Thursday, May 30th, 2013
While DSM-5 should be reflecting consensus, it has certainly spurred many reactions – from inside the ranks.
Consider that the National Institute of Mental Health – the primary funding agency for mental health research in the US – will essentially ignore the DSM-5 in favor of its own research-based criteria. In other words – the DSM-5 is not especially informative for those who do research on mental health.
Consider the serious critique of the process offered by Allen Frances, M.D., in his book Saving Normal: An Insider’s Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. Dr. Frances was chair of the DSM-IV Task Force, and as such has an insider’s viewpoint on the whole process. The bottom line for him is that the DSM-5 not only does not improve on what we had before, it makes matters worse, primarily by introducing new disorders and making decisions about diagnostic criteria without sufficient evidence or grounding. The bigger point is that the diagnostic approach is losing the ability to discriminate behaviors that are part of the normal spectrum (and reflective of normative variation) and those that are truly problematic for individuals and deserving of diagnosis as a way of guiding treatment.
So what do we make of all this? I have two reactions.
I’m not all that concerned about the NIMH part of this. The reality is that researchers frequently look at “psychiatric disorders” in a number of ways – and not by following whatever clinical system is in place. That’s the point of research – to come up with something better. The problem, though, is that while there has been a lot of research that impacts our understanding of the various disorders, it has not yielded a radically different way of defining them clinically. It’s the goal, but it’s far from the reality.
That’s where “Saving Normal” comes into play. It’s hard to see that substantial progress was made at the research end to justify a whole new system. The choices made in DSM-5 are bringing more uncertainty to an already uncertain process. Let’s look at kids briefly. What’s especially troubling is that some kids who need treatment may no longer meet criteria for a disorder (like the estimated 10% reduction rate in diagnosing Autism Spectrum Disorder) – whereas others who exhibit potentially age-appropriate typical behaviors (like tantrum tantrums) may be diagnosed with the rather shaky Disruptive Mood Dysregulation Disorder.
So where are we at? Diagnoses need to be made. Kids (and adults of course) need treatment. A diagnostic system for psychiatric disorders is going to be very fuzzy at best. Wouldn’t the best approach be to introduce changes for a given disorder when the evidence suggests it is the time to do so – rather than arbitrarily replace one system with another at a designated time in the future? In this day and age, wouldn’t that be feasible?Add a Comment