Debate over DSM-V reveals mainstream mental health is now worried about overreaching

The draft of DSM-V is out for review, and it’s garnering some attention. Wednesday’s story from the New York Times made it to their top ten stories hit list, and last night the News Hour featured a moderately lively DSM debate (lively for PBS, only moderately so for psychiatrists) between Dr. Alan Schatzberg, who’s involved in developing DSM-V, and Dr. Allen Frances, who’s not but was involved in developing DSM-IV (the current edition). Among other disagreements between these two Alans, er, Allens, Allen Frances offered the following:

And we thought we were being really careful about everything we did, and we wanted to discourage changes. But, inadvertently, I think we helped to trigger three false epidemics, one for autistic disorder that you mentioned, another for the childhood diagnosis of bipolar disorder, and the third for the wild overdiagnosis of attention deficit disorder.

And my concern has been that the ambitions expressed by those working on “DSM-V” would lead to unintended consequences, with many patients being created through new categories or the lowering of thresholds of existing categories, people who probably don’t need the treatment that they might receive, but would probably receive if they get a diagnosis.

Later, Alan Schatzberg responded that members of the DSM-V development committee:

have been very careful to define the threshold for patients being in distress, being impaired, and being able to obtain or receive a diagnosis. We try to be — refine on those criteria from “DSM-IV” to make it tighter. In fact, I think “DSM-V” will reduce the number of patients who receive diagnoses.

Let’s take a moment here to think about what these guys are saying. I’m less impressed by what they said specific to “false epidemics” and tightening thresholds–although it’s pretty important–and more impressed by the larger, almost meta-admission that a major problem in mental health practice is that it has the power to pathologize what may be normal problems, and a troubling history of doing so. Although others have made good arguments that there are serious consequences when mental health overreaches it’s boundaries, it seems to me that these Alan/Allens’ admission signify a turning point. Up until recently, mainstream psychiatrists and psychologists have mainly tried to convince people that mental health problems are real, and that they are serious. Now it seems some are saying that mental health practitioners need to be a lot more careful about what they classify as disorder, as they have the power to do more harm than good if they push it too far. Of course, this is also consistent with the first rule of medical school: Above all, do no harm.

The draft of DSM-V comes at a time when American mental health is under attack. After several years of scandals involving prominent research psychiatrists in the pay of pharmaceutical companies, a few high profile studies suggesting that many people who get psychotropic drugs don’t really need them, and a number of disorganized psychosocial missions in disaster zones, releasing a new DSM is bound to be a controversial act. In this light, the committee’s decision to present a draft and solicit comment is a welcome measure. Although undoubtedly many comments will be of the Tom Cruise variety (google “Tom Cruise demeaning Brooke Shields for her post-partum depression” if you don’t know what I’m talking about), many will prove ultimately very helpful to the process. Review DSM-V and make a comment yourself, here.

PS: Note that some places refer to the new manual as “DSM5” rather than “DSM-V.” Which will win? Roman numerals are more stately perhaps (and consistent with DSM tradition), but DSM-V may run into the problem of getting mixed up with “DMV”–which would drive us all crazy.

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