Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

There are no laboratory tests for psychiatry, no bright lines to say who is sick and who is well. The Diagnostic and Statistical Manual of Mental Disorders, or DSM, has come to be regarded as the bible of psychiatric diagnosis. First published in 1952 and revised several times since then, it improved the reliability of subjective diagnoses. But Dr. Allen Frances says it’s also had harmful unintended consequences. He was once dubbed “the most powerful psychiatrist in America” by The New York Times. Now he says the DSM has contributed to psychiatric fads, diagnostic inflation and over-medication. He believes the latest version threatens to turn everyday living into psychiatric disease. He joins Diane to discuss his new book, “Saving Normal,” and how to rein in psychiatry and drug companies.

Guests

  • Dr. David Kupfer chair of the DSM-5 Task Force and professor of psychiatry at the University of Pittsburgh School of Medicine.
  • Dr. Allen Frances professor emeritus and former chair of psychiatry and behavioral science department at Duke University; chair of the DSM-4 Task Force; and leadership group member on the DSM-3 and DSM-3-revised.

Read An Excerpt

Excerpt from the book “Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life” by Allen Frances. Published by William Morrow. Copyright © 2013 by Allen Frances. Reprinted with permission.

Transcript

  • 11:06:56

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. The diagnostic and statistical manual of mental disorders, the DSM, is used to determine treatment decisions, insurance eligibility, disability payments and special services. A 5th version of the manual has been approved by the American Psychiatric Association. Dr. Allen Frances chaired the task force that wrote the 4th edition.

  • 11:07:29

    MS. DIANE REHMNow he's written a critical, new book titled "Saving Normal." He joins me in the studio to talk about what he calls out-of-control psychiatric diagnoses, DSM-5, big pharma and the medicalization of ordinary life. You can join us 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. Good morning to you, Dr. Frances, thanks for being here.

  • 11:08:05

    DR. ALLEN FRANCESGood morning.

  • 11:08:08

    REHMGood to have you here. For the subtitle of your book, you have "Normal" and then you have "An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis" and so on. Why are you revolting?

  • 11:08:34

    FRANCESI'm very concerned that the wrong people are getting too much treatment and the right people are getting too little treatment. Twenty-five percent of our population would qualify for psychiatric diagnosis in any given year and 50 percent, lifetime.

  • 11:08:51

    FRANCESBut most of those people, many of them at least, have a very marginal problem that probably shouldn't have been diagnosed and many people are getting medicine they don't need.

  • 11:09:03

    REHMSo you're saying that mental illness is now being too broadly defined?

  • 11:09:11

    FRANCESAnd the real problem is that at the very same time people who are really sick are deprived of treatment, don't have adequate housing. A million psychiatric patients have wound up in prison for nuisance crimes that could have been prevented if they were properly diagnosed and treated. And one third of people with severe depression have no contact with a mental health clinician at all.

  • 11:09:36

    REHMOkay, so you were chair of the DSM-4. We now have the DSM-5. Why didn't you revolt at the DSM-4? What's the difference between four and five?

  • 11:09:55

    FRANCESI learned a very important lesson. We tried to be as conservative as you could be with absolutely modest ambitions and meticulous methods and we turned down 92 of 94 suggestions we received for new diagnoses.

  • 11:10:13

    FRANCESBut despite our efforts, there have been three epidemics of psychiatric disorders all occurring in kids since the DSM-4 was published.

  • 11:10:21

    REHMGive me an example.

  • 11:10:23

    FRANCESAttention deficit disorder has tripled. Autism has gone up by almost 40 times. Childhood bipolar disorder has gone up also by 40 times and adult bipolar disorder has doubled, all since DSM-4.

  • 11:10:37

    REHMSo how has that happened? Couldn't it be that society itself is placing more stress on both children and adults and therefore the number of people suffering has gone up?

  • 11:10:55

    FRANCESYeah, I don't buy that argument at all. I think human nature is remarkably stable and labels can change on a dime, that the increase in the rates of disorders doesn't come because people are sicker. It comes because we're labeling things in a much looser way.

  • 11:11:11

    FRANCESAnd if you look at human history, our ancestors lived in much worse conditions than any of us are living in. And people in Iraq, Afghanistan, many parts of the world have stresses that we can't even imagine.

