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What Spitzer told me, in essence, is that when clinicians ignore such contextual factors, they'll see mental disorders where there are none. In these cases, diagnoses are assigned unnecessarily. And this of course helps us unravel what we encountered in the Canadian study—younger children in the classroom being diagnosed with ADHD. The context of their relative age had not been taken into account. When a consideration context is omitted, in other words, damaging diagnostic oddities ensue.

4

In 1994, Spitzer's revolutionary
DSM-III
had finally reached the end of its shelf life. It was now time for it to be replaced by a new edition of the manual, entitled
DSM-IV
. The person who replaced Spitzer as chair of the new
DSM
was a psychiatrist called Dr. Allen Frances. Frances was appointed chair for many reasons. First, at that time he was head of psychiatry at Duke University, so he was believed to have the credentials. Also, the APA made it clear it wanted someone who had dabbled in many fields. Frances again seemed to fit the bill; not only had he trained in psychoanalysis, but he had conducted research on other therapeutic approaches, including studies of medications for depression and anxiety. Furthermore, because Frances had been minimally involved in the construction of Spitzer's
DSM-III
, he knew how diagnostic books are made and so could apply that knowledge in the construction of
DSM-IV
.

When I interviewed Frances in May 2012, his
DSM-IV
was still being used and sold around the world. This meant that apart from one minor revision in 2000, the manual he published in 1994 has for two decades shaped research and practice within the global psychiatric community.
33
What I wanted to know from Frances, therefore, was whether, with the benefit of hindsight, he felt his
DSM-IV
Taskforce had made any mistakes. In short, did his manual unleash any unintended negative consequences that he now regrets?

“Well, the first thing I have to say about that,” answered Frances confidently, “is that
DSM-IV
was a remarkably unambitious and modest effort to stabilize psychiatric diagnosis, and not to create new problems. This meant keeping the introduction of new disorders to an absolute minimum.”

What Frances meant by this was that his taskforce only added around eight new disorders to the main manual.
34
This indeed is a modest amount considering that Spitzer had introduced around eighty. And yet, from another standpoint, this claim to modesty is somewhat wobbly—it ignores that Frances also included an additional thirty disorders for “further study” in the appendix, and that he subdivided many existing disorders too. So if we include these appendix disorders and subdivisions (all of which patients can be diagnosed with), Frances actually expanded the
DSM
from 292 to 374 disorders.

But obviously Frances, and I believe wrongly, had chosen not to count the inclusions and subdivisions, for indeed, as he continued: “Yet despite that