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Friday 6 September 2013

DSM-5 :The dangers of diagnostic inflation in psychiatry + the vital principle of 'Watchful Waiting' - 2012 - Journal of Psychotherapy and Psychosomatics

The dangers of diagnostic inflation in psychiatry

Alan Frances, the coordinator of the official diagnostic classification in psychiatry that was published in 1994 (DSM-IV), takes a very critical stand against current developments of psychiatric classification in the current issue of Psychotherapy and Psychosomatics.

There are converging pressures on psychiatrists, primary care physicians, and other mental health workers to over diagnose and over treat mental illness. The two diagnostic systems in use worldwide are ICD-10 (published in 1992) and DSM-IV (published in 1994 and very slightly revised in 2000). Their predecessors DSM-I (published in 1952 in conjunction with ICD 6) and DSM-II (in 1968 with ICD 8A) provided a broad based psychiatric classification that was likely to identify significant rates of psychiatric disorder in the general population. However, lacking any reliable method of psychiatric diagnosis, it was impossible to ascertain just how high these rates might actually be.

Criterion-based diagnosis was introduced as an innovative method to improve reliability, first with the narrowly drawn Feighner criteria in 1972, then expanded in the Research Diagnostic Criteria in 1975, and finally much expanded and made official with the publication of DSM-III in 1980. DSM-III offered a common clinical and research language that made it possible to study the prevalence of mental disorders within the community. It was a splitter’s system with many narrowly defined, high prevalence diagnoses. Not surprisingly, the introduction of DSM-III resulted in a rum of diagnostic inflation that greatly expanded the boundary of mental disorders at the expense of the shrinking province of normality.

DSM-IV took a conservative approach aimed at avoiding further exacerbation of diagnostic inflation. Epidemiological studies show that the overall prevalence of psychiatric disorders in adults stabilized. Nevertheless, DSM-IV was itself a contributor to three false-positive ‘epidemics’: adult bipolar disorders, attention deficit hyperactivity disorder, autistic disorder and childhood bipolar disorder.

Unfortunately, DSM-5, scheduled to appear in May 2013, proposes another grand expansion of mental illness, with suggestions that taken together may create tens of millions of additional new patients, all by arbitrary diagnostic fiat. It has been subjected to withering (and much deserved) criticism in the international press. Having lost faith in DSM 5 credibility, 47 mental health associations have endorsed a petition requesting an independent scientific review. Constant delays and disappointing results in its field testing guarantee that DSM 5 will be rushed, radical, and reckless- with the potential to cause great harms to individuals and to public policy. According to the Authors, all this will happen in three ways.

First, DSM-5 plans to introduce five new, high prevalence disorders at the populous and fuzzy boundary with normality (mixed anxiety depression, binge eating, mild neurocognitive, mood dysregulation, and attenuated psychotic symptoms). Second, DSM-5 will reduce thresholds in the criteria sets of very common disorders in a way that may make them much more common (especially generalized anxiety and adult attention deficit). Finally, creating spectrums of autism and addictions will likely broaden their purview. The DSM-5 principle has been to avoid false negatives at all costs and to worry not at all about false positives. In contrast, the Authors believe the false positive problem in psychiatric diagnosis is now far worse than the false negative problem. Certainly many severely suffering potential patients do not get the treatment they could clearly benefit from, but this is not due to diagnostic thresholds being set too high and it will not be corrected by creating new and unproven mild boundary disorders. On the other hand, false-positive diagnoses create huge and obvious problems: unnecessary, harmful, and expensive treatments; stigma; lowered expectations and a reduced sense of personal responsibility; misallocation of resources from the really ill to the worried well; difficulties getting insurance; excessive disability; forensic complications, and more.

Stepped diagnosis and treatment are based on a model of health care delivery in which the first-line efforts are the least intensive of those available that are still likely to provide a significant health gain. More definitive diagnoses and expensive treatments are preserved for people who are not able to benefit from the simpler, stepped, first-line interventions. Continuous assessments of the patient’s condition are crucial – with timely ‘stepping up’ if a lesser intervention is not achieving a significant health gain. Stepped care starts with a stepped diagnosis. Prior to a definitive diagnosis, the primary care doctor or mental health professional takes the following steps:

(1) Gather baseline data. For moderate and severe problems go directly to step 6. For mild, first-onset, and/or stress reactive problems continue to the next step. (2) Normalize problems without devaluing or minimizing the patient’s pain or distress. Reassure the patient that his or her emotions are an expectable response to the stressors in his or her life. Speak in terms of ‘problems’ or ‘difficulties’, actively avoid terms like ‘depression’ or ‘psychiatric illness’. (3) Watchful waiting – a period of continued assessment, monitoring, and scheduled follow-up with no pretence of a definitive diagnosis or active treatment. (4) Minimal interventions aimed at stress reduction, such as bibliotherapy or computer-aided therapy. Make explicit that these are not offered to treat a psychiatric disorder that has already been defined. A major advantage of these minimal interventions is that they harness the person’s capacity for self-help as much as possible . (5) Brief counseling – simple techniques derived from cognitive behavior therapy, problem solving therapy, or solution-focused brief therapy to teach new attitudes and coping skills in dealing with stressors. (6) The definitive diagnosis is made and definitive treatment is begun whenever symptoms persist to cause clinically significant distress or impairment.

Although step 6 and further is beyond the scope of this paper, the Authors think it is important to stress that the process of (pre)diagnostic reasoning does not end with a DSM diagnosis and pharmaceutical treatment. A DSM diagnosis should be the beginning of a diagnostic process and individualized treatment in which psychotherapeutic interventions may follow pharmacological treatment and vice versa.

Stepped diagnosis is a tool to help physicians and mental health workers make more accurate diagnoses and to reduce the provision of unnecessary and possibly harmful treatment. It is intended to reduce false-positive diagnoses and consequential artificially elevated rates of mental illness without risking missed diagnosis and under treatment. It should also improve the allocation of resources by redirecting diagnosis and care away from those who do not really need them towards those who really do. Mild psychiatric presentations often resolve with the passage of time, placebo effect, and minor interventions. It is cost and stigma saving to adequately reimburse careful evaluations as a means of reducing overdiagnosis and avoiding unnecessarily intensive treatments.

Psychiatry can enhance its credibility and improve its results by sticking to its appropriate target population of the moderately and severely ill. Stepped diagnosis will keep the worried well from being mislabeled as mentally disordered.

  • Full bibliographic informationBatstra, L. ; Frances, A. Holding the Line against Diagnostic Inflation in Psychiatry. Psychother Psychosom 2012;81:5-10

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