Risk/Benefit Ratio for Further Expanding Bipolar Disorder
By Allen Frances, MD
March 27, 2012
… Across the board, DSM-5 proposals consistently fail on 4 counts:
- their exclusive emphasis on eliminating missed diagnosis with a concomitant lack of concern about false positive over-diagnosis;
- their neglect of risks when considering benefits;
- their indifference to historical expectations regarding reliability,
- the lack of empirical support for suggestions that can have profound real life consequences.
There has been a doubling in the ratio of bipolar to unipolar depression since DSM-IV. Some of this growth was the anticipated result of our introducing Bipolar II as a new diagnosis in DSM-IV. Some was caused by massive drug company marketing with resulting loose diagnostic and prescription habits—especially in primary care practice. DSM-5 should be promoting more careful diagnosis of Bipolar Disorder, not a further reckless expansion.
5. if a change results in more medication, they support it if at all possible.
I doubt that members of the Task Force would admit the truth of my number 5. if asked, or even to themselves. They just find themselves following that path over and over. I expect it’s downright Freudian, as in unconscious. Maybe a better term would be Harry Stack Sullivan’s term, "selective inattention." They just don’t notice that it’s happening. To admit the truth of number 5. would be personally painful, so the mind just goes around full awareness. Each of the changes has a rationalization attached that they believe. And if any of them were to read this, they would likely say, "See, those psychoanalysts make up stuff like that all the time" without giving it much thought.
But that’s the way my mind and the minds of the people I’m around work. When I write a prescription I don’t really want to write, I always have my reason, but there’s a discomfort. One has to learn to catch that discomfort before it evaporates, because if you don’t, you’ll develop a pattern of overlooking it, and do the same not right thing again and again. We’re told that if we insisted on having a Task Force without drug company connections, we wouldn’t have any experts at all. The obvious response would be to forget the revision altogether until that situation is rectified – because if that’s true, we already don’t have any experts. People who do the Frances four and the 1boringoldman number 5. aren’t running on expertise in the first place.