Avoiding Misdiagnosis of DSM Disorders

By John T. Tennison, MDCopyright February 12, 2015


For someone to be correctly diagnosed with a “mental disorder” by DSM standards, THREE sets of characteristics must be present.  One of the most common causes of misdiagnosis is when an untrained or poorly-trained person attempts to use only the disorder-specific criteria, which are only 1 set of characteristics that must be considered to assure that a “mental disorder” has been correctly diagnosed according to DSMstandards.

The THREE sets of characteristics which must be present to assure correct diagnosis are:

1. The DSM “Definition of a Mental Disorder (page 20 of DSM-V, [This is the same definition that was used in prior editions of the DSM]):

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.  Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.  An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.  Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

2. Chapter/Section-Specific Criteria
3. Disorder-Specific Criteria

For example, a common error made with regard to diagnosing Pedophilic Disorder is to apply criterion A of the Disorder-Specific criteria for Pedophilic Disorder in a literal fashion.

When taken out of context of the whole DSM-V, criterion A of Pedophilic Disorder gives the impression that behavior alone can qualify for satisfying criterion A.  Indeed, because of the poor wording of Criterion A for Pedophilic Disorder, a reasonable person who is nonetheless untrained in the application of the whole DSMcould conclude that behavior alone was intended to be sufficient to satisfy Criterion A of Pedophilic Disorder.  However, the general definition for “Mental Disorder” on page 20 of the DSM-V makes it perfectly clear that behaviors caused by mental disorders MUST reflect “a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.”

In contrast, it is not difficult to imagine scenarios whereby sexual activity with a child or rape more generally are not caused by “a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.”

          For example, a contract-terrorist at a time of war or in the context of rivaling drug cartels might very well sexually terrorize the wife and children of an enemy or competitor.  Such terrorization is not a “mental disorder,” but instead is a criminal enterprise with the intent of winning a war or demotivating competitors, and is not necessarily reflective of the terrorist being sexually attracted to children or women or men or whoever is being sexually assaulted for terroristic purposes.

Moreover, even when sexual assault of a child is caused by a mental disorder, it is not necessarily caused by “Pedophilic Disorder.”  The DSM-V makes this perfectly clear by including a section titled “Differential Diagnosis” within the section on Pedophilic disorders.  Other specific disorders listed which, besides Pedophilic disorder, can also be associated with sexual activity/assault of children include Antisocial Personality Disorders, Substance Use Disorders, and Obsessive-Compulsive disorders.

Despite Dr. Allen Francis and Dr. Michael First having repeatedly made these points, and despite the DSM-V carrying over the same language and criteria in the DSM-IV as used for Pedophilia, misdiagnosis is still rampant, not only from untrained individuals, but even by reputable psychiatrists and psychologists who should know better.

          One highly-prominent example of the point being made that behavior alone was never intended to be the basis for diagnosing Pedophilic Disorder (previously known as Pedophilia in the DSM-IV) occurred in an editorial in the American Journal of Psychiatry in October of 2008

Here are some excerpts from that editorial:

American Journal of Psychiatry 165:20, October 2008

“Issues for DSM-V:  Unintended Consequences of Small Changes:  The Case of Paraphilias”

Editorial by Michael B. First, M.D., and Allen Frances, MD

[Michael First was the “Editor, Text and Criteria” of the “Task Force on DSM-IV”; and was “Co-Chairperson” of the “Work Groups for the DSM-IV Text Revision.”]

[Allen Frances was “Chairperson” of the “Task Force on DSM-IV”; and was “Co-Chairperson and Editor” of the “Work Groups for the DSM-IV Text Revision.”]

Taken together, Dr. First and Dr. Frances are the two most authoritative individuals with regard to the intent of wording used or adopted in the DSM-IV or DSM-IV-TR.  During their tenure over the creation of the DSM-IV and DSM-IV-TR, the phrase “or behaviors” was added to Criterion-A of the Paraphilias.  Dr. First and Dr. Francis consider this addition to have been a “mistake” with “unintended consequences.”  Because of misunderstandings and misdiagnosis that have occurred, Dr. First and Dr. Frances strongly recommended in 2008 that the phrase “or behaviors” be removed from “the DSM-V (if not sooner).”  Regretfully, that did not happen.

Nonetheless the intentions of Dr. First and Dr. Frances are still evident in the general “Definition of a Mental Disorder” in DSM-V and in the Differential Diagnosis sub-section in the section on Pedophilic Disorders.

