DSM5 Task Force: Do Not Go to the Mass Media-Do Your Homework

As I was driving to work on February 10, 2010, I listened to the National Public Radio host Melissa Block talking about how children labeled “bipolar” may get a new diagnosis.¹ I was shocked that the chair of one of the DSM5 work groups, David Shaffer, MD, would discuss a controversial diagnostic topic with the media. The impetus for writing this commentary is my empathy for millions of parents who have children with a mental disorder-whether experts call it “bipolar disorder” or the newly manufactured “temper dysregulation disorder” (TDD) proposed by the DSM5 work group. The parents of afflicted children need all the help and education they can get from experts in child psychiatry, and the last thing they need is confusion and extra stress in their lives.

Let me set the record straight. . . . I am not a child psychiatrist or an expert on childhood ailments, but I know enough to say that neither Dr Shaffer nor the work group has any scientific evidence to back up the newly manufactured TDD. Dr Shaffer went even further and declared that temper dysregulation disorder will be seen as a brain or a biological dysfunction, but not necessarily as a lifelong condition like bipolar. I would like the DSM5 experts to share with the psychiatric community their scientific evidence regarding the biological nature of TDD.

The interview with Dr Shaffer reminded me of the wrong and unproven schizophrenogenic mother hypothesis of Fromm-Reichmann in the 40s as a cause of schizophrenia.^2,3 In the case of TDD, the situation is made worse because of the creation of an entirely new, scientifically unproven disorder. If TDD turns out to be a false disorder, every theory and all the research related to the TDD will be a waste.

The science of classification (taxonomy) has the following 9 important functions as described in textbooks and papers^4-9:
• Economizing memory, meaning that describing a group of individuals subsumes the description of each individual in the group
• Summarizing the information and attaching a convenient label to it
• Easing the manipulation and retrieval of information
• Conceptualizing clinical diagnostic entities for human illnesses and using them in clinical practice
• Identifying and assigning previously unallocated entities to their appropriate categories and assigning individual patients to an appropriate diagnosis
• Communicating clinical information (diagnoses) to other health care providers, families, and health care systems administrators
• Describing and simplifying the attributes and relationships of subjects in different diagnostic entities • Generating and testing hypotheses (eg, testing and choosing effective interventions to improve the clinical outcomes of different diagnostic entities)
• Assessing the clinical needs of diagnostic entities and predicting their course and outcomes

None of the functions of classification includes manufacturing and selling of new mental disorders to the public as the DSM5 work group is doing with the TDD.

Mental disorders can be classified using-a categorical model or a dimensional model.^10-21 The categorical model used in DSM assumes discrete disease entities of mental disorders; these entities do not cover the heterogeneity of patients seen in clinical practice. This limitation has resulted in the overuse of the not otherwise specified (NOS) category by clinicians.¹³ In an attempt to solve this problem, each new DSM edition has expanded and added new disorders and new subtypes. A good example is the addition of bipolar II disorder in DSM-IV to capture patients with hypomanic episodes and major depression.

Advocates of the dimensional model argue that their model may solve this and other problems inherent in the categorical model.^12-15 The DSM5 Task Force decided to include a dimensional component in DSM5.22,23 I wonder if Dr Shaffer and his colleagues have developed (or are developing) a mood spectrum dimension that can be the scientific solution to misdiagnosis.

Did the DSM5 work group think about the basic expected consequences of creating a new mental disorder? Did they consider the possibility of creating a false epidemic of a new mental disorder? Will the TDD cause unnecessary panic and confusion for the public? What guidelines do child psychiatrists and clinicians need to use to diagnose and treat the new TDD? How about the disruption of research efforts such as meta-analyses? Concerning the unintended consequences of making new DSM changes, Allen Frances, MD, has elaborated on them in his criticism of the DSM5 process.²⁴

Dr Shaffer argues that many children who have received a diagnosis of bipolar disorder do not meet the essential diagnostic criteria-namely a discrete weeklong episode of mania or a 2-week-long episode of depression. If this is the case, the problem appears to be that clinicians do not apply DSM criteria correctly. As Verheul²⁰ said, “a classification system can be theoretically sound, valid and provide perfect coverage, yet be completely worthless when it is not used at all or when it is not used correctly.”

Maybe we need to educate and train clinicians to use the DSM system correctly. If the DSM5 Task Force approves TDD, what will the DSM experts do when clinicians do not use the new criteria of TDD correctly? Dr Shaffer admits that he does not know whether psychiatrists or psychologists will actually change their ways with the new TDD. I have to agree with him on this one.

