The outpouring of rage against the DSM-5
among mental health professionals is startling in its volume and scope—a virtual in-house outbreak of oppositional defiant disorder, and surely the most intense and widespread challenge to DSM’s legitimacy in its 62-year history.
Even more surprising is that the widely acknowledged chief spokesperson for the opposition is none other than Allen Frances—perhaps the last person you would expect to trash this latest, biggest DSM. An eminent psychiatrist, researcher, and writer on a host of issues (including personality and anxiety disorders, chronic depression, schizophrenia, AIDS, and psychotherapy), former chair of the psychiatry department at Duke University, and founder of two psychiatric journals, he himself helped prepare DSM-III
, and, in what would be the capstone of an illustrious career, chaired the task force that published DSM-IV
in 1994. Indeed, in a New York Times
article in April of that year, author Daniel Goleman called him “perhaps the most powerful psychiatrist in America.” And yet today, he’s become a de facto spokesperson for the anti-DSM movement among mental health professionals.
------------------------------------------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.Read the full interview with Allen Frances, "The Two Sides of the DSM-5 Controversy: A Step Backward," in the March/April 2014 issue of Psychotherapy Networker magazine.