Allen Frances and the Spurious Medicalization of Everyday Problems

Philip Hickey, PhD
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On April 5, Allen Frances MD, published an article on the Huffington Post blog.  The title is Can We Replace Misleading Terms Like ‘Mental Illness,’ ‘Patient,’ and ‘Schizophrenia’  It’s an interesting piece, and it raises some fundamental issues.

Here are some quotes from the article, interspersed with my comments.

“Those of us who worked on DSM IV learned first-hand and painfully the limitations of the written word and how it can be tortured and twisted in damaging daily usage, especially when there is a profit to be had.”

The fact that words can acquire multiple, and even contradictory, meanings is well known to most high school graduates.  People of all walks of life are generally sensitive to this reality, and take steps to clarify their meanings, especially with regards to words that are known to be ambiguous.

In the above quote, Dr. Frances is, I believe, implying that he and the other members of the DSM-IV work group chose their words carefully, but that their meanings were corrupted in “damaging daily use.”  Additionally, he appears to ascribe blame for this process to the drive for profits, presumably on the part of pharma.

But this is not consistent with the fact that ambiguity and a general lack of verbal precision are primary characteristics of successive revisions of the DSM, including DSM-IV.  In DSM-IV’s criteria for attention deficit hyperactivity disorder, for instance, the term “often” occurs in every criterion item, even though its lack of clarity, and its potential for abuse, are obvious.

. . . . . 

“This did not stop the widespread misuse of the terms Attention Deficit Disorder, Asperger’s Disorder, Bipolar Disorder, PTSD, Paraphilia and others. The lesson: If some wording in DSM can possibly be misused for any purpose, it almost certainly will be.”  [Emphasis added]

Here again, the impression being given is that Dr. Frances and his team defined these various terms judiciously and with precision, but that others came along afterwards and “misused” these carefully crafted definitions for their unstated, but presumably venal, purposes, while the injured innocents of the DSM-IV work groups could only watch in dismay from the sidelines.

The reality, of course, is quite different.  All of the definitions, in every edition of the DSM, are notoriously vague, and are subject to diverse interpretation.  This vagueness has consistently served the interests of psychiatry in expanding its scope and influence.  DSM-IV was simply one of the steps in this process, and the notion that Dr. Frances and/or other members of the work group were naïve to this dynamic is simply not credible.

. . . . . 

“‘Mental illness’ is terribly misleading because the ‘mental disorders’ we diagnose are no more than descriptions of what clinicians observe people do or say, not at all well established diseases. For example, the term ‘schizophrenia’ just describes a heterogeneous set of experiences and behaviors; it doesn’t at all explain them and eventually there will be hundreds of different causes and dozens of different treatments. ‘Schizophrenia’ is certainly is not one illness.”

This is in marked contrast to what Dr. Frances and his task force wrote in the DSM-IV section on schizophrenia:

 “The essential features of Schizophrenia are a mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period (or for a shorter time if successfully treated), with some signs of the disorder persisting for at least 6 months (Criteria A and C).” (p 274)

The clear implication here is that “Schizophrenia” (with a capital S!) is a single unified entity that can be recognized by its characteristic signs and symptoms.

In addition there are numerous phrases and sentences that imply clearly that, as far as the authors were concerned, schizophrenia is a unified condition.  These include “The individual with Schizophrenia…”; “Individuals with Schizophrenia…”; “The onset of Schizophrenia…”; “…the symptoms of Schizophrenia…”; ”…prevalence of Schizophrenia…”; “…age of onset for the first psychotic episode in Schizophrenia…”; “…course and outcome in Schizophrenia…”; etc…  In no part of the DSM-IV entry is there the slightest intimation that “schizophrenia” is anything other than a single unified “disorder.”

So again, it seems reasonable to ask:  what has changed?  Is there some new science that has debunked the old unified illness notion?  Or is it simply the case, as many of us on this side of the issue have maintained for years, that the unified illness notion was never more than a convenient psychiatric fiction, devoid of any scientific underpinning, which Dr. Frances is now disavowing.

Note particularly in the above quote from Dr. Frances’ current paper, the phrase:  “…it [schizophrenia] doesn’t at all explain them [the problematic experiences and behaviors]…”

Here again, this represents a marked departure from DSM-IV, where schizophrenia (the unified disorder) is clearly presented as the cause of the so-called symptoms.  In the section on schizophrenia (p 277) it states:

“Although quite ubiquitous in Schizophrenia, negative symptoms are difficult to evaluate because they occur on a continuum with normality, are nonspecific, and may be due to a variety of other factors (e.g., as a consequence of positive symptoms, medication side effects, a Mood Disorder, environmental understimulation, or demoralization).”

