As I was sitting around catching up on some mental health news on Saturday, I inadvertently stumbled upon another manufactured news cycle about the DSM 5. Considering no new significant research findings were released in the past week on the DSM-5 revision efforts, I was a little surprised.
This latest fake news cycle started on Thursday, apparently with the release of a Reuters news story from Kate Kelland. Kelland notes the newest concern comes from “Liverpool University’s Institute of Psychology at a briefing in London about widespread concerns over the manual.” There’s no link to the briefing. And I’m not sure what a “briefing” is — a press conference? (And since when is a press conference a news item? It’s not really equivalent to a new research study, is it?)
Kelland fails to note that Europe and the U.K. don’t actually use the DSM to diagnose mental disorders — it’s a U.S. reference manual for mental disorders diagnosis. So while it’s nice that some Europeans are expressing concern about this reference text, their concern isn’t exactly much relevant. Context is everything, and Reuters failed to provide any useful context in that article.
Sadly, Reuters is a brand name. And once you write an article under that brand name, it cascades down an entire news cycle. Let’s follow it for fun!
Reuters begins with:
Millions of healthy people – including shy or defiant children, grieving relatives and people with fetishes – may be wrongly labeled mentally ill by a new international diagnostic manual, specialists said on Thursday.
In a damning analysis of an upcoming revision of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM), psychologists, psychiatrists and other experts said new categories of mental illness identified in the book were at best “silly” and at worst “worrying and dangerous.”
Wow, glad there’s no fear-mongering going on there. A nice, balanced approach to the news.
These are the same “experts” who have been beating their drum all fall and winter, but who decided to convene a press conference in the UK last week to generate more press. And more press they did generate.
The Kelland article again regurgitates half-truths about the issue, such as this beauty:
More than 11,000 health professionals have already signed a petition […] calling for the development of the fifth edition of the manual to be halted and re-thought.
Apparently Reuters doesn’t do any fact checking any longer. As we discussed more than a month ago, not all of the “signatures” are mental health professionals — only approximately 88 percent self-reported they were. Sloppy reporting from Reuters.
The rest of the “briefing” was simply rehashing all of the same old arguments that both we and many, many others have already covered. It’s silly and a little demeaning to try and argue these things in the press, over and over again, because it comes down to one set of professional opinions against another. Whose set is “better” or more legitimate? Nobody can tell, because nobody has access to the future.
Oh. Except for Allen Frances, M.D. He has apparently left his position as a doctor and taken up residency as a psychic, because he told the U.K.’s Telegraph,
“DSM5 will radically and recklessly expand the boundaries of psychiatry. Many millions will receive inaccurate diagnosis and inappropriate treatment.,” said Allen Frances of Duke University, North Carolina.
Wow, really? You always seem to miss mentioning how the current DSM-IV — overseen by the same Allen Frances — has done exactly the same thing (according to its critics).
Because this press conference — uh, I mean “briefing” — was conducted in the U.K. by U.K. organizations, it was picked up in the U.K. media. (Here’s a nice summary of the coverage.)
Now, in order to capitalize on this new news cycle in the U.S., American outlets needs to bring their own sexy angle to the story.
A day after the UK press conference, ABC News took the bait and Katie Moisse wrote it up as though the petition was a new thing (it was started in October 2011 and had 10,000 signatures two months later, in December 2011). Our knight in shining armor against the DSM-5, Allen Frances, again is liberally quoted:
“You can’t have one professional organization, like the American Psychiatric Association, responsible for something so important,” he said.
The change of heart is amazing. When the APA was signing checks to Frances, he had no problem supporting them. Now that he’s out of the process, he suggests the APA shouldn’t be the one publishing the reference text.
Keep in mind, the use and adoption of the DSM is completely a market-driven, voluntary choice. Nobody is demanding professionals use the DSM to diagnose mental disorders in the U.S. Another international system already exists called the ICD-10, and is used throughout the rest of the world. All the 600,000+ U.S. mental health professionals need do is agree to start using that instead of the DSM. It doesn’t require government intervention, and it doesn’t require endless hand-wringing.
