DSM-5: A Disaster for Children

On 22 May, the American Psychiatric Association (APA) published DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, after months, perhaps even years, of speculation about its contents.

If people make the mistake of following DSM-5, pretty soon all of us may be labelled mad.

- Allen Frances, Psychiatrist and former Chairman of the DSM task force

“A legal document facilitating the medication of millions”

Psychology Today
By Helene Guldberg, Ph.D.
June 14, 2013

On 22 May, the American Psychiatric Association (APA) published DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, after months, perhaps even years, of speculation about its contents.

Its critics warned thatDSM-5 would lead to the further overdiagnosis of children and adults. The Economist reported that 11 per cent of American school-age children have been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and that DSM-5 would likely lead to even more ADHD diagnoses. Considering the majority of those diagnosed are on prescription drugs, this is a worrying development. So worrying, in fact, that Dr Allen Frances, Professor Emeritus at Duke University and former Chair of the task force that developed DSM-IV, writes: ‘If people make the mistake of following DSM-5, pretty soon all of us may be labelled mad.’

Many years before the publication of DSM-5, Chicago-based professor Christopher Lane raised serious concerns about overdiagnosis and overmedicalisation in his book Shyness: How Normal Behaviour Became a Sickness.

‘Our quirks and eccentricities – the normal emotional range of adolescence and adulthood – have become problems we fear and expect drugs to fix’, Lane wrote in 2008. ‘We are no longer citizens justifiably concerned about our world, who sometimes need to be alone. Our afflictions are chronic anxiety, personality or mood disorders; our solitude is a marker for mild psychosis; our dissent, a symptom of oppositional defiant disorder; our worries, chemical imbalance that drugs must cure.’

In Shyness, Lane charted how the Diagnostic and Statistical Manual was transformed – by a handful of psychiatrists behind closed doors – from the thin handbook it was in the 1970s into the hefty tome it is today, with hundreds of new, poorly specified and poorly researched syndromes being added. I asked Lane whether he would make the same criticisms of DSM-5 as he did of DSM-IV – both in terms of the process and the outcome of the revisions.

Christopher Lane: I would, yes. The outcome this time is painfully similar to that of earlier editions. But there were notable differences in the process, including the sheer number of people working on the new edition.

The DSM-5 task force made all kinds of announcements before publication about having made an effort to be more transparent and responsive to the concerns of mental health professionals, many of whom had been troubled by the low thresholds given a litany of psychiatric disorders. And, true enough, the APA did offer a brief window for commentary on proposed changes and did abandon its initial support for psychosis risk syndrome, a proposal so poorly defined it actually would have been dangerous in its implications. The APA also set a cap on honoraria that participants could accept from the drug companies ($10,000 each year). Previously, there had been no cap – and no conflict-of-interest forms distributed or signed.

But the new edition introduces so many new problems – including its dramatically lowered thresholds – that it is arguably a lot more hazardous than earlier editions. The latest one also approves such controversial additions as disruptive mood dysregulation in children and, for the appendix, internet addiction. Given how poorly these conditions were rated by the APA’s own field trials, which were flashing warning signs about unreliability, that they went ahead with them really is a serious concern.

DSM-5 is also, frankly, a disaster for children assigned behavioural disorders. It sets the threshold for such disorders far too low, as it does for many other, poorly defined conditions such as generalised anxiety disorder, with which it’s now even easier to be diagnosed and thus, by extension, medicated.

Helene Guldberg: You wrote in your Psychology Today blog last year: ‘Although the APA can’t officially accept an ounce of responsibility for the 40-fold increase in diagnoses of bipolar disorder in children, shortly after DSM-IV eliminated ‘mania’ as a required symptom for bipolar disorder type 2, the organisation does fortunately seek to remedy the diagnostic crisis. The problem is it has taken entirely the wrong action, devising a new disorder to conceal problems in the framing and real-world application of previously defined ones.’ You warned that DSM-5 was certain to ‘include highly controversial changes’. So did this turn out to be the case?

CL: Unfortunately yes. Children exhibiting prolonged temper tantrums can now be diagnosed with disruptive mood dysregulation disorder. That’s along with ADHD, oppositional defiant disorder, and bipolar disorder, which are already in the manual and share a great deal of overlap. And the elimination of the bereavement exclusion clause will mean that depression can now be diagnosed among the recently bereaved after just two weeks. David Kupfer, chair of the DSM-5 task force, told the New York Times that psychiatrists and GPs would just need to exercise ‘good solid clinical judgment’ in distinguishing between mourning and depression, when at 14 days both share a large number of symptoms, including insomnia, loss of appetite, listlessness, and intense mood swings.

The knock-on effect of these decisions—the unintended consequences that are frustratingly obvious and easy to predict – are truly what concern me. Because even when there’s an uproar – and there was this time over the decision to delete the bereavement exclusion clause, with the Lancet calling the proposal ‘dangerously simplistic’ and ‘flawed’ – the APA showed that it is largely impervious to even such expert medical concern.

Read entire article here:  http://www.psychologytoday.com/blog/reclaiming-childhood/201306/dsm-5-disaster-children