The statement that negative symptoms may be due to “other factors” clearly implies that in other cases, they are due to (i.e. caused by) schizophrenia.  Note, incidentally, that one of the other factors that is given as causative of negative symptoms is “a Mood Disorder,” again clearly implying that those “disorders” also are being conceptualized and presented as the causes of the “negative symptoms.”

. . . . .

“The ‘mental illness’ term also lends itself to a simple-minded biological reductionism that pays insufficient attention to the psychological and social factors that are crucial in understanding anyone’s problems. Everyone complains about ‘mental illness,’ but nobody has come up with a better substitute.”

The DSM-IV entry on Schizophrenia runs to 16 pages – p 274-290.  In all of that text, there is only one reference to environmental factors:

“Although much evidence suggests the importance of genetic factors in the etiology of Schizophrenia, the existence of a substantial discordance rate in monozygotic twins also indicates the importance of environmental factors.” (p 283)

and there is no specific reference to “…psychological and social factors that are crucial in understanding anyone’s problems.”  Additionally, on page 275, DSM-IV states:

“…positive symptoms may comprise two distinct dimensions, which may in turn be related to different underlying neural mechanisms…”

which at the very least suggests a “simple-minded biological reductionism.”  So, again, what we have is Dr. Frances lamenting a situation of which he and his colleagues were some of the primary architects.

And the old chestnut — we all hate the term “mental illness, but alas, nobody has come up with a better substitute.”  This, I suggest, is less than candid.  There are lots of better (i.e. more accurate) terms, e.g., problems of thinking, feeling, and/or behaving.  It is difficult to avoid the conclusion that psychiatrists cling to the term “mental illness,” not because they can’t come up with anything better, but rather because it serves as an integral part of the spurious medicalization of these problems.  If the concept of “mental illness” were to be eliminated, as it should be, then psychiatry’s justification for its role in this area would also go.  The notion that the APA, with all its talent and its prestigious PR company, couldn’t come up with a better term if they wanted to, is simply not remotely credible.

Note also that Dr. Frances’ concern about the term “mental illness” is because “…it lends itself to a simple-minded biological reductionism that pays insufficient attention to the psychological and social factors…”  And this, of course, is a valid concern.  But it is not the core concern.  The core concern with the term “mental illness” is that the problems it purports to delineate are not illnesses at all.  The spurious medicalization of these problems is the fundamental error from which all of psychiatry’s excesses and venality flow.  It is also the issue that they simply refuse to address.

. . . . . 

Dr. Frances expresses some reservations about the use of the term “patient,” because it implies  “…participation in a hierarchical relationship that brings with it little responsibility for shared decision making.”  Then he continues:

“But I have also never been comfortable with cold, market-sounding terms like ‘client,’ ‘consumer,’ ‘customer’ or ‘service user.’ These are business terms and lack the connotation of caring and responsibility associated with helping a ‘patient.’…Unless someone comes up with a better term, I think it would be better to rehabilitate the connotation of ‘patient’ rather than replace it, making clear that it implies full partnership in a therapeutic relationship.”

Here again, I suggest that Dr. Frances is being less than candid.  Social workers refer to the people they serve as “clients,” and the word has never suggested connotations of coldness or market place values in that context.  In fact, in my experience, social workers, other than those who have been co-opted by psychiatry, are arguably the most compassionate and client-centered professional group in this field.  And there are lots of other words, e.g. – and this is pretty radical – “person.”  And in fact, Dr. Frances’ own DSM-IV routinely uses the word “individual.”

If, as appears to be the case, Dr. Frances is arguing that psychiatrists cling to the term “patient” because it reflects their values of caring and warmth, all I can say is that I find this difficult to reconcile with the fact that the 15-minute med check has become psychiatry’s standard practice, and that the psychiatric falsehood – “a chemical imbalance just like diabetes” has been, and continues to be told to countless millions of psychiatric “patients.”

Dr. Frances expresses the belief that the word “patient” should be rehabilitated to make it clear that the term implies “full partnership in a therapeutic relationship.”  But he’s neglecting the fact that the term “patient” already has a perfectly valid and generally accepted meaning:  a person who is sick and who goes to a physician for assessment and/or healing.  And this, I suggest, is precisely why psychiatrists, including Dr. Frances, cling to the term – because when used in the psychiatric context, it embodies within its meaning the fiction that the problems “treated” by psychiatrists are illnesses requiring medical intervention.

. . . . . . . . . . . . . . . .

 Dr. Frances then quotes from a debate that he had with Anne Cooke PhD, editor of the BPS report Understanding Psychosis.  He notes that they are in agreement on some issues.

“We certainly join forces in worrying that loose usage and commercial gain have extended the terminology of mental ‘illness’ to many expectable problems of everyday living that are much better explained by psychological factors and social context and better described using everyday language.”

But:

“…we part company when you suggest that all diagnostic labels can be easily and safely. Your suggestion would have disastrous consequences for those who have severe psychiatric problems.”

