What Would A Useful DSM-5 Look Like? And An Update On The Petition Drive

The petition to reform DSM-5 continues to gain momentum. In its first full week, more than 2300 people have already expressed their disapproval of the DSM-5 proposals and their desire to see dramatic changes. And the numbers are growing each day. You can join them at http://www.ipetitions.com/petition/dsm5/.

The next, naturally arising question is what would a properly done DSM-5 look like. The three missing steps in the DSM-5 process have been: 1) its failure to do rigorous, independent, and evidence based reviews of the science supporting each proposal; 2) its failure to search out all the possible risks and unintended consequences; and 3) its field trial design that will yield no useful information. The first two can still be corrected- the third is a lost cause.

Past experience has proven convincingly that DSM-5 is incapable of doing unbiased, systematic, and credible reviews of its own proposals. The scientific review committee has completely discredited itself with its very first decision- its rapid and unaccountable approval of Disruptive Mood Dysregulation Disorder. This makeshift, highly risky “diagnosis” was invented just six years ago and has been researched by a grand total of one group; providing no grounds for any confidence in DSM-5 scientific judgment or rigor.

It is very long past time for DSM-5 proposals to be subjected to completely independent and systematic reviews of the type done by the Cochrane group. DSM-5 has clearly lost the confidence of its consumers. Only an independent review can restore it. I am convinced that any real scientific review will unequivocally disqualify most (if not all) of the new diagnoses and lowered thresholds suggested for DSM-5.

Does this mean we should stick with DSM-IV just as it stands? I think not. DSM-5 does have one crucial responsibility that only it can fulfill-attempting to correct the already existing inflation in rates of psychiatric diagnosis and the current excessive use of medication. Overdiagnosis and overtreatment has occurred partly because the DSM definitions are sometimes too loose, but mostly because they are applied too loosely or ignored altogether by busy and largely untrained primary care physicians (who do much of the diagnosing and most of the prescribing of psychotropic medication).

Recent figures from the CDC (discussed in a previous blog) show that the very patients who most need medications too often don’t get them, while those who don’t really need medication are receiving far too much. We are now stuck with the worst combination of under treatment of the sick and over treatment of the well-a perfect storm of misallocated resources, stigma, and unnecessary and dangerous drug complications.

The DSM’s didn’t cause most of the overdiagnosis and DSM-5 can’t be expected to completely bring it under control. But DSM-5 must stop recklessly promoting even more diagnostic inflation and instead must do whatever is within its power to cure the existing problem.

The first step would be to determine which diagnoses have quickly attained excessive popularity. An independent Cochrane type review of survey data, clinical databases, and jumps in drug sales could be helpful in identifying current diagnostic fads. It can safely be assumed that any diagnosis that suddenly increases its reach 2- to 40-fold is likely being carelessly diagnosed. Human nature doesn’t change fast, but diagnostic habits do-especially under pressure from drug companies.

The limited DSM-5 tools to cure false epidemics may seem weak when compared with massive drug company misinformation campaigns and the lack among primary care physicians of sufficient training in psychiatric diagnosis. But in any sensible world DSM-5 would at least try its best to restore good diagnostic habits.

How to do this?
•First-a newly added section of text should be included for every one of the DSM-5 disorders teaching clinicians how to accurately making that diagnosis (and thus how to avoid false positives).
•Second-DSM-5 should borrow from the “black box” method of warning clinicians and patients of the potential risks posed by medications. Each suspect diagnosis in DSM-5 should be accompanied by its own black box that warns of the ways it has been overused and suggests how it can be applied properly. The DSM-5 disorders most in need of such flagging would include at a minimum: attention deficit; autism; bipolar; generalized anxiety; major depression; post-traumatic stress; somatic disorders; and paraphilia, not otherwise specified.
•Third-the diagnostic criteria for some of the disorders need to be clarified and made more rigorous.
•Fourth-the requirement that symptoms cause clinically significant distress or impairment needs to be strengthened to distinguish disorder from the symptoms of everyday life.
•Fifth, APA should sponsor DSM-5 conferences to educate clinicians and encourage more precise and less precipitant diagnosis.

The great value of this new, more rigorous version of DSM-5 would be its attempt to restore balance, tame wild overdiagnosis, and discourage careless treatment. In contrast, the great risk of the current version of DSM-5 is that it will feed diagnostic exuberance to the point that soon everyone will have a mental disorder (or even two or three) and will be receiving unnecessary medication-while the really ill are neglected for lack of attention and resources.

The petition is really the last best hope for the independent review that will be necessary to produce a safe and useful DSM-5. Here again is its address http://www.ipetitions.com/petition/dsm5/. Take a look and if you agree, please sign on and send it to your colleagues.