1 Boring Old Man

Diagnostic Inflation: Causes and a Suggested Cure
^{Batstra, Laura PhD; Frances, Allen MD}

^{There have been a striking diagnostic inflation and a corresponding increase in the use of psychotropic drugs during the past 30 years. DSM-5, scheduled to appear in May 2013, proposes another grand expansion of mental illness. In this article, we will review the causes of diagnostic exuberance and associated medical treatment. We will then suggest a method of stepped care combined with stepped diagnosis, which may reduce overdiagnosis without risking undertreatment of those who really need help. The goal is to control diagnostic inflation, to reduce the harms and costs of unnecessary treatment, and to save psychiatry from overdiagnosis and ridicule.}

Recurrence of Depression After Bereavement-Related Depression: Evidence for the Validity of DSM-IV Bereavement Exclusion From the Epidemiologic Catchment Area Study
^{Wakefield, Jerome C. PhD, DSW; Schmitz, Mark F. PhD}

^{The DSM-IV diagnostic criteria for major depressive disorder exclude bereavement-related depressive episodes that are brief and lack certain severe symptoms and are thus better explained as normal grief responses. However, the DSM-5 Task Force proposes to eliminate this exclusion because of a lack of evidence that such episodes differ relevantly from standard major depression. Using the two-wave longitudinal Epidemiologic Catchment Area Study, we compared 1-yr depression recurrence rates at wave 2 of four groups at wave 1 baseline: [1] those with no history of depressive disorder [n = 18,239], [2] those who had only lifetime excludable bereavement-related depression [n = 25], [3] those with brief-episode [<=2 months duration] lifetime standard depressive disorder [n = 446], and [4] those with nonbrief lifetime standard depressive disorder [n = 581]. The recurrence rate in the excludable-depression group [3.7%] was not significantly different from the no-history group [1.7%] but was significantly and substantially lower than in the brief and nonbrief standard depression groups [14.4% and 16.2%, respectively]. These findings confirm findings reported by Mojtabai [Arch Gen Psychiatry 68:920–928, 2011] using a different data set and time frame and thus substantially strengthen the support for the validity of bereavement exclusion and for its preservation in the DSM-5.}

DSM-5 Further Inflates Attention Deficit Hyperactivity Disorder
^{Batstra, Laura PhD; Frances, Allen MD}

^{Since the publication of DSM-IV in 1994, attention deficit hyperactivity disorder [ADHD] prevalence and medication use unexpectedly increased significantly. In this article, we explore the DSM-5 proposals for ADHD that are likely to further increase its prevalence. We also address the possible harmful consequences of further expansion of this already broad, defined, and inflated DSM category.}

Behavioral Addiction—Quo Vadis
^{Mihordin, Ron MD, JD, MSP}

^{Behavioral addiction is a new class of psychiatric disorders being considered for inclusion in the next edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [DSM-5]. In this article, pathological model railroading disorder is introduced as a vehicle for highlighting and discussing the foreseeable risks and benefits of legitimizing behavioral addiction as a diagnostic class in DSM-5.}

Hebephilia and the Construction of a Fictitious Diagnosis
^{Good, Paul PhD; Burstein, Jules PhD}

^{As mass media and the advertising industry sexualize children at earlier ages, DSM-5 is considering a proposal for a new mental disorder involving sexual attraction to adolescents. Despite the fact that most men are sexually aroused by pubescent teens, some clinicians and researchers believe they have identified a new subgroup of chronically impaired men who are compulsively drawn to older children. We discuss the proposal and conclude that it is insufficiently documented and that with such potentially serious medicolegal consequences, inclusion in the new manual is not advised. Clinically, there are insufficient data showing the construct to be reliable and valid. Forensically, a new diagnosis of hebephilia is likely to be used to justify indefinite civil commitment and other onerous punishments.}

Mixed Anxiety Depression Should Not Be Included in DSM-5
^{Batelaan, Neeltje M. MD, PhD; Spijker, Jan MD, PhD; de Graaf, Ron PhD; Cuijpers, Pim PhD}

^{Subthreshold anxiety and subthreshold depressive symptoms often co-occur in the general population and in primary care. Based on their associated significant distress and impairment, a psychiatric classification seems justified. To enable classification, mixed anxiety depression [MAD] has been proposed as a new diagnostic category in DSM-5. In this report, we discuss arguments against the classification of MAD. More research is needed before reifying a new category we know so little about. Moreover, we argue that in patients with MAD symptoms and a history of an anxiety or depressive disorder, symptoms should be labeled as part of the course trajectories of these disorders, rather than calling it a different diagnostic entity. In patients with incident co-occurring subthreshold anxiety and subthreshold depression, subthreshold categories of both anxiety and depression could be classified to maintain a consistent classification system at both threshold and subthreshold levels.}

