In an editorial in the May 17, 2013 online edition of Annals of Internal Medicine, the man who led the development of the last version of the psychiatric manual says the new version “will probably lead to substantial false-positive rates and unnecessary treatment.”
Allen Frances, MD, chaired the task force responsible for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV issued in 1994. In the editorial, he said the new version “introduce[s] several high-prevalence diagnoses at the fuzzy boundary with normality.”
As a result, the new manual will allow doctors to apply disease labels to individuals who may be unhappy or offensive but are still normal. This would include those experiencing “the forgetfulness of old age” as well as children with severe, chronic temper tantrums and individuals with physical symptoms with no medical explanation.
Frances said he was also worried that new marketing pushes from the pharmaceutical industry are seeking to exploit what he believes are “loose” diagnostic criteria in the new edition. “Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form,” he wrote.
Along with others, Frances has published open letters, blog posts, articles in mental health journals and consumer media, and two books to repeatedly blast his successors for missing deadlines, failing to conduct the types of research he believed were required, and shutting him and his allies out of the process. The developers of the new manual and American Psychiatric Association officials who commissioned the work have called the DSM-5 process more transparent than ever before.
In the editorial, Frances argued that, the new criteria have not been adequately tested. In particular, he wrote, the testing process lacked “adequate consideration of risk–benefit ratios and the economic cost of expanding the reach of psychiatry.”
He pointed to dramatic increases in diagnoses of such conditions as autism and related disorders, attention deficit-hyperactivity disorder, and bipolar disorder over the past 20 years. These increases, he suggested, reflect “overdiagnosis” and serve as examples of what can go wrong when diagnostic criteria are drawn too loosely.
The DSM has, he said, “acquired perhaps too much real-world influence as the arbiter of who gets what treatment and whether it will be reimbursed; who is eligible for disability benefits, Veterans Affairs benefits, and school and mental health services; and who qualifies to receive life insurance, adopt a child, fly an airplane, or buy a gun.”
He urged physicians to “use the DSM-5 cautiously, if at all.”