May 20

“Saving Normal” by Allen Frances: DSM-5 Issues

My advice – the best protection against wild over-diagnosis is to ignore DSM 5. It is not official. It is not well done. It is not safe. Don’t buy it. Don’t use it. Don’t teach it. Allen Frances, MD, Saving Normal (Psychology Today blog)

But what does Allen Frances, MD, know anyway?

Well, for starters, he chaired the DSM-IV task force. Two, he’s a psychiatrist, educator, and researcher who’s intensely interested in this subject and has been writing prolifically about it. He has a whole blog called DSM5 in Distress and another called Saving Normal, the title of his brand new book. Three, besides the just released Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, by the end of May his Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5 will also be available. 

Allen Frances to Michael MechanicMother Jones, that one of his main concerns is the increasing diagnoses of everyday problems and their treatment with drugs. “The drug companies have marketed heavily to primary-care doctors, who now prescribe 80 percent of psychiatric medication. That is amazing. Most psychiatric diagnosis is being done in seven-minute sessions with doctors who are not very interested or well trained in psychiatry.”

In a post on his Saving Normal blog, Frances advises therapists to just keep using the DSM-IV if we don’t like the changes. Or, he adds, “buy one of many alternative guides to psychiatric diagnosis that will be available (COI disclosure- I have written one of these myself). Or…download the ICD-9-CM codes completely for free at” (The latter is the International Classification of Diseases.)

What Frances wants all consumers of mental health services to know: “Don’t lose faith in psychiatry, but don’t accept psychiatric diagnosis or treatment on faith — particularly if it is given after a brief visit with someone who barely knows you. Be informed. Ask lots of questions. Expect reasonable answers. If you don’t get them, seek second, third, even fourth opinions until you do.”

He adds the following conclusion:

A psychiatric diagnosis is a milestone in a person’s life. Done well, an accurate diagnosis is the beginning of increased self understanding and a launch to effective treatment and a better future. Done poorly it can be a lingering disaster. Getting it right deserves the kind of care and patience exercised in choosing a spouse or a house.

Remember that psychiatry is neither all good or all bad. Like most of medicine, it all depends on how well it is done.

May 14

“The Book of Woe” Takes On the Upcoming DSM-5

Gary Greenberg, The Book of Woe: You could think of the DSM as a handbook designed to help doctors recognize the varieties of psychological travail, not unlike the way Audubon’s field guides help ornithologists recognize birds. You could think of it, as some people (especially its critics) do, as the Bible of psychiatry, providing a scriptural basis for the profession. You could think of it—and this is what the APA would like you to do with the DSM-5—as a living document, akin to the U.S. Constitution, a set of generalizations about the present, flexible and yet lasting enough to see an institution into the future. Or you could think of the DSM as a collection of short stories about our psychological distress, an anthology of suffering. You could think of it as the book of our woes. 

I have to admit I’ve never felt comfortable with any past version of the DSM, or Diagnostic and Statistical Manual of Mental Disorders. Some of this is personal, as in growing up in the era when homosexuality was deemed a mental disorder. But most of it is professional, as in not feeling able to fit most people’s symptoms and issues neatly into medicalized categories—but having to, mostly for insurance purposes.

I’m hardly the only one with discomfort, though. If this wasn’t already clear to me, it’s been made much more so by the various public protests against the soon-to-come long-in-the-making revision, the DSM-5.

One particularly vocal critic is Gary Greenberg, a therapist who participated in field trials that contributed to the foundation of the DSM-5. His own new treatise is called The Book of Woe: The DSM and the Unmaking of Psychiatry. Or, as journalist Gene Weingarten remarks, “This could be titled The Book of … Whoa!” As in, stop the madness (of DSM-ness) already!

In 40 years, the psychiatrists behind developing the DSM in all its incarnations still haven’t been able to get it right, Greenberg essentially states in The Book of Woe: “Psychiatrists have gotten better at agreeing on which scattered particulars they will gather under a single disease label, but they haven’t gotten any closer to determining whether those labels carve nature at its joints, or even how to answer that question. They have yet to figure out just exactly what a mental illness is, or how to decide if a particular kind of suffering qualifies.”

Not only does the DSM lead to the probable over-diagnosis of common life issues, says Greenberg (and other critics), but it also enables the American Psychiatric Association (APA) to make tons of money off concepts that lack provability.

There are no biological tests, for example, no proven courses of treatment for major DSM disorders, no way to know if one clinician’s diagnosis of an individual’s condition is better than the next clinician’s, not enough elimination of cultural bias.

Martha Stout, herself an author of books about psychiatric issues, concludes (New Republic) that it’s worth reading The Book of Woe for at least three reasons:

  • For increasing our understanding of DSM‘s reach. It “profoundly influences nothing less than humankind’s beliefs about itself. The DSM tells people all over the world how to figure out who is normal and who is not, and there are few questions by which human beings are quite so universally intrigued.”
  • To be reminded or informed of the continual view-changing regarding diagnoses, including the effects of evolving “cultural beliefs and bigotry.”
  • Realizing the extent of the business side of all this. The DSM-IV, for example, brought the APA a hundred million dollars. Each clinician who buys the DSM-5 will shell out $199.

Personal disclosure: I’ve never bought a DSM in its fullness. But the smaller “Desk Reference” edition, which I have gotten, will go for close to $70.

Publishers Weekly: “Deploying wised-up, droll reportage from the trenches of psychiatric policy-making and caustic profiles of the discipline’s luminaries, Greenberg subjects the practices of the mental health industry—his own included—to a withering critique. The result is a compelling insider’s challenge to psychiatry’s scientific pretensions—and a plea to return it to its humanistic roots.”