Category: Health and Wellness
It's not too late to save 'normal'
Psychiatry's latest DSM goes too far in creating new mental disorders.
By Allen Frances
March 1, 2010
As chairman of the task force that created the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994, I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences.
Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics" -- attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many "patients" who might have be en far better off never entering the mental health system.
The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
The manual, prepared by the American Psychiatric Assn., is psychiatry's only official way of deciding who has a "mental disorder" and who is "normal." The quotes are necessary because this distinction is very hard to make at the fuzzy boundary between the two. If requirements for diagnosing a mental disorder are too stringent, some w ho need help will be left out; but if they are too loose, normal people will receive unnecessary, expensive and sometimes quite harmful treatment.
Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status -- to say nothing of stigma and the individual's sense of personal control and responsibility.
What are some of the most egregious invasions of normality suggested for DSM-V? "Binge eating disorder" is defined as one eating binge per week for three months. (Full disclosure: I, along with more than 6% of the population, would qualify.) "Minor neurocognitive disorder" would capture many people with no more than the expected memory problems of aging. Grieving after the loss of a loved one could frequently be misread as "major depression." "Mixed anxiety depression" is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.
T he recklessly expansive suggestions go on and on. "Attention deficit disorder" would become much more prevalent in adults, encouraging the already rampant use of stimulants for performance enhancement. The "psychosis risk syndrome" would use the presence of strange thinking to predict who would later have a full-blown psychotic episode. But the prediction would be wrong at least three or four times for every time it is correct -- and many misidentified teenagers would receive medications that can cause enormous weight gain, diabetes and shortened life expectancy.
A new category for temper problems could wind up capturing kids with normal tantrums. "Autistic spectrum disorder" probably would expand to encompass every eccentricity. Binge drinkers would be labeled addicts and "behavioral addiction" would be recognized. (If we have "pathological gambling," can addiction to the Internet be far behind?)
The sexual disorders section is particularly adventurous. "Hyper sexuality disorder" would bring great comfort to philanderers wishing to hide the motivation for their exploits behind a psychiatric excuse. "Paraphilic coercive disorder" introduces the novel and dangerous idea that rapists merit a diagnosis of mental disorder if they get special sexual excitement from raping.
Defining the elusive line between mental disorder and normality is not simply a scientific question that can be left in the hands of the experts. The scientific literature is usually limited, never easy to generalize to the real world and always subject to differing interpretations.
Experts have an almost universal tendency to expand their own favorite disorders: Not, as alleged, because of conflicts of interest -- for example, to help drug companies, create new customers or increase research funding -- but rather from a genuine desire to avoid missing suitable patients who might benefit. Unfortunately, this therapeutic zeal creates an enormous blind spo t to the great risks that come with overdiagnosis and unnecessary treatment.
This is a societal issue that transcends psychiatry. It is not too late to save normality from DSM-V if the greater public interest is factored into the necessary risk/benefit analyses.
Allen Frances is professor emeritus and former chairman of the department of psychiatry at Duke University.
I totally agree that many people are diagnosed with disorders or syndromes when in fact, they just have a much smaller problem that should be dealt with on its own. I really think that scientists make up a lot of these disorders just to have something to blame for and justify strange behavior.
Wow, thanks for posting this. It was quite interesting and useful, especially for someone like me who eventually wishes to go into the mental health profession. It is also extremely accurate. It does not seem to downplay legitimate mental disorders, but does address some very serious and, I think, real problems with the mental health system. The only thing it does downplay is that I do think that often times these, "experts," are actually in league with the pharmaseutical companies. I would even go so far as to say there are some so-called experts who ultimately would not want these mental disorders cured. Think of the revenue that treatment for mental disorders brings in that would be lost if some of these were cured, even controlled well. Mind, I think experts like that in the minority, and usually the author of the articlwe is right, this overzealousness is out of a genuine desire to help people. But I think the other kind are out there.
this is why I don't trust most people in this field, nor the field itself. Everyone wants either to pump people full of drugs without truly seeing what's wrong with them, to profit off the mentally ill in some way aor to honestly help them but it so confused that they make mistakes and wind up hurting people. I have a funny feling that we're all gonna be branded as one thing or another sooner or later and that insurance companies, employers, friends, family and everyone in between will use this to further divide society in a negative way. Good going!
I do think there is a place for the mental health system, but it has to ride a very fine line. I'm not ashamed to admit that I have gone to counseling for various things before, and it has helped me greatly. It's not been an easy process, but I'd have been in a lot bigger trouble without it.
Anyone will make mistakes and sometimes hurt people. We're all humans and not perfect. The mental health system, any profession at all, is therefore not perfect. So yes, even the best of counselors will make mistakes sometimes, but that is only natural, and they gain experience by learning from them. I know the mental health system clearly has problems, but I also wouldn't throw the baby out with the bathwater, so to speak.
Going to counseling and even seeking some therapy doesn't necessarily mean you have a mental illness. It just means that you're having a little trouble with something that you would like to seek expert advice on. Having had indirect experience in the matter with a few of my family members, I am very bothered by the fact that some people seem to believe that drugs are the solution to every problem. Are we helping the problem by doing this? Or are we just making it worse?
thanks for posting such a great article. for the most part, i totally agree with the author.
for the record, normal is a setting on a drier. reality is a variable.
if we study anthropology or watch shows like taboo on the nat geo channel, we learn that different cultures hav a myriad of the standards that qualify as normal behavior.
