|Allen Frances, MD
PsychiatristAllen Francis was chairman of the task force that developed the last edition ofdiagnostic Bible in Psychiatry, the DSM. It was the fourth edition andcame out in 1994. As someone intimately involved in the process offormulating changes in the diagnostic nomenclature, he became concerned when hebegan to notice that the changes he helped create in the DSM were beginning tolead to the "upcoding" or expanding of psychiatric diagnoses toinclude normal but problematic variants of human behavior.
Withwidespread changes in insurance plans that paid far more to psychiatrists formedicating many so-called "biological" disorders than for providingpsychotherapy for what used to be called "neuroses" or "actingout," along with major pushes by pharmaceutical companies to expand theindications of their lucrative new drugs to larger and larger numbers ofpeople, more and more people were being medicated with potentially toxic drugsfor what are, for all intents and purposes, disorders of behavior and relationships. This has been a major theme of this blog.
[For clarification, I should note that diagnosesin psychiatry are not based on the causes of disorders (etiology),but on descriptions of the typical behavior, emotional and cognitive attributes that are seen in various syndromes. A syndrome is a group of symptomsthat collectively indicate or characterize a disease, psychological disorder,or other abnormal condition. These characteristics tend to cluster together andcan be distinguished from one another using epidemiology (thestudy of the risk factors, distribution, and control of disease in populations) and the presence of similar descriptions throughout history, as well as through the combined presence of a group of particular symptoms with the absence of other co-occurring symptoms and attributes.
The classification of psychiatric disorders isnot based on causes because, in many if not most cases, we have not been able to track downan exact cause (due to our limited understanding of the brain and itsrelationship to behavior and mentation), and also because almost all psychiatricdisorders have multiple biological, psychological, and socio-cultural riskfactors. In fact, "risk factors" rather than "causes"is probably the preferred term that should be used in psychiatry, because there are no necessary orsufficient antecedents to the development of the various disorders.
Nonetheless, all psychiatric diagnoses are notcreated equally. Some - like schizophrenia - have been well described,and consistently so, for hundreds of years in multiple cultures. Thedefining characteristics of many other conditions, like ADHD for example, aresort of voted on by committees of "experts," many of who haveconflicts of interest because they get money from the pharmaceutical companies. In those cases, the decisions about diagnoses are sort of like the onesmade by the Council of Nicaea, during which various Christian Bishopsliterally voted on which of the many Gospels were the word of God, and whichwere not].
Dr.Francis has become a leading critic of the plan to come out with a neweredition of the diagnostic manual, to be called the DSM-5 (I guess romannumerals have become passe). He worries that upcoding will get evenworse with many of the new proposals, and medications even more widely mis-prescribed. And not just bypsychiatrists. 80% of anti-depressants, for example, are prescribed byprimary care physicians, and most stimulants by pediatricians.
Andjust wait and see what happens if psychologists ever get prescribingprivileges, which they desperately seek! Psychotherapy as we know it maydisappear completely.
I also thinkthat, since for most psychiatric conditions we do not know a whole lot moreabout the causes of the various psychiatric conditions than we did when the DSM-IV was published, coming out with anew diagnostic manual is premature to say the least. Also, since the current research base uses current definitions, changing all of the definitions can be very destructive tobuilding on our scientific knowledge in the future.
Some of thesuggested changes seem to center around the idea of "spectrum"disorders, in which various disorders are grouped together because some of thesymptoms sort of look alike.
Just recently, the American Psychiatric Association (APA) recruited a newpublic relations spokesman, formerly of the US Defense Department, who wasquoted as saying that "Francis is a 'dangerous' man trying to undermine anearnest academic endeavor." It sounds like, rather than address thewell-thought-out criticisms of Dr. Francis, the APA has elected to circle thewagons defensively and engage in ad hominem attacks.
"The piece in Time Magazine managesto raise again the silly APA suggestion that my objections to DSM-5 aremotivated by a feared loss of royalties. Let’s set the recordstraight—hopefully for the last time. The royalties on my DSM IV handbook areabout $10,000 a year—not at all commensurate with all the time I have spenttrying to protect DSM-5 from making all its repeated mistakes.
"My motivation for taking on thisunpleasant task is simple—to prevent DSM-5 from promoting a general diagnosticinflation that will result in the mislabeling of millions of people as mentallydisordered. Tagging someone with an inaccurate mental disorder diagnosisoften results in unnecessary treatment with medications that can have veryharmful side effects. I entered the DSM-5 controversy only because I hadlearned painful lessons working on the previous three DSM’s, seeing how theycan be misused with serious unintended consequences. It felt irresponsible tostay on the sidelines and not point out the obvious and substantial risks posedby the DSM-5 proposals.
"I don’t consider myself a dangerous manexcept insofar as I am raising questions that seem dangerous to DSM-5 becausethere are no convincing answers. My often repeated challenge to APA—provide uswith some straightforward answers to these twelve simple questions:
1. Why insist on allowingthe diagnosis of Major Depressive Disorder after only two weeks of symptomsthat are completely compatible with normal grief?
2. Why open the floodgatesto even more over-diagnosis and over-medication of Attention Deficit Disorderwhen its rates have already tripled in just 15 years?
3. Why include a psychosisrisk diagnosis which has been rejected as premature by most leading researchersin the field because it risks exacerbating what is already the shamefuloff-label overuse of antipsychotic drugs in children?
4. Why introduce DisruptiveMood Dysregulation Disorder when it has been studied by only one research teamfor only six years and risks encouraging the inappropriate antipsychotic drugprescription for kids with temper tantrums?
5. Why sneak in Hebephiliaunder the banner of Pedophilia when this will create a nightmare in forensicpsychiatry?
6. Why lower the thresholdfor Generalized Anxiety Disorder and introduce Mixed Anxiety Depression whenboth of these changes will confound mental disorder with the anxieties andsadnesses of everyday life?
7. Why have a diagnosis forMinor Neurocognitive Disorder that will unnecessarily frighten many people whohave no more than the memory problems of old age?
8. Why label as a mentaldisorder the experience of indulging in one binge eating episode a week forthree months?
9. Why introduce a systemof personality diagnosis so complicated it will never be used and will givedimensional diagnosis an undeserved bad name?
10. Why not delaypublication of DSM-5 to allow enough time to complete the previously plannedand crucial second stage of field testing that was abruptly cancelled becauseof the constant administrative delays in completing the first stage?
11. Why should we acceptambiguously worded DSM-5 diagnoses whose reliability barely exceeds chance?
12. And most fundamental:Why not allow for an independent scientific review of all the controversialDSM-5 changes identified above—proposed by 47 mental health organizations asthe only way to guarantee a credible DSM-5? What is there to hide and what harmis done by additional careful review?
"If I am a dangerous man, it is because Iam exposing DSM-5’s carelessness and thus putting at risk APA’s substantialpublishing profits. During the past 3 years, I have made numerous attempts,private and public, to warn the APA leadership of the troubles that lie aheadand to implore them to regain control of what was clearly a runaway DSM-5process.
"This has had no real effect other thandelaying publication of DSM-5 for a year and the appointment of an oversightcommittee that turned out to be toothless. I am reduced now to just one meansof protecting patients, families, and the larger society from the recklessnessof the DSM-5 proposals—repeatedly pointing out their risks in as many forums aspossible."
Wellsaid, my good man. It seem to me that the APA is at risk of being dangerous, not Dr. Francis.