The NY Daily News ran with the latest news cycle today with their own unique spin. This newspaper initially claimed that “DSM-5 lists Internet addiction among mental illnesses.” The headline was later changed to, “DSM-5, the new mental illness ‘bible,’ may list Internet addiction among illnesses.” Note that “may” was slipped in, and of course, typical of Internet news articles, no mention was made of the edit to the headline to reflect that absolutely nothing has changed about the status of Internet addiction in the new DSM-5. It will still likely not appear except in a general “behavioral addiction” disorder category — something we’ve known for about 2 years now.
Probably mostly unnoticed in this latest blip in the DSM-5 news cycle is this thoughtful article over at Medscape about the bereavement exception for depression. Well worth a read, as it actually is a nicely balanced piece of actual journalism. It’s thoughtful, examines both sides of the issue without bias, and presents a wealth of data to let the reader draw their own conclusion.
A refreshing change from the dribble passing for journalism from Reuters and others these days.
So a quick recap — no new news has occurred with the DSM-5. Some professionals who started a petition back in October 2011 held a press conference, and some news media attended it, and decided to write up these professionals opinions. These opinions are in opposition to other professionals’ opinions.
I will make a prediction right here and now, much like the psychic Allen Frances: When the DSM-5 is published next year, the world will not end. We will not face a new epidemic of diagnoses of any of the disorders listed therein. And mental health professionals will adapt to the new changes with little effort on their part.
For further reading…
Read the Reuters story: New mental health manual is “dangerous” say experts
Read NY Daily News story: DSM-5 lists Internet addiction among mental illnesses
Read the ABC News story: American Psychiatric Association Under Fire for New Disorders
Read the Fierce Pharma story (with links to UK coverage): Psychologists petition against DSM-5 revisions
14 comments
Dr Grohol,
Do you dispute the 4000% increase in BD diagnosis in America after DSM-IV came out, or the relation of DSM-IV’s criteria and definition changes to that increase?
Hi Dave,
Regardless of whether I dispute it or not, do you have any scientific research to trace the actual cause of the increase?
Second, should we use as one gauge for whether we update diagnostic criteria or not the incidence of diagnosis of such criteria? We wouldn’t dream of doing this in medicine (e.g., look at the increase of cancer diagnoses in the 1970s and 1980s), so why would we believe it’s okay for mental disorders?
Dr. Grohol,
Thank you for your thoughtful post and candid, balanced message about the DSM-5. The process of developing the DSM-5 has been transparent to an extreme, with robust opportunities for the public (including patients) and professionals to weigh in and be involved in the process. A main goal of revisions of diagnostic criteria is finding the appropriate balance between making sure those who need treatment get treatment, while not risking overdiagnosis in those who don’t actually have a disorder. The many, many people involved in developing the DSM-5 are basing all of their recommendations on vast wealths of research and field trials. I can’t imagine a more evidence-based process that truly puts the interests of patients first.
Claudia Reardon, MD
I heartily agree with Dr. Grohol’s assessment that the DSM-5 revisions are being falsely turned into a potential return to asylum era psychiatry. When in fact the expansion of certain diagnoses would allow for early intervention, making less invasive treatment like psychotherapy, not more medications, feasible more often. I am starting to wonder exactly in whose interests these protests actually are.
Dr Grohol,
I hope you will be forthright and include this follow-up to our first exchange, as unfortunately your response might misdirect readers.
Firstly, you avoided my question by answering it with another question. I would like to resubmit that question to you: Do you agree or dispute a false bipolar epidemic was caused by DSM-IV?
Meanwhile, let’s examine some points in your article objectively:
“UK/EU physicians do not use DSM.”
Nationality has no bearing whatsoever on anyone’s accuracy.
“..not all .. are mental health professionals — only approximately 88 percent”
Perhaps some petioning opinions should be disregarded; you don’t mention the opinions of the remaining many-thousands of mental health professionals in the 80%.
