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.)