This online-first article will have minor typographical differences from the final, printed version. Annals of Internal Medicine Ideas and Opinions The New Crisis in Confidence in Psychiatric Diagnosis Allen Frances, MD

n the early 1970s, 2 highly publicized studies showed The DSM-5, the recently published fifth edition of the Ithat psychiatric diagnosis, as it was then conducted, was diagnostic manual, ignored this risk and introduced several unreliable and inaccurate. The first found that British and high-prevalence diagnoses at the fuzzy boundary with nor- U.S. psychiatrists came to different diagnostic conclusions mality. With the DSM-5, patients worried about having a when viewing the same patients on videotape (1). The sec- medical illness will often be diagnosed with somatic symp- ond found that healthy volunteers claiming to hear voices tom disorder (5), normal grief will be misidentified as ma- were admitted to psychiatric hospitals for extended stays jor depressive disorder, the forgetfulness of old age will be despite subsequently acting normally (2). Was psychiatry confused with mild neurocognitive disorder, temper tan- entitled to a place among the other medical specialties trums will be labeled disruptive mood dysregulation disor- when its diagnoses were so random? The response was der, overeating will become binge eating disorder, and the quick and effective. The Diagnostic and Statistical Manual already overused diagnosis of attention-deficit disorder will of Mental Disorders, Third Edition (DSM-III), published in be even easier to apply to adults thanks to criteria that have 1980, featured definitions of mental disorders that, when been loosened further. properly used, achieved reliability equivalent to that of These changes will probably lead to substantial false- most medical diagnosis. The DSM-III stimulated an out- positive rates and unnecessary treatment. Drug companies pouring of psychiatric research. In most medical schools, take marketing advantage of the loose DSM definitions by mental health research now ranks behind only internal promoting the misleading idea that everyday life problems medicine in National Institutes of Health funding. are actually undiagnosed psychiatric illness caused by a Unfortunately, the extensive research has had no effect chemical imbalance and requiring a solution in pill form. on psychiatric diagnosis, which still relies exclusively on This results in misallocation of resources, with excessive fallible subjective judgments rather than objective biologi- diagnosis and treatment for essentially healthy persons (who may be harmed by it) and relative neglect of those cal tests. Brain complexity makes the translational step with clear psychiatric illness (whose access to care has been from basic science to clinical practice more difficult in psy- sharply reduced by slashed state mental health budgets) chiatry than in other fields of medicine. Biological find- (6). Only one third of persons with severe depression re- ings, however exciting, are never robust enough to become ceive mental health care, and a large percentage of our test-worthy because within-group variability cancels out swollen prison population consists of true psychiatric pa- between-group differences. We will be stuck with descrip- tients with no other place to go. Meta-analysis shows that tive psychiatry for the foreseeable future. the results of psychiatric treatment equal or surpass those Psychiatric diagnosis is facing a renewed crisis of con- of most medical specialties (7), but the treatments must be fidence caused by diagnostic inflation. The boundaries of delivered to patients who really need them instead of being psychiatry are easily expanded because no bright line sep- squandered on those likely to do well on their own. arates patients who are simply worried from those with The DSM-5 did not address professional, public, and mild mental disorders. The DSM-III opened the door to press charges that its changes lacked sufficient scientific loose diagnosis by defining conditions that were no more support and defied clinical common sense. It was prepared than slightly more severe versions of such everyday prob- without adequate consideration of risk–benefit ratios and lems as mild depression, generalized anxiety, social anxiety, the economic cost of expanding the reach of psychiatry just simple phobias, sexual dysfunctions, and sleep disorders. when the field is about to achieve parity within an ex- The fourth edition of the DSM (DSM-IV), published panded national insurance system (8). I found the DSM-5 in 1994, tried to hold the line against further diagnostic process secretive, closed, and disorganized. Deadlines were inflation by taking the conservative stance of discouraging consistently missed. Field trials produced reliability results all changes and requiring substantial scientific evidence for that did not meet historical standards. I believe that the them (3). Of 94 suggested new diagnoses, the DSM-IV American Psychiatric Association (APA)’s financial conflict added only 2, but this caution did not prevent the unex- of interest, generated by DSM publishing profits needed to pected occurrence of 3 market-driven diagnostic fads. In fill its budget deficit, led to premature publication of an the past 20 years, the rate of attention-deficit disorder tri- incompletely tested and poorly edited product. The APA pled, the rate of bipolar disorder doubled, and the rate of refused a petition for an independent scientific review of autism had a more than 20-fold increase (4). The lesson the DSM-5 that was endorsed by more than 50 mental should be clear that every change in the diagnostic system health associations (9). Publishing profits trumped public can lead to unpredictable overdiagnosis. interest.

