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. ( )

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. ( )

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. ( )

This is an interesting and much-needed commentary on the excessive prescription of medications and misuse of psychiatric diagnoses. The guilt throughout this book is palpable; the author, sharing responsibility for the production of DSM-IV, didn't prevent the misuse of medications and diagnoses. While this book does say that everyone is different and that's fine, the message gets lost, as there is an inconsistency of audience. A slightly better organization of the book (perhaps one section aimed with a message for individuals, medical professionals, Big Pharma and legislation) might help solidify the message.

In this century, we live in an instant gratification culture. You can have just about anything shipped to you in two-days or less after ordering from the internet. So, why, then, should it not be possible to instantaneously "fix" your mood or behaviors. It becomes easier for an individual to blame an inherent condition that needs medication to control than it is to develop new coping mechanisms or deal with life's miseries. And society tells the individual this is acceptable. ( )

Six-word review: Well-documented indictment of medical profiteering.

Extended review:

When you put a profit motive behind finding as much as possible wrong with as many people as possible, suddenly and frighteningly a lot of people have something wrong. And nothing lends itself better to free-wheeling commercialization than people's emotional states. Because not everybody has a sore foot or hearing loss, but everybody has troubles sometimes and everybody feels bad sometimes. And when people feel bad, they want to feel better.

And the pharmaceutical industry is right there with its hand out.

Two hands, in fact: one to dispense from a bottomless barrel of meds for every describable ailment, and one to rake in obscenely huge profits from true believers and cynics alike.

Diagnostic inflation and overmedication are the two dominant themes of Allen Frances' book. Dr. Frances, the psychiatrist who headed the DSM-IV (1994) team, doesn't limit his discussion to psychotropic medications, but they are a primary target.

The DSM is the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition (DSM-5, 2013). A revenue-generating publication of the American Psychiatric Association, it was until its third edition in 1980 a relatively obscure document intended as an aid to professional diagnosis, initially in a military context. It was never meant to be a "bible" or to govern the relationships between therapists and clients, never mind furnishing criteria for insurance claims. With the upsurge in psychiatric research and practice in the 1970s and the explosion of psychotropic medications in the 1980s, the detailed classification of mental conditions became dramatically relevant.

And suddenly so did the DSM.

As Dr. Frances documents in disturbing detail, it was the vastly profitable pharmaceutical industry that stood to gain the most from those developments.

The selling of health to moneyed interests compromises everything from the integrity of practitioners to the well-being of the patients, many too young, too old, or too impaired to make their own choices.

A primary casualty of this seismic shift in the medical and pharmaceutical landscape is the concept of normality. By loosening diagnostic criteria, the therapeutic community's chief reference work ends up classifying anything outside of a narrow range as a disorder. The result is the medicalizing of life's ordinary ups and especially downs. Too much energy or too little, a spell of sadness, a display of eccentricity: diagnosis by checklist will give it a name, and then off you go to your pharmacy, hoping for a small copayment and instant relief.

Frances' courageous book calls his peers and colleagues to account, faulting them not for their lack of integrity but for their lack of judgment (page 288). He shows no mercy to Big Pharma, however, for capitalizing on people's natural desire to cope with their problems and grasp at easy remedies--and, what's worse, for manufacturing crises in mental and physical healthcare for its own gain.

Even more harmful than turning the vicissitudes of life into illnesses and relatively healthy people into patients is creating false epidemics of disorders such as ADHD, autism, and PTSD. Once attached, those labels adhere like leeches and can compromise for a lifetime a person's self-confidence, employability, access to healthcare and coverage, and quality of life. Dr. Frances relates several harrowing accounts of patients whose iatrogenic conditions might well have sunk them. Anyone who feels anything strongly or does anything passionately becomes a candidate for therapeutic intervention. And once plugged into the system, many become captives of it. "We have to address the fact," says Frances, "that the misuse of legal drugs has now become a bigger public health problem than street drugs. It is unacceptable that 7 percent of our population is addicted to prescription drugs and that fatal overdoses with them now exceed those caused by illegal drugs" (page 211).

Frances reserves special attention for the well-known placebo effect: "Modern drug companies have made big bucks capitalizing on the power and ubiquity of the placebo response. The best way to get great results with a pill is to treat people who don't really need it--the highest placebo response rates occur in those who would get better naturally and on their own" (page 99).

Does Dr. Frances have solutions to propose? He does, although without expressing much optimism. It must begin, he says, with the political will to do what must be done, and that means that public servants must wean themselves from the creamy persuasion of Big Pharma's virtually unlimited financial resources. A section called "Dismantling the Marketing Machine" lists fourteen policy changes that would act to curb the powers wielded in the interests of corporate greed. The media have an enormous role to play as well: once seduced by the magic of promised cures, they are now wising up and showing some well-placed skepticism. Doctors and patients themselves also figure in the picture, and Frances outlines action steps for them.

A key part in the process of trend reversal belongs to the DSM, and the author calls for its drastic revision as well as a reduction in reliance on it throughout the medical, educational, and legal systems.

As a layperson, I'm not qualified to evaluate this book with respect to the healthcare industry. However, it seems like an important book to me, and the author's passion for his subject is unmistakable. Saving Normal has significantly heightened my awareness of some issues that I'd already been paying attention to and opened my eyes to others. Assuming that the author's credentials are as represented and his documentation reliable, I think it has to be taken seriously. I don't know if most people would want to learn something from this book, but most people could.

The extent to which I engaged with it shows in my pencil work. In general, I regard a nonfiction book as a dialogue, and my side of the exchange takes the form of underscores, ticks in the margin, and annotations, sometimes extensive. I read this one hard; scarcely a page is unmarked. I found plenty here to think about and plenty to come back to.

Nonetheless, I do have a few quibbles with it. The book needed at least one more thorough, sentence-shaking, word-wrangling line edit. (Every time an author makes a change, remember, what you have is unedited text. The number of errors introduced in the course of incorporating changes is potentially limitless.) At several points, I wrote in the margin, "Naptime for editors." There is unexplained insider jargon. There is inconsistent use of abbreviations and failure to expand at first occurrence. There are shifts in audience focus: sometimes the author seems to be addressing the public, sometimes fellow medical professionals, and sometimes people he knows personally. There are egregious sentences such as this: "The value of early intervention to prevent psychosis rests on three fundamental and necessary pillars--diagnosing only the right people, having a treatment that is effective, and also safe" (page 198). There is a lot of trouble with parallel structure, especially with correlatives. There are instances of illogical order of presentation and downright ambiguity. There's a Bible misquote on page 170--and no excuse for it, either, since it's so readily checked.

Yes, I know it isn't easy to get all this stuff right. That's why people hire professional editors. And when one is too familiar, too close to the material, or just worn out, maybe you need another one.

A notable drawback to utility is the fact that the ample chapter notes are headed by chapter numbers, without page references; but the running heads in the chapters give title only and not chapter number, so that when you want to look up a note, you first have to page back in the chapter to find out the number of the chapter you're in. This is something that a fresh editorial eye ought to have spotted in page proofs right away.

A book that aspires to making a difference--indeed, becoming an agent for major change--deserves every measure of care that can be lavished on it. An extra two months' attention before press time might have been just the prescription it needed. ( )