This is an important book by the psychiatrist who chaired the DSM-4 task force, which produced the 1994 edition of the “bible” of psychiatric disorders, a reference used almost universally by American psychiatrists, psychologists, counselors, and health insurance companies. The author has concluded that the Diagnostic and Statistical Manual (DSM) has contributed to a serious overdiagnosis of largely well people as mentally ill, as well as failing to treat people who really need help. At once highly polemical but carefully nuanced, Frances carefully documents all claims with 15 pages of academic footnotes and references.
How has this diagnostic debacle happened? Frances identifies numerous reasons and rightly assigns blames in multiple directions. Psychiatrists and other therapists are too quick to diagnose. Unlike most physical disorders, which can be definitely assessed, mental disorder diagnosis involves a lot of judgment and subjectivity. Moreover, many clinicians have their “pet” diagnoses that they readily see in all sorts of people. Another problem is that insurance requirements insist that a patient has a clinical diagnosis on the first session for insurance reimbursement; Frances reminds us that many other countries do not require diagnoses until later. Frances also blames the DSM taxonomy, especially its DSM-4 (1994) and DSM-5 (2013) incarnations, for not requiring stringent enough criteria for complex diagnoses. For example, the DSM-4’s loosening of required symptoms for autism helped produce the booming numbers of autism spectrum diagnoses.
Although he lauds the motives of those who worked on DSM-5, and concedes that some problems with DSM-4 were addressed, he notes that pressure to complete the often-delayed project, as well as the exclusive involvement of psychiatrists at the expense of other professionals, has probably set the stage for future diagnostic fads.
Some of Frances’ harshest criticisms are saved for big pharmaceutical companies and their aggressive marketing to physicians and advertising directly to the public, which is permitted almost nowhere else in the world. Although always acknowledging that for some people some drugs are crucial and probably lifesavers, Frances fears may others are hurt by taking very powerful drugs they do not need.
Does this overdiagnosis matter? Frances argues very strongly that it matters a lot. It can stigmatize someone, forever saddling them with a diagnosis, even one later shown to be in error. The stigma may sometimes have concrete consequences. He gives examples of people with erroneous retracted diagnoses who were refused insurance coverage or even lost their jobs because of the diagnosis. Perhaps the most serious consequence of overzealous diagnosis has been the overuse of powerful legal psychiatric drugs. Antipsychotic drugs (e.g., Abilify, Risperdal, Zyprexa, Seroquel) are very potent drugs with documented success in reducing symptoms of schizophrenia, and sometime bipolar, but they are increasingly prescribed for lesser disorders, often by family doctors with limited training in psychopharmacology. While side effects are less dramatic than the 1960s antipsychotics, they are still substantial, including obesity and increased probability of diabetes and heart disease.
The book has some fascinating historical perspective on treating mental illness, from ancient shamans to the process of developing the various DSM diagnostic categories in the last 50 years. Frances also examines trendy “Psychiatric Fads” of the past, present, and future, going back all the way to demonic possession and vampire hysteria to neurasthenia and hysteria of a century ago to the more contemporary overdiagnosing of multiple personality disorder in the 1980s.
The present psychiatric diagnostic fads include the recent enthusiasm for diagnosing (and treating) Attention Deficit Disorder (ADD), Autism, Childhood and Adult Bipolar Disorder, Post-traumatic Stress Disorder (PTSD), and Sexual Disorders. It is essential to note that Frances is not saying these disorders do not exist and should never be treated but rather that they are too quickly and often diagnosed in basically “normal” people.
For example, Major Depression is diagnosed in someone merely going through the usual processes of grief, which shows many of the same symptoms, or people with a shy personality are diagnosed with Social Phobia.
What is to be done? Clinicians should be slower to diagnose, getting to know the patient well over several sessions before offering a diagnosis. Patients should take a more active role in documenting their own symptoms, seeking second opinions, and learning more about possible disorders they might have.
Drug companies should not be allowed to advertise to the public or provide lavish parties and promotional activities for physicians. Insurance companies should not require instant diagnoses before adequate information is gathered. The DSM should tighten up on behavioral diagnostic symptoms to make it harder to “qualify” as having some disorders.
This is an important for anyone who has received a psychiatric diagnosis or treatment, or been close to someone who has, to read.
Richard Harris is a Manhattan resident and a Professor of Psychological Sciences at KSU.