We thank Psychiatric Times and Dr. Allen Frances for making the DSM-V's development an interesting debate to follow. However, we believe that Dr. Frances' invitation to the research community should also be extended to frontline clinicians like us, and we worry about the implicit infallibility assigned to the medical research community.
In our view, the imminent perpetuation of several diagnostic artifacts included in DSM-IV-TR not only poses risks to the health and well-being of our patients, but also raises questions regarding the reliability of several diagnoses. As has been noted,1,2,3, the psychoanalytic orientation of psychiatry at the time DSM-III and DSM-IV were created generated pseudo-diagnoses that are now used by the HMOs to deny inpatient treatment. These pseudo-diagnoses also contaminate data in expensive studies, such as the Multimodal Treatment Study of Children with ADHD (MTA)4. Specifically: Oppositional-Defiant Disorder (ODD), Conduct Disorder (CD), Disruptive Disorder NOS, Borderline Personality Disorder (BPD), and Intermittent Explosive Disorder (IED) are labels that emerged as "solutions" to explain syndromes clinicians were observing in the 1970s and 80s. We believe that, in fact, psychiatrists were encountering social anxiety, obsessions, bipolar spectrum disorders, psychosis, PTSD, phobias, and even complications of sexual abuse in children--but were discouraged by the prevailing orthodoxy from identifying these conditions by their real names.
Today, children with defiant and aggressive behavior due to pathologically elevated mood are called "ODD with comorbid ADHD," because they are restless and inattentive. We believe these symptoms are usually due to agitated manic states. Moreover, when these so-called "ADHD symptoms" are treated with amphetamines, the patient's condition typically worsens and may eventuate in assaultive behavior-at which point, the patient "graduates" to the additional diagnosis of Conduct Disorder! Worse still, the patient is then labeled "unruly" or "incorrigible" when he "refuses to change his behavior despite adequate treatment." In our collective experience, many such patients end up in Residential Treatment Centers and Juvenile Detention Centers. Sadly, we have found an abundance of such "violent kids" who are still prescribed stimulant medications while incarcerated.
We also applaud Dr. Frances for addressing the "false epidemics of autism and attention-deficit-disorder," because we rarely see "heavy weight champions" joining the ranks of Hagop Akiskal,5 Charles Huffine, Andy Pumariega and a few others, who have directly defied some of the DSM's diagnostic guidelines.
We acknowledge that we lack randomized, controlled double-blind studies to confirm our observations-but we have many years of "eye-opening" experience that should not be ignored or considered irrelevant. Collectively, we manage the treatments of thousands of people whose lives have been transformed for the best by the diagnostic approach we advocate: avoiding the use of DSM labels like ODD, CD, BPD, and all the other "disorders" that are already explained by well-established diagnoses, for which we have effective treatments.
Daniel Pistone, M.D.
Manuel Mota-Castillo, M.D.
Roberto Chaveve M.D.
Mota-Castillo, M., It is Really ODD?; Psychiatric Times Vol. 21, No. 3, 2004
Huffine, C., M.D. "Should the Conduct Disorder diagnosis be struck from the DSM-V?" Clinical Psychiatric News, Volume 28(4), 2000.
Atkins, D.L., Pumariega, A.J., Montgomery, L., Rogers, K., Nybro, C., Jeffers, G., Sease, F. Mental Health and Incarcerated Youth: Prevalence and Nature of Psychopathology. Journal of Child and Family Studies. 8(2): 193-204, 1999.
Akiskal, H., Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psych Scand. Psych.; 110: 401-407, 2004
Jensen, P., M.D., Findings from the NIMH Multimodal Treatment of ADHD (MTA): Implications and Applications for Primary Care Providers; J. of Dev. & Behav. Ped., Vol 22, No. 1, 2001.