Allen J. Frances is an American psychiatrist who has become famous for his critique of the DSM-5, the fifth edition of the Diagnostic and Statistical Manual Mental Disorders. He was also the former chair of the task force that published the DSM-IV, the fourth edition of the DSM. The DSM is published by the American Psychiatric Association (APA) and it is the authoritative text used in the US to diagnose psychiatric disorders and offers treatment recommendations. The DSM-5 was published very recently, on May 18th this year.
The publication of the DMS-IV resulted in something called diagnostic inflation, which is when behaviours which are normal become diagnosed as mental illness, leading to an over-diagnosis of mental illness. Diagnostic inflation is a result of loose, broad diagnostic criteria which makes it easy and quick to diagnose some behaviour as an indication of a mental disorder. Frances would later criticise the DMS-IV, saying that the criteria should have been tighter and more specific.
A consequence of the DSM-IV’s loose definition of any given mental illness was more and more people becoming ‘mentally ill’. There were dramatic increases in the number of children being diagnosed as having attention deficit disorder (ADD), autism and bipolar disorder. The industry that has, of course, benefited from this diagnostic inflation was the pharmaceutical industry (aka Big Pharma). Through a combination of over-diagnosis and drug company marketing, many children are now unnecessarily taking prescription drugs for an apparent ‘mental illness’. Big Pharma has no influence in the drafting of the DSM, but they eagerly wait until its publication in order to look for marketing opportunities.
In terms of the DSM-5, Frances has criticised not only the loose definitions of ADD, autism, addictions, personality disorders and bipolar disorder but has also been puzzled by the addition of new disorders. The addition of Social Anxiety Disorder (SAD) for example, is problematic because it is defined in such a way that it could be mistaken for shyness. That said, there are obvious, clear-cut cases where someone’s anxiety in social situations is so extreme and debilitating that it should rightly be classified as a disorder. However, as a result of the broad definitions in the DSM-5, individuals with different personality traits or eccentricities may seek medical treatment when it is not necessary. SAD has been included in the DSM since 1980, but at that time it was defined in a much more specific way.
Nowadays, Big Pharma has hijacked the irresponsibly broad definition of SAD, with companies such as SmithKline Beecham marketing its anti-depressant Paxil for social phobia since 1999. What we are seeing is the medicalisation of ordinary personality traits, such as shyness, which is very normal. In addition, certain levels of anxiety and nervousness can be normal and do not require the intervention of psychoactive drugs. The same seems to be true of ADD and ADHD (attention deficit hyperactive disorder). You have to ask yourself: is a child’s inability to concentrate in a classroom or during a task a sign of a mental disorder or a sign of a pressured environment which is antagonistic to their natural behaviour? Children are playful and energetic, simple as that, and I do not think that constitutes a malfunctioning in normal behaviour. In an interview, Frances said: “We’re turning being young into a mental disorder and that makes no sense at all.”
It seems that the changes in education and the rise in diagnostic inflation is the root cause of the rapid increases in cases of ADD and ADHD. A negative consequence of this over-diagnosis is that many children will come to believe that they have a defect, which can be very isolating and embarrassing. The stimulating drugs that these children are prescribed, such as Ritalin (which has a similar chemical structure to cocaine and has withdrawal symptoms, indicating physical addictiveness) can be very risky, especially for children.
Frances is worried that the DSM-V will turn everyday problems – anxiety, low mood, changes in mood, shyness, and so on – into mental disorders. When people are prescribed medication which they do not need – such as anti-depressants which affect the serotonin system in the brain – then the results can be harmful, not to mention a waste of money. One of the worst revisions in the DSM-5, Frances argues, has been the deletion of ‘bereavement’ as an exception to major depressive disorder. In the DSM-IV, cases of bereavement, where the symptoms match those of a major depressive disorder, were considered an exception, since bereavement is a natural human response to a distressing situation. In the DSM-5, however, this exception has been deleted, meaning that people who are bereaved can be diagnosed as having major depressive disorder. Other inappropriate consequences will be the diagnosis of forgetfulness at old age as a mild neurocognitive disorder, temper tantrums in kids as a disruptive mood dysregulation disorder, and worrying about cancer into somatic symptom disorder.
Frances says the DSM-5 needs to be more impartial and less influenced by ‘fads’ in psychiatry, personal biases, and other social and cultural factors. Frances’s most recent book, Saving Normal, details how Big Pharma is on a crusade to turn eccentricity into a mental illness. In it, he says:
Nature picks diversity; we pick standardization. We are homogenizing our crops and homogenizing our people. And Big Pharma seems intent on pursuing a parallel attempt to create its own brand of human monoculture.
He argues that this pervasive influence of Big Pharma is an impressive marketing tactic, but it is evil, nonetheless. Diversity and eccentricity should be valued, not medicalized and demonised. Some of the best geniuses in the world have been eccentrics.
Frances advises that “Drug companies should stop acting like drug cartels, irresponsibly pushing product where it will do more harm than good.” He goes on to argue that many psychiatrists, who follow the diagnostic categories in the DSM-5, are betraying the Hippocratic Oath. This ancient oath, which has guided medical practice for millennia, says that it is the duty of any doctor to do no harm. In a 2013 paper entitled The New Crisis of Confidence in Psychiatric Diagnosis, Frances writes, “psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests.”