There’s an obvious typo here, but it seems clear that Dr. Frances is stating that there would be disastrous consequences if diagnostic labels were dispensed with in the case of people with “severe psychiatric problems.”

There are two noteworthy points here.  Firstly, Dr. Frances has started referring to the DSM “diagnoses” as “diagnostic labels,” which is interesting.  Secondly, his use of the term “severe psychiatric problems” implies the existence of a discreet, identifiable set of problems, in the same way as the phrases “severe cardiac problems” or “severe kidney problems.”  In fact, this is not the case.  The DSM-IV definition of a mental disorder embraces all significant problems of thinking, feeling, and/or behaving, including expectable problems of everyday living.  If an expectable problem of everyday living, e.g., bereavement, crosses a  vaguely defined threshold of significance, then it is, by Dr. Frances’ own DSM-IV definition, a psychiatric problem.  And if it crosses an equally vaguely defined threshold of severity, then it becomes a severe psychiatric problem.

But even if we set that issue aside, the question still remains as to why dispensing with psychiatric “diagnoses” would result in disastrous consequences.  Dr, Frances tells us why.

“Here’s why: An adequate differential diagnosis of delusions and hallucinations requires full consideration of whether the problems are best described as: ‘Substance Induced Psychotic Disorder’, ‘Psychotic Disorder Due To A General Medical Condition’, “Delirium’, ‘Dementia’, ‘Schizophrenia’, Brief Psychosis’, Delusional Disorder’, ‘Bipolar Disorder’, ‘Major Depressive Disorder’, ‘Catatonia’, Obsessive Compulsive Disorder’, or ‘Sleep Disorder’. Each of this has different implications and calls for different actions. Only when all have been ruled out, can one conclude before that the experiences have no clinical significance and can be described adequately with everyday language.”

So in plain “everyday language,” what Dr. Frances is saying is this:  If a person is expressing delusional beliefs and hallucinating, we need to explore the nature and causes of the delusions and hallucinations if we want to adequately define and identify the problem.  So we have to compare the precise details of the individual’s presentation with the various DSM entities mentioned in order to get the correct “diagnosis.”  But he’s already told us that one of the “diagnoses” (schizophrenia) is merely a heterogeneous set of experiences and behaviors.  So it’s difficult to imagine what benefits would accrue from this kind of “differential diagnosis,” over and above a description of the problem in plain language.  Is Dr. Frances suggesting that the statement:  John is hallucinating and paranoid because he has been using PCP, is less informative than the statement:  John has Substance-Induced Psychotic Disorder?  It’s also difficult to imagine what “disastrous consequences” might result from the observation that Mary is expressing delusional beliefs because of a brain tumor, that would be averted by the formula Mary has Psychotic Disorder due to a general medical condition.

In fact, it is a general contention on this side of the issue that psychiatric “diagnoses” militate against the exploration of the nature and causes of the presenting problems, in that psychiatrists routinely terminate this kind of enquiry once they have determined the “diagnosis.”  And these are the very “diagnoses” that Dr. Frances earlier conceded are purely descriptive with no explanatory significance.

. . . . . . . . . . . . . . . . 

“Labels can help a great deal. They can hurt a great deal. They can provide clarity, but they can also badly mislead. The words we use in mental health all carry the heavy baggage of misleading and potentially stigmatizing connotation. They are vastly overused to describe mild problems of everyday life better described with everyday language. But we need diagnostic labels for the ‘severely ill’ and all suggested replacements are much more harmful than helpful.”

So Dr. Frances concedes that the words used in mental health are vastly over-used to describe “mild problems of everyday life,” but once again, he doesn’t seem to be acknowledging that his own DSM-IV was one of the great contributors to this process.  Psychiatric proliferation and expansion were both well under way by the time he convened his work force, but his final product endorsed every single aspect of DSM-III that had enabled and facilitated the expansion, e.g.:

  • the adoption, with only minor, inconsequential changes, of DSM-III’s all-embracing definition of a mental disorder;
  • the use of inherently vague language in the criteria sets;
  • the use of polythetic (two out of five, six out of nine, etc.) criteria sets;
  • the decision not to revert to DSM-I’s widespread use of the term “reaction,” which recognized that the problems being addressed were reactions of the individual to psychological, social, and biological factors;
  • the insistence, in the definition of a mental disorder, that the problems reside “in an individual,” as opposed to the person’s circumstances or environment;
  • the extensive use of the “not otherwise specified” (NOS) category, which essentially enabled psychiatrists to expand the so-called nosology more or less as they wished.

In addition to this, DSM-IV introduced specific innovations that also facilitated expansion of psychiatric turf into “the problems of everyday life.”

Firstly, it was DSM-IV that made it possible for an individual to be labeled “bipolar” without ever having displayed a manic episode.

