Allen Frances, MD
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Author Contributions: Conception and design: A. Frances.
Analysis and interpretation of the data: A. Frances.
Drafting of the article: A. Frances.
Critical revision of the article for important intellectual content: A. Frances.
Final approval of the article: A. Frances.
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Timothy Kling MD
Outer Banks Center for Women
August 6, 2013
Well said. I agree completely.
Donald Venes, MD
August 16, 2013
The Sartorial Splendor of the DSM?
"Many, many years ago lived an emperor, who thought so much of new clothes that..." Hans Christian Andersen, 1837
Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany
August 28, 2013
Confidence and diagnostic uncertainty
In his opinion article, Frances is correct that changes in diagnostic systems can lead to overdiagnosis, and that everyday life problems could be misclassified as an illness. As physicians and as patients we do not like diagnostic uncertainty, the possibility of inaccurate diagnoses and unnecessary or harmful ‘treatment’, and we know how this can be echoed in the media.There are several aspects readers should consider: Revising a diagnostic manual is not unique to psychiatry. The definition and treatment recommendations of various diseases, such as hypertension have been adjusted numerous times in the past. Recent discussion on obesity shows that even having a biological measure does not always allow the clear separation of what is ‘normal’ and what is not, and whether one or the other comes with health benefits (Rexford SA and Mitchell AL. Science 2013;341: 856). It is not the aim of the DSM-5 to pathologize grief or forgetfulness. However, in every memory disorder clinic there are too many demented patients, whose healthcare providers told them for too many years their memory problems would reflect normal aging. This prevents therapy, and, as in every other medical specialty, psychiatric therapy is not always pharmacologic. Putting drug company interests and the complex process of revising a diagnostic manual in the same context is misleading. It is always the physician who establishes a diagnosis. We have to carefully consider given criteria, and we must make a judgment whether or not they are met. Then we decide how to monitor, educate, or treat our patients. Any psychiatrist who does not recognize a difference between normal grief and major depression should not consult a manual but rather ask himself, whether he is qualified to be a physician. Advances in neuroscience may ultimately contribute to but do not currently allow the definition of causal categories for major psychiatric diseases. The emergence and disappearance of etiology-oriented disease classification approaches have always been a part of psychiatry, creating categories such as ‘organic’, ‘endogenous’ and ‘psychogenic’ disorders in the early 20th century. Such models reflect both the desire for simplistic causal explanations as well as a generation’s limited insight into the structure and function of the brain. In the search for causes and ‘objective biological tests’, we have to acknowledge, as Frances did, that we still know far too little about the brain to achieve this goal. Until then, descriptive classification systems will keep us open-minded.
Allen Frances, MD
September 12, 2013
Thank you to Dr Markus Donix for his comment: 'Confidence and diagnostic uncertainty'. While he and I agree on most points, I fear that Dr Donix under estimates the risk that DSM 5 will cause harmful unintended consequences. It certainly is not be 'the aim of the DSM-5 to pathologize grief or forgetfulness,' but will it will almost surely have this result-particularly since primary care doctors, not psychiatrists, do most of the diagnosis and prescription of psychiatric drugs. There are no effective treatments for grief or forgetting and the false positives are much more common than missed cases. It is also nave to ignore the large influence of drug company marketing on physician practice.
Frances A. The New Crisis of Confidence in Psychiatric Diagnosis. Ann Intern Med. ;159:221–222. doi: 10.7326/0003-4819-159-3-201308060-00655
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Published: Ann Intern Med. 2013;159(3):221-222.
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