The International Reaction to DSM-5

The intense level of international interest in DSM-5 is a great surprise. Although DSM has become a research standard around the world, it is rarely used by clinicians outside the US and therefore poses a much lesser threat to their patients.

So why all the prominent newspaper, magazine, TV, and radio coverage especially in Germany, the Netherlands, England, Belgium, France, Italy, Australia, Japan, and Brazil?

Partly, there is concern that the noxious effects of DSM-5 may spread beyond our boundaries. The excessive diagnosis of ADD and autism began in the US, but these false epidemics are catchy and have now become a worldwide phenomenon.

A great example: It was announced last week that a team from Cambridge University is going to China to hunt for autism and that they anticipate placing the label on 14 million Chinese. The power of facile labeling never fails to amaze and frighten me.

And beyond the obvious practical consequences, people everywhere wonder about the cultural implications of a suddenly expanding psychiatry that is so rapidly shrinking the realm of normal. What does it say about a society if all its members are defined as sick?

The one thing that is not at all surprising in all the media coverage is its consistent tone of heated DSM criticism. People living in other countries can no more understand the lack of common sense in DSM-5 than they can understand why it remains legal in the US to own an assault rifle.

Here is a telling excerpt from a story that appeared last week in a German national newspaper. The association DGPPN described in the article stands for German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology [the English-language website refers to it as the German Association of Psychiatry, Psychotherapy and Psychosomatics], whose annual meeting is the largest in Europe and almost as large as the one held by the American Psychiatric Association. Its views on DSM-5 will carry considerable weight in Germany and be influential far beyond.

“The specialist organisation DGPPN advises against overdiagnosis in the DSM-5. There is the danger of pathologising ordinary states of suffering as well as natural adaptation and aging processes," says Wolfgang Maier, president of the DGPPN and director of the psychiatric clinic of the University of Bonn, in a statement on Monday.

“The statement names a number of examples, where the new catalogue shifts the boundaries between health and sickness in an inadmissible way," according to the DGPPN. Thus, in the DSM-5, a sadness of over 2 weeks after a death shall be diagnosed as depression if it shows its usual symptoms: cheerlessness, lack of drive/energy, indifference, sleeping problems, lack of appetite.

“Such an overdiagnosis constitutes a threat, which is put up with by the APA authors with open eyes,” says DGPPN president Maier. “Their premise is, we prefer false positive diagnoses before we fail to see a real sick person.” But this is, according to Maier, a calculation that doesn't work, alone for economical reasons, at least not in Germany. One should always take into consideration that a diagnosis entitles the person affected to a provision of medical care through the system, whose resources are limited. The consequence could be that for the psychically truly sick, there will be fewer possibilities for treatment.

The credibility of DSM-5 has been irrevocably compromised by the recklessness of its decisions; the weak scientific support; and the poor reliabilities in the failed DSM-5 Field Trials. I doubt DSM-5 will remain the international standard for research journals; it will almost certainly not gain any clinical following outside the US; and it will also probably lose its role as the lingua franca of American psychiatry.

What can be done now to restore credibility? If APA were really serious about DSM-5 being a living document and subject to correction, it would immediately commission a neutral Cochrane-type review of its changes to evaluate whether they stand up to real evidence-based scrutiny. I am convinced that none would (with the possible exception of autism).

Of course, it would have been far better had DSM-5 heeded much earlier the many calls for an independent review of its scientific justification. Psychiatry would have been saved much embarrassment had DSM-5 been either self-correcting or amenable to outside correction.

But, it is much better to do this far too late than not at all. Better to admit to mistakes and regain credibility, than to soldier on and be ignored.

We must protect against the real danger that all of psychiatry will be tainted by the folly of DSM-5. This would be unfair to clinicians and dangerous for patients. Psychiatry is an essential and successful profession when it sticks to what it does well. DSM-5 was an aberration-not a true reflection of the field.

There is only one possible good that can come from this unfortunate episode. Perhaps the concern over DSM-5 will generate a serious discussion on how best to correct overdiagnosis; overmedication; and the excessive authority that has been given to psychiatric diagnosis in school decisions, disability determinations, benefit eligibility, and in forensics. Psychiatric diagnosis has become too important for its own good.