A diagnostician well-trained in the practice of correctly using the DSM will be aware of the nuanced issues raised by Dr. First and Dr. Frances.  Unfortunately, far too many evaluators, including psychologists and even psychiatrists make diagnoses based on the literal wording of ONLY disorder-specific criteria taken out the context of the overall DSM; and out of the context of knowledge of the clarifications made by such experts as Dr. Frist and Dr. Frances.

In their editorial, Dr. First and Dr. Frances wrote:

“Although DSM-IV-TR includes many close judgment calls, it contains only one outright mistake:  in criterion A of the paraphilia section.  The unintended consequences following what we thought was a small wording change provide a cautionary tale for DSM-V.”

“….criterion A was amended (by adding “behavior” along with “fantasies” and “urges”) to emphasize that it is behavior that most typically brings individuals to clinical attention.”

“The minor adjustment in criterion A” caused “serious problems.”

           “The addition of “or behaviors” [starting with DSM-IV and continued with DSM-IV-TR] led some forensic evaluators to conclude that sexual offenders might qualify as having a mental disorder based only on their having committed sexual offenses (e.g. rape).  In many states with sexually violent predator statutes, the diagnosis of mental disorder is necessary to trigger indefinite civil psychiatric commitment for sexually violent offenders after their prison terms are completed.”

“The revised criterion A wording has sometimes been used to justify making a paraphilia diagnosis based solely on a history of repeated acts of sexual violence, which is then argued as satisfying the statutory mandate for the presence of a ‘mental abnormality’.  This certainly was never our intent in DSM-IV.  Defining paraphilia [or “paraphilic disorders” as they are now called] based on acts alone blurs the distinction between mental disorder and ordinary criminality.”

“We regret the confusion caused and have two recommendations:  1) although the contentious issue of sexually violent predator commitment cannot be resolved by a simple DSM wording change, we feel it is important to set the record straight and restore criterion A to its DSM-III-R wording (i.e., remove the phrase “or behaviors”) in DSM-V (if not sooner); 2) tinkering with criteria wording should be done only with great care and when the advantages clearly outweighthe risks, both because of the potentially unforeseen consequences of rewording criteria and because of the disruptive nature of all changes.”

If recommendation #1 is followed, then the following Criterion-A wording [as used in the DSM-IV, DSM-IV-TR, and DSM-V]

“A.  Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child (generally age 13 years or younger).”

would become [as used in the DSM-III-R]:

“A.  Over a period of at least 6 months, recurrent intense urges and sexually arousing fantasies involving sexual activity with a prepubescent child or children (generally age 13 years or younger).

[Note:  “Prepubescent” should be also well defined for correct diagnosis.  For example someone who commits “rape” by statutory definition is not necessarily a “pedophile” or someone who has “Pedophilic disorder.”]

Another article that makes the point that sexual behaviors involving children or minors are not necessarily indicative of Pedophilic Disorder was by Allen Francis, M.D. in the Psychiatric Times, July 8, 2011.  In this article, titled “Going For Wins in Sexually Violent Predator Cases,” Dr. Francis summarizes his findings of having reviewed “close to 100 reports prepared by state evaluators (all psychologists).”

Dr. Francis writes, “This is, of course, a very small sample, but the results are unanimous enough to draw some interesting and very troubling early inferences.”

Dr. Francis notes three types of mistakes that occurred frequently in reports he had reviewed:

          “The most common error was to assume that a behavior alone (the act of rape) can by itself somehow qualify someone for a mental disorder diagnosis of Paraphilia.” [now known as “Paraphilic Disorders” in the DSM-V]


“There was little (and always unconvincing) attempts to establish grounds for paraphilia beyond the fact that the sex crime had been committed.”


          “The second most common mistake was to declare idiosyncratically that sex with a post-pubescent teenager indicates paraphilia.  Statutory rape is a crime.  It is not included anywhere in DSM-IV as mental disorder and should not be considered grounds for diagnosing one.” [DSM-V also rejected rape as a mental disorder.]


          “The third mistake was to assume that any act of sex with a child represents pedophilia – even in cases where it is clearly no more than an opportunistic or disinhibited exploitation that is not at all representative of the individual’s preferred or obligatory pattern of typical sexual arousal.”

Although DSM-V does not make the point as explicitly as it could, by including a section on “Differential Diagnosis” in its Pedophilic Disorder section, DSM-V recognizes that not all acts of sex with a child are caused by Pedophilic Disorder.

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