Saving Normal by Allen Frances

Author:Allen Frances
Language: eng
Format: epub
Publisher: HarperCollins
Published: 2013-03-11T04:00:00+00:00

CHAPTER 6

Fads of the Future

Pride goeth before the fall.

PROVERBS 16:18

DSM-5 HAS JUST been published—not a happy moment in the history of psychiatry or for me personally. It risks turning diagnostic inflation into hyperinflation—further cheapening the currency of psychiatric diagnosis and unleashing a wave of new false epidemics.1,2 The economic equivalent would be printing up loads of new money when prices are already rising way too fast. DSM-5 is a cautionary tale of soaring ambition, poor execution, and a closed process. The good news is that a last-minute reform effort, instigated by a new leadership team at the American Psychiatric Association, eliminated about one third of the worst changes that would have opened the floodgates of diagnostic inflation even further. The bad news is that, despite this, DSM-5 kept the other two thirds and will significantly add to, not correct, the already existing problems of overdiagnosis and overtreatment.3

Ambition—Icarus Flies Too High and Flames Out

In preparing any DSM, it is wise to be extremely modest—underpromise and then work like hell to overperform. DSM-5 got this backward—it wildly overpromised, then failed to meet minimal performance standards.

The excessive DSM-5 ambition to effect a paradigm shift in psychiatric diagnosis expressed itself in three different initiatives. First was the unrealistic goal of transforming psychiatric diagnosis by somehow basing it on the exciting findings of neuroscience. This would be wonderful were it possible, but the effort failed for the obvious reason that it is still a bridge too far. Neuroscience will inform everyday psychiatric diagnosis only at its own slow and steady pace; it cannot be rushed forward before its time—and that time is decidedly not yet.

Ambitious goal two was to expand the boundary of clinical psychiatry—copying other specialties of medicine by pursuing the brave new world of early illness identification and preventive treatment. The irony, of course, is that excessive early screening is just now being discredited across many of the medical specialties that had served as the exemplars for DSM-5.

The third DSM-5 ambition is the least dangerous and most attainable. The idea is to make psychiatric diagnosis more precise by quantifying disorders with numbers, rather than merely naming them. Done well, this would be a good idea—but DSM-5 developed unnecessarily complex dimensional ratings that could never be used clinically.4,5

Icarus flew too close to the sun, melted his wings, and fell into the sea. DSM-5 tried to achieve three impossibly ambitious paradigm shifts in psychiatry and failed in all three. The messy process undeservedly tarred the credibility of psychiatry—the field is a lot better than anyone would assume watching the DSM-5 follies unfold. Trying to be great prevented DSM-5 from being good enough.6

Methods Matter

DSM-5 was not prepared with method in mind. Distracted by fantasies of creativity, it ignored mundane necessities like efficiency, punctuality, consistency, and quality control. Doing a DSM is not conceptually difficult. The tough part is attending to all the organizational details. It requires constant monitoring of the work groups to ensure they are following the common goal and preparing a consistent product. The

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