Secondly, there occurred in DSM-IV a general liberalizing of the criteria for many of the so-called diagnoses.  “ADHD” is a good example.  DSM-III listed 14 criteria items for this label; DSM-IV listed 18.  One DSM-III item was dropped.  The additional five items in DSM-IV are:

“1 (a)  often fails to give close attention to details or makes careless mistakes in  schoolwork, work, or other activities.” (p 83)

This is almost a defining feature of early childhood.

“1 (e)  often has difficulty organizing tasks and activities”

Again, a fairly common attribute of young children.

“1 (f)  often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such  as schoolwork or homework)”

Note the use of the word “or.”  So if the child avoids, dislikes or is reluctant to do his/her homework, this criterion is endorsed.  I suggest that very few children actually like doing homework!

“1 (i)  is often forgetful in daily activities” (p 84)

Again, the pathologizing of the normal.

“2 (c)  is often ‘on the go’ or often acts as if driven ‘by a motor'”

The use of colloquialisms here is especially interesting, in that expressions like “always on the go” and “like he’s driven by a motor” are things that parents often say about their young children without any pathologizing connotations or intent.  By including these expressions in this list of “symptoms,” Dr. Frances and his team have effectively pathologized these descriptors, and brought psychiatric scrutiny to bear on children so characterized.

In addition, the following fairly extreme item in DSM-III

    “(14)  often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking” (p 53) [Emphasis added]

was liberalized in DSM-IV to the much more banal

     “2 (c)  often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)” (p 84)

In DSM-III, the “age of onset” had to be before the age of seven.  In DSM-IV, this requirement has been eased to “Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.” [Emphasis added] (p 84)

And, perhaps most significantly of all, in DSM-III the label ADHD is clearly conceptualized as pertaining to childhood.  DSM-IV, however, states:

“In most individuals, symptoms attenuate during late adolescence and adulthood, although a minority experience the full complement of symptoms of Attention-Deficit/Hyperactivity Disorder into mid-adulthood.  Other adults may retain only some of the symptoms, in which case the diagnosis of Attention-Deficit/Hyperactivity Disorder, In Partial Remission, should be used.  This diagnosis applies to individuals who no longer have the full disorder but still retain some symptoms that cause functional impairment.” (p 82)

In the light of all this, it is difficult to accept Dr. Frances’ contention that the proliferation and expansion of psychiatric “diagnoses” was not an integral part of his, and psychiatry’s overall plan.

And incidentally, psychiatry’s usual response to this particular criticism is that they must update the criteria, as more knowledge is gained about the “illnesses.” But this is untenable.  The only definition of the “illness” is the one given in the DSM.  There is no deeper entity to which the criteria refer.  What psychiatrists call ADHD is nothing more than a loose clustering of vaguely described habitual behaviors and omissions.  Psychiatry can add to, or modify, the list at will.  In stark contrast to real medicine, there is no reality to which these additions or modifications must conform.  If the APA decides that  “…is often forgetful in daily activities” is a “symptom” of the “illness” known as ADHD, then that decision makes it so.  And if the decision represents a liberalization of the criteria, then, literally overnight, more people will now “have” the “illness.”  And given that this process has been going on for the past fifty years, it is difficult to avoid the conclusion that it is intentional.

. . . . .

Dr. Frances’ position in this and other recent papers appears to be that in general, psychiatric “diagnoses” and “treatment” are OK, but that they are being overused by unscrupulous practitioners with the encouragement of pharma, and perhaps other monied interests.

And of course the expansion of psychiatric “treatment” is indeed a huge problem.  But it is a problem of Dr. Frances’ own making – a fact which, to the best of my knowledge, he has never conceded.

But, even more importantly, the expansion is not the critical issue.  The central issue is the spurious medicalization of non-medical problems in the first place.  There are no more grounds for considering severe depression an illness than there are for mild depression.  Severe and persistent inattentiveness is no more an illness than mild or transient inattentiveness.

It is from this spurious medicalization that all of psychiatry’s excesses flow.  Once psychiatry recognized that they could create illnesses by fiat, then the door was opened, and remains open, for unlimited expansion and pathologizing.  And Dr. Frances’ DSM-IV was a major – and perhaps the major – step in this process.

42 COMMENTS

  1. To build upon the conclusion of this excellent article, perhaps we could as the question: “From whence all the spurious medicalization and pathologizing?” In other words, why does psychiatry so relentlessly seek to medicalize and pathologize behavior?

    An honest inquiry into the history of psychiatry reveals the answers to such questions. The DSM-V is only the latest iteration (albeit an insidious one) of psychiatry’s quest to vanquish responsibility and liberty.

    Gary Greenberg’s “The Book of Woe” is a fun read. (http://www.amazon.com/The-Book-Woe-Unmaking-Psychiatry/dp/0399158537) Besides the obvious financial incentives that drove the creation of a new edition of the Bible of Psychiatry, there are fascinating political motivations at play in the upper echelons of psychiatric hegemony.

