Dr. Allen Frances presented his views on the problems brought by the latest update of the Diagnostic and Statistical Manual of Mental Disorders (DSM). He also presented the real concerns evidenced by his fellow professionals and the members of the public at large. The lecture that he delivered in the lecture theater of Robert Dean Institute was attended by many people (Ici-berlin.org., 2015). Dr. Frances concerns were on the increasing misuse of the psychiatry diagnosis that ends up putting healthy people at risk due to the side effects of psychiatric medications (Frances, 2012). He said that anyone living a normal life must experience ups and downs, stresses, disappointments, setbacks, and sorrows. These challenges are a normal part of human life, and psychiatrists should stop classifying normal behaviors as psychiatric conditions (Ici-berlin.org., 2015). Today, millions of people who are just but worried are being diagnosed as having mental disorders, and they are receiving unnecessary treatments.
Dr Frances traced the antecedent of psychiatry from the Sharmans, Hippocrates, Christianity, Galen, Priest and gods, Arabs enlightenment, Sydenham, Pinel, Linnaeus, Freud, Kraeplin, Spitzer and the DSM (Frances, 2012). The common thread was to associate deviant behavior with the interest of certainty so as to take good care of people with various problems and those who were behaving badly. It ranged from the interpretation of which spirit was angry and what was necessary to appease it. The management of mentally disturbed people moved from the aggressive interventions to a focus on what was wrong with the affected individual and how well the person could be treated (Ici-berlin.org., 2015).
The notion of personality was introduced during the Galen’s time. The first classification of temperament and the idea of understanding the person both well, and the sick came from the four theories of humor (Frances, 2009). Christianity brought the concept of war between good and evil, and this led to a period of severe reactions to those who deviated as it was seen as a sign of possession (Frances, 2012). The Arabs in this period were very civilized, and they didn’t demonstrate any problem accepting mental illness. People with mental illness were not harshly judged, but there was a restriction of funds from the family with a person who was suffering from mental illness. Arabs doctors lived together with their patients, and it’s believed that they were among the earliest culture to begin classifying diseases (Frances & Widiger, 2012).
The taxonomist Linnaeus had a formative influence on the classification. He had traveled widely, and this enabled him to come across very many species (Ici-berlin.org., 2015). Pinel came after Linnaeus, and he is referred to as the father of modern psychiatry. He developed a more humane approach to psychiatric treatment (Frances, 2009). Sydenham also hailed around this time, and he introduced the notion of syndromes. Kraeplin took the concept of disease classification to a higher notch by arguing that it’s good to have a classification system and then attempt to follow this with an explanatory model (Frances, 2012). Freud was a neurologist, but he saw that there was the need to develop theories that explained the concept of the unconscious mind.
Pre-World War 2 there was a growing necessity for the US to collect statistics about mental disorders that were uniform (Frances, 2009). The need for uniformity led to the development of a new psychiatric manual after the war that was used to categorize mental disorders. It was formalized into the first DSM-1. International Classification of Diseases (ICD) also had their section of mental disorders. By around 1980s, there was an increasing risk of the psychiatric classification becoming irrelevant because each diagnostic category’s reliability was very low. This problem was addressed by the DSM task force that led to the introduction of DSM-III (Frances & Widiger, 2012). DSM-III was a more precise diagnostic criterion, a multiaxial system and it used a descriptive approach that was neutral to etiological theories. Development of DSM-III coupled with the emergence of semi-structured interviews helped professionals to read from the same page (Frances, 2012).
Despite the development of the DSM classification, people continued to misuse this classification as they used it as a bible rather than a guidebook (Frances, 2009). Psychiatrists conceptualized the entities in it, and the patients were in danger if their symptoms were not apparent in the symptom checklist (Frances, 2012). The more complex the category was, the less reliable the diagnosis was. Despite the advances in genetics and imaging over the last thirty years, it has not helped in the advancement of psychiatric pathology. It’s easy to understand the normal, but very difficult to comprehend processes in individuals when things go wrong. The understanding of the mechanisms of the brain has remained elusive despite the increase research findings in this area (Frances & Widiger, 2012). It is evidenced by the fact that even today there is no firm definition of mental disorder.
