Helene Guldberg reviews Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life by Allen Frances.
Frances’ arguments about the dangers of inflating psychiatric conditions and psychiatric diagnosis are persuasive — maybe more so because he honestly admits to his own role in developing such an inflation. He is keenly aware of the risks of diagnostic inflation ‘because of painful firsthand experience’, he writes. ‘Despite our efforts to tame excessive diagnostic exuberance, DSM-IV had since been misused to blow up the diagnostic bubble’. He is particularly concerned about the exponential increase in the diagnosis of psychiatric conditions in children, writing: ‘We failed to predict or prevent three new false epidemics of mental disorder in children — autism, attention deficit, and childhood bipolar disorder. And we did nothing to contain the rampant diagnostic inflation that was already expanding the boundary of psychiatry far beyond its competence.’
Take Attention Deficit Hyperactivity Disorder (ADHD), which is ‘spreading like wildfire’. This diagnosis is applied so promiscuously that ‘an amazing 10 per cent of kids now qualify’, Frances writes. He points out that in the US, boys born in January are 70 per cent more likely to be diagnosed with ADHD than boys born in December. The reason diagnosing ADHD is so problematic is that it essentially is a description of immaturity, including symptoms such as ‘lack of impulse control’, ‘hyperactivity’ or ‘inattention’. Boys born in January are the youngest in their school year group (in the US) and thus they are more likely to be immature; in the UK, the youngest children in a school classroom are born in August, and so here, August-born kids are more likely to be diagnosed with ADHD. We have medicalised immaturity.
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Until 1980, the DSMs were ‘deservedly obscure little books that no one much cared about or read’. DSM-I (published in 1952) and DSM-II (published in 1968) were ‘unread, unloved and unused’. Now, says Frances, this ‘bible’ of psychiatry ‘determines all sorts of important things that have an enormous impact on people’s lives — like who is considered well and who sick; what treatment is offered; who pays for it; who gets disability benefit; who is eligible for mental health, school vocational and other services; who gets to be hired for a job, can adopt a child, or pilot a plane, or qualifies for life insurance; whether a murderer is a criminal or mental patient; what should be the damages awarded in lawsuits; and much, much more’.
Today, as a result of various trends, including the impact of the DSMs, many human behaviours, quirks, eccentricities and woes which in the past would have been seen as parts of the rich tapestry of life are now branded mental disorders.