    No matter how the robber barons of the psychopharmaceutical industrial complex attempt to rationalize their misdeeds, the fact remains that, underneath the slick veneer of “compassion” and “concern” for the “mentally ill” lies an opprobriously dark history of stigmatization, drugging, torture, coercion, abuse and murder.

    • Dr. Speaking of responsibility: I would be tickled pink to face what I consider as Alice’s Restaurant level charges from 1989, which remain on my record. I never had the right to defend myself, as I was in disposed at Springfield Hospital in Maryland, where I was allegedly being helped. I believe that I conducted myself with dignity throughout the process, and I believe that I established proper and friendly protocol with the arresting officer along with the orderlies.
      Do you have any idea how to go about reopening a case so as to use as leverage to highlight the absurdities of the claims of psychiatry.’For what it is worth, I believe that in the last 25’years I have established myself as a Bono fide human being.

  2. I agree, thank you again, Dr. Hickey. I particularly appreciate the following comment:

    “In fact, it is a general contention on this side of the issue that psychiatric ‘diagnoses’ militate against the exploration of the nature and causes of the presenting problems, in that psychiatrists routinely terminate this kind of enquiry once they have determined the ‘diagnosis.'”

    My doctors who misdiagnosed the common adverse and withdrawal effects of a bad drug cocktail as “bipolar,” “paranoid schizophrenia,” and “depression caused by self,” based upon lies from alleged child molesters with medical evidence of the child abuse and prior easily recognized iatrogenesis, and then created psychosis with their neuroleptics, couldn’t answer my “hyper” questions of etiology, given my lack of personal or family history of “mental illnesses.”

    And how do we know the most common cause of schizophrenia and bipolar, the “serious mental illnesses,” is not psychiatrists misdiagnosing the central symptoms of neuroleptic induced anticholinergic intoxication syndrome as “bipolar” or “schizophrenia?” Especially given the “gold standard” treatment for these illnesses, the neuroleptics, are also known to cause the symptoms of the serious “mental illnesses.”

    “neuroleptics … may result in … the anticholinergic intoxication syndrome … Central symptoms may include memory loss, disorientation, incoherence, hallucinations, psychosis, delirium, hyperactivity, twitching or jerking movements, stereotypy, and seizures.”

    “Dr. Frances expresses the belief that the word ‘patient’ should be rehabilitated to make it clear that the term implies ‘full partnership in a therapeutic relationship.'” Does this mean Dr. Frances agrees that forced treatment should be abolished?

    Thanks for all you do, Dr. Hickey.

  3. I particularly appreciate your comments on ‘severe mental illness”For example:

    “Secondly, his use of the term “severe psychiatric problems” implies the existence of a discreet, identifiable set of problems, in the same way as the phrases “severe cardiac problems” or “severe kidney problems.” In fact, this is not the case. ”

    I fear that even when the ‘less ill’ (for lack of a better term) have found more humane and hopeful treatments, the severely ill will still be left behind to endure forced medication (even when it does not make them better), simply because we do not have the places or sanctuaries needed to meet their often extreme needs.

    • Hi Sa – To me, it seems true enough that all talk of efficacy in behavioral healthcare that happens without mention of either the fact that psychiatry is not genuinely medically involved in treating diseases or that its entitlements to extra-judicial authority in placing persons under care involuntarily keep it from having to prove its worth to them, or both, is talk that misleads. The two basic operative points in what creates the difference between perceived and real value to psychiatrically determined interventions are just this spurious idea of diseases and this insistence on intractably dangerous and impossibly widespread incompetence that psychiatry strives to eradicate from society. These issues underpin every aspect of research into efficacy and appropriateness of interventions. So you’re right to worry, because all the happy talk of reform or potential improvements in outcomes reasonable enough to hope for–without changing the dynamics of the system, does mean that the most incapacitated persons will become increasingly cut off. They will have to rely on this one caregiver’s-bold-conscience-at-a-time reform strategy we see so much of here. The ordinary run of discussions that could take place about government support for entitlements to bill for involuntary patients, and widespread academic, corporate, and media support for the cult of authority based on diagnosing mental diseases, just are the two main forces behind the current paradigm. Why are they treated as peripheral issues to the shoddiness of current practices by all but several important authors, those like Dr. Hickey and Bonnie Burstow? Meanwhile, these two writers in particular always leave me reflecting on the obvious truth that we can in general always do better for themselves when we face the music than when we withdraw from accountability. What lengths people won’t go to in their replies to abolitionist arguments in order to keep their bubbles from bursting. But if they didn’t, what would they do with all their opinions about what’s best for people who don’t ask for their help, or who wouldn’t if they had some other kind of opportunity like real sanctuary?

