Thursday, May 23, 2013

Soon, we'll all be labelled mad


May 23, 2013

By Allen Frances

"WE ARE all mad here," explains the Cat to Alice when she wonders about the strangeness of Wonderland. Well, life is starting to follow art. If people make the mistake of following DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), the new diagnostic manual in psychiatry that was published on Saturday, pretty soon all of us may be labelled mad.

When I worked on the task force for DSM-4, we were very concerned about taming diagnostic inflation - but we only partly succeeded. Then four years ago, I became aware of the excessive enthusiasm around all the new diagnoses being proposed for DSM-5, including many that were untested. I hate to rain on anyone's parade, but I knew this would be disastrous for the millions of people who were likely to be mislabelled, stigmatised and given excessive treatment.

In the United States, the "sick" are distinguished from the "well" by the diagnostic and statistical manuals developed by the American Psychiatric Association. The problem is that definitions of mental disorders are already written too loosely and are applied much too carelessly by clinicians, especially by the general practitioners who do most of the prescribing of psychiatric drugs.

And things are about to get much worse. Under DSM-5, diagnostic inflation looks set to become hyperinflation and will lead to an even greater glut of unnecessary medication. I would qualify for a bunch of the new labels myself - and you might too.

The grief I felt when my wife died would now be called "major depressive disorder"; forgetfulness in older age "mild neurocognitive disorder"; my gluttony now "binge eating disorder"; and my hyperactivity "attention deficit disorder". As for my twin grandsons' temper tantrums, this could be misunderstood as "disruptive mood dysregulation disorder". And if you have cancer and your doctor thinks you are too worried about it, there's "somatic symptom disorder". It goes on, but you get the idea.

About half of Americans already qualify for a mental disorder at some point in their lives and the rates keep skyrocketing, especially among children. In the past 20 years, the prevalence of autism has increased, childhood bipolar disorder has multiplied fortyfold and attention deficit disorder has tripled.

One consolation: The children are not suddenly getting much sicker - human nature is pretty stable. But the way we label symptoms follows fickle fashions, changing quickly and arbitrarily. And freely giving out inaccurate diagnoses can lead to grave harms - medication that isn't needed, stigma, lower self-confidence and reduced self-expectation.

There are also downstream effects. Many parents panicked about the alarming rise in rates of autism and fell for the disproven belief that it was caused by vaccination. Trying to avoid a false epidemic of autism caused by nothing more than changed labelling meant they stopped vaccinating their children and exposed them to the very real measles outbreak that recently occurred.

And medication use is out of control - 20 per cent of Americans regularly use a psychotropic drug; 10 per cent of teenage boys are taking a stimulant for attention deficit hyperactivity disorder (ADHD); 25 per cent of our active duty troops report abuse of a prescribed medicine; and the US has more deaths from prescription drug overdoses than from street drugs.

In Britain, you are protected against the worst effects of diagnostic and drug exuberance. Doctors use ICD-10, the classifications compiled by the World Health Organisation, not DSM-5; they follow prudent guidelines from Nice, which sets the standards for health treatment in Britain; the British-based Cochrane group emphasises evidence-based medicine; GPs do less prescribing; and drug companies exert much less power and cannot advertise directly to consumers as they do in the US. But the measles outbreak and ADHD rates prove Britain is not out of the woods. Bad ideas from America sometimes have much more influence than they deserve.

My advice is to be an informed consumer. Never accept a diagnosis or a medication after a cursory evaluation. A psychiatric diagnosis can be a turning point in your life - as important as choosing a spouse or a house. Done well, it can lead to life-improving treatment; done poorly, it can lead to an inaccurate label and harmful treatment.

People who have mild and transient symptoms don't need a diagnosis or treatment. The likelihood is they are visiting the doctor on one of their worst days and will get better on their own. Medication is essential for severe psychiatric problems but does more harm than good for the worries and disappointments of everyday life. Better to trust time, resilience, support and stress reduction.

The writer is professor emeritus at Duke University, North Carolina. The full version of this article can be found on The Conversation (, which carries analysis by academics and researchers in Australia.

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