Allen Frances

Author Allen Frances was chair of the task force who updated the APA's diagnostic and statistical manual for mental disorders (DSM) to its fourth edition in 1994. This book is largely his polemic against the diagnostic inflation that resulted since its release. Frances cautions about the lack of specificity with many diagnoses today. As the title suggests, fewer and fewer people are considered normal anymore and this poses a major problem. The eccentric, different, and unique can now be diagnosed from an ever-expanding list of new psychiatric disorders. The road back to saving psychiatry will be a long one he says, but is achievable.… (plus d'informations)

If this book doesn't leave you feeling conflicted, perhaps you've been hanging around with the wrong sort of people.

Unlike a lot of the reviewers of this book, I didn't get it as a LibraryThing review copy. I bought it myself, because I'm involved in some of the controversy in psychiatry, and I wanted to see what Dr. Frances had to say. And certainly there is much that is good and valuable here. That the pharmaceutical industry is out to feather its own nest is obvious, and that they manipulate the research process seems pretty clear. That the creation of the DSM-5 was too secret is clear -- the result of that secret process was that one major section (personality disorders) was voted down after its completion; the DSM-5 still uses the DSM-IV-TR criteria for personality disorders. That there are some bogus, or at least unhelpful, diagnoses in DSM-5 is also pretty clear -- do we really need four different diagnoses for alcohol problems (Alcohol Use Disorder, Alcohol Intoxication, Alcohol Withdrawal, and Unspecified Alcohol-Related Disorder, plus a whole raft of diagnoses where alcohol makes something else worse), and similarly for cannabis, caffeine, phencyclidine, opioids, and more? Couldn't we just have "Drug intoxication," etc., and specify the drug? We'd even be ready, in that case, when new drugs come along.

And yet... Dr. Frances specifies three diagnoses he particularly regrets, as they have caused "epidemics": Autism, ADHD, and Bipolar II.

I will grant that the hypomania of Bipolar II does not need treatment in itself -- indeed, it often results in brilliant work, and it's sad to have to control it. On the other hand, if there is no Bipolar II diagnosis, then a person who suffers only hypomania and depression isn't left with any possible diagnosis except major depressive order -- and will get put on an antidepressant, and there is strong albeit anecdotal evidence that antidepressants turn hypomania into full-blown mania. So there needs to be some way to say that these people can't just be treated as ordinary depressives.

As for ADHD -- well, I know someone who has it, and she really does need her Adderall to function properly. She's been on it for a decade, and she hasn't increased her dose, and she's dangerous without it. It's not as if she wants the stuff -- she tells me it's great to not have to take it. But she can't get any work done, and has lousy impulse control. Are there people getting drugs who don't really have ADHD? Maybe. But for the ones who need it, Dr. Frances, they need it.

And then there is Autism. This is the one I know best. This one doesn't really fit Dr. Frances's model, because autism hasn't really been over-pharmaceuticalized. (Oh, there are a couple of companies pushing drugs -- Risperidone and Aripiprazole, AKA Risperdal and Abilify -- for autism, and this is truly immoral because those drugs are anti-psychotics, and dangerous, and most of the time they don't work. But there are no drugs approved for autism in general, and no signs of any coming down the pipeline.) And guess what: I have autism, and I can tell you that it's real. Oh, "my" autism may not be the same as the non-verbal kid in the corner who is constantly pounding his head against the wall. That's a different question. But I have a condition that makes it effectively impossible for me to live a "normal" life despite having high intelligence. I suppose you could call it Avoidant Personality Disorder plus Social Anxiety Disorder plus Executive Function Disorder plus Sensory Processing Disorder plus Pragmatic Social Disorder plus only Dr. Frances knows what else. But autism is a lot simpler than five or six different diagnoses that, in any case, don't have any more treatment than autism!

The point is, just because we see an explosion of cases as soon as a new type of diagnosis is announced doesn't mean that the diagnosis shouldn't exist. There is a sort of excluded middle here: Dr. Frances seems to think that everything in the DSM-5 is in there so that we can force treatment on people. I would view it a different way. The diagnoses in the DSM-5 exist to tell us what sorts of supports people will need if they need support at all. If they don't, fine. You can diagnose something without treating it -- just as you can say "that person has brown hair" without saying "we have to convince her to dye it purple."

Also, I have to note, Dr. Frances is sometimes a little too willing to supply false history (e.g. how he knows so much about the shamans of prehistory is beyond me -- we call it "prehistory" because nobody knows what happened!).

Ultimately, one of the problems of psychiatry is that there are researchers, and there are clinicians, and their needs aren't the same. Dr. Frances is a researcher, and he produced a researcher's book (referring to the DSM-IV, which he edited, not this book). His general critique is good and valid. Psychiatry needs better diagnostic tools, and we need better ways to figure out what will help actual individuals. The DSM-5 was a very mixed bag in this regard. Big Pharma is no help. But pretending that everyone is normal is no help, either.… (plus d'informations)

I was disappointed. Frances is criticizing "out of control psychiatric diagnoses" from within the system, so the findings feel bland and non-actionable. I'm more of a fan of the style of The Emperor's New Drugs by Irving Kirsch, who gets to the heart of the problem and proposes solutions.

Also, from Frances's title "Saving Normal," I wanted and expected a more philosophical discussion than I got, about the value of accepting human differences, vs. what we have now, a runaway proclivity in American culture to exclude minority cultures of all kinds, by labeling deviant behaviors as sick or bad. It's a great topic and I hope another smart person comes along to tackle it for real.… (plus d'informations)