DSM-5 = Pandora's Box?

Alan Frances, Chair of the DSM-IV Task Force, turns a critical eye (free registration required) to many of the proposed DSM-V changes.

First, on changes that will increase diagnosis rates:

In terms of content, most concerning are the many suggestions for DSM5 that would dramatically raise the rates of mental disorder. These come in 2 forms:

1. New diagnoses that would be extremely common in the general population (especially after marketing by an ever alert pharmaceutical industry)

2. Lowered diagnostic thresholds for many of the existing disorders.

DSM5 would create tens of millions of newly misidentified false positive “patients,” thus greatly exacerbating the problems caused already by an overly inclusive DSM4.7

The greatest general impact would come from the suggestion to eliminate the “clinical significance” criterion required in DSM4 for each disorder that has a fuzzy boundary with normality (about two-thirds of them). These were included to ensure the presence of clinically significant distress or impairment when the symptoms of the disorder in mild form might be compatible with normality.

Medicalizing Normal Grief. DSM5 would reverse 30 years of diagnostic practice and allow the diagnosis of Major Depression to be made for individuals whose grief reaction symptomatically resembles a Major Depressive episode … Of course, grief would become an extremely inviting target for the drug companies.

He is also concerned about changes to substance use disorders and the addition of behavioral addictions:

Addiction Disorder. DSM5 proposes to eliminate the distinction between substance abuse and substance dependence, lowering the threshold for diagnosing the new unified category― “addiction”―that would be introduced to replace them both. This confounding of episodic binge use with continuous compulsive use loses valuable clinical information about their very different treatment and prognostic implications. It also seems unnecessarily stigmatizing and misleading to label with the loaded word addiction those whose problem is restricted to intermittent substance use

Behavioral Addictions category would be included with the substance addictions section and would start life with one disorder, Pathological Gambling (transferred from Impulse Disorders section). Next in line might be a new category for Internet Addiction. This could provide a slippery slope leading to the back door inclusion of a variety of silly and potentially harmful diagnoses (ie, “addictions” to shopping, sex, work, credit card debt, videogames etc, etc, etc) under the broad rubric of “behavioral addictions not otherwise specified.”

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