* OPENING PANDORA'S BOX 19 *
THE WORST ADVICE OF DSM V
by By Allen Frances MD (Head of the Task Force of DSM IV) diagnostic
* New problem: * The
SYNDROME RISK OF PSYCHOSIS is certainly the most troubling of
suggestions for DSM5. The false positive rate would be alarming
-70 to 75% in most studies, more careful, and apparently much higher
once the diagnosis is official in general use, and
becomes a target for pharmaceutical companies (8).
hundreds of thousands of teenagers and young adults (especially, it seems,
those included in Medicaid) would receive an unnecessary prescription of antipsychotics
atypical (9) There is evidence that atypical antipsychotics
prevent psychotic episodes, but it definitely
cause large and rapid weight gain (see the recent warning by the FDA) and are associated
with reduced life-expectancy by say nothing about
its high cost, other side effects and stigma.
This suggestion could lead to a public health catastrophe and there
field test may be able to justify its inclusion as an official diagnosis
. The identifi attempt early treatment of individuals at risk
is well-intentioned, but dangerously premature. We expect
until there is a specific diagnostic test and treatment
insurance. The
MIXED ANXIETY DEPRESSIVE DISORDER touches
nonspecific symptoms that are widely distributed in the general population and would from then on
more immediately become one of the most common mental disorders in the DSM5
. Naturally the rapid upliftment
epidemic proportions could easily be assisted by pharmaceutical marketing.
Apparently, the medication would not be much more effective than placebo at
because of the high response to placebo in mild disorders (10).
The COGNITIVE DISORDER LOW is defined by
nonspecific symptoms of reduced cognitive performance, which are very common (perhaps ubiquitous) in
people over 50. To protect against false positives is a criterion that requires
objective cognitive assessment to confirm that the individual has
decreased cognitive performance, but achieving a significant reference point
is impossible in most instances, and the threshold has been
willing to include a massive 13.5% of the population (eg
., the percentage of population between the first and second standard deviation
). Moreover, the suggestion is likely to target testing
ignored in primary care settings where the bulk of diagnoses
be made.
medicalize cognitive declines expected in the age
result in a very unnecessary treatment with ineffective drug prescriptions and quack remedies
. This, undoubtedly, achieved great popularity, as it surely will
high placebo response rate.
Binge Eating Disorder (Binge Eating Disorder) will
general population rate (estimated at 6%) and this will probably be much higher
when the diagnosis is made popular and is done in primary care schemes
. The tens of millions of people who give these
binge once a week for 3 months could suddenly have a mental œdesorden
€ â € "subjecting them to stigma and
proven ineffective medications.
DYSFUNCTIONAL MESS CHARACTER The dysphoric is one of the most dangerous and poorly conceived
suggestions for an ill-DSM5 medicalizació n
oriented character of the outbursts. € â € œdiagnósticoâ
be very common in every age of the general population and could promote
expansion in the use of antipsychotic medications, with all the serious risks described
up for patients. Apparently, the Working Group
trying to correct the excessive diagnosis of bipolar disorder in childhood
, but your suggestion is so poorly written that it could not in any way
achieve that goal, however
could create a new monster.
The poor implementation of this diagnosis would provide an excuse
coat and take personal responsibility for forensic nightmare.
is a bad way to start.
COERCIVE DISORDER Parafil The cluster would expand the criminal sexual
liable for punishment because they have a permanent civil
€ â € which mental œdesorden includes cases of sexual coercion. This disorder was
initially considered for inclusion in the DSM III R (under the name of
paraphilic rape) but was rejected because it was impossible to differentiate
valid and reliable
those violators whose actions are the result of a paraphilia the vast majority of rapists
motivated by other factors (such as power). Given the facts (recognized in
reasoning section) that most rapists are
aware enough to deny the sexual fantasies and
unreliability (not available) laboratory testing, the diagnosis is inevitably
based only on the behavior of the
person, leading to a potentially alarming rate of false positives, with subsequent punishment wrong
undefined (11).
Hypersexuality disorder will be a gift for seekers of excuses
in false positives and forensic potential disaster. Another clear
wrong starting point.