The main problem with psychiatric classification is the fact that definitions in the DSM are only theoretical in nature and also open to multiple interpretations (Ici-berlin.org., 2015). For the manual to be useful, it has to identify which disorders have enough evidence to be listed. If the sick person happens to be in the boundary how can the clinician involved figure out how to treat that patient. Unlike the past, when DSM systematization promoted research, it’s now withholding it back because there are no advances in psychiatric diagnosis (Frances & Widiger, 2012). For instance, after a period of 30 years in this research, there are still no identified biological tests for psychiatric pathologies. The psychiatrist can give a precise diagnosis if the there is a disorder that is clearly defined, but even in this case they must work within their competence (Frances, 2009). When there are unwarranted assumptions about the diagnosis of a psychiatric condition, the clinician can bring more harm than good.
Frances warns that mislabeling everyday problem as mental disease has a shocking implication of the individuals and the society (Frances, 2012). People must learn to differentiate between normal and real mental conditions. He argues that stigmatizing a healthy individual as suffering from mental disorders makes such a person be subjected to taking psychiatric medications that have harmful side effects (Ici-berlin.org., 2015). Frances caution that the new edition of the psychiatric bible the DSM-5 will turn millions of healthy people into mental patients. Frances argues that the real mentally ill patient will be neglected while the many “worried well” will be given the bulk of all psychiatric medications. He continues to argue that the DSM-5 will benefit pharmaceutical companies that will reap big profits from the sale of psychiatric drugs (Frances & Widiger, 2012).
There is some area of concerns in the use of DSM-5. They include the use of subsyndromal disorders, the confusion of whether to focus on a particular behavior or symptoms, the misuse of the manual itself and the judgment in the forensic area (Frances, 2012). Inflation of diagnostic inflation with an unprecedented number of children and adults being treated for diagnosing disorders is also noted. This inflation is thought to be brought by the increased number of possible diagnostic disorders (Frances, 2009). The pains and aches of everyday life are being pathologised with consequent over-diagnosis and over-medication. Research shows that half of the children diagnosed with autism grow out of it. In addition to the probable damage to the developing brain, there are also dangerous side effects associated with these medications such as diabetes, cardiovascular diseases, and increased obesity. A recent research done in America showed that there are more emergency admissions because of prescription drug overdose than from the illegal drugs (Ici-berlin.org., 2015).
There are also real concerns about the accuracy of the data in the DSM-5 it as well as the processes that were used in its development. On the DSM-5 committee, experts have been isolated from the more extensive feedbacks and data that come from the fields is not submitted. The available data shows very poor reliability and validity (Frances & Widiger, 2012). There is also an emphasis on the early recognition and treatment at the public level, which has resulted in the dramatic increase in misdiagnosis and unnecessary medical interventions. The committee experts concentrate on the missed diagnosis and research has proved that in US the average consultation last about seven minutes in the doctor’s office. The concerns become vivid, especially where the experts’ research translates into clinical practice (Frances, 2012). The reliability of the diagnosis that is reached in a research clinic is entirely different from that one achieved in a real life situation or practice.
Most busy doctors learn to use the DSM manual as a bible and follow up their diagnosis with medication sample provided by the pharmaceutical company for this disorder (Frances & Widiger, 2012). This situation increases the likelihood of making an inaccurate diagnosis and also wrong prescription of drugs that have the ability of causing harm to the affected individual due to their dangerous side effects (Frances, 2009). The psychiatrist should strive to make an accurate diagnosis and prescribe the right medication to contribute to the attainment of good health. The concept of early diagnosis and treatments should be understood well to avoid increased cases of misdiagnoses, over-treatment and stigma. Understanding that concept will assist in reducing too much influence of pharmaceutical companies and also minimize the misallocation of the scarce resources (Frances, 2012).
Dr. Frances was surprised by the approval of DSM-5 by the American Psychiatric Association (Frances, 2009). The approval did not take into consideration the scientifically unsound and unsafe changes in the DSM-5 will have on the health of the public. He advised the public and the clinicians not to follow it blindly as it can lead to massive over-diagnosis or harmful over-medication. He told them just to avoid the ten changes that do not make sense if they wanted to be on the safe side. DSM-5 has not been in a position to self-correct or even listens to the views of the outsiders. The motives of people working in the DSM-5 have been questioned (Ici-berlin.org., 2015). It is eluded that some have ties with pharmaceutical companies, and hence they benefit from the increased sale of prescribed psychiatric drugs. This illusion explains why they don’t want to drop some of the unsafe changes in the DSM-5 so that they can continue benefiting from the overtreatment brought by these changes (Frances & Widiger, 2012).
New diagnoses in mental health are more dangerous than new drugs because they influence whether millions of people are placed on drugs, mostly by primary care doctors after brief visits (Frances, 2012). Before new diagnoses are introduced, they deserve the same attention that we devote to new drugs. This role has proved to be impossible to APA displaying this association as incompetent in its duty. Dr. Frances discusses the list of DSM-5’s ten worst changes that need to be reviewed and corrected. Normal grief will be interpreted to mean major depressive disorder. Thus medicalizing and trivializing our ordinary, necessary and expected emotional reactions to the loss of a loved one (Frances, 2009). This misdiagnosis can make affected individuals begin taking medications that can have a harmful effect on them.
DSM-5 will turn temper tantrums into disruptive mood dysregulation disorder. This decision was reached after only one research group (Frances, 2009). There is confusion on how this untested diagnosis will work in real life situation, but one evidence is that it will only exacerbate instead of relieving the already excessive use of medications in young children. In the past two decades, child psychiatry has increased the prevalence of three disorders, namely attention deficit disorder, autistic disorder and childhood bipolar disorder. The association should have started by solving these past witnessed problems in child psychiatry instead of increasing their diagnoses and over medicating them (Frances, 2012). The APA should take time to educate its practitioners on the danger of excessive treatments in children.
The usual forgetting seen in old age will mean mild neurocognitive disorder. These misdiagnoses will lead to an increase in false positive population of the people who are not at special risk of developing dementia (Frances, 2012). This condition has no effective treatment even to those who are sick and hence there is no benefits of mislabeling healthy people like having this condition. Most of the adults will qualify for the attention deficit disorder. These misdiagnoses will lead to increase in the misuse of stimulants so as to keep the body active. The normal action of overeating as a sign of gluttony or availability of good tasting food will be interpreted to mean the person is suffering from binge eating disorder (Frances, 2009).
The changes in DSM-5 definition of autism are expected to result in lower rates (Ici-berlin.org., 2015). This minimization can be seen as beneficial in the essence that the diagnosis of autism will be more accurate and concrete. Here the problem will be on the misleading promises that will have no impact on the rates of disorders or service delivery (Frances & Widiger, 2012). People who abuse drugs for the first time will be labeled as core hard addicts. It has also introduced the concept of behavioral addiction in everything that we like such as the internet and sex (Frances, 2009). The usual worries of life are misdiagnosed as generalized anxiety disorder. In forensic settings, it has added more problems in the misdiagnosis of PTSD.
Dr. Frances has demonstrated that indeed misuse of psychiatric diagnoses is real. Many practitioners do not have the relevant knowledge that is necessary to make the right diagnoses (Frances, 2012). They just follow the DSM as a bible instead of using it as a guidebook. They go to an extent of using the medication provided by the pharmaceutical companies even without confirming their integrity. The APA made a mistake of approving DSM-5 without caring for the concerns of the public and other psychiatric experts. It has led to the increased number of misdiagnoses and over-medication we are experiencing today (Frances, 2009). The APA should consider revising DSM-5, and this time listen to the views of outsiders, so as to remove or rectify the unnecessary changes in it.
- Frances, A,. (2012). The Uses and Misuses of Psychiatric Diagnosis. Retrieved 22 January 2015, from https://www.blackdoginstitute.org.au/docs/TheUsesandMisusesofPsychiatricDiagnosisbyProfessorAllenFrancesMD.pdf
- Frances, A. (2009). A warning sign on the road to DSM-V: beware of its unintended consequences. Psychiatric Times, 26(8), 1-4.
- Frances, A. J., & Widiger, T. (2012). Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Annual Review of Clinical Psychology, 8, 109-130.
- Ici-berlin.org,. (2015). ICI Berlin: Situating Mental Illness. Retrieved 22 January 2015, from https://www.ici-berlin.org/videos/situating-mental-illness/part/2/