Understanding the Dangers of Diagnostic Epidemics

At first glance you'd think that eminent psychiatrist and researcher Allen Frances, a man the New York Times once referred to as “the most powerful psychiatrist in America,” would be the last person to trash DSM-5. But as the chair of the task force that published DSM-IV, Allen learned first-hand how, even when motivated by the best of intentions, changes in the “bible of psychiatry” can have large-scale negative consequences no one can foresee.

In this video clip Allen talks about the dangers of overdiagnosing people who don’t need it and giving treatments to others that will only make them worse. In the Networker Webcast series The Uproar Over DSM-5, he goes on to detail the principles of sound diagnosis.

As he put it in an interview in the March/April 2014 issue of the Networker, “When I began working on DSM-IV, I was concerned that it would extend what was already an excessive diagnostic enterprise. So we developed strong rules to try to contain the beast. Of the 94 suggested new diagnoses that were offered, we included only two, but those two—bipolar disorder and Asperger's—became epidemics of their own.”

Although the debate about DSM-5 continues, it remains the single most influential book shaping psychotherapy today. Still, with Allen as a de facto leader for the anti-DSM movement, this newest edition may go down in history as the most controversial mental health classification scheme ever devised.

The Uproar Over DSM-5
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Video Transcript

Rich Simon: Take us back historically a little bit. So you were part of the taskforce for DSM-III. That was a beginning of a sea change as you yourself have said. What was your sense of the enterprise at that point in your professional career?

Allen Frances: Well, I was very concerned when I began working on DSM-IV that this would extend even further what was already clearly an excessive diagnostic enterprise. So we developed very strong rules that would hopefully contain the beast. In order to get a new proposal accepted into DSM-IV, there had to be a very rigorous, three stage process of literature reviews, data reanalysis, field trials.

And we disciplined the experts with the idea that unless the data jumped up and grabbed you by the throat, we weren’t going to make changes, and 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 bite us, and the diagnoses of Bipolar II and of Asperger’s led to many epidemics of their own.

The lesson here was that even if you worked very hard to limit diagnostic inflation through the definitions, if the drug companies can advertise freely as they have been, they’re able to create demand even if the system has discouraged it.