in his debt…

Posted on Monday 3 December 2012

Something extraordinary happened in psychiatry in our recent past. Something that I could never have imagined in my wildest dreams. The two men who had shepherded the revolution in psychiatric diagnosis [DSM-III, DSM-IIIR, DSM-IV, and DSM-IVTR], Drs. Robert Spitzer and Allen Frances, not only became critics of the DSM-5 Revision, they came out of retirement and took their complaints to the street – particularly Dr. Frances who kept us informed about what the Task Force was doing and where they were going off track in his blogs, articles, op-eds, and speeches:
DSM5 in Distress
The DSM’s impact on mental health practice and research
Psychology Today: DSM5 in Distress
by Allen Frances, M.D.
March 6, 2010 through December 2, 2012
If you don’t know how all of this came about, Gary Greenberg‘s 2010 article in Wired is the definitive narrative:
Inside the Battle to Define Mental Illness
The Book of Woe
By Gary Greenberg
December 27, 2010
Concretely, Dr. Frances’ tireless campaigning alerted us to some of the more inappropriate diagnostic categories being considered and was influential in keeping them out of the final revision. Even more, he pointed out the closed shop nature of the DSM-5 process, the encouragements for overdiagnosis and overmedication, and the idiosyncratic pet projects of the Task Force members. But his lasting contribution will be that he was an insider who spoke frankly and openly about many of the broad misdirections of modern psychiatry. In his career including being Chairman at Duke and Director of the DSM-IV Revision, he has long been a leader in our field. His willingness to stand up for psychiatry by opposing this misbegotten revision of our diagnostic system was unprecedented – a courageous extension to an already distinguished career. Maybe he couldn’t totally stop this ill-conceived revision, but in the process of trying, he turned on some lights that will be seen for some time. We are in his debt…
DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes
APA approval of DSM-5 is a sad day for psychiatry
Psychology Today: DSM5 in Distress
by Allen J. Frances, M.D.
December 2, 2012

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense…
    December 4, 2012 | 8:43 AM

    Mickey, you are usually careful to keep things in perspective. Lauding Allen Frances as a hero (my words, not yours) seems somewhat out of place, at least based on Paula Caplan’s experience. May I quote her here (from
    “Several years ago, psychiatrist Allen Frances, probably the single individual responsible for the pathologizing of millions more human beings than anyone else in history, began lighting into the people preparing the DSM-5, the edition due to be published in 2013. He claimed that what they were doing was unscientific and would cause harm. Frances had headed the Task Force that prepared the DSM edition that is currently in use and has been since 1994, the DSM-IV (and its slightly revised offspring, DSM-IV-TR, of which he was one of three editors). He was the person who had invited me to serve on two of his Work Groups, telling me that for his edition, “this time” the decisions would be based on the science, and “this time” they would have open and honest debate. I smiled to myself when he told me that, because that was what Robert Spitzer, who oversaw the production of the two previous editions, had said about his. But I wanted to believe what Allen told me. After two years, I quit his Work Groups when I saw how he and his colleagues used junk science to support whatever they wanted to do and ignored, distorted, or frankly lied about well-done research when it failed to support their aims. I also quit when I saw that, despite my sending them reports of people harmed by their labels, he and his colleagues failed to act to try to prevent that harm, and some even claimed publicly that they caused no harm.

    When criticizing the DSM-5 leaders, Frances writes as though his critique had sprung straight out of his own head, failing to cite the enormous number of people who had legitimately voiced those criticisms about his own editions.

    Furthermore — and strangely — although he has actually gone so far as to say that there is no good definition of mental disorder, declaring that it’s “bullshit,” he nevertheless continues to spend a great deal of time claiming that for his editions of the manual, the process was painstakingly scientifically grounded.

    One might say that there’s no harm in Frances’s railing against DSM-5 and that in fact he is doing a service by pointing out its dangers. There are several problems with that, however, and I will state one here: Because of the drama of his position, having headed DSM-IV and now casting himself as Cassandra for DSM-5, so much attention has been focused on the forthcoming edition that the harm currently being done every day by his own editions is being overlooked. Certainly neither Frances, who apparently no longer belongs to the APA for reasons the APA will not disclose, nor anyone currently within the APA has taken steps to redress any of that harm.”

