Reading Saving Normal, Allen Frances's book about DSM-5 is fascinating because it is so rare for members of the psychiatric establishment to be quite so frank about the arguments and policies that led to the formulation of our current psychiatric diagnostic categories. For example, there has been a great deal of discussion of the process that led to the vote for the removal of homosexual tendencies from the DSM in 1973, but the psychiatrists talked about it in scientific terms saying little about the personal events that led to their decisions. It was only in the last decade that the fuller back story began to emerge about Robert Spitzer, such as in a New Yorker article The Dictionary of Disorder. But here we have Frances, who was chairman of the DSM-IV Task Force, talking about his experiences in creating the DSM-IV, his take on the work of Robert Spitzer being the controlling force behind DSM-III and DSM-III-R, and his analysis of the errors in those who have put together DSM-5. If he has pulled any punches, it is hard to guess where. He seems to be giving his considered but unedited opinion.
It is also surprising to have a prominent psychiatrist who was such a pillar of the psychiatric establishment be so forthright in his condemnation of the pharmaceutical industry and the widespread use of psychiatric medication. While Frances defends the judicious use of medication for serious mental illness, he argues that the bulk of the pharmacological treatment of the worried well is unhelpful and inappropriate. He further argues that there needs to be a massive overhaul of prescription practices of potentially addictive medications, which would solve what is now the biggest substance abuse problem that the USA faces. His suspicion of Big Pharma was always there, but he explains how his opinion of them got worse as he saw them promote profits over patient welfare for decades; he writes at one point "The pharmaceutical industry will do its best to mislead you.". Often, his views are surprisingly close to the most trenchant critics of psychiatry.
Frances explains that although he attempted to be very careful in putting together DSM-IV and keep it guided by scientific principles, the changes that went through allowed three main errors in the diagnostic criteria, allowing explosions in the diagnosis of autism, attention deficit, and childhood bipolar disorder. He is very clear that these are not real rises of mental illness, but are cases of normal young people being treated as if they have a mental disorder. While many parents have mixed feelings about their children receiving these diagnoses, some welcome them because their children then qualify for special education, and presumably the parents are under subtle or not-so-subtle pressure to authorize medication for their children's difficult behavior.
Both in his Saving Normal blog and in this book, Frances has been highly critical of many proposals for DSM-5. He argues that the team that put the manual together has less experience in the dangers than he did when he was put in charge of DSM-IV, and that their inexperience shows in poorly formulated diagnostic criteria which will very likely open the floodgates to new categories of "so called" mental illness. He devotes 3 chapters to psychiatric fads of the past, present and future, putting his criticism in historical context.
Yet although his approach is comprehensive, it is not scholarly. His surveys of science, history, sociology, and philosophy are brief and eclectic. Sometimes they are entertaining, and at other times they seem so idiosyncratic as to be easily dismissible. For example, in Part I of the book, Frances provides 3 chapters on the notion of what counts as normal, and he covers the problems of some of the standard approaches, such as using statistics and lab-tests. But he says with a few pages that philosophy, sociology and anthropology have no answers to the question. He mentions a few figures and ideas, but he completely ignores all the current literature on the nature of normality in these fields. His conclusion is that no definition of normality is useful for psychiatry. His final position is therefore hard to define, but it seems to be that mental disorders are real, treatment should aim to help patients, and diagnostic categories should facilitate treatment. He does say that normal is a fuzzy concept, so there is no clear division between normal and abnormal. He looks to the history of psychiatry as a guide to avoiding the mistakes that have been made previously. So his position seems to be that the overdiagnosis of autism, for example, is a scientific mistake, making factually incorrect assumptions about what counts as autism. But when we ask how do we know what the limits of normality should be?, his answer seems to be that we should let experience and history be our guide. That isn't enough to justify the view that it is factual or scientific rather than a fundamentally normative issue. On the other hand, his idea that is helpful to look to the past and see the abuses of over-treating people or mislabeling them as being ill as a way of controlling them is certainly plausible -- we would want those formulating the DSM to be very much aware of that history.
Theoretical and methodological questions run all through the book, underlying Frances's central claims about the difficulties of ordinary life and our emotional reaction to them being normal. At the same time, there is indication that the issues are practical and empirical: people are resilient and recover on their own from life's difficulties, and treating them with medication introduces risks and interferes with the process of learning life's skills. Frances does not produce much in the way of scientific evidence for this, but he seems to assume it is an empirical question. He is not against the use of psychotherapy as a way to get through difficult times, but psychiatrists do not need to be involved in that treatment.
Much of the rest of Saving Normal is devoted to setting out what counts as good psychiatric diagnosis and treatment, and what problems occur when it is done badly. Only a few chapters are directly about the problems with DSM-5, and readers can find those criticisms on Frances's Saving Normal blog and his other published writings in the last few years.
Are his fears that we will move to an age of massive diagnosis and overtreatment of psychiatric disorders well justified? Is his suspicion of the pharmaceutical companies reasonable? Will DSM-5 be the disaster that Frances predicts? Are practicing psychiatrists trained so badly or so under the influence of Big Pharma that they will over medicate their patients even more than they do now? Lay readers are as always placed in a difficult position when seeing disputes between different experts. Before writing off DSM-5, it would be good to see what those who have actually put together the manual have to say for themselves. Frances has certainly made a strong case and has given readers enough reason to be very careful when seeking psychiatric help.
© 2013 Christian Perring
Christian Perring, Professor of Philosophy, Dowling College, New York