Inside the Battle to Define Mental Illness

By Gary Greenberg *

*Every so often* Al Frances says something that seems to surprise even him.
Just now, for instance, in the predawn darkness of his comfortable, rambling
home in Carmel, California, he has broken off his exercise routine to
declare that “there is no definition of a mental disorder. It’s bullshit. I
mean, you just can’t define it.” Then an odd, reflective look crosses his
face, as if he’s taking in the strangeness of this scene: Allen
Frances,
lead editor of the fourth edition of the American Psychiatric Association’s
*Diagnostic and Statistical Manual of Mental Disorders* (universally known
as the *DSM*-IV ), the guy who wrote
the book on mental illness, confessing that “these concepts are virtually
impossible to define precisely with bright lines at the boundaries.” For the
first time in two days, the conversation comes to an awkward halt.

But he recovers quickly, and back in the living room he finishes explaining
why he came out of a seemingly contented retirement to launch a bitter and
protracted battle with the people, some of them friends, who are creating
the next edition of the DSM. And to criticize them not just once, and not in
professional mumbo jumbo that would keep the fight inside the professional
family, but repeatedly and in plain English, in newspapers and magazines and
blogs. And to accuse his colleagues not just of bad science but of bad
faith, hubris, and blindness, of making diseases out of everyday suffering
and, as a result, padding the bottom lines of drug companies. These aren’t
new accusations to level at psychiatry, but Frances used to be their target,
not their source. He’s hurling grenades into the bunker where he spent his
entire career.
One influential advocate for diagnosing bipolar disorder in kids failed to
disclose money he received from the makers of the bipolar drug Risperdal.

As a practicing psychotherapist myself, I can attest that this is a
startling turn. But when Frances tries to explain it, he resists the kinds
of reasons that mental health professionals usually give each other, the
ones about character traits or personality quirks formed in childhood. He
says he doesn’t want to give ammunition to his enemies, who have already
shown their willingness to “shoot the messenger.” It’s not an unfounded
concern. In its first official response to Frances, the
APAdiagnosed him with “pride of authorship” and
pointed out that his royalty
payments would end once the new edition was published—a fact that “should be
considered when evaluating his critique and its timing.”

Frances, who claims he doesn’t care about the royalties (which amount, he
says, to just 10 grand a year), also claims not to mind if the APA cites his
faults. He just wishes they’d go after the right ones—the serious errors in
the DSM-IV. “We made mistakes that had terrible consequences,” he says.
Diagnoses of autism ,
attention-deficit hyperactivity disorder, and bipolar disorder skyrocketed,
and Frances thinks his manual inadvertently facilitated these epidemics—and,
in the bargain, fostered an increasing tendency to chalk up life’s
difficulties to mental illness and then treat them with psychiatric drugs.

The insurgency against the DSM-5 (the APA has decided to shed the Roman
numerals) has now spread far beyond just Allen Frances. Psychiatrists at the
top of their specialties, clinicians at prominent hospitals, and even some
contributors to the new edition have expressed deep reservations about it.
Dissidents complain that the revision process is in disarray and that the
preliminary results, made public for the first time in February 2010, are
filled with potential clinical and public relations nightmares. Although
most of the dissenters are squeamish about making their concerns
public—especially because of a surprisingly restrictive nondisclosure
agreement that all insiders were required to sign—they are becoming
increasingly restive, and some are beginning to agree with Frances that
public pressure may be the only way to derail a train that he fears will
“take psychiatry off a cliff.”

At stake in the fight between Frances and the APA is more than professional
turf, more than careers and reputations, more than the $6.5 million in sales
that the DSM averages each year. The book is the basis of psychiatrists’
authority to pronounce upon our mental health, to command health care
dollars from insurance companies for treatment and from government agencies
for research. It is as important to psychiatrists as the Constitution is to
the US government or the Bible is to Christians. Outside the profession,
too, the DSM rules, serving as the authoritative text for psychologists,
social workers, and other mental health workers; it is invoked by lawyers in
arguing over the culpability of criminal defendants and by parents seeking
school services for their children. If, as Frances warns, the new volume is
an “absolute disaster,” it could cause a seismic shift in the way mental
health care is practiced in this country. It could cause the APA to lose its
franchise on our psychic suffering, the naming rights to our pain.
(Emphasis in red added - B.M.)