I wonder if it Has ever occured to these professionals that many of the true creative and inventive geniuses were wa-a-a-ay out on the cutting edge or fringe? Diversity in abilities and experiences is what makes societies function. conforming us all to "normal" whatever that is, will stifle progress and adventure.
As it has said, I too believe there is a menage a trois beetween psychiatrists, medical docs, and the big pharmaceutical manufacturers. Reinforcing the typical american philosophy of "get a result without working for it" by prescribing a pill for every problem is becoming more prevalent. Watching these commercials about what is depression makes it seem as though everyone should be on something.
All that aside, I am a part of a family with inherited depression. my dad, my brother, some of my children, and I are so blessed. I could sit and talk to a helping professional until the cows come home. I'd have some sort of problem because my brain is missing a chemical. In my case and many others, I thanks the lord that we have a better life through chemistry.
Yes, drugs have improved significantly over the past century, but are their no alternative options for this?
for many mental health issues i think that drugs may be the best choice. schizzophrenia, spelling, is one example. ditto many forms of depression.
I'm sure these drugs are affective, but I'm also pretty sure that chemicals that can alter your emotions are probably not very good for the body/brain.
I personally believe that treatment where mental illness is concerned should be a combination of both meds and counseling. Meds will help the chemical part, and will help you at least get through your day a little easier. But counseling helps get to the root of the problem, the issues in one's life that have often caused trouble. It helps one identify triggers, develop effective coping skills, etc. Too often our society only pays attention to the drugs, and overlooks the therapy portion of treatment.
sister dawn,
i totally agree. for many people, mental health treatment should be a double pronged fork. the drugs give us the space to figure out and reconsider our lives.
as for the not taking drugs, lest we forget, that before their advent, mental health facilities were scary places indeed. people used to do such things as scream incessantly for hours, rip out their tongues, do bodily harm to themselves, and hurt staff as well ss other patients. The straight jacket, thought is seems cruel, was often a survival mechanism as was sheetting people and putting them in cold baths to calm down. that's where the term bedlam came from. True, in many cases, the drug industry has gone too far in the other direction.. many people can live marginally functional lives because of pharmaceuticals.
I agree that in severe cases, drugs probably should come into play, but my sister, for example, complained that she had a bit too much energy to focus all the time in school, and was automatically diagnosed with ADHD. Now, isn't that a bit extreme? Shouldn't these professionals first consider other reasons for this problem before diagnosing this disorder and prescribing meds for it?
Agreed completely with the last post. It's one thing if the person is going to cause bodily harm to themselves or others. Then I would support some kind of medical treatment, whether synthetic or otherwise. But if it's just a matter that can be worked out with counseling I think that should be tried first.
This article brought to mind something i read about several years ago. It's called Teen Screen, and it's a test that they were trying to make a requirement for all high school students to take which rated their mental health. The supporters went to great lengths to make sure every student in the schools that approved it would take it, including using a law (I forget the name off the top of my head) that bypassed parental consent. If the parents did not sign a form stating their child could take this mental health screening, it was automatically assumed that they were allowed to. Columbia University developed the test if memory serves me correctly.
Now when I read about it I thought it was bad, but then it hit close to home last September when I learned that the school I previously attended was going to start using it. I was not gonna just sit back and let my boyfriend take this horrible test, when it's proven to have anywhere from a 75-85% failure rate. Failure in this case means misdiagnosis, leading to unnecessary drugging, the burden of stigma, and a devastating emotional effect that could probably cause depression in itself. It was tough, because my boyfriend saw no harm in it and was confident he would "pass" (though the concept of passing or failing a mental health screening is just horrible to me, but the stakes are really that high in that case), and he said he "knew all the right answers." Yeah, tell that to the majority of mentally healthy kids who were unnecessarily hospitalized and misdiagnosed! Needless to say I did finally convince him to not go near that thing with a ten foot pole! If you want to read more about this problem, go to
http://www.teenscreentruth.com/
Take a look around, it's quite interesting, and this latest DSM seems to be just more of that.
Are you serious? that's horrible. Honestly, so many school officials are making kids believe that their future is determined by the results of a test. It's sick, in my opinion.
Yeah, and he brought me a copy of the god-awful thing so I could take a look at it. Basically it had all these questions like, "do you despise yourself?" and "how do you feel about your family?" It had a rating system, some of the questions were on a scale from 1-10, and some were like sometimes, most of the time etc. And then, the same question would be asked a couple pages later but with slightly different wording to try and throw you off. Yeah, it was horrible.
the whole issue of mental health in schools is an interesting one. Did you know that the states of Maryland and Northern virginia have the highest rates of ADHD, ADD, and autism in the nation? Behavioral health professionals and social Scientists have studied this. "what," they asked, "is different about this part of the country?" Well, dear gentle and soohn to be outraged readers, it was determined that these areas are closer to the tits of nanny government. Therefore they were most aware of how to get the money forhaving kids with mental problems in their schools. did you know that every time a child with one of the big three as is diagnosed and reported the schools get a certain amount from the feds?
Emotional l testing in schools is very scary. AS we know, with the right hand and the wrong motives, statistics can say whatever we want. Hope I don't sound like a synical paranoid whacko.
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If it weren't for a good pediatrician, my daughter would have been consigned to the add train. After testing her in his office, he wrote on her school report "this child needs a better teacher. she has no problem."
You guys are getting right back to the points the article is rightly making. ADHD is diagnosed far too often, as are many other mental illnesses. It's even more worrisome that is happening in children so young.