“…miss mentioning how the current DSM-IV — overseen by the same Allen Frances — has done exactly the same thing…”
A lack of mentioning DSM-IV does not negate a statement about DSM-V. If anything, the former leader of DSM, having watched its aftermath for 17 years, might have more insight than most.
“…now that he’s out of the process, he suggests the APA shouldn’t be the one publishing the reference text. ”
It took a decade for negative outcomes of DSM-IV’s methodology to become apparent. By that time Frances worked elsewhere. This is irrelevant, and again, does not negate the warnings.
And your response to me:
“Regardless of whether I dispute it or not, do you have any scientific research to trace the actual cause of the increase?”
One does not need scientific research when one steps in dog poo to realize something went wrong, that it was related to the last step, and more importantly, to reconsider stepping there again.
The exponential increase of BD disgnoses as soon as DSM-IV expanded BD categories and criteria is obvious proof that a checklist approach (especially one with incomplete characterizations such as “Bipolar Not Otherwise Specified”) can lead us all like lemmings off a cliff.
http://tinypic.com/m/fd9fut/2
We are systemically leading society (doctor and patient alike) down the path of inability to think outside the box. Or in this case, outside the DSM.
It had some bad consequences before, so why would we believe there will be a different outcome this time?
Hi Dave,
1. I disdain emotional-laden terminology when trying to have a discussion, such as the word “epidemic.” I believe all mental disorders have the potential to be misdiagnosed and over-diagnosed because most of their diagnosis is done by family physicians and primary care physicians — not mental health professionals. In that context, I believe that bipolar disorder can be “over” diagnosed — especially in children (which isn’t even recognized as a distinct disorder in DSM-IV — demonstrating that you don’t need a reference text in order to create an “epidemic” of overdiagnosis).
2. I stand corrected on this point.
3. When respected news agencies don’t bother fact-checking the data they report, they add to the misrepresentation of that data. For instance, putting the 11,000 number into some context would be invaluable. Is this 50 percent of mental health professionals?
In the U.S., it’s less than 2 percent. Once you add in all the mental health professionals around the world, it’s far less than 1 percent.
While I think it’s interesting that less than 1 percent of mental health professionals have signed the petition, it’s not really a number that suggests this is a major concern among most — or even many — professionals.
4. & 5. I think the lack of a frank discussion of Allen Frances’ motivations in this matter is unfortunate. His opinion holds a lot of weight, yet he has apparently chosen to wield it in such a way that ensures it will result in little change.
The DSM revision process is and always will be imperfect, upsetting some professionals in every edition because some are just against “change.” Given your suggestion that it took a decade after the DSM-IV to come out before we had sufficient data on it, it would seem to suggest we wait a decade until the data on the proposed criteria have been fully vetted in the research?
6. And here’s what I expected — when asked for the data, one falls back on rhetoric.
I would also kindly point out that virtually every major mental disorder in the DSM-IV has a “NOS” category. With your logic, we would’ve also expected to see an “epidemic” increase across the board in NOS diagnoses since the release of the DSM-IV — an epidemic of NOS, if you will.
That, of course, has not occurred.
John
Dr Grohol writes:
“Kelland fails to note that Europe and the U.K. don’t actually use the DSM to diagnose mental disorders — it’s a U.S. reference manual for mental disorders diagnosis. So while it’s nice that some Europeans are expressing concern about this reference text, their concern isn’t exactly much relevant.”
From speaking to UK mental health professionals, my understanding is that both ICD-10 Chapter V and DSM-IV are used in England and Scotland.
DSM-IV is also used in research in the UK and EU and both systems are used in legal proceedings in the UK. In addition to the US, DSM-IV is used in Canada, Australia, New Zealand, India and China.
There are a number of UK and international members on the 13 DSM-5 Work Groups – there are, for example, two UK researcher clinicians informing the deliberations of the Somatic Symptom Disorders Work Group. A significant number of UK researchers and clinicians were invited to give presentations in the 13 2004-2008 APA/NIH/WHO DSM-5 Research Planning Symposia.
