American Psychiatric Association’s Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains descriptive criteria for classifying 297 disorders.[1] While this exhaustive publication of disease classification makes the diagnostic process seem relatively straightforward, disease definition has historically been complicated by social and economic interests. Jackie Leach Scully, a bioethicist at Newcastle University, explains this phenomenon with the example of homosexuality and its changing societal conceptions in the realm of disease. Originally thought to be the result of a hormonal imbalance, “its pathological identity changed as it was re‐categorized as an organic mental disorder treatable by electroshock and sometimes neurosurgery.”[2] Emphasizing the importance of the DSM, Leach Scully points out that it was not until the DSM-IV removed homosexuality in 1952 that it was formally de-pathologized.[3] Disease classification contributes to social stigma and therein holds ethical weight on a societal level. In addition to social factors, economic interests influence disease definition and diagnostic criteria. Leach Scully highlights the case of female sexual dysfunction as an example of economic forces coming together to create a medical condition, explaining that the incredible success of Viagra led drug companies to “identify an equivalent market (that is, condition) in women.” In this way, commercial interests can influence the medical and public health fields to define new diseases.

Recently, the American Psychological Association has loosened the criteria that qualify an individual for an attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) diagnosis. Psychology Today explains this loosening appeared in the DSM-5 in two ways: “1) reducing the number of symptoms required for adults from 6 to 3; and 2) relaxing the requirement that the onset of symptoms must have occurred before age 7 (by allowing the onset to be up to age 12).”[4] Corporate interests remain entangled in this process of disease diagnosis, as The New York Times explains that the American Psychiatric Association “receives significant financing from drug companies.”[5] The lowered thresholds for ADD/ADHD criteria creates ethical concerns with regard to increased potential for misdiagnosis, which results in serious physical and financial consequences of unnecessary prescription and also inhibits the judicious and equitable distribution of healthcare.

Relaxed criteria for ADHD diagnosis could logically lead to an increase in ADHD rates, though it is important to note that this increase could just as likely be driven by misdiagnoses as by increased detection.

Relaxed criteria for ADHD diagnosis could logically lead to an increase in ADHD rates, though it is important to note that this increase could just as likely be driven by misdiagnoses as by increased detection. Psychology Today details the inherent tradeoff between selectivity and specificity of the criteria, concluding, “The lowered thresholds would misidentify adults with fairly mild attention problems as having ADD. Often, they will be given stimulant treatment that can have harmful side effects and complications.”[6] In the short-term, diagnosed persons may experience decreased appetite and sleep disturbances as a consequence of unneeded stimulants.[7] The burden of these side effects negatively affect the quality of life for any person taking the medication, but subjecting patients to these strains on daily life is only justifiable if they relieve a proportionally greater burden of illness–the alleviation of mild attention difficulties may not necessarily outweigh the side-effects of medication. Long-term side effects have yet to be fully researched. Uncertainty concerning the risks of medicating healthy people heightens the ethical irresponsibility inherent in relaxing a disease’s diagnostic criteria.

In addition to personal tolls on health and quality of life, overdiagnosis imposes financial and social burden on a societal level. The pharmaceutical costs of inappropriately diagnosed ADHD amount to $320m-$500m in the US.[8] Beyond healthcare costs, overdiagnosis can influence the social dynamics surrounding the disease on a broader scale. Dr. Rae Thomas of the Centre for Research in Evidence-Based Practice and her colleagues note that mental health diagnoses carry with them social stigma that can serve to disadvantage children because “teachers and parents have low academic expectations of them potentially creating a self-fulfilling prophecy.”[9] Therefore, a misdiagnosis can bring lifelong consequences in the form of worse academic performance and the resultant impacts on career outlook due to the weight of social stigma. For children actually suffering from the disorder, Dr. Thomas continues, “Reducing the threshold for diagnosing ADHD devalues the diagnosis in those with serious problems.”[10] On the societal level, therefore, misdiagnosis resulting from loosened criteria negatively impact both children affected and those unaffected by ADHD.

Finally, lowered diagnostic thresholds hinder the judicious and equitable distribution of healthcare. Jackie Leach Scully elaborates, “If we want to ensure that limited healthcare resources are appropriately distributed, for example, we must have a reasonably clear idea, first what a disease is.”[11] As a matter of course, if people with mild attention difficulties are improperly diagnosed and treated for ADD and ADHt, they unnecessarily drain some of the supply of not only medication but also of appointment time and specialist attention. The misallocation of necessary health resources from people with the greatest need violates principles of justice and logic.

The World Health Organization (WHO) has provided a detailed analysis and procedural account of what make for ethical disease diagnosis and criteria development.[12] Criteria should be deliberately restrictive with a high degree of precision and supported by research and testing, according to the model. WHO also suggests an exclusion clause, which would further protect against misdiagnosis by identifying symptoms that should exclude a patient from a particular diagnosis.

Psychiatrists and physicians should remain conscious of the prudent guidelines put forward by WHO because the ethical burden attached to their practices is highly significant.

Psychiatrists and physicians should remain conscious of the prudent guidelines put forward by WHO because the ethical burden attached to their practices is highly significant. Misdiagnosis resulting from a lack of deliberately restrictive criteria and exclusion clauses can contribute to adverse health effects in addition to undue financial burden. Furthermore, the social stigma of diagnosis may manifest in differentiated treatment by teachers and parents that hinders a student’s academic potential via a self-fulfilling prophecy. Potentially of most importance, however, is the issue of distributive justice. Medical treatment and advice is, in a majority of contexts, a zero sum game: every healthy person that receives treatment as a result of misdiagnosis necessarily takes away from the resources and time that could be used to serve those with the greatest need. From a utilitarian point of view, then, loose criteria inhibit medical communities from doing the most amount of good by relieving suffering where it actually exists.

[1] Rosenberg, Robin S. “Abnormal Is the New Normal.” Slate, April 12, 2013. Accessed October 31, 2016.

[2] Leach Scully, Jackie. “What Is a Disease?” EMBO Reports 5, no. 7 (July 1, 2004): 650-53.

[3] Ibid.

[4] Frances, Allen J., MD. “DSM5 Plans To Loosen Criteria For Adult ADD.” Psychology Today. April 20, 2010. Accessed October 31, 2016. https://www.psychologytoday.com/blog/dsm5-in-distress/201004/dsm5-plans-loosen-criteria-adult-add.

[5] Schwarz, Alan. “The Selling of Attention Deficit Disorder,” New York Times, December 14, 2013.

[6] Frances, Allen J., MD., 2.

[7] Batstra, Laura, and Allen Frances. “DSM-5 Further Inflates Attention Deficit Hyperactivity Disorder.” The Journal of Nervous and Mental Disease 200, no. 6 (June 2012): 486-88. doi:10.1097/nmd.0b013e318257c4b6.

[8] Thomas, R., G. K. Mitchell, and L. Batstra. “Attention-deficit/hyperactivity Disorder: Are We Helping or Harming?” Bmj 347 (November 05, 2013). doi:10.1136/bmj.f6172.

[9] Ibid.

[10]Thomas, R., G. K. Mitchell, and L. Batstra. (2013)

[11] Leach Scully, Jackie. (2004)

[12] The ICD-10 Classification of Mental and Behavioural Disorders : Diagnostic Criteria for Research. Report. World Health Organization. Geneva: World Health Organization, 1993.