Friday, June 28, 2013

Introducing Allen Frances

Allen Frances was the editor of the DSM-IV, first published in 1990.  He is now the fiercest critic of its next major revision, the DSM-5.  For over three years, he has been blogging weekly to this end at Psychology Today.  This week I will summarize his steady drumbeat.  I hope soon to publish an open letter to him.

Frances' complaint in a nutshell is that the DSM-5 creates fad diagnoses and changes criteria of older diagnoses to medicalize a whole range of normal behavior and miseries.  The link lists these problem diagnoses and a number of the following points, in an article published all over town last December.

These issues have been discussed widely, in public and private circles.  I am not qualified to address each point, though I did give a series over to one of them, the bereavement exclusion.  The best of the batch, if I do say so myself, is Grief/Depression III - Telling the Difference, which got quoted in correspondence among the big boys.


So, on the ten issues Frances listed above, his point of view did not prevail. He now has a full time career, re-revising the DSM-5 in letters to the editor and on the talk show circuit. In March he added A twelfth DSM 5 mistake on female sexual dysfunction.  I missed #11.  Anybody know what it is? -- Leave a comment.

Paradigm Shift: DSM and NIMH

Frances from the beginning argued for a conservative approach to revision, changing only those points where the science has overwhelmingly indicated that his own work needs to be superseded, and to the end of stemming the tide of more and more people diagnosed and receiving some sort of medication.  That was his intent in the work he led to revise the DSM-III, edited by his mentor, Robert Spitzer.  So he objected early to the revisers' premature and unrealizable goal - to produce a paradigm shift in psychiatry.

In April, 2013 Thomas Insel, Director of NIMH published the first draft of NIMH's new Research Domain Criteria (RDoC).  His statement referred to the then upcoming publication of DSM-5, and addressed its limitations, that of validity.  It defines mental illnesses by statistical clusters of symptoms, not by objective laboratory data.  New research funding by NIMH will be based on the assumption (paradigm) that mental illnesses are biological illnesses. Research must not be constrained by DSM categories.

Frances jumped on Insel's statement as a repudiation of the DSM-5, hammer[ing] the nail in its coffin.  He seems to have missed Insel's assertion that DSM-5 makes only minor changes from DSM-IV.  Insel used the word tweaking... mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published.  He also missed Insel's first announcement in 2009 that NIMH was moving in this direction, when Insel could only have been referring to DSM-IV.

DSM-5 revisers knew this day was coming.  Their efforts to incorporate it into their work, for example, by trying to identify the risk of schizophrenia in its developmental stages, instead of its full fever, proved fruitless.  Indeed, while the DSM franchise will continue to guide clinical practice in the near future, there is no way to merge the two approaches. Frances is correct, it was a premature and unrealizable goal.  Though I doubt he anticipates that DSM-IV will join DSM-5 in that inevitable pyre.

Nasser Ghaemi, from Tufts University, says that this is a generational conflict.  The revisers of all three works, including DSM-III from 1980, are from the same generation, mostly the same people, who have dominated the field with what he calls a cynical pragmatism, using the process of diagnosis to force clinicians to practice the way they think clinicians should.  [My next section, Concern for Patients will provide examples of how this works.]  NIMH has finally weighed in, insisting that science replace paternalism.

This patient and my overmedicated peers whose DSM-IV diagnoses change each trip to the hospital respond, Where are the matches?

Concern for Patients

Frances frames his objections to DSM-5 revisions as a concern for patients.  By that he mostly means people who, he believes, ought not to be patients.  Seemingly small changes can result in the mislabeling of millions of 'patients' who are then subjected to unnecessary and often harmful treatments, stigma, costs.

He is appalled at the epidemic of mental illness in the US, an epidemic he believes to be driven by loopholes in the DSM that give entry to pharmaceutical companies' sales pitches.  He regrets that DSM-IV failed to predict or prevent subsequent huge increases in the diagnosis of ADD, autism and adult bipolar disorder.  In other articles, he includes PTSD in this list of illnesses that DSM-IV failed to prevent by tightening criteria so that sufferers do not qualify for diagnosis and do not receive medication.  Or any other treatment.  Or the stigma of having the kind of illness that he treats.