  • 11:11:26

    REHMIs there a difference between how ADD was defined in DSM-4 and how it's defined now?

  • 11:11:38

    FRANCESWell, let me be clear. We have a huge problem with ADD now that DSM-5 will make worse. An amazing Canadian study found out that using the current criteria, the best predictor of whether a kid has ADD is whether he's born in December or January. Get it? School year begins January 1st, the cut-off date.

  • 11:12:01

    FRANCESThe youngest kids in the class who are naturally going to be less mature and more active are being misdiagnosed. We're taking childhood and making it into a mental disorder and 20 percent of American teenage boys now qualify for ADD. Ten percent of them are on medication.

  • 11:12:20

    FRANCESWe should be spending the $9 billion we're spending on ADD medication, much of that should be going into the school system for more physical education and for smaller classes.

  • 11:12:28

    REHMSo what you're saying is that not only have definitions broadened, but that in response to those broadening definitions, doctors are handing out more medications. Doctors are handing out broader arrays of prescriptions for the same disorder that 20 years ago perhaps had a much smaller population to serve.

  • 11:13:08

    FRANCESYeah, what's happened is that 80 percent of psychiatry is no longer done by psychiatrists. Eighty percent of psychiatric medication is given out by non-psychiatric doctors.

  • 11:13:18

    REHMHow so?

  • 11:13:20

    FRANCESThe drug companies got tremendous incentives and tremendous resources to market. In 1997, three years after DSM-4, they prevailed on the government to allow them to market directly to consumers, something they can't do anywhere else in the world but New Zealand.

  • 11:13:39

    FRANCESThe courting of doctors has been intense and now the typical diagnosis is not made by psychiatrists after a careful evaluation. A typical diagnosis is made after seven minutes by someone with very limited training in psychiatry eager to get the patient out of the office, very influenced by drug salesmen and often having free samples.

  • 11:14:02

    REHMTell me how that diagnosis is made.

  • 11:14:07

    FRANCESPoorly. A psychiatric diagnosis is an important moment in a patient's life. Done well, it leads to wonderful things, done poorly, it can be very, very harmful. I'd liken it to getting married, to buying a house, buying a car. A person shouldn't get a diagnosis and should not accept pills after a seven-minute evaluation.

  • 11:14:29

    FRANCESMost people seeing a doctor on the worst day of their life will get better just through natural resiliency, time, resources from family and the community and what we're doing is jumping ahead, giving diagnoses carelessly to people who don't really need them.

  • 11:14:47

    REHMBut how is the doctor making this diagnosis? What kinds of questions? What kinds of presentation is the parent making? There are lots of things that go into a diagnosis surely?

  • 11:15:03

    FRANCESThere should be, but usually there aren't. The insurance company requires that the doctor makes a diagnosis and give a code after the first visit or else he won't be paid for it. So everything conspires to really loose, really fast diagnoses that are made off the top of the head. If something can be misused in the diagnostic system it will be misused.

  • 11:15:27

    REHMGive me another example in addition to ADD where you think this DSM-5 is going to take us even further than it's already gone.

  • 11:15:41

    FRANCESWell, first of all, let me make clear DSM-4 has taken us further than it should be. This is not a problem of the future. We have a problem right now that the DSM-5 will make worse. The rates of autism have gone up almost 40 times in the last 20 years.

  • 11:15:57

    FRANCESIt's not because of vaccinations. It's not because there's more autism in the population. It's because autism has become the key to getting school services, smaller class sizes, individual attention. Autism, we put in Asperger's in DSM-4. That's part of what led to this tremendous increase. But it was a clinical diagnosis. We never imagined that it would be so closely coupled to school services.

  • 11:16:21

    REHMBut at the same time, look at the population at the other end of the age spectrum. You've got Alzheimer's increasing by I don't know what percentage, but a lot because the population is aging. In the same way, you have the incidence of Parkinson's disease on the increase because of aging.

  • 11:16:55

    REHMCouldn't it be that there are now more problems in society creating this, you know, whether it's in utero, whether it's after a child is born, conditions that lead to a greater incidence of autism and at the other end of the spectrum Alzheimer's?