    • Sa – From what I gather about your understanding of your son’s needs and your (mutual, right?) ideas of causes, you should be able to take this as confirmation, strictly, for the positive outlook you can have for his recovery, as you’ve based your hope for that on learning all of what you can ideally do to make self-help worth it and to let life count naturally.

      http://www.research.ed.ac.uk/portal/files/11821926/Neural_Sufficiency_Reductionism_and_Cognitive_Neuropsychiatry.pdf

      You could already have read something like this, since it fits in with your theories. It’s short and not very technical and would also serve in helping to pre-empt assumptions and detect the inconsistencies of medicalization arguments. If you haven’t read anything like this before, your level of awareness is all the more impressive, and this little gem of an explanation can still work as a way to make “normal” a much bigger category than it usually represents. It fits in with the “Understanding Psychosis” themes, and so on.

  4. Dr. Hickey, this is by far the best critical analysis of Dr. Frances and his positions on the DSM and “mental illness” I’ve ever seen. We can expect a non-response from Dr. Frances to your post because the points you made are self-evident and damage his claims beyond repair. This post is one of your “greatest hits.” Bravo!

  5. Thank You Dr. Hickey ,
    This helps me see more clearly that the consecutive DSM manuals are really instruction manuals sanctioning psychiatrists to progressively evermore easily shanghai any human being to a drugged and/or electrified, available for further experimentation ,shortened lifetime of lowered expectations, stigmatization, coercion , and extorted compliance to benefit the ( shanghai & drugaslave 4life cashflocartel) or the (neo-spanish inquisitional pac-man 4 $$$) better known as the psychiatricpsychopharm-industrialcomplex. Do they label people because identifying tattoo’s might start an outright rebellion ?

        • I could be wrong, but believe he was referring to the long-term damage done by being on psychiatric drugs long term. Iatrogenic refers to “damage or illness caused by medical examination or treatment.” There are an increasing number of studies now showing that the longer people stay on psychiatric drugs, the worse their outcomes. This could be an association or causation, but what is pretty sure is that psychiatric drugs are not helping people recover (better than without them) in the long term.

          I think the other damage being done is the psychological damage of being told you have a “mental illness”, which is then expected to be life-long and incurable, creating internal stigma. We also have studies, for example John Read’s, showing that people who identify as having a mental illness do worse than people who have similar symptoms but do not identify as such.

        • I was dealing with iatrogenesis prior to coming into contact with psychiatry, my PCP wanted to cover up her husband’s “bad fix” on a broken bone, so she put me on an antidepressant, but lied, and claimed it to be a “safe smoking cessation med.” It does happen, Cpuusage.

        • Cpuusage – Nice handle, btw. Listen, on your long conceptualizing spin-out about mental illness and reality–take it from someone who has plenty of them, but isn’t seeing his chips down too much at the moment, you shouldn’t let yourself get too much in over your head trying to fight the hydra of social injustices. Some time ago, Fiachra, who comments here, posted this very helpful link for this particular social injustice demon-head of ours, biopsychiatry. Just a short article by one of her countryman, that happens to speak more or less directly to what you are saying, if I get you right.

          http://www.irishtimes.com/news/health/the-great-illusion-1.662763

          Notice that Browne’s emphasis on the when and how of making the diagnostic cravings of psychiatry functionless has to do with going beyond “methodological individualism”–that is, locating the whole of what defines persons within they themselves, whereas the truth that he indicates understanding is that part of who you are exists actually in the hearts and minds of others who know and understand you for themselves, however variously or well. And notice also, his notion of the how and when of radical change having to do with creating as yet unrealized modes of asylum (or sanctuary…). In this take on him,then, his manner of emphasis also implies that the systematic, stigmatizing uses to which psychiatric labels are put in the meantime ARE spurious. At least, I don’t as yet see him backsliding and “re-packaging” psychiatry, and don’t believe he is excusing his present way of employing psyhciatric terminology to lead people into more freedom from coercion and aimlessness who have suffered because of becoming patients. He means to convert sufferers from believing in mental diseases to seeing themselves responsible and capable of significant growth and change. Elsewhere he says he learned uniquely from his clients some new independence of mind for himself. That seemed believable, too. I think you will like his friendly authoritative style of elucidation. Take it easy–

          • Fully agree with the article.

            “The person has to do the work of changing themselves, with the support and guidance of a therapist.

            In these situations, the only way for healing to take place is for the person to open up the trauma and fully experience it so that it can become simply a memory. Then they will no longer be troubled by it.

            I feel the sort of therapeutic interventions that could give these individuals a foothold towards health would be, firstly, the establishment of a personal therapeutic relationship.

            What we urgently require is a new form of asylum, a therapeutic community that provides a warm, loving, human context within which a person can grow, develop a healthy lifestyle, learn to work and manage themselves.”

