A Critic of The DSM Revision Process

Allen Frances, one of the psychiatrists on the APA task force that drafted the DSM IV, has become one of fiercest critics of the secrecy surrounding the present task force’s effort to draft the future DSM V. An excellent article on this struggle to refashion what’s amounts to the shrinks’ Dead Sea scrolls into the next edition of the shrinks’ best selling bible of diagnosis can be found at Wired Magazines website, Inside the Battle to Define Mental Illness.

I’ve been amused in Dr. Frances to find myself agreeing with a psychiatrist who otherwise would have seemed, to my way of thinking, mainstream and medical model.

Frances, who claims he doesn’t care about the royalties (which amount, he says, to just 10 grand a year), also claims not to mind if the APA cites his faults. He just wishes they’d go after the right ones—the serious errors in the DSM-IV. “We made mistakes that had terrible consequences,” he says. Diagnoses of autism, attention-deficit hyperactivity disorder, and bipolar disorder skyrocketed, and Frances thinks his manual inadvertently facilitated these epidemics—and, in the bargain, fostered an increasing tendency to chalk up life’s difficulties to mental illness and then treat them with psychiatric drugs.

If you have heard anything about Dr. Joseph Biederman and his part in the recent childhood Bipolar epidemic. Dr. Allen Frances points out that this epidemic would not have taken place if the DSM IV had not opened to the door to diagnosing bipolar disorder in children in the first place, and therefore I imagine part of his motivation here may be a matter of penance for his own role in that epidemic. One of his concerns was that the present task force could be paving the way for another such epidemic with proposal of a pre-psychotic condition referred to as psychosis risk syndrome.

This new disease (psychosis risk syndrome) reminded Frances of one of his keenest regrets about the DSM-IV: its role, as he perceives it, in the epidemic of bipolar diagnoses in children over the past decade. Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold. Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes. In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose money he’d received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times reported that Biederman told the company his proposed trial of Risperdal in young children “will support the safety and effectiveness of risperidone in this age group.”) Frances believes this bipolar “fad” would not have occurred had the DSM-IV committee not rejected a move to limit the diagnosis to adults.

Psychosis risk syndrome is no longer slated for the DSM V. Instead it has been replaced with something called attenuated psychotic symptoms syndrome.

When the rough draft of the DSM-5 was released, in February 2010, the diagnosis that had galvanized Frances—psychosis risk syndrome—wasn’t included. But another new proposed illness had taken its place: “attenuated psychotic symptoms syndrome,” which has essentially the same symptoms but with a name that no longer implies the patient will eventually develop a psychosis. In principle, Carpenter says, that change “eliminates the false-positive problem.” This is not as cynical as it might sound: Carpenter points out that a kid having even occasional hallucinations, especially one distressed enough to land in a psychiatrist’s office, is probably not entirely well, even if he doesn’t end up psychotic. Currently, a doctor confronted with such a patient has to resort to a diagnosis that doesn’t quite fit, often an anxiety or mood disorder.

Regardless of the label for it, I imagine they will have to come up with a drug treatment for it, and ultimately the course of this syndrome could be either to blossom into full blown psychosis, or to relapse into “normality”, the one “sickness” most doctors are unwilling to treat.

I had felt inclined to respond to a recent article in the New York Times about mental health conditions at Stony Brook University with a blog post about how, no, it isn’t that schools of higher education are getting “sicker” students than they used to be getting, it’s that there are more young people with psychiatric labels now, and a psychiatric label has never been something to prevent a person from going to college. Dr. Frances responded with his own letter to the New York Times in which he attributed this phenomenon, as do I, to over-diagnosis.

The exploding rate of “severe” psychiatric illness on campus is most likely caused by overdiagnosis — not by a decline in the mental health of college students. The people are the same, but the boundary of psychiatry has expanded at the expense of normality.

The childhood “mental illness” label was much less common, tended to be less severe, and was thought of as more treatable just a few years back. I, for one, don’t attribute our present epidemic to a sudden surge in genetic mutations, nor do I attribute it to a raging outbreak of pre-natal negligence.

Psychiatric diagnosis and treatment are enormously helpful for those with severe and persistent symptoms. By all means, let’s diagnose and medicate students who really need it. But the huge increases in the rate of mental illness almost surely represent a medicalization of the expectable difficulties many students have in adjusting to college life.

I doubt that the divide between those with, and those without, severe and persistent “symptoms” is nearly as large as Dr. Frances imagines it to be. I wouldn’t be in too much of a rush to “diagnose and medicate” students either, and certainly not without their consent. The advance of medicalization, on the other hand, is a problem that some of us would very much like to see reversed, as this advance spells absolute disaster and doom for large numbers of people. Reversing this advance is a matter of ending some of the practices that lead to, and sustain, our current epidemic in “mental illness” labeling.