  • 11:17:24

    FRANCESWell, I think Alzheimer's is strictly related to age and as we get to live longer, we run the risk of Alzheimer's. I think with autism it's almost impossible to believe that we've had a 40-fold increase in the behaviors that would be diagnosed.

  • 11:17:42

    FRANCESIt makes much more sense to see this as the result of the fact that educational decisions in the school systems are being based by the requirement that the diagnosis be present. It would be much better to de-couple educational needs from clinical diagnosis.

  • 11:18:00

    REHMWhat do you mean by that?

  • 11:18:03

    FRANCESIn order to get special school services, individual attention, smaller class sizes, a kid has to have a diagnosis of autism. When you give a benefit because of a diagnosis, that diagnosis will increase. The rates will go way up. I want kids to have school services, but it shouldn't be based on a psychiatric diagnosis which was created by researchers and clinicians with no expertise in school services.

  • 11:18:26

    FRANCESEducational decisions about who gets what service in schools should be based on educators using educational tools to make decisions about what's best.

  • 11:18:36

    REHMDr. Allen Frances, he's professor emeritus and former chair of the Psychiatry and Behavioral Science Department at Duke University. His new book is titled "Saving Normal." Short break.

  • 11:20:05

    REHMAnd welcome back. Here in the studio, Dr. Allen Frances. He is professor emeritus, former chair of the psychiatry and behavior science department at Duke University. He was chair of the DSM-4 Task Force. He's written a new book titled "Saving Normal: An Insider's Revolt Against Out-of-Control-Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life." And now joining us from his office in Pittsburgh is the chair of the DSM-5 Task Force, Dr. David Kupfer. Good morning to you, sir. Thanks for joining us.

  • 11:21:04

    DR. DAVID KUPFERGood morning, Diane. How are you?

  • 11:21:05

    REHMI'm fine, thank you. Talk about why a new version of the DSM is being published now?

  • 11:21:14

    KUPFERWell, it's been actually almost 20 years since the last DSM, the DSM-4 was published. And there has been a lot of both information improvement and, if you will, diagnostic criteria science advances, that it seemed very appropriate to begin a process sometime ago to update the DSM. And so the intent is to more precisely diagnose mental disorders. There are a number of things, as we approach this milestone, that we believe the DSM-5 will represent the best clinical guide -- and it is a guide for diagnosis.

  • 11:22:04

    KUPFERAnd a number of those changes that we have made have been within the context knowing that many of the areas that can withstand, if you will, improvement in more precise diagnostic criteria are along the childhood and adolescent continuum. And so consequently, the entire book has been organized along developmental lifespan within each chapter.

  • 11:22:30

    REHMAll right. And knowing that you have been listening since the top of the hour to the comments of Dr. Frances, can you talk about or respond to his concerns that both the DSM-4 and the DSM-5 are contributing to what he calls a false epidemic of Attention-Deficit Disorder and Autism?

  • 11:23:07

    KUPFERYes. Well, first of all, you and I can't really predict, if you will, how the DSM-5 will influence the prevalence and incidence of these particular disorders. We have been very much aware of what has happened since the advent of DSM-4. And so consequently we've paid a tremendous amount of attention in looking at the diagnostic criteria for Autism Disorder, Autism Spectrum Disorder and ADHD.

  • 11:23:40

    KUPFERAnd having spent a good bit of time reviewing those diagnostic criteria, we've made some major changes with Autism. And we believe that the field trials and what has been done already in using the new sets of criteria of Autism Spectrum, clearly lead to more precise diagnostic criteria, lead to better levels of determining, if you will, levels of severity that we had previously. And at least the data to date shows that children that need services are getting the services that are appropriate.

  • 11:24:25

    KUPFERThe prevalence of the overall disorder for Autism Spectrum is not leading us to another very, very large rise. And I would say that as long as clinicians are using the precise criteria that will be in the DSM-5, I believe that we have the best clinical approach to making the diagnosis for Autism Spectrum Disorder.

  • 11:24:51

    REHMAll right.

  • 11:24:52

    KUPFERAnd I would say the same thing abide certainly for ADHD, as the committee reviewed both all of the information concerning young people with ADHD as well as adolescents and adults with ADHD.