The Epidemic of Mental Illness

Frances has a receptive ear in me - he has a receptive ear in almost everybody in every part of the business, except Eli Lilly and Pfizer, when he says that we are overmedicated/ overmedicating.

But did the pharmaceutical companies use DSM-IV to create a mental health epidemic?  Or did they exploit the suffering that really is out here, folks, and doctors' good faith efforts to relieve it?

Here is the thing.  Suicide rates are soaring -- the most visible and objective measure of the culture's pain.  DSM did not create that cold hard fact, nor can it change it.  The economy is restructuring to raise a whole raft of suicide risks.  Unemployment would top that list.  But work speed ups, taking work home, longer hours, less sleep and general stress also impact suicide rates.  Money managers and bankers commit suicide when their nefarious work is discovered and even when their innocent work bankrupts others.

These same factors serve to increase the rates of domestic and child abuse, creating trauma that sets the stage for the whole panoply of mental illnesses.

Meanwhile, No Child Left Behind plus tax cuts and budget slashing are restructuring our schools to eliminate every cushion that would soften these blows: recess, arts, music, sports, libraries.

Not to mention our Fast Food Nation diet.

And two wars fought with limited resources, hence multiple tours of duty, war crimes ordered on a regular basis, and the majority of soldiers' injuries of the sort that damages brains.

There is even scientific evidence that links genetic abnormalities with the rising age of paternity.  The age of the father is a risk factor for autism.

Under the circumstances of the last ten years, it is hard to imagine how we could not be having an epidemic of mental illness.

Preventing Mental Illness

PTSD can be prevented and the rate of adult bipolar reduced by preventing trauma.  ADD and ADHD can be prevented by enriching children's environments and allowing a positive outlet for their natural exuberance.  It is not clear that jiggering criteria to reduce the number of people diagnosed will do anything to improve our mental health.

Saving Normal?

But that seems to be Frances' goal.  He takes offense at the notion that 20% of people in the US are now diagnosed, the estimate that half the population will experience a mental illness sometime in our lives, i.e., be labeled, not normal.

It may not be evident to my normal readers how deeply offensive the title of this book is.  If I were still doing my OMGThat'sWhatTheySaid series, it would top 2013's list.  We should not be making patients out of people who are basically normal and ignoring those who are really sick, says Frances.

Gee, I thought I was a basically normal person who spends a lot of time managing a serious mental illness.  For more on this, I characterized mental illness as normal experiences piling on to create not normal suffering in Defending DSM-V - Sort Of.

Ronald Pies takes on the logical difficulties in Frances' position.  He agrees with Frances - lots of people agree with Frances that many patients are inappropriately medicated.  That said, and lots of people keep saying it, DSM is a diagnostic manual, not a prescriptive one.  This part must be teased out from Frances' frontal assault on his own profession.  Pies defends psychiatry, and proves a better friend to people with mental illness with the following:

Psychiatry's ethical aim is the relief of suffering and incapacity.  So long as the patient is experiencing a substantial or enduring state of suffering and incapacity, the patient has disease (dis-ease).  To assert this is not to medicalize normality, but to affirm what physicians have recognized as an ethical imperative, for millenia: the need to relieve the misery of the patient.

Frances keeps churning out the articles.  I knew who authored DSM 5 Badly Flunks the Writing Test before I opened the link. Eighteen problems with DSM 5 were identified in this one -- Even my casual and selective reading picked up egregious errors on almost every page I read.  If he wants to go there, is his egregious error #5 the problem, or is it #7?  And couldn't chapter one of his own book be read as an argument for DSM-5's call on #11?

I await DSM-5 Badly Flunks the Spelling Test.

Stigma

Okay, I will stop here before I relapse into the snarkiness that made me put off this post for so long.  Or am I too late?  In my defense, I know I have company in my feelings of frustration, that a man with such credibility wastes it by debunking his own franchise, when he could be using it to focus on the legitimate issue of overmedication.  The enemy is not diagnosis.  It is poor treatment.  And the engine is not DSM, whether III, IV, IV-TR or 5.  It is in the economics.