International research and opinion has fed into the development of DSM-5 and the next edition of DSM will have international ramifications – clinically, for the research field and for forensics.
Is it not a little arrogant to dismiss concerns for proposals coming from outside the US?
i really feel like the whole dsm 5 thing has too many people in a tizzy. And to be honest i like some of their changes. The idea of lowering the symptoms needed for some of disorders is needed. I mean i have met a few people who i have felt were quit frankly on the cusp of having a mood disorder but they wee missing a few symptoms.
@ dave the increase in Bd or adhd for that matter has nothing to do with dsm changes. Every doctor is prone to mistakes regardless.
Dr G,
Thanks for your response.
I have met several families in person with children who were incorrectly diagnosed with BD– and who were later cured by very different diagnoses and treatment. And thus, my stance on DSM risks.
You might find Dr Littel’s take on DSM methodology this interesting:
http://www.madinamerica.com/2012/01/bipolar-everywhere/
That’s an interesting point about Frances’ choice in communication methods. I rather suspect that he felt any other method would have less, if not zero impact. Nonetheless, it seems unfortunate you zinged him for non-disclosure. He started off with that disclosure in the Psychiatric Times 2 years ago. I suggest there isn’t a need to preface his every paragraph with it.
http://www.psychiatrictimes.com/dsm-5/content/article/10168/1425378
@ ‘anonymous Jen’, what you wrote is a sentiment not a fact, without supportive facts or data to back it up.
Hi Dave —
There always has been and always will be misdiagnosis when it comes to any medical disease or mental disorder. A diagnostic manual or any diagnostic system will never be 100 percent perfect.
The fact is, the diagnosis you’re complaining about — bipolar disorder in children — is not a recognized nor official DSM diagnosis. How can we complain that it’s a DSM problem when the diagnosis is not even in the DSM?
To me, this seems more clearly a problem with the professionals who are making these diagnoses, based upon their reading of the research literature. Since all professionals are given wide latitude in their diagnostic judgment, none of this would be affected by whatever is done or not done in the DSM-5. In other words, even if the DSM-5 didn’t include a childhood bipolar disorder diagnosis, it will continue to be diagnosed.
As for Allen Frances, here’s his short disclaimer from 2 1/2 years ago from the article you referenced:
The “trust me, this isn’t my own personal bias” has a name in psychology — confirmation bias or “myside bias” (which we previously wrote about here). All people — even experienced and thoughtful researchers — experience this bias.
I’ve never disagreed and said there weren’t areas of improvement for the DSM-5. Any system is going to have such areas (even the DSM-IV), and some of the petitioners’ points are well-taken. But they are not new and there was no new news here.
Last I point out — as I’ve done time and time again — that the developers of the DSM have noted they intend to keep the DSM-5 version updated more frequently to reflect our current knowledge and understanding. This is a stake in the ground for a process that will hopefully see updates every 4 or 5 years — instead of every 20 or 25.
John
Thank you Dr. Grohol, for all of your thoughts and comments. I couldn’t agree more!
Bottom line is we have to go forward with thoughtful diagnosis of children and adults with psychiatric illness. DSM V is likely not to be perfect, but we should work with it, learn from it and use it to help our patients as best we can instead of criticizing and further stigmatizing our patients.
Thank you for a very insightful and thoughtful commentary highlighting some of the “news manufacturing” that’s going on in the “controversy” over DSM-5. It’s nice to know that someone can cut through the spin once in a while.
“Keep in mind, the use and adoption of the DSM is completely a market-driven, voluntary choice. Nobody is demanding professionals use the DSM to diagnose mental disorders in the U.S.”
I wish I could have got here sooner, but that is just life. When you make the statement about the DSM being volunteer you are completely correct. But if I could ask, when the third parties get ready to cut a check, what is it they want to see? Exactly, the current DSM diagnosis.
It does not have to be legally required, it is required for survival.
Anyone that does not recognize an epidemic is not looking at the situation. Not one specific disorder, but over the entire spectrum.