Frances - Saving normal : an insiders revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life

To Donnamy partner in every word

Contents

I can calculate the movement of stars but not the madness of men.

I SAAC N EWTON

S OMETIMES YOU CAN get into a whole lot of trouble just minding your own business at a cocktail party. The time was May 2009. The party was a gathering of psychiatrists attending the annual meeting of the American Psychiatric Association. The place was the Asian Art Museum in San Francisco. The trouble was getting stuck in a bitter, public controversy about the nature of normal and the proper role of psychiatry in defining it.

I happened to be in town for something else and really had no interest in the meetings, but the party was a nice chance to catch up with old friends. For almost a decade, I had been pretty much a dropout from psychiatryretiring early to care for my ailing wife, to babysit my mob of grandkids, to read, and to be a beach bum. Previously, my work life had been driven, probably qualifying as hyperactive. I led the Task Force that developed DSM-IV and also chaired the department of psychiatry at Duke, treated many patients, did research, and wrote some books and papers. It seemed like I was always chasing the clock and losing the race. Even a furtive look at the sports section of the New York Times felt like a stolen and forbidden pleasure. It was now a delight to simply kick back, read Thucydides, feel the sun on my face and the wind in what was left of my hair. No e-mail address, few phone calls, and absolutely no responsibilities beyond my family.

I have only one superstitionan irrational, but abiding, belief in the law of averages, that things equal out in the end. I know they dontbut superstitions die hard. I think the probability gods were bored the night of the party and decided to use me for their entertainment. Perhaps they had calculated that my life had become too carefree. Why not even the score by throwing my way a few chance tranquility-disrupting conversations? Within an hour, my comfortable sideline perch was lost, and I was forced to take sides in what has become a civil war for the heart of psychiatryfighting a mostly losing battle to protect normality from medicalization and psychiatry from overexpansion.

Why me and why that night? It happens that several of my friends were bubbling over with excitement about their leading roles in preparing DSM-5 . They could talk of little else. DSM stands for Diagnostic and Statistical Manual . Until 1980, DSM s were deservedly obscure little books that no one much cared about or read. Then DSM-III burst on the scenea very fat book that quickly became a cultural icon, a perennial best seller, and the object of undue worship as the bible of psychiatry. Because it sets the crucial boundary between normality and mental illness, DSM has gained a huge societal significance and determines all sorts of important things that have an enormous impact on peoples liveslike who is considered well and who is sick; what treatment is offered; who pays for it; who gets disability benefits; who is eligible for mental health, school, vocational, and other services; who gets to be hired for a job, can adopt a child, or pilot a plane, or qualifies for life insurance; whether a murderer is a criminal or a mental patient; what should be the damages awarded in lawsuits; and much, much more.

Having worked for twenty years on the periodically updated editions of the DSM (including DSM-III, DSM-IIIR, and DSM-IV ), I knew the pitfalls and was wary about the risks inherent in any revision. In contrast, my friends were new to the game and excited about their role in preparing DSM-5 . They intended to add many new mental disorders and to loosen the rules on how to diagnose the existing onesthey were overvaluing hoped-for benefits, blind to the downsides.

I understood their enthusiasm and eagerness to make a difference. Back in 1987, a week after finding out I would lead the DSM-IV effort, I took a long walk on the beach. I am not usually a person given to brooding, but I had much to think about. For about an hour, I felt an exhilarating sense of power as I plotted possible ways to change and improve psychiatry. My concern was that psychiatric diagnosis had come too far, too fast, and was changing too rapidlythere were too many categories and too many people being diagnosed. My three bright ideas were to raise the bar for disorders that seemed too easy to diagnose, to collapse together or eliminate the disorders that didnt make much sense, and to describe personality by flexible numbers, not rigid names.

In the second hour, reality set in and forced me to shoot down every one of my own pet projects. On reflection, I realized that in trying to correct problems Id be creating new ones. And, more to the point, I realized that there was no reason why I (or anyone else) should trust me or my pet ideas. All changes to the diagnostic system should be science driven and evidenced based, not influenced by my personal whims or anyone elses. The method for doing DSM-IV needed to emphasize checks and balances in order to protect against individuality, arbitrariness, and diagnostic creativity. We would require that new proposals be subjected to a probing review of the scientific literature meant to focus on its risks and pitfalls. There would be painstaking data reanalyses and field trials. We would deep-six everything risky and/or without clear scientific merit. My hunch that high standards would eliminate almost all changes turned out to be truethere werent compelling scientific data to back up the many proposals we eventually received. The basic science of psychiatry was daily coming up with exciting insights into how the brain works, but none of this translated one bit into how we should diagnose and treat patients.

I knew that we couldnt afford mistakes in DSM-IV , even small ones. DSM had become too powerful for its own good and for societys. Even seemingly minor changes could have a disastrous impact. And now DSM-5 seemed poised to make some really big errors. In aggregate, the new disorders promoted so blithely by my friends would create tens of millions of new patients. I pictured all these normal-enough people being captured in DSM-5 s excessively wide diagnostic net, and I worried that many would be exposed to unnecessary medicine with possibly dangerous side effects. The drug companies would be licking their chops figuring out how best to exploit the inviting new targets for their well-practiced disease mongering.

I was keenly alive to the risks because of painful firsthand experiencedespite our efforts to tame excessive diagnostic exuberance, DSM-IV had since been misused to blow up the diagnostic bubble. Even though we had been boringly modest in our goals, obsessively meticulous in our methods, and rigidly conservative in our product, we failed to predict or prevent three new false epidemics of mental disorder in childrenautism, attention deficit, and childhood bipolar disorder. And we did nothing to contain the rampant diagnostic inflation that was already expanding the boundary of psychiatry far beyond its competence. If a cautious and generally well-done DSM-IV had probably resulted in more harm than good, what were the likely negative effects of a carelessly done DSM-5, driven by its grand but quixotic ambition to be paradigm shifting?

The stakes were too high for me to ignoreboth for the mislabeled new patients and for our society. Because of diagnostic inflation, an excessive proportion of people have come to rely on antidepressants, antipsychotics, antianxiety agents, sleeping pills, and pain meds. We are becoming a society of pill poppers. One out of every five U.S. adults uses at least one drug for a psychiatric problem; 11 percent of all adults took an antidepressant in 2010;