Frances' peers can take up the defense of their profession.  They are up to the task.

I have not found his peers addressing the stigma he stirs against people who seek help.  I don't really expect them to have an ear for it.


But I do have an ear.  And on that issue, I will address him directly.

photo of Allen Frances and book jacket from Amazon.com
Wailing Wall by Gustav Bauernfeind (1848-1904) in public domain
photo of Thomas Insel in public domain
photo of book burning Book Burning by Patrick Correia, used under the Creative Commons license
photos of Nassir Ghaemi and Ronald Pies used by permission
flair from Facebook.com
artwork of children playing by Hannie Mein Schieringerweg Comenius Leeuwarden, used under the Creative Commons license

5 comments:

  1. Hi, Willa--

    Excellent commentary, and many thanks for the call out to my articles on Psychiatric Times. As I suggest in my piece on Medscape

    http://www.medscape.com/viewarticle/805365

    the DSM-5 is not a "bible" and is certainly flawed in many ways--but it doesn't deserve the dismissive drubbing it has gotten in the media, often by folks who panned it before they read it!

    And you are right: diagnosis is not the enemy: inadequate, poorly-conceived, or unavailable treatment are the real culprits. Meanwhile, I'll be interested in your further thoughts on "stigma"--a term which also causes much mischief, as blogger Sandy Naiman has pointed out.

    My own view is that psychiatric diagnosis does not cause stigma: ignorance and prejudice toward those with psychiatric disorders cause stigma. We won't reduce "stigma" by reducing diagnosis, but by reducing ignorance and prejudice regarding the disorders we diagnose!

    Best regards,

    Ron

    Ronald Pies MD

    ReplyDelete
  2. We are on the same page, Ron. I broke my ban on the word 'stigma' [see http://prozacmonologues.blogspot.com/2011/02/its-not-stigma-its-prejudice-and.html] only to address Dr. Frances' use of it.

    In brief, when patients use 'stigma', we are internalizing the prejudice of others. When others use it, they are asking us to bear the responsibility for their prejudice. And as Dr. Frances demonstrates, that prejudice begins in many doctors' offices.

    In the late 80's, gay people learned that Silence Kills. They (we) got noisy. Which was good for AIDS research. John McManamy ran the numbers: for every dollar the NIH invests in an HIV/AIDS patient, depression and bipolar patients get one penny. I ran them for deaths, which improves the picture a bit: for every $11 the NIH spends per AIDS death, suicide gets $1.

    I refuse receipt of other people's prejudice. I figure my life depends on it.

    ReplyDelete
  3. Right on, Willa! Many thanks for your brave and clear voice, amidst a cacophony of insults and invective.

    Best regards,
    Ron

    ReplyDelete
  4. Diagnosis is not the enemy, unless the person who diagnoses you is influenced by stereotypes when he/she decides what treatments to recommend. I am convinced the majority of those of us who suffer from cyclic mood disorders are out in the wild, undiagnosed, untreated, and highly functional (at least until antidepressants, alcohol, or recreational drugs bring us to a bipolar diagnosis). When I see a highly functional person whom I recognize as potentially suffering from bipolar disorder, I hesitate to recommend treatment. The average psychiatrist is clueless about people who have bipolar disorder but aren't a wreck. They're highly likely either to misdiagnose and maltreat with antidepressants or to tell the person they'll have to be on heavy-duty psych drugs for the rest of their life, even if that means they will become significantly lower functioning due to the drugs' effects.

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  5. Joanne, I am at the point, I get anxious when I recommend treatment to people with depression. My recommendations are accompanied by huge warnings, that they do their own careful screening (MDQ) for BPII before they take ADs, not to expect the doc to catch it.

    I'll be taking this line a step farther in this week's post. The prejudice shows up not only in the treatments recommended but also in the medical care withheld! Like, maybe Frances has a point - turns out you get better medical treatment if the doc doesn't know you have a mental illness.

    ReplyDelete