  • 11:25:08

    REHMNow if I may, let me ask you also about Dr. Frances' concern that now big pharma is taking advantage of these criteria as set out in the DSM and using that to advertise directly to the public creating in their minds the idea that they must go to the doctor with a child who may have been born in December and January, who may be younger than classmates, who may be a bit on the overactive side and to find within seven minutes that that child has ADD.

  • 11:26:11

    KUPFERWell, the first thing to say, of course, is that the DSM is a guideline for clinical diagnosis. It is not a guide -- a treatment guidebook. And therefore there are no recommendations specifically that lead to pharmacologic interventions or behavioral interventions. I do think that, again, the use of the definitive criteria is the best approach in well-trained clinicians. One of the things that we are doing again in DSM-5 is making it electronically available with references. We are expecting that it will be a much better educational tool. It will be clearer.

  • 11:26:58

    KUPFERAnd we do believe that if it is used appropriately we hope that clinicians will find that they will get a much better assessment to then make more precise treatment recommendations, whether those treatment recommendations be pharmacologic or behavioral or psychotherapeutic.

  • 11:27:19

    REHMBut, Dr. Kupfer, considering the fact that most doctors these days have very, very little time to spend with a patient, and most doctors are not psychiatrically trained, and yet have these medications available to them, are you at all concerned that young kids may be being too soon and too much medicated by ordinary physicians who are not investigating fully whether a child has ADHD or is actually Autistic?

  • 11:28:14

    KUPFERI am concerned that all clinical evaluations, whether they be for psychiatric purpose or whether they be for medical purposes such as the diagnosis of diabetes or hypertension, be conducted in a such a way that there is sufficient time and training and expertise to make the right diagnosis. What I suggest, that you well know, we are talking about what are the resources available and how are we, in a sense, allowing ourselves as a society to conduct the diagnostic work ups that we need for what may turn out to be chronic medical and psychiatric problems.

  • 11:28:58

    REHMBut the question becomes, I mean, Dr. Kupfer, it's almost mind blowing that these centers for disease control has reported that the rates of autism have jumped to 1 in 50 children. And that becomes 40 times greater than it was 20 years ago, and up from 1 in 80 just last year, and 1 in more than 1100 just years ago. So it begs the question, are these diagnoses been made too readily available by individuals who may not be completely trained to make such a diagnosis, even if you are providing these textbooks online or providing the information they can look for and access immediately on the computer?

  • 11:30:20

    KUPFERYes. I am going to say the following, which is that if various type of surveys are conducted where only one or two questions might be asked, we might wind up saying that the rate of, for example, obesity or hypertension is 80 percent of the population. When we've conducted so far with the new sets of DSM-5 criteria for autism spectrum disorder, we have not seen the levels of prevalence that had been reported by the CDC.

  • 11:31:01

    REHMOne Tweet reminds us that the DSM has, shall we say, made some mistakes in the past, that homosexuality was finally removed from the DSM as a mental health disorder. How long did that take, Dr. Kupfer?

  • 11:31:32

    KUPFERWell, it did not take that long, if you will, and it was removed quite a bit ago in terms of the DSM. So it was certainly not part of the DSM-4 and obviously it would not be part of the DSM-5.

  • 11:31:48

    REHM1972 doesn't seem all that long ago. My concern is that people hearing this program, people hearing that the criteria for ADD is going to be expanded, people hearing that the diagnoses for Autism is going to be expanded may be looking at their children differently when a doctor who is not trained as a psychiatrist and who has not gone through that really thorough examination makes such a diagnosis and hands out a pill. What is in the DSM to stop that doctor?

  • 11:32:47

    KUPFERThe main thing is that based on the DSM-5 that will come out, the criteria for ADHD and the criteria for Autism Spectrum Disorder will not be expanding. If anything, we believe that what we have learned from the past has led us to put clearer levels of distress impairment and levels of severity. And so therefore if anything, the expectation over the next few years is that the diagnosis in terms of the number of people with these disorders will not necessarily go up.

  • 11:33:29

    KUPFERI do want to say one thing about the DSM-5, if I have a moment...

  • 11:33:33

    REHMSurely.