            Great! Sign me up! Where & how do i access all that exactly? It’s ideal Worlds.

  6. Holy cow:

    “Firstly, it was DSM-IV that made it possible for an individual to be labeled “bipolar” without ever having displayed a manic episode.”

    A neat trick, to be sure, but at least DSM-IV ruled out a bipolar diagnosis in people who exhibited manic behavior that was clearly a side-effect of antidepressants (ADs), as Dr. Hickey reported here: https://www.madinamerica.com/2015/01/antidepressant-induced-mania/
    But as he also mentioned, DSM-V allows manic behavior that occurred as an AD side-effect as a symptom of a bipolar disorder. Why? Well, from 2004:

    “A review of antidepressant-induced hypomania in major depression: suggestions for DSM-V”
    http://onlinelibrary.wiley.com/doi/10.1046/j.1399-5618.2003.00084.x/

    …whose authors concluded, per the abstract: “Depressed patients who experience antidepressant-associated hypomania are truly bipolar.”

    Really and truly, but says who? Not Dumb and Dumber, but Chun and Dunner. I’d never heard of either author, but you might have.

    The second author is D.L. Dunner, notorious friend to drug makers. He was listed as an expert witness for the defense of the disgraced Dr. Schulz in the U of M case in which a Seroquel clinical trial resulted in the death of a young man. http://www.circare.org/dw/dunner_20071112.pdf
    And more, here: http://en.m.wikipedia.org/wiki/David_L._Dunner#Pharmaceutical_controversies
    Dunner shares authorship with the disgraced Dr. Nemeroff, too.

    Meanwhile, Chun as lead author makes as much sense as Pee Wee Herman in that role. He has no other publications. He was a student at U of W’s medical school at the time, but doing what? His subsequent internship and residency were in family medicine at Sutter Health in Sacramento. He now specializes in podiatry and sports medicine in Honolulu, according to his listing on Kaiser’s site. He claims to be an assistant clinical professor at the university’s John A. Burns School of Medicine, although it seems U of H, per my search of their faculty database, is not aware of this.

    Not only will this denial of AD-induced manic symptoms add to the diagnosis- and drug-loads of depressed individuals, I assume it will lead to the omission of manic behavior from lists of adverse events in clinical trials of ADs.

    Looking ahead to DSM-VI, we can expect that any psychiatric symptoms that do not meet strict criteria for a diagnosis of catatonia will be ascribed to the new Bipolar Disorders, types III to IXX.

    ADHD, whose DSM-V criteria will be deemed “too detailed and boring,” will be renamed amphetamine-deficiency disorder.

    Are you ready for your dose-up?

    • I think that change in the DSM5 is one of the most deplorable. But I think it had to be changed because there are likely millions of people, including hundreds of thousands of children, who’ve been misdiagnosed as bipolar, due to antidepressant induced mania or other adverse effects – too many legitimate potential malpractice suits to not change it.

      “Firstly, it was DSM-IV that made it possible for an individual to be labeled “bipolar” without ever having displayed a manic episode.”

      In the off chance Dr. Allen looks at this, I’d like to inform him of what psychiatrists in practice now claim are “manic” symptoms:

      – “driving to Chicago” (from the suburbs to have lunch with my brother)
      – a $400 donation to a children’s charity (which I could afford)
      – the various known adverse effects of Wellbutrin, Voltaren (NSAI), and Ultram (a synthetic opioid)
      – disgust at 9.11.2001
      – contemplation of returning back to school for a Masters degree
      – belief in God / the Holy Spirit

      None of these are actually symptoms of “mania.” Perhaps, the DSM writers should take into consideration how truly inane, or unethical, it appears those within your field actually are?

      • When I first learned about ‘bipolar’ it was still called manic-depressive disorder (or disease)

        I prefer the old name as it describes two affective states. Bipolar, in contrast, describes the person.

        I wonder if treating mania with sedatives and depression with antidepressants would work better than these horrendous mood stabilizers?

        I wonder if the switch to the name bipolar was done to meds could be prescribed for daily use rather than episodically.

        My iatrogenic symptoms arose from a nursing mistake while I was recovering from a major surgery (abdominal)

        The resulting manic behavior got me into the meat grinder of psychiatry. I finally managed to get off everything and all is well.

        The last sad sack I tried to comply with wanted to me to take an antidepressant, and sedative, and a mood stabilizer.

        An up pill, a down pill, and stay in the middle pill.

        Not quite sure but does that not sound like a recipe for stasis?

        And by then I was only dealing with the hellish dread/terror “depression” which many experience during protracted withdrawal.

        Did you have morning terror/dread experience?

      • I see your point about the reason for removing the deplorable DSM-iv diagnosis of bipolar in children without mania. It is odd.