    December 4, 2012 | 10:51 AM

    I concur. The opaque cargo science process that is the paradigm for the creation process of the modern DSMs allows/promotes the problems that have reached their current zenith in the DSM 5. The zealotry of Kupfer and others found a mechanism that lent itself well to exploitation. Just as pharmaceutical companies did. This is not a coincidence. It says something about how flawed Spitzer’s/Frances’ approach was to begin with. The modern DSM creation process was opaque and opinion driven with pretensions of scientific basis and transparency from III onward.

    Scientists and clinicians need to look to making institutional change. To shifting in a meaningful way the way power is distributed within them.

    1BOM, you can agree with many of his criticisms of DSM 5, but the process he pioneered excelled at freezing out conflicting views and presenting an illusion of consensus and provided very fertile ground for a new set of oligarchs.

    They differed in terms of kappa and their zealotry was not aimed at being atheoretical, as his zealotry had been, but in many many ways they were using Spitzer’s and Frances’ playbook.

    December 4, 2012 | 2:05 PM

    Thanks for the comments. I’m aware of his previous positions. There are more than either of you mention that have bothered me along the way. But to my way of thinking, both Frances and Spitzer represent something that I respect – they changed. The fact they were both psychanalytically trained, then became Gurus in the DSM Revolution, then opposed this DSM-5 debacle looks to many as being fickle, blowing with the wind, maybe even opportunistic.

    Spitzer is a decade older than I am. Frances is my age, but ahead because I had another career first [Internal Medicine]. But I’ve sailed the turbulent seas of the same psychiatry they have, and fled academia in response. To have stayed would’ve required making radical changes that weren’t in me to make. Tom Insel was something of a hippie do-gooder who chose a Jungian analyst for his personal therapy while in residency. John Rush [STAR*D, TMAP] was a Cognitive Behaviorist studying with Aaron Beck, himself a trained psychoanalyst. Even Thomas Szasz was in training as an analyst. I was a research Rheumatologist measuring the binding coefficients of the autoimmune antibodies and doing electron microscopy of capillaries in Progressive Systemic Sclerosis. This era of medicine has been quite a ride for all.

    I particularly respect Dr. Frances for this:

    At the party, Frances and Carpenter began to talk about “psychosis risk syndrome,” a diagnosis that Carpenter’s group was considering for the new edition. It would apply mostly to adolescents who occasionally have jumbled thoughts, hear voices, or experience delusions. Since these kids never fully lose contact with reality, they don’t qualify for any of the existing psychotic disorders. But “throughout medicine, there’s a presumption that early identification and intervention is better than late,” Carpenter says, citing the monitoring of cholesterol as an example. If adolescents on the brink of psychosis can be treated before a full-blown psychosis develops, he adds, “it could make a huge difference in their life story.”

    This new disease reminded Frances of one of his keenest regrets about the DSM-IV: its role, as he perceives it, in the epidemic of bipolar diagnoses in children over the past decade. Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold. Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes. In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose money he’d received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times reported that Biederman told the company his proposed trial of Risperdal in young children “will support the safety and effectiveness of risperidone in this age group.”) Frances believes this bipolar “fad” would not have occurred had the DSM-IV committee not rejected a move to limit the diagnosis to adults.

    Frances found psychosis risk syndrome particularly troubling in light of research suggesting that only about a quarter of its sufferers would go on to develop full-blown psychoses. He worried that those numbers would not stop drug companies from seizing on the new diagnosis and sparking a new treatment fad—a danger that Frances thought Carpenter was grievously underestimating. He already regretted having remained silent when, in the 1980s, he watched the pharmaceutical industry insinuate itself into the APA’s training programs. (Annual drug company contributions to those programs reached as much as $3 million before the organization decided, in 2008, to phase out industry-supported education.) Frances didn’t want to be “a crusader for the world,” he says. But the idea of more “kids getting unneeded antipsychotics that would make them gain 12 pounds in 12 weeks hit me in the gut. It was uniquely my job and my duty to protect them. If not me to correct it, who? I was stuck without an excuse to convince myself.”

    At the party, he found Bob Spitzer’s wife and asked her to tell her husband (who had been prevented from traveling due to illness) that he was going to join him in protesting the DSM-5.