  • 11:33:33

    KUPFER...which is to say that it is going to be a living document. We are not going to wait 20 years to be able to make adjustments if there are any, if you will, unintended consequences. I agree with my colleagues in the past that unnecessary epidemics can be avoided. And the lack of precision and the lack of training often lead to, if you will, a different set of expectations and perceptions, both on the public's part and unfortunately also in the eyes of clinicians and schools. And we would like to avoid that as much as possible in the future.

  • 11:34:19

    REHMDr. David Kupfer. He is chair of the DSM-5 Task Force. I know you have to leave us, Dr. Kupfer. I want to thank you for joining us.

  • 11:34:34

    KUPFERWell, thank you very much for having me, Diane.

  • 11:34:36

    REHMIndeed. And you're listening to "The Diane Rehm Show." I understood there was to be no interaction between the two of you, Dr. Frances. What's your reaction to what you heard Dr. Kupfer say?

  • 11:34:56

    FRANCESThe problem is the DSM-5 has introduced a number of new diagnoses that are very -- possibly will become topics for epidemics. And it's reduced the thresholds for a number of existing diagnoses.

  • 11:35:12

    REHMFor example.

  • 11:35:13

    FRANCESADHD, it's reduced the number of criteria items and it's raised the age of onset from seven to twelve. It'll be much easier for kids and adults, especially adults to get the diagnosis of ADHD. It's introduced the concept that grief can be easily turned into major depressive disorder. If you've lost the person you love most in the world and two weeks later you experience sadness, loss of interest, trouble with appetite and sleeping and less energy, in DSM-5 that can be major depressive disorder.

  • 11:35:49

    REHMI had understood perhaps from many, many years ago that that grieving period could last as much as a year and be within normal range. You're telling me now that if I go to the doctor, God forbid, after I lose someone close to me two weeks later, that doctor is going to say I need to give you medication?

  • 11:36:20

    FRANCESAnd a drug company salesman can convince him using DSM-5 as his text that his is a legitimate diagnosis two weeks after losing a loved one.

  • 11:36:30

    REHMWhat's happening to feelings that all of us have? Are they to be neutralized by medication?

  • 11:36:41

    FRANCESWell, the problem is we're medicalizing things that are part of everyday life. In DSM-5, if you have cancer and you worry too much about the physical symptoms that you're experiencing, it will be the doctor's choice, and he can easily give you the diagnosis of Somatic Symptom Disorder. One-sixth of people with cancer will get an added psychiatric diagnosis of Somatic Symptom Disorder merely because they worry about their symptoms. One-fourth of people with chronic pain will be diagnosed as Somatic Symptom Disorder.

  • 11:37:17

    FRANCESI'm 70 years old. My memory's getting worse. That could very easily be mild Neurocognitive Disorder. My grandchildren have temper tantrums. That could be Disruptive Mood Dysregulation Disorder. And I have more.

  • 11:37:34

    REHMDr. Allen Frances. He is the author of a new book titled "Saving Normal: An Insider's Revolt." We'll take your calls when we come back.

  • 11:40:02

    REHMAnd the full title of Dr. Allen Frances' new book is titled, "Saving Normal: An Insider's Revolt Against Out-Of-Control Diagnosis, DSM-5, Big Pharma And The Medicalization Of Ordinary Life." We're going to open the phones now, first to Black Mountain, N.C. Good morning, Cindy.

  • 11:40:32

    CINDYGood morning, Diane. Thank you very much for having this subject on your show. I have a comment and a question.

  • 11:40:39

    REHMSurely.

  • 11:40:42

    CINDYMy younger daughter has Asperger's syndrome and my baby brother has Asperger's syndrome. My granddaughter has full-blown autism. I'm very discouraged when I hear things that blame their diagnosis on the DSM-4 (sic) and that since it was published the diagnosis of Asperger's has increased exponentially. I've heard this on several shows. Isn't it possible that when the DSM-4 was published the increase in diagnosing a child with Asperger's was because it just became easier to spot it and treat it?

  • 11:41:30

    CINDYWhen my daughter was diagnosed she was eight years old. Nobody in her school had ever heard of it. And that's it.

  • 11:41:41

    FRANCESWell, Cindy, I'm really pleased to hear that you're getting the treatment and the care you need and that it's worked for you. We expected the rates to go up about three or four times. And I think the destigmatization has been helpful in bringing people needed services that they otherwise wouldn't have gotten. But there's been a big overshoot. And you couldn't possibly have 40 times as many people. I think you may be in the category of those who were helped by it, but lots of people have been harmed. And it's a very stigmatizing diagnosis that's being given out very loosely.