 In today’s era of evidence-based medicine, clinical research and scientific evidence is the solid ground of medicine and psychiatry.²⁵ If the DSM5 work group embarks on the road of “pseudoscience” and the creation and selling of mental disorders to the public, this may signal the decline of the DSM classification system. I would like to remind the DSM5 experts of a historical lesson: psychoanalysis and psychoanalysts enjoyed more than half a century of hegemony in the United States and ended up bankrupt because they did not back up their theories with scientific research.

Since the experts in the field do not agree on the diagnosis, why do we need to confuse the public and parents by going to the mass media? Do not take me wrong. . . . I am a proponent of free speech and free media. However, I implore the DSM5 work group to do their homework at home. The true home for scientific discussions on psychiatric nosology belongs to research proposals, field trials, scientific journals, and conferences.References
1. Spiegel A. Children labeled “bipolar” may get a new diagnosis. All Things Considered. National Public Radio. Februay 10, 2010. http://www.npr.org/search/index.php?searchinput=Dr+Shaffer&tabId=all&dateId=0&programId=0&topicId=0. Accessed April 19, 2010.
2.  Fromm-Reichmann F. Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry. 1948;11:263-273.
3.  Neill J. Whatever became of the schizophrenogenic mother? Am J Psychother. 1990;44:499-505.
4.  First MB, Pincus HA, Levine JB, et al. Clinical utility as a criterion for revising psychiatric diagnoses. Am J Psychiatry. 2004;161:946-954.
5.  Andreasen NC, Black DW. Introductory Textbook of Psychiatry. 3rd ed. Washington, DC: American Psychiatric; 2001.
6.  Kendell RE. The Role of Diagnosis in Psychiatry. London: Blackwell Scientific Publications; 1975.
7.  Spitzer RL, Fleiss JL. A re-analysis of the reliability of psychiatric diagnosis. Br J Psychiatry. 1974;125: 341-347.
8.  Millon T. Classification in psychopathology: rationale, alternatives, and standards. J Abnorm Psychol. 1991;100: 245-261.
9. Sokal RR. Classification: purposes, principles, progress, prospects. Science. 1974;185:1115-1123.
10.  First MB. Clinical utility: a prerequisite for the adoption of a dimensional approach in DSM. J Abnorm Psychol. 2005;114:560-564.
11.  Frances AJ, First MB, Widiger TA, et al. An A to Z guide to DSM-IV conundrums. J Abnorm Psychol. 1991;100:407-412.
12.  Widiger TA, Clark LA. Toward DSM-V and the classification of psychopathology. Psychol Bull. 2000;126: 946-963.
13.  Widiger TA, Samuel DB. Diagnostic categories or dimensions? A question for the Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition. J Abnorm Psychol. 2005;114: 494-504.
14.  Van Os J, Gilvarry C, Bale R, et al. A comparison of the utility of dimensional and categorical representations of psychosis. UK700 Group. Psychol Med. 1999;29:595-606.
15.  Peralta V, Cuesta MJ, Giraldo C, et al. Classifying psychotic disorders: issues regarding categorial vs. dimensional approaches and time frame to assess symptoms. Eur Arch Psychiatry Clin Neurosci. 2002;252:12-18.
16.  Watson D. Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V. J Abnorm Psychol. 2005;114:522-536.
17.  Sprock J. Dimensional versus categorical classification of prototypic and nonprototypic cases of personality disorder. J Clin Psychol. 2003;59:991-1014.
18.  Kraemer HC. DSM categories and dimensions in clinical and research contexts. Int J Methods Psychiatr Res. 2007;16(suppl 1):S8-S15.
19.  Carson R. Dilemmas in the pathway of the DSM-IV. J Abnorm Psychol. 1991;100:302-307.
20.  Verheul R. Clinical utility of dimensional models for personality pathology. In: Widiger T, Simonsen E, Sirovatka P, Regier D, eds. Dimensional Models of Personality Disorders: Refining the Research Agenda for DSM-V. Washington, DC: American Psychiatric Association; 2006:203-218.
21.  Trull T. Dimensional models of personality disorder: coverage and cutoffs. In: Widiger T, Simonsen E, Sirovatka P, Regier D, eds. Dimensional Models of Personality Disorders: Refining the Research Agenda for DSM-V. Washington, DC: American Psychiatric Association; 2006:171-188.
22.  Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. The conceptual development of DSM-V. Am J Psychiatry. 2009;166:645-650.
23.  Helzer J, Kraemer H, Krueger R, et al. Dimensional Approaches in Diagnostic Classification: Refining the Research Agenda for DSM-V. Arlington, VA: American Psychiatric Association; 2008.
24.  Frances A. A warning sign on the road to DSM-V: beware of its unintended consequences. Psychiatric Times. 2009;26(8):1, 4, 5, 8, 9.
25.  Ghaemi SN. The case for, and against, evidence-based psychiatry. Acta Psychiatr Scand. 2009;119:249-251.