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5?: Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder
^{Wakefield, Jerome C. PhD, DSW}

^{The proposed changes to DSM-5 will create new categories of mental disorder [referred to here generically as Prolonged Grief Disorder’’ [PGD]] to diagnose individuals experiencing prolonged intense grief reactions to the loss of a loved one. Individuals could be diagnosed even if they have no depressive or anxiety symptoms but only symptoms typical of grief [e.g., yearning, avoidance of reminders, disbelief, feelings of emptiness]. The main challenge for such proposals is to establish that the proposed diagnostic criteria validly discriminate a genuine psychiatric disorder of grief from intense normal grief. With this test in mind, I evaluate the soundness of four empirical arguments and one conceptual argument that have been put forward to support such proposals: [1] PGD has discriminant validity because distinctive, pathognomonic symptoms distinguish it from normal grief; [2] PGD has discriminant validity because it identifies grief symptoms that are of greater absolute severity than in normal grief; [3] PGD has predictive validity because it implies a chronic, interminable process of grieving, thus a derailment of the normal process of grief resolution; [4] PGD has predictive validity because it predicts negative mental and physical health outcomes unlikely in normal grief; and [5] PGD has conceptual validity because grief is analogous to a wound or, alternatively, lengthy grief is analogous to a wound that does not heal. Upon close examination, each of these arguments turns out to have serious empirical or conceptual deficiencies. I conclude that the proposed diagnostic criteria for PGD fail to discriminate disorder from intense normal grief and are likely to yield massive false-positive diagnoses. Consequently, the proposal to add pathological grief categories to DSM-5 should be withdrawn pending further research to identify more valid criteria for diagnosing PGD.}

Psychotropic Marketing Practices and Problems: Implications for DSM-5
^{Raven, Melissa MPsych[Clin], MMedSci[ClinEpid]; Parry, Peter MB, BS}

^{Abstract: The descriptive diagnostic model since DSM-III has often led to “cookbook” diagnosis and assumptions of “chemical imbalance” for psychiatric disorders. Pharmaceutical companies have exploited this in their marketing. This includes promoting self-diagnosis with online checklists. Significant overprescribing of psychotropics has resulted. DSM-5 will provide new disorders and broader diagnostic criteria that will likely exacerbate this. Most psychotropic prescribing is done by primary care physicians, who are problematically excluded from DSM-5 field trials and are influenced by industry-funded key opinion leaders who may promote diagnosis of subthreshold cases. More lax criteria will increase diagnosis of subthreshold cases. Expansion of not otherwise specified [NOS] categories can be used to justify off-label promotion. Pediatric bipolar disorder, constructed within the bipolar disorder NOS category, became an “epidemic” in the United States, fuelled by diagnostic upcoding pressures. Disruptive mood dysregulation disorder may similarly cause overdiagnosis and excessive prescribing, as will other new disorders and lower diagnostic thresholds.}

A Critique of the DSM-5 Field Trials
^{Jones, K. Dayle PhD, LMHC}

^{This article provides an overview and critique of the field trials for the current revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]. The purpose of the DSM-5 field trials was to evaluate the use, feasibility, safety, reliability, and validity of the DSM-5 proposals. In this article, the procedures for evaluating these properties of the DSM-5 are reviewed, and several concerns—such as delays, disorganization, missed deadlines, field trial cancelations, lack of adequate validity testing, and high clinician attrition rates—and their likely impact on the field trial results are presented.}

We learned crucial information from the field trials, which involved more than 3000 patients who were assessed by a variety of clinicians in large medical centers, community clinics, and individual practitioners’ offices nationwide. Of interest, 2 diagnoses that are not changing appreciably from DSM-IV, major depressive disorder and generalized anxiety disorder, had relatively poor performance in terms of reliability. These findings raise important issues concerning the diagnostic dilemmas inherent in reliably assessing disorders that are frequently comorbid with other conditions. They provide obvious direction for further adjustments to the manual – refinements that can be introduced efficiently in the future Web-based releases envisioned for DSM-5. Indeed, the Internet provides the opportunity to revise the DSM as convincing new data become available, and it enables us to position the DSM as a living document, one that is as up-to-date as possible, rather than scrambling to catch up. That’s the issue at the heart of the current manual’s deficiencies, which have become apparent over time.

As Dr. Allen Frances concedes in his recent Medscape interview, DSM-IV never dealt adequately with childhood and adolescent disorders for numerous reasons. In addition, it offered a fuzzy delineation of disorders that led to the inflated number of comorbidities we see today and clouded matters more with its "not otherwise specified" diagnostic designation. Some have argued that the publication of DSM-5 should be delayed. But the current manual’s shortcomings, particularly in the area of childhood disorders, compel us to move forward now, with changes supported by the most credible research available and the practical experiences provided by our field trials.