  • 11:42:17

    FRANCESEvery week I get a bunch of emails from parents whose lives have been devastated, whose kids have been harmed by a diagnosis given out carelessly that didn't make sense. So--

  • 11:42:27

    REHMBut if medication helps then how is that harmful?

  • 11:42:33

    FRANCESWell, autism doesn't have a medication, but the school services can help. And the problem is to get them to the people who really need them. So we need to be providing more services to people who really need them, and less services to people who don't. And there's been a big overshoot.

  • 11:42:49

    REHMAll right. To Cleveland, Ohio. Michelle, you're on the air.

  • 11:42:55

    MICHELLEHi, Diane. Hi, Dr. Frances. Thank you for taking my call.

  • 11:42:58

    REHMSurely.

  • 11:42:59

    MICHELLEI just have a comment. I'm a mental health professional, licensed in both Florida and Ohio. And Dr. Frances, I completely agree with you. The number of children out there that are getting diagnosed with really severe, severe diagnosis and then given medication, stunts their emotional growth. And we are producing adults--soon-to-be adults that will have no coping skills whatsoever, but believe that they simply need to take a medication. Cognitive behavioral therapies are incredibly effective. And I have met very few conservative psychiatrists that just recommend therapy.

  • 11:43:40

    MICHELLEThey're prescribing Seroquel. They're prescribing Xanax. And these are for young children and teenagers. And it's just so disappointing and unfortunate because in 10 years and in 15 years these are going to be our adults that are basically going to have no coping skills or strategies of life skills. And it's just so discouraging as a professional out there.

  • 11:44:07

    FRANCESWell, I think it's very important that we treat the people who need it and protect the people who don't from treatment that's not necessary for them. We've taken individual difference, developmental lags and we've turned these into medical and mental disorders, often at great expense to the patient. It's so easy to give a diagnosis. It can take five minutes. But that diagnosis can haunt a family and haunt the person for a lifetime. So what I'm asking for is accurate diagnosis. The people who need it are being ignored. The people who don't need it are being excessively diagnosed, excessively treated. I agree with you completely.

  • 11:44:46

    REHMHere is an email from Treva, who says, "In the 1920s my grandmother visited the doctor for stomach problems and she was sent to have all of her teeth removed. I believe what her doctor did was the best he knew at the time, but looking back from today's perspective what a travesty. I wonder how this age is going to be judged in the future? My 13-year-old son recently observed he was the only boy in his circle of friends who was not on medication for their behavior.

  • 11:45:41

    FRANCESThis is what makes me sad and scared. Hippocrates, the father of medicine, said, "First do no harm." Antipsychotic medications have brought in $18 billion of revenue, lots of that for kids. Kids gain a pound a week on antipsychotic medications, going from 110 pounds to 122 pounds in three months, with the risk of diabetes, of later heart disease, possibly a shortened life expectancy. Now, antipsychotics are wonderful drugs for those who need them, but because of the drug company marketing, because of the loose diagnosis, because half of this medicine is being given by non-psychiatrists, we're flooding kids with medicine that has obvious immediate harms and possibly long term consequences.

  • 11:46:35

    FRANCESWe need, as a society, to get more cautious in diagnosis and more tolerant of individual difference.

  • 11:46:43

    REHMAll right. To Mitchellville, Md. Hi there, Hank.

  • 11:46:47

    HANKHi, how are you?

  • 11:46:48

    REHMFine, thanks. Go right ahead, sir.

  • 11:46:52

    HANKYes. My question is this, I know that about probably 20 to 25 years ago there was instituted what is called the autism waiver, in which families could apply for funding, not having to pass a means test in order to get services for their children, particularly preschool children. And I'm wondering how that funding source may have contributed to the increase in diagnosis of autism.

  • 11:47:22

    FRANCESPsychiatric diagnosis has become way too important, too important in school decisions, too important in disability decisions, too important in the court. Whenever a diagnosis determines something outside its competence, the diagnosis will be done loosely. And I think that's the problem with the overshoot in autism. That we should be basing school decisions on school needs, not on a clinical diagnosis created by people who don't know the first thing about school services.