BEHAVIORAL ADDICTIONS The category would be included in the section
addictive substances and could come to life with a disorder, GAME
Pathologists (transferred from compulsive disorders section). This
provide a slippery slope toward inclusion by the back door
a variety of silly and potentially harmful diagnoses
(eg.: â € œadiccionesâ € to buy, sex, work, credit card and debt
, video games, etc., etc.) under
broad heading of â € œadicciones behavioral otherwise unspecified €. The construct
conductualesâ € â € œadicciones medicalizació n represents an election
of life, provides a ready excuse to download
personal responsibility, and easily be used incorrectly in forensic schemes.
lower thresholds
* * Major impact
generally build on the suggestion of removing the criterion of â € œsignificación
€ clínicaâ DSM4 required in each disorder has a fuzzy
limit of normal (about two thirds of
them.) Were included to ensure the presence of
clinically significant distress or impairment when symptoms of the disorder in
benign forms may be compatible with normality.
removing this requirement would reduce the role of clinical trial as a guard at
determine the presence or absence of mental disorders, and thus increase the already inflated
rates of psychiatric diagnosis.
attention deficit / hyperactivity disorder.
DSM4 definitions of change (along with a marketing activ extremandamente
pharmaceutical companies), contributing to higher rates of ADD-
accompanied by a widespread abuse of stimulant medications to improve the performance
and the emergence of a large secondary market illegal. (12) There are 4 suggestions DSM5
for overdiagnosis exists that would make this much worse.
"The first change is to raise the required age of onset of 7 to 12 (13)
" The second is to allow diuagnóstico based only on the presence of
symptoms requiring no disability.
"The third is to reduce by half the number of symptoms required for
adults.
These 3 changes significantly reduce the specificity of
diagnosis of ADD in adolescents and adults and will result in a further flow of
false positives and resulting misuse of incentives for performance improvement
(14).
-The fourth change is to allow the diagnosis of ADD in the presence of autism.
This could create false interaction of two epidemics, promoting the use of stimulants increased
in a particularly vulnerable population.
addiction disorder. DSM5 proposes to eliminate the distinction between abuse
substance and substance dependence, lowering the threshold for diagnosing new category
œadicciónâ € â €, which would introduce to replace both.
This confusion of episodic abuse continued compulsive use
lost valuable clinical information about their very different treatments and prognostic implications
. It also seems unnecessarily stigmatizing and carrying
erroneously labeled with the word addiction heavy
those whose problem is restricted to intermittent use of substances.
Autism spectrum disorder Asperger disorder
collapse in this new unified category. Although this consolidation
appeals to some experts, it remains controversial and has serious problems. Those with Asperger
(which is much less disabling)
be stigmatized by association with the classic autistic disorder). Moreover, in usual practice daily
conducted by non-experts, the concept of spectrum easily feed
€ â € œepidemaâ of poorly defined autism as a dissolution
triggered by the introduction of the DSM4 Asperger (15).
medicalization of normal grief. DSM5 reverse 30 years of practice
diagnosis of Major Depression, being made in those individuals whose
reaction al duelo sintomáticamente recuerda un Episodio Depresivo Mayor (por
ej.: dos semanas de ánimo depresivo, pérdida de interés en actividades,
insomnio, pérdida de apetito, y problemas en concentrarse inmediatamente
posteriores a la pérdida del cónyuge, serán un desorden mental). Esto es un
sorprendente y radical cambio que podría ayudar a algunos individuos, pero
causará un enorme problema de falsos positivos -especialmente desde que hay
mucha variabilidad individual y cultural en el sobrellevarlo. Por supuesto,
el duelo se transforma en un blanco extremadamente invitante para las
compañías farmacéuticas.
La PEDOHEBEFILIA es uno the schemes suggested criteria more
poorly described and feasible. Expanding the definition of pedophilia to include pubertal medicalizaría
criminal behavior and subsequently lead to the previously described
abuse of psychiatry
legal system. Indeed, sex with child victims should impact as a
important public policy matters, but this should be accompanied by
legal status and appropriate penalties, not by yourself * *
mental disorder. Effacement
SYSTEM
MULTIAXIAL This would result in the loss of much valuable clinical information
. Multiaxial diagnosis
provides a disciplined approach to distinguish between state and trait (
axis I versus axis II) for determination of medical conditions (axis
III) and stressors (Axis IV) at diagnosis and treatment of psychiatric disorders
. It GAF scores (axis IV) estimate provides the most convenient and familiar
overall functioning.
offered no comparative reasoning to make a change so radical. Several minor changes
Numerous minor editorial changes intended to help clarify
schemes existing criteria. Some of these
appear to be improvements, many are trivial, and some are worse than their counterparts
DSM4. Any possible gain
editorial changes should be weighed against the risks that the new version will create its own scheme
unintended consequences. The old, tried and true schemes
criteria have withstood the test of time-sometimes
for 30 years without creating forensic problems. Furthermore, even small changes can have a dramatic
impact on the definition of cases and the rate of disorders resulting
, without compromising the interpretation of
all clinical and epidemiological research has been done before, versus
is made after DSM5.
