DSM-5: Psychiatry's Contested Bible - Page 2

By Michael Dhar 04/05/13

The new 1,000-page psychiatrists' Big Book will redefine addiction. Critics are already demanding a boycott. The Fix guides you through the highlights.

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Who objects to the changes and why?

Better science behind psychological diagnoses? Earlier detection and treatment? What’s not to love about the new DSM? Quite a bit, according to critics. 

The first, loudest and longest-dissenting voice belongs to the man who ran the revision of the guide's previous incarnation, the DSM-IV: Allen Frances, MD, a professor emeritus in the department of psychiatry at Duke University Medical School, has penned one vitriolic editorial after another since 2009, calling the fifth edition “clearly unsafe and scientifically unsound” and accusing his own profession of being “in the business of inadvertently manufacturing mental disorders.”

What troubles Frances most is “diagnostic inflation.” His particular bugaboos include: “binge eating disorder,” defined by excessive eating 12 times in three months; the spectrum approach to substance disorders that lumps first-time abusers with hard-core addicts, despite vastly different treatment needs; and the recognition of behavioral addictions, “creating a slippery slope that can spread to make a mental disorder of everything we like to do a lot.” 

Frances is not alone. An open letter from more than 50 mental-health associations says that, despite the APA's goal of a more scientific manual, science is precisely where the DSM-5 fails. Evidence does not support the new disorders or the dimensional measures, the letter says.

It also called for an independent scientific review of the proposed changes—a call the APA flatly refused, saying, “There is in fact no outside organization that has the capacity to replicate the range of expertise that DSM-5 has assembled.” In turn, many of the groups behind the original open letter have now called for a boycott of the DSM-5.

 What will be the consequences of more diagnoses? 

Most observers agree that the DSM-5 will result in many more people getting diagnosed. This is likely to result in earlier treatment, and it is in this shift of resource allocation from, for example, the late-stage alcoholic to the “almost” alcoholic that all Hell breaks loose.

The bulk of early interventions may be wasted on many people who are unnecessarily diagnosed and do not need treatment.

Healthcare policy today places a premium on prevention. Second best are early detection and treatment, which result in better outcomes and lower costs than treating later-stage, acute disease—no minor concern in an age of out-of-control healthcare spending. The DSM-5 revision was guided by the same principles that pushed prevention in the nation's healthcare overhaul (popularly known as "Obamacare"), O’Brien tells The Fix. The substance use scale will steer more people who have taken the first steps toward developing a substance use problem into treatment, he says: “You save $7 for every $1 you spend on early care.” 

Critics contend, however, that the bulk of early interventions will be wasted on many people who, having been diagnosed unnecessarily, don't need treatment. That, they allege, will leave many others with severe substance use problems—and inadequate resources for treatment—out in the cold. “Our scarce mental-health resources are already distributed in an irrational manner," Allen Frances wrote in Bloomberg News in December. "We badly shortchange those with clear psychiatric disorders while overtreating essentially normal people.” 

Such diagnostic expansion will occur in many areas, critics say—but the boycott group specifically calls out lowered diagnostic thresholds for alcohol use disorder as one example. And at least one study supports that worry; research in Australia found that the DSM-5 recommendations would increase diagnoses of alcoholism by a whopping 61.7%. Such a large increase, due mainly to the criteria scale approach, could cause demand for services to overwhelm healthcare institutions, said Lisa Mewton, PhD, of University of New South Wales in Australia, the lead author of the study. (Two US studies predicted much more reasonable increases, however.) 

“Over-medicalization” is the core of the problem, Peter Kinderman, PhD, co-chair of the boycott group and professor of clinical psychology at the University of Liverpool, tells The Fix. The DSM-5 turns isolated and unrelated psychological or social problems into symptoms and force-fits them into a medical condition, he says: “Problems should be treated as problems, not illnesses.”

Kinderman paints gambling, for example, as a psychological problem that should receive psychological intervention. Once labeled an illness, he argues, it's likely to be treated with medicines, expanding the market for drug makers. 

Charles O'Brien, who has developed several new medications for addiction during his career at U Penn, agrees that the new DSM will lead to more use of psychoactive drugs for addiction. But that's because such treatments are more effective, he says. He relates the results of a CNN investigation, in which five addiction centers refused to use drug treatments, despite seeing evidence of their efficacy: All patients at those centers relapsed.

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