  • 11:47:51

    REHMSo you're turning the responsibility over to teachers?

  • 11:47:59

    FRANCESIt certainly makes more sense for educators to decide educational needs, than for a pediatrician who sees a kid for 10 minutes, giving a diagnosis and have that be determinate.

  • 11:48:12

    REHMOkay. So if the kid on the third row is acting out, acting out, acting out, a teacher may not want a child who is acting out, but who is otherwise totally normal.

  • 11:48:32

    FRANCESAnd the problem is the class sizes are way too big. Lots of schools don't have physical education so kids can blow off steam. We shouldn't be spending $9 billion on drugs, medicalizing normal kids. We should be giving them a better school experience.

  • 11:48:49

    REHMAll right. Let's go to Julie in St. Louis, Mo. Good morning.

  • 11:48:54

    JULIEHi, thank you so much for taking my call, Diane.

  • 11:48:57

    REHMSure.

  • 11:48:57

    JULIEI just want to say that I so appreciate the level of discourse you bring to the radio.

  • 11:49:02

    REHMThank you.

  • 11:49:02

    JULIEI'm calling as a parent of a child with autism. We got our diagnosis after a two and a half hour evaluation by a very reputable neurologist. And Dr. Frances' claim that the diagnosis has increased in frequency as a result of the DSM is, I think, reaching. I think there are many things that contribute to the significant increase in the diagnosis. And I have to tell you, as a parent, believe me when I tell you, there is no way we sought this diagnosis. And there is no way that we saw any advantage in acquiring this diagnosis, in terms of educationally speaking or otherwise.

  • 11:49:46

    JULIEBelieve me, it's not something that parents are looking for, to give their children some sort of an academic edge, you know, by getting services. And it certainly was not given to us with a wink and a nod saying, okay, here you go. Now, your child's going to have a leg up at school. It's just really, to me, improbably and sort of fantastic.

  • 11:50:11

    FRANCESWell, I think we introduced Asperger's in DSM for precisely the reasons you're suggesting. It's a very helpful diagnosis that's useful in many situations. The problem is the overshoot. And there's no way that there could possibly be a 40 times increase. So your experience is perfect for you and I wish it were always like that, but in other situations the diagnosis is being used too loosely, in a way that stigmatizes kids.

  • 11:50:38

    REHMAll right. To Houston, Texas. Good morning, David.

  • 11:50:44

    DAVIDGood morning. Thank you for having me.

  • 11:50:47

    REHMSurely. Go right ahead, sir.

  • 11:50:49

    DAVIDI just want to speak--well, let me say Amen to what both of you are saying. I'm a school psychologist. I've been on faculty at Baylor College of Medicine and Texas Children's Hospital here in Houston. Let me give you a report from the trenches. And I'll limit myself just to the diagnosis of autism. It not only is true, Diane, that a physician untrained in psychiatry can make that diagnosis, I have people in my department that are 26 years old with a masters degree and it's legal for them to make the diagnosis of autism.

  • 11:51:16

    DAVIDSo this problem that Dr. Frances is pointing to, of people wanting the services, is only compounded by people that are very narrowly trained making diagnoses. And when I train interns I call it name-that-tune problem. Of course, most of them are too young to remember the game show. But these young school psychology trained people will see one or two things, toe walking. Maybe they'll see a little hand flapping. And boom, they want to rather certainly and proudly say, oh, that's autism. And I'm having to fight these kids and say, whoa, whoa, whoa, it's got to be like the big dipper, it's got to have all the stars before that's the constellation.

  • 11:51:58

    DAVIDThis individual differences concept that Dr. Frances talked about is so critical.

  • 11:52:03

    FRANCESYeah, we have to let kids be kids. So I think some of the callers obviously have kids who need help and it's wonderful that they're now getting it, but I think lots of kids are mislabeled because they're the slightest bit different than someone else.

  • 11:52:17

    REHMDavid, I don't understand how a 26-year-old who is not even trained in psychiatry or even perhaps psychology is allowed to make such a diagnosis. Where does that permission come from?