dimensional values Three dimensional ratings (for severity
co-morbidity and personality traits) are suggested for DSM5. The dimensions are mostly appropriate
stop
describe phenomena distributed on an ongoing basis, that can be reduced to numbers.
has been widely accepted for decades that add dimensions
help solve the problem of fuzzy boundaries categorical system
increasing the accuracy of psychiatric diagnoses. Unfortunately, all
However, the field has never achieved consensus on which dimensions to choose and how to measure
better. Further, and most crucial, clinicians are
dimensional scores too unfamiliar and uncomfortable to be used in daily practice
and all efforts to include even a few simple dimesionales
scores in the previous DSMs
have found resistance and denial on the part of clinicians. Dimensional
proposals are especially problematic DSM5-ad hoc,
impractically complex, vague, untested and premature. The poorly executed
introduction of bulky dimensions DSM5
easily give a bad name and poison the necessary foundation for later acceptance.
is also possible that the use of dimensions can create unintended consequences
insurance, disability and forensic examinations. The possible introduction of dimensions
by DSM5
has long been oversold as a paradigm shift. With a few exceptions, it would probably advisable to include
dimensional scores suggested in Appendix DSM5
, or in a separate volume of diagnostic tools.
SEVERITY SCORES FOR EACH MANUFACTURED DISORDER. In fact, this
approach was tested for 8 categories in the DSM III R, but was abandoned in the DSM4
because it anchors
severity scores were not validated and the system was too bulky for use
clinical routine. Severity scores suggested for DSM5 are surprisingly inconsistent
crossings in format and quality and long
ad hoc, extremely complicated and totally impractical
for use in clinical conditions. MEASUREMENTS
SYMPTOMS € â € œCRUZADOSâ that exist between a number of different diagnoses
to supplement categorical diagnoses
primary. Such an assessment may be useful in certain frames, but
too large for use in routine clinical practice.
SCORES FOR PERSONALITY DIMENSIONS. These would, in theory,
clear advantages over the clumsy approximation of the assessment of personality.
In practice, however, the multiple, complicated, confusing and voluminous
suggested by the DSM5 systems would be too unfamiliar and
consume too much time to ever be used by clinicians.
Another side effect is the elimination of manual
five personality disorders (paranoid, narcissistic, histrionic, dependent, schizoid
).
* Conclusions *
possibly be argued by the management of excessive DSM5 I'm prematurely
alarmist, they are still in the early stages of
DSM5 process, and that some of the suggestions problems
will eventually expelled in the field tests. This is putting the cart (the
field test) before the horse (eg.:
criteria have schemes useful for testing) and is missing the point that DSM5
has been and remains in serious trouble. I feel it is my responsibility to give clear
alarm now because of that the past performance driving
DSM5 not inspire confidence in its future ability to avoid serious errors.
What makes me so pessimistic conclusion? Each step in the development of DSM5
was secret and disorganized. Management has established a consistent line
record of proposing unrealistic plans and unable to achieve
timelines, with erratic and unpredictable courses
repeatedly failed deadlines. I, for example, announced last May at the annual meeting
APA (and in the press) that the field tests
DSM5 would begin in the summer [boreal] 2009. So it happened that none
the necessary preparatory steps had been completed and that
field trials should be postponed for at least a year. During the
past six months, there have been several successive targets dates for publishing
DSM5 projects, each of which went unfulfilled
causing unexplained delays. Poor planning
and execution have already forced a one-year delay in the projected date of publication of DSM5
(to May 2013).
DSM5 The process is already three years old. For now, careful
editorial process should result in proposals which have all been refined
all plausible and consistent and clearly written.
field tests are difficult and expensive and makes sense only for testing precise formulations criterial
schema that has a real chance to be included in the manual
-not for the poorly made and deflected suggestions that have already been published
. It seems prudent to identify and root out problems now, unless
stealthily slip in what appears to be a possible mad rush to complete
DSM5. My fear is argued that,
left to its own devices, without continued pressure and external
assistance, the process DSM5 could never produce a quality product
(even with the deadline of 2013).
There are, however, a critical process that demands a clear DSM5
rebuttal. It has been argued that those working in the
DSM5 have financial conflicts of interest and / or professional
leading them to make decisions that increase the rates of psychiatric diagnoses (eg.:
to benefit pharmaceutical companies, or increase funding of research
or expand job opportunities for workers
mental health). I know most of those working in the
DSM5 and I can assure you that this accusation is completely false. They have the highest integrity and
are doing (what I think is often wrong and even dangerous
) tips because they sincerely and naively
to believe that's where science is leading, not for any personal gain or
professional.
How can people so smart and careful to make as many bad
suggestions? It has been my consistent experience (gained working in the three previous
DSMs) that each group Work always has a strong (and often
irresistible) urge to expand the boundaries of the disorders in
section. The expected diagnosis imperialism
Working Groups should always be recognized and resisted. The experts,
conceivably high value placed on reducing false negatives for
your favorites disorders and negate the need to resort to the tag â €
Oeno € otherwise specified. They hope in this way
identify patients early and institute ongoing treatments that are effective in reducing
chronicity of the disease.
Unfortunately, members of the Working Group usually have a blind spot-related
aside
any effort to reduce false negative rate must inevitably raise the rate of false positives
(often dramatically, with fatal consequences).
is inherently difficult for experts, with its highly selected
clinical experience and research, fully appreciate how poorly
their research results can be generalized to
daily practice, especially if it is driven by
harassed primary care physicians in an environment heavily influenced by marketing
pharmaceutical companies. They can consistently
underestimate the costs and risks of medication treatments when provided to
those who do not really need. If we are ever to achieve the desired
advantage of early detection of cases, we must first have
specific diagnostic tests and treatments safe and effective. In contrast
the suggestions of the peculiarly dangerous DSM5 show
combination of non-specific diagnoses and inadequate, leading to
not tested and potentially harmful treatments.
I want to emphasize that the problems in this project
DSM5 are not all the fault of the Working Group members who worked under very little
promising conditions. DSM5 options is poorly conceived and executed
because of the interaction of 4
unfortunate decisions made by management DSM5:
1. Unnecessary requirement of confidentiality agreements, which isolated
Working Groups of the usual and necessary corrective
interaction with the field.
2. Severe restriction of the directors of a small and highly selected group
.
3. Establish the expectation that the Working Group should be more innovative
aware of risks / benefits.
4. Provide well-working groups with little guidance,
consistency and editorial assistance.
Because of the nature secret and closed DSM5 process, the expected
enthusiasm of the experts who understand the working groups have been balanced
not as it should always be, with knowledge of the practical real-world clinical
and careful risk analysis /
benefits of possible unintended consequences of each suggestion.
would be irresponsible now rest in the complacent assumption that all these problems
eventually be eliminated. By their actions and inactions
previous DSM5 address has sacrificed any faith
€ â € œbeneficio of doubt that the process will correct itself in a way that ensures
the elimination of all harmful possibilities.
There are, however, some cause for measured optimism about the future of
DSM5 process based on the fact that it does respond, but reluctantly
to external pressure. There have been significant and encouraging
improvements during the past months. An Oversight Committee was
DSM5 finally cited and has played a beneficial role in correcting the most egregious
methods and earlier deadlines. The plan conceived
unfortunately driving field tests before having a public review of the criteria
was abandoned and the field testing and unrealistic deadlines for
the publication were extended in one year. Additional
time provided by the extension of deadlines, if properly used, would be sufficient to produce
DSM5 useful.
What do I need to do next? The responsibility (and opportunity) to rescue the DSM5
falls more heavily on the field and eventually in
Oversight Committee. Now finally DSM5 drafts are open
for a comprehensive review is for the field to be active in
identify problems and provide the necessary pressure to ensure they are corrected.
My recommendations to the Oversight Committee are:
1. Extend the period scheduled for public review at three months.
2. Use this time to ensure the careful editing of each word in
each item of each scheme of criteria in order to provide clarity and consistency
is now sadly missing and
absolutely necessary before any significant field testing can begin.
3. Publish the methods of field testing for public review.
4. Appoint three subcommittees to report to the Oversight Committee
(respectively responsible for monitoring the forensic review, the analysis
risk / benefit and field tests).
5. Published literature reviews and plans for harmonization
to ICD-11 [ICD-11].
each future step in the preparation of DSM5
should involve active interaction with the field and the Monitoring Committee and its subcommittees. The unnecessary secrecy
caused the current problems and only
total transparency and openness to the outside the fix.
I had the space and knowledge to identify only problematic DSM5
points that were the most obvious to me. The rest is
you. Please take the time to review options DSM5 (at
least in their areas of interest) and send their comments.
can find it in * www.dsm5.org *
TRANSLATION: Gabriel Vulpes
Note:
We thank our colleague Gabriel Vulpes which has been translated and
sent this article written by the Head of Task Force
DSM IV, published in Psychiatric Times (www. psychiatrictim es.com). English version
http://www.psychiat
rictimes. com / display / article/10168 / 1522341? PageNumber = 1 & rd = 0
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