kids 6 to 18 years old who three or more times a week have "temper outbursts that are grossly out of proportion in intensity or duration to the situation." It actually started out as "temper dysregulation disorder with dysphoria" (tantrums, plus you feel bad) but got changed so as not to openly malign tantrums. But the diagnosis still focuses on them, and critics say it is so broad and baggy that it’s ridiculous—and dangerous. Duke University psychiatrist Allen Frances, who chaired the revision of DSM-IV in 2001, says the DMDD diagnosis "will turn temper tantrums into a mental disorder." In a recent blog post at Huffington Post, Frances put DMDD at the top of his list of DSM-5 diagnoses we should "just ignore," because "a new diagnosis can be more dangerous than a new drug." Clinical social worker and pharmacist Joe Wegmann called DMDD a diagnosis based on "no credible research" that would help drive a "zealous binge" of overdiagnosis. Is the outcry legitimate? Or are Frances and Wegmann just having themselves their own conniption fit?
DMDD's defenders say they actually hope the new diagnosis will slow a growing tendency to misdiagnose troubled, disruptive kids with bipolar disorder. Since 2001, the rate of bipolar-disorder diagnosis among children and teens has jumped more than 4,000 percent (that's right, times 40), despite controversy over whether bipolar disorder even occurs in kids. Bipolar disorder often gets treated with combinations of antipsychotic and mood-stabilizing drugs (lithium and Risperdal, for instance) that have strong side effects, and it carries a huge stigma and attendant effect on self-image. At first glance, DMDD seems a decent alternative. The hallmarks of a pediatric bipolar diagnosis, for instance, center largely on hyper-arousal, hyper-reactivity, and hyper-irritability—in other words, irritable kids who get excited and overreact, perhaps by having tantrums. A kid who scores high in those areas, and whose parents or teachers have trouble dealing with the behavior (or act in ways that exacerbate it), might get pegged as bipolar, with the sad outcome of taking powerful and questionable drugs and carrying a troubling label. DMDD, its advocates say, offers an alternate diagnosis that would carry less of a stigma and less likelihood of drug treatment.
We should never fail to help a child who is deeply struggling or in danger of entering a world of madness or uncontrollable behavior. But can a loosey-goosey diagnosis limit the damage of another diagnosis whose boundaries have grown vague and overextended? If the new alternative is ill-defined, almost certainly not. You can't solve overdiagnosis and blurred boundaries by prescribing more diagnoses with blurry boundaries. And by the slim evidence at hand, DMDD's boundaries are vaporous.
In October, University of Pittsburgh psychiatrist and bipolar disorder researcher David Axelson published the results of a series of tests he did on the DMDD diagnosis. He found, for starters, that kids diagnosed with DMDD had symptoms that overlapped heavily with those of kids who were diagnosed with two existing disorders, conduct disorder and oppositional defiant disorder—an overlap that suggests that no new catchall is needed. Axelson also found that a DMDD diagnosis predicted future mood or behavioral problems only weakly. This strengthens the argument that the problems these kids exhibit will usually fade away on their own.
Finally and most fatally, when clinicians at different clinics examined different populations of kids who had similar sets of symptoms, they diagnosed DMDD at wildly different rates. This violates the central premise of the DSM—that a disorder should be defined by distinct symptom clusters that most trained clinicians will recognize. In other words, if 10 diagnosticians examine the same kid, a solid majority should agree on whether they see DMDD. This didn't hold. DMDD doesn't just fail to predict a particular path through life. It fails to predict itself.
DMDD is not the only disputed call in DSM-V. The new edition also loosens the criteria for major depression and generalized anxiety disorder, two diagnoses that some doctors feel have already run rampant. In addition, eating "more than normal" 12 times in three months can now fetch you a "binge eating disorder" diagnosis. (No exceptions, it appears, for the holidays.) Just when many feel psychiatry should pull back from a rush to diagnosis, the APA seems to be accelerating.
It's tempting to suspect the APA committee is in bed with the big pharmaceutical companies. Allen Frances sees a cause both more innocent and harder to address: "The natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80 percent of psychiatric drugs are prescribed)."
Frances thinks too that the APA may be pushing a new edition because it wants to create the impression that psychiatry is advancing when it's not. The editors promised a paradigm shift—and thus they must deliver. Plus, the DSM makes a ton, and the APA could use the money.
One larger question is whether the DSM model is an anachronism. Psychiatric epidemiologist Jane Costello, resigning in protest from the DSM-5's Child and Adolescent Disorders workgroup in early 2009, complained that it simply makes no sense to rework an entire diagnostic framework all at once, which no other specialty does. Indeed it would be perfectly possible, and far cheaper, to update particular diagnoses or groups of diagnoses separately, as evidence dictates, and simply post the updates online—much as the Oxford English Dictionary and Encyclopedia Britannica now do. But then you couldn’t produce and sell a must-have best-seller.
I hope I'm not having a disproportionate reaction here, but it appears that the APA may be producing and marketing this heavy, consequential book not because the science demands or even justifies it but because psychiatry feels it needs some Big New Ideas, and the APA, having promised a book of them, is determined to print and sell it—even if the ideas are small and the thinking stale. There are good reasons to publish and bad reasons to publish. Those would be bad ones.
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