  • 11:52:40

    DAVIDWell, let me be fair to the person, the degree in Texas is called the LSSP and the license emanates from the same board that licensed me as a fully doctoral level psychologist. But the problem is in schools, this licensed specialist in school psychology, this credential can be obtained with a masters degree only, and as I say, in fairness to them, they are trained in school psychology, but even school psychology is such a narrow focus that these kids are getting a broad-based education in psychopathology or even the problems of developmental issues, etcetera. And they're just making these diagnoses way too quickly and then they're being pressured to make them, as Dr. Frances alluded to, by the people wanting, unnecessarily the services.

  • 11:53:33

    DAVIDI agree with Dr. Frances. I'm thrilled when we can give services to children that are adequately and appropriately diagnosed, but it is an epidemic that my psychology friends and I talk about, that these 26, 27-year-olds are diagnosing. Look, I'm in one school district, one small school district in Texas. I'm one of five psychologists. I have five autism evaluations per week, referrals that is.

  • 11:53:59

    REHMWow. That's quite a story. And you're listening to "The Diane Rehm Show." Thanks for your call, David. And let's go to San Diego, Ca. Good morning, Jillian.

  • 11:54:15

    JILLIANGood morning, Diane. Thank you for having me.

  • 11:54:18

    REHMSure.

  • 11:54:18

    JILLIANI would like just to comment. I've been listening to the show for the last 40 minutes and I really just want to provide a viewpoint from a pediatric practitioner's perspective.

  • 11:54:30

    REHMSure.

  • 11:54:30

    JILLIANI’m a pediatric nurse practitioner and I work in primary care pediatrics. So I do see a lot of these children on a daily basis, mainly for well-child checks, lots of times with a lot of concerns as far as inattention, depression, behavioral problems. And I just wanted to say that as a practitioner, we definitely do not, you know, see a patient in our officer--at least personally I do not and I know most all of the providers that I work with that do prescribe for ADHD, really take this very seriously. They use a lot of different, I guess, resources. They take a lot of information. They see these children over multiple visits. And we do not, by any means, see a patient in our office, have a parent say, my child isn't paying attention, and hand out a pill.

  • 11:55:29

    JILLIANThat is just not how it works in our practice.

  • 11:55:33

    REHMWell, I'm--

  • 11:55:33

    JILLIANAnd I can't speak for other--

  • 11:55:34

    REHMSure.

  • 11:55:34

    JILLIAN--provides, if they do that, but--

  • 11:55:36

    REHMSure.

  • 11:55:36

    JILLIAN--I just want to make sure you give us our due course. We have--

  • 11:55:39

    REHMAbsolutely.

  • 11:55:40

    JILLIAN--definitely, you know, see these children a lot and just because a criteria is changing in a book, I'm not going to be more likely to diagnose this child. We definitely take a lot of time and a lot of care into when or if a child would need medication.

  • 11:55:57

    REHMI'm glad to hear that.

  • 11:55:59

    FRANCESAnd good for you. I just wish that the rest of the country were following that practice.

  • 11:56:03

    REHMAnd here's a tweet which says, "My Texas school district encourages an ADHD diagnosis before kids can receive services for dyslexia and learning abilities."

  • 11:56:24

    FRANCESThat's the problem.

  • 11:56:29

    REHMSo where are we going with this, Dr. Frances?

  • 11:56:31

    FRANCESI think lots of things should happen. This is a complex problem. It won't have a simple solution. I think we should be tightening up diagnosis, there should be big, black box warnings in DSM-5 for those diagnoses that are being loosely delivered. I think it's very important to tame the drug companies. It's like tobacco. If they can advertise, they will take advantage of that freedom. They don't have the freedom to advertise to consumers anywhere else except New Zealand. Stop them from advertising.

  • 11:57:02

    REHMAnd it's important for parents to ask questions.

  • 11:57:07

    FRANCESParents should never accept a diagnosis on faith.

  • 11:57:13

    REHMThe book is titled, "Saving Normal: An Insider's Revolt Against Out-Of-Control Diagnosis, DSM-5, Big Pharma And The Medicalization Of Ordinary Life." Dr. Allen Frances is the author. Thanks for being here.

  • 11:57:35

    FRANCESThank you.

  • 11:57:35

    REHMAnd thanks all for listening. I'm Diane Rehm.

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