        The handling of ADHD in DSM also includes a diagnosis of ADHD Lite for people who do not meet all the criteria for ADHD proper.

        That just has to be to create business for doctors and increase drug sales.

  7. Philip, thank you for cleverly picking apart Frances’ deceptive statements.

    If Frances were most self-aware and honest, he might have admitted the following: “My entire career has been devoted to furthering the erection of a fraudulent house of cards, i.e. psychiatry based on diagnosis. This pseudo-science is now coming under increasingly harsh attack; therefore we should move to abandon psychiatry based on diagnosis.”

    But to admit that would make him look either like a complicit fool, or a clever deceiver who profited from what he knew was a false system to begin with. To avoid being viewed in these roles, it is easier for him to assume the role of the innocent hyena that gnaws at the bones of psychiatry’s carcass, while simultaneously preserving a few of those bones to protect his pseudo-contributions. This situation reminds me of a different version of Lord of the Rings’ Gollum: Someone has lost his “precious”, but can’t give it up entirely.

    As for “what are people experiencing then?” (Cpuusage), they are experiencing innumerable different degrees and kinds of emotional distress. However Philip’s point was that these kinds of distress cannot be reliably organized into diagnoses, as Frances implied, and Philip took even further. In other words, the distress/problems/suffering all exist, but the diagnoses based on them do not.

    A good metaphor might be how randomly picking out a group of stars and saying it’s “XYZ constellation” doesn’t mean that constellation is really out there: those particular stars in the so-called XYZ constellation are no more related to each other in nature than they are related to any other individual star or group of stars.

  8. Allen Frances is playing a dual role. This chief architect of the DSM-IV would position himself as chief demolitionist of the DSM-5. Why? Allen Frances is setting himself up as “the” authority. Allen Frances would be the save psychiatry from it’s detractors. How? In recent years, while the DSM-5 was being revised and published, he authored two books. Saving Normal. Most people noted that one. What they may have missed is that he also published a Essentials of Psychiatric Diagnosis meant to guide psychiatrists back from the path of excess, too. One book for the laity, and another for the experts. In other words, he’s up to this old psychiatrist’s trick, saving normal by vanquishing non-normal. If you think Frances has found the psychiatrists “key of Solomon” it works, if not, not. All this goes hand in hand with Frances extending a hand to Eleanor Longden, of the Hearing Voices Network, one day, and to E. Fuller Torrey, of the Treatment Advocacy Center, the next. Is Allen France remorseful over the DSM-IV? Perhaps, but only in so far as it serves Allen Frances, critic of the DSM-5, authority on serious mental illness, and savior of psychiatry. As far as it goes, I’m sick of hearing his name. There are other voices out there, and more deserving voices at that.

  9. Nicely done, Phil. The critique of Frances here is important. Both Spitzer (chair of DSM-III) and Frances (Chair of DSM-5), besides themselves affirming the medical model, would like the world to believe that what they did was just fine–as opposed to what the subsequent DSM-5 chair did. Not remotely so, and something that it is critical that we continue to challenge.

    • This question is difficult to answer, being phrased in a generalized and broad way (i.e. “everything that goes with mental illness” – what does that mean? – and “psychosis and mental illness” – these are not reliable conditions that can be as clearly discussed as diabetes or lupus).

      I also think you may be inferring intentions into the author that he did not have. Perhaps you feel that he is saying that severe psychosis and mental illness should be termed an “everyday problem”, but you might be assuming something he thinks that he in fact does not. He mentioned a whole range of problems, less and more severe, in the article, not just psychotic experience.

      In as much as psychotic experience and severe emotional distress can be viewed as logical reactions to abnormal or overwhelming experience, then these experiences can be viewed as understandable reactions that “normal” people can meaningfully relate to, without judging or labeling the person undergoing the extreme experience. Calling the presence of delusions/hallucinations or suicidal ideation an “everyday problem” would not be taking things at all seriously enough, and would be demeaning to the sufferer. But I am sure Hickey did not intend that… Severe emotional-psychological distress needs to be respected, understood, and taken very seriously. However, I would say (and Hickey surely would agree) that does not mean that such distress has to be called an “illness” and given a medical label.

      • “In as much as psychotic experience and severe emotional distress can be viewed as logical reactions to abnormal or overwhelming experience”

        i disagree that is always the case with psychosis/schizophrenia – you appear to be favouring the ‘social recovery’ model, loved by anti-psychiatry.

        i’d love someone to understand my experiences – have never comes across anyone that does.

      • I think psychosis can be understood as often an extreme version of everyday problems (though it can a also of course be a side effect of some medical or drug problems.)

        “Normalizing” is a method used within CBT for psychosis, to help people understand how their psychotic experiences may be understood as on a continuum with everyday problems, even if toward an extreme end of that continuum. For more on that approach, check out https://www.madinamerica.com/2014/07/normalizing_psychosis/