1 Boring Old Man

NIMH vs DSM 5: No one wins, patients lose
Saving Normal: Psychology Today
by Allen Frances, M.D.
May 10, 2013

The flat out rejection of DSM 5 by National Institute of Mental Health is a sad moment for mental health and an unsafe one for our patients. The APA and NIMH are both letting us down, failing to be safe custodians for the mental health needs of our country. DSM 5 certainly deserves rejecting. It offers a reckless hodgepodge of new diagnoses that will misidentify normals and subject them to unnecessary treatment and stigma.

The NIMH director may have hammered the nail in the DSM 5 coffin when he so harshly criticized its lack of validity. But the NIMH statement went very far overboard with its implied promise that it would soon find a better way of sorting, understanding, and treating mental disorders. The media and internet are now alive with celebrations of this NiMH ‘kill shot’. There are chortlings that DSM 5 is dead on arrival and will perhaps take psychiatry down along with it.

This is misleading and dangerous stuff that is bad for the patients both institutions are meant to serve. NIMH has gone wrong now in the very same way that DSM 5 has gone wrong in the past – making impossible to keep promises. The new NIMH research agenda is necessary and highly desirable- it makes sense to target simpler symptoms rather than complex DSM syndromes, especially since so far we have come up empty. And the new plan will further, and be furthered, by the big, new Obama investment in brain research. But the likely payoff is being wildly oversold. There is no easy solution to what is in fact an almost impossibly complex research problem…

What Dr. Frances is talking about is, in my mind, the false dichotomy of this DSM-5/RDoC debate. The DSM-5 process and the RDoC hype both flounder in the same way, trying to knock the ball out of the park. What we needed from the DSM-5  was to just get on base. We need a cleaner, more accurate, clinical diagnostic system and we didn’t get it. They were so busy swinging for the fences that they didn’t make the simple changes that could’ve made a big [and helpful] difference.

So what is a patient or potential patient or parent to make of the confusing struggle between NIMH and DSM5 debacle? My advice is to ignore it. Don’t lose faith in psychiatry, but don’t accept psychiatric diagnosis or treatment on faith- particularly if it is given after a brief visit with someone who barely knows you. Be informed. Ask lots of questions. Expect reasonable answers. If you don’t get them, seek second, third, even fourth opinions until you do.

A psychiatric diagnosis is a milestone in a person’s life. Done well, an accurate diagnosis is the beginning of increased self understanding and a launch to effective treatment and a better future. Done poorly it can be a lingering disaster. Getting it right deserves the kind of care and patience exercised in choosing a spouse or a house. Remember that psychiatry is neither all good or all bad. Like most of medicine, it all depends on how well it is done.