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The Debate Over DSM-5

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A Step Backward: An Interview with Allen Frances

You’ve been one of the most outspoken critics of DSM-5, but your ultimate target is really something you call diagnostic inflation. What’s diagnostic inflation, and why should we all be concerned about it?

Allen Frances: Putting aside all the problems with DSM-5, the simple fact is that psychiatric diagnosis has become way too loose. Today, 25 percent of Americans meet the criteria for a diagnosis in any given year. Twenty percent of us take psychotropic medication; that’s one in five people. We now have more deaths in emergency rooms from prescription drugs than from street drugs. Pill popping is rampant, along with all the unnecessary side effects of drugs. The new DSM will just make this worse.

How did psychiatry get itself into that situation?

Frances: Obviously there are any number of causes, but a key turning point goes back over 30 years to the enormous popularity of DSM-III. Before that, psychiatric diagnosis was fairly irrelevant, but once DSM-III became such a bestseller year after year, it attained tremendous influence beyond the therapy room, affecting decisions regarding school placements, disability decisions, courtroom verdicts, who could adopt a child, even who could fly a plane. All sorts of things in society are now determined by diagnosis.

A second major factor was the rise of Prozac in the 1980s and the tremendous profitability of psychiatric drugs. Drug companies, with their expensive marketing efforts, began to have more and more influence in shaping the practice habits of doctors, and later of the public, by convincing people that they were sick.

Third was the insurance company requirement that a doctor give a diagnosis if he wanted to get paid for a patient visit. As a result, doctors began seeing people for only about seven minutes before making a diagnosis. A psychiatric diagnosis is a critical moment in a person’s life, like getting married or buying a house. It shouldn’t be made after seven minutes.

A fourth factor was the drug companies’ market-driven realization that, while there were only about 40,000 psychiatrists, there are more than half a million primary care doctors. So they started pushing psychiatric diagnosis and the prescription of medication onto primary care. They began with the message that psychiatric diagnosis was really simple and the result of chemical imbalances. So increasingly, primary-care doctors began diagnosing in a few minutes and handing patients a prescription or, even better, a free sample. So we’ve gotten into a position where most of the psychiatric diagnosis is being done in just a few minutes, often by a primary-care doctor with little psychiatric training, and with tremendous encouragement by drug companies. This has been the perfect storm that’s led to loose diagnosis and excessive medication.

As the head of the DSM-IV Task Force back in 1994, how did you try to address these problems?

Frances: When I began working on DSM-IV, I was concerned that it would extend even further what was already an excessive diagnostic enterprise.

So we developed strong rules to try to contain the beast. To get a new proposal accepted into DSM-IV, there had to be a rigorous, three-stage process of literature review, data reanalysis, and field trials. And we told the experts that unless the data jumped up and grabbed us by the throat, we weren’t going to make changes.

By and large, we were successful. Of the 94 suggested new diagnoses that were offered, we included only two. But those jumped up, and they did ultimately bite us. The new diagnoses of bipolar II and of Asperger’s became epidemics of their own. Since DSM-IV, the rate of bipolar disorder has gone up by 40 percent, and autism has also gone up by about 40 percent. Even with all our caution, we helped create these epidemics.

The lesson here is that even if you work incredibly hard to limit diagnostic inflation, the power of drug companies to advertise freely can create demand, even if the system has discouraged it. In fact, I’ve been so involved in critiquing DSM-5, not because I’m against psychiatry—far from it!—but because I think accurate diagnosis is so important. That’s why, in addition to diagnostic inflation, I’m equally concerned about the fact that we have one million psychiatric patients in jail because they haven’t received accurate diagnosis and enough treatment or a decent place to live. Only one-third of patients with severe depression today get to see a mental health practitioner. So I’m concerned with both ends of the misallocation—that we’re terrifically overdiagnosing people who don’t need it, and giving treatments to others that will only make them worse.

Do you believe that only people with medical training should prescribe psychiatric drugs?

Frances: The real problem is that most psychiatric drugs are being prescribed by primary-care doctors with very little training in understanding mental illness. I think anyone who’s well trained in diagnosis and understands the proper use of the medication, including psychotherapists, should be able to prescribe. Most of all, I’m concerned about anyone prescribing who does it too quickly and doesn’t understand the value of really knowing the patient, whether that prescriber is a psychiatrist or primary-care doctor or nurse practitioner.

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2 comments

  • Comment Link Sunday, 20 April 2014 18:43 posted by jeffrey von glahn

    There’s only one problem with the DSM. It’s one that will sneak right by you if you don’t know it’s there. The DSM is used to make a diagnosis – and that is precisely the problem. It is the problem because the field of mental health, in its current incarnation, has confused the terms “diagnose” and “understand.” To “diagnose” is to recognize by signs and symptoms, as in medicine, and that action carries with it the assumption that symptoms have a stable cause, whether genetic, biochemical, or neurological. All people who have the same diagnosis can be treated in exactly the same way. “Understand” (from an on-line dictionary) means to know how something works or happens, or how someone thinks or feels or behaves. To “diagnose” and to “understand” are different ways of conceptualizing psychological problems. Allen Frances had a telling assessment of the medical diagnose view: After “30 years of an amazing revolution in neuroscience and genetics…we don’t have a single biological test for mental illness, and our treatments are no better than they were 60 years ago.” Apparently, that was as far a Frances was willingly to go as he didn’t offer an alternative. An alternative is the “understand,” or experiential, approach, which many experienced clinicians operate by but rarely, if ever, say so in public. Here it is assumed that symptoms have an experiential causation, and since all interpersonal experience is unique the therapist has to rely on her experience to understand the client, and which she also uses as the basis for deciding how to interact with the client. What quite likely keeps anyone from going even this far in their thinking is that supporting a client’s account of his experiencing, rather than following a theory of what the client is supposed to be experiencing, raises the bugaboo of the client getting “emotional.” That, of course, immediately raises the specter of “re-traumatization.” This notion, although well-intended, strikes fear into the hearts and minds of even the most committed therapist as it proclaims that heightened emotional experiencing, and deep crying in particular, is tantamount to malpractice. What has been overlooked is the difference between what I’ve offered as the unforced/forced distinction of emotional experiencing (See my article on therapeutic crying in the May/June, 2012 issue). Emotional experiencing that arises coincident with the support the client receives for his experiencing is unforced or unprompted and is therapeutic. Sufficient support for a client’s experiencing allows an inherently natural healing process to proceed, just as protection from further injury or infection and sufficient physiological support allows a physical healing process to proceed. When emotional experiencing is activated by an unexpected and threatening stimulus, it is forced and not therapeutic because the nervous system is too overloaded to process the experience in a healing way. The ill-conceived notion of “re-traumatization” deprives many clients every day of a profound therapeutic experience and it keeps psychotherapy in its own Dark Age.

  • Comment Link Friday, 28 March 2014 14:57 posted by Kathleen Levenston

    Thank you for bringing attention to this problem; we tend to pay a lot of attention to the side effects of medication but not to the side effects of psychiatric diagnoses themselves.