    He changed his mind, in part because of remorse about earlier decisions. There are many other examples. I can’t imagine anyone making it through the last 40 years, particularly in academic psychiatry, who wasn’t all over the map. That’s not an excuse for the past, but it’s sure better than the alternative – the people who barreled ahead without reflection.

    I’m a psychoanalyst, and I’ve had to realize that many of the criticisms leveled at us were dead on target, not an easy pill to swallow. The things I write in this blog are not remarkably different from things I felt twenty years ago, just more informed, but for most of that time, I stayed in a foxhole – something I’m not terribly proud of. I feel good about my clinical work in those years, but I also feel like a draft dodger, fleeing from the fog of a war that I didn’t understand – but now wish I’d tried harder to make sense of

    When I wrote, “a courageous extension to an already distinguished career” above, I actually had Henry, the protagonist in Stephen Crane’s Red Badge of Courage, in my mind. He was a soldier who had not been the soldier he wanted to be, but found an honorable way to get back in the fray in the end. That’s what I see in Allen Frances. It’s similar to what I sometimes see in the mirror. But there are few heros in this story…

    December 4, 2012 | 3:23 PM

    Thank you very much for your reflective and thoughtful reply. It contains much for me to ponder.

    Mark Kramer
    December 4, 2012 | 5:37 PM

    Wonderfully candid material.

    With this I am going to invite some present, some fairly high profile warriors to tune in here. Many are those are who I believe to have made sincere efforts along the way to acquire personal and professional understanding. Some have only worked professionally without much self awareness and no mea culpas. Others are drop outs, who’d had enough of the confusion I hope they will come. I hope they will not recoil permanently upon receiving some of the potentially angry barbs cast their way here.


    So much of what I read here is relevant to one’s search for understanding – deeply personal and professional.

    The thing that would make this more spectacular than it already is for me if each participant would find it in themselves to offer how they are related to past, or current, “life disruptive psychological distress” (DPD*) – there would often be more than one reason. e.g.,

    1) a parent of a child or a spouse a child of a a parent w/ DPD
    2) a person w/ DPD
    3) by profession:
    – MD + specialty (endocrine, neurology, family practice, psychiatrist)
    – PhD psychologist or LCSW (researcher/clinician)
    – MS psychologist or LCSW
    – Psychiatric Nurse Practioner
    – Alternate therapy practioner (giving type, accreditation, or training/ apprentice work)
    – professional or near professional web master devoted to DPD
    – professional journalist
    – politician, government employee working on ethics cases
    -professional ethicist
    – lawyer (working for defendant or plaintiff)
    – insurer

    I can understand the need for anonymity in some. However, your specific affiliation(s) w/ DPD allows me to understand your thoughts in context – in terms of your potential C.O.I. and your history. It is exactly what you wanted from me. It is what I’ve given you in revealing terms.

    Much of this is about the hegemony of Bio. Psychiatry, if not M.D.s trained in psychiatry (and its recent scandals) vs. the rest of the world (each w/ its own set of scandals) .

    Without this kind of information. many would lightly assume that some comments (whether on potential target or not) are prompted by a political Conflict of Interest – i.e., to diminish terminally the authority of psychiatrists in the field of mental health in order to clear the way for your own. It’s OK. But say it, if it is so. I for one would not consciously make the fallacy of association: however, I would be able to search for what data speaks to your position, vs. data that some of you present wh/ attempts to tear down the most potent political authority in the field. It is fair. And fairness is part of the gist here.

    Now that I am activated for now, my gist is to struggle w/ how my profession (i.e, psychiatric medicine ) can re-conform to its aspirations as a meritocracy in the service of lightening human suffering. I am just beginning to see it – where it went terribly wrong now; what was terribly right, too. Those inflections have little to do w/ Charlie and gang. It has to do w/ something much more fundamental – buried in the book chapter I inadvertently authored here .


    * it is phrased as DPD b/c that is not necessarily a mental disorder requiring medical or non-medical intervention.

    December 5, 2012 | 10:30 PM

    My state and clinic are gearing up for changes in the ICD which will guide (drive) reimbursement. Nobody cares about DSM 5.

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