This article was published at www.annals.org on 17 May 2013.

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Ideas and Opinions The New Crisis in Confidence in Psychiatric Diagnosis

The APA has been responsible for the diagnostic sys- Requests for Single Reprints: Allen Frances, MD, Duke University, tem for 100 years, having initially accepted the task when PO Box 39950, Durham, NC 27710. it was too unimportant for anyone else to care. However, Author contributions are available at www.annals.org. the DSM has since acquired perhaps too much real-world influence as the arbiter of who gets what treatment and whether it will be reimbursed; who is eligible for disability References benefits, Veterans Affairs benefits, and school and mental 1. Kendell RE, Cooper JE, Gourlay AJ, Copeland JR, Sharpe L, Gurland BJ. health services; and who qualifies to receive life insurance, Diagnostic criteria of American and British psychiatrists. Arch Gen Psychiatry. adopt a child, fly an airplane, or buy a gun. 1971;25:123-30. [PMID: 5569450] New psychiatric diagnoses are now potentially more 2. Rosenhan DL. On being sane in insane places. Science. 1973;179:250-8. [PMID: 4683124] dangerous than new psychiatric drugs. Diagnostic expan- 3. Frances AJ, Widiger T. Psychiatric diagnosis: lessons from the DSM-IV past sions lead to drug company promotions that dramatically and cautions for the DSM-5 future. Annu Rev Clin Psychol. 2012;8:109-30. increase the use of unnecessary medications, with high cost [PMID: 22035240] 4. Batstra L, Hadders-Algra M, Nieweg E, Van Tol D, Pijl SJ, Frances A. and potentially harmful side effects. In the United States, Childhood emotional and behavioral problems: reducing overdiagnosis without we carefully monitor new drug development but do not risking undertreatment. Dev Med Child Neurol. 2012;54:492-4. [PMID: have an effective system to vet the safety and efficacy of 22571729] new psychiatric diagnoses. The problems associated with 5. Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ. 2013;346:f1580. the DSM-5 prove that the APA should no longer hold a 6. Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet monopoly on psychiatric diagnosis. Another mechanism EJ, et al. Use of mental health services for anxiety, mood, and substance disorders for revising the diagnostic system must be developed. in 17 countries in the WHO world mental health surveys. Lancet. 2007;370:841- My advice to physicians is to use the DSM-5 cau- 50. [PMID: 17826169] 7. Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of tiously, if at all. It is not an official manual; no one is psychiatric and general medicine medication into perspective: review of meta- compelled to use it unless they work in an institutional analyses. Br J Psychiatry. 2012;200:97-106. [PMID: 22297588] setting that requires it. The codes needed for reimburse- 8. Frances A. How Many Billions a Year Will the DSM-5 Cost? Bloomberg Web site. 20 December 2012. Accessed at http://mobile.bloomberg.com/news/2012 ment are available for free on the Internet (10). -12-20/how-many-billions-a-year-will-the-dsm-5-cost-.html on 6 May 2013. 9. Division 32 Committee on DSM-5. The Open Letter to DSM 5 Task Force. From Duke University, Durham, North Carolina. Coalition for DSM-5 Reform Web site. Accessed at http://dsm5-reform.com/the -open-letter-to-dsm-5-task-force on 6 May 2013. 10. Centers for Disease Control and Prevention. International Classification of Potential Conflicts of Interest: Disclosures can be viewed at www Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Atlanta, GA: .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNumϭM13 Centers for Disease Control and Prevention; 2012. Accessed at www.cdc.gov -0997. /nchs/icd/icd9cm.htm on 6 May 2013.

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Author Contributions: Conception and design: A. Frances. Final approval of the article: A. Frances. Analysis and interpretation of the data: A. Frances. Administrative, technical, or logistic support: A. Frances. Drafting of the article: A. Frances. Collection and assembly of data: A. Frances. Critical revision of the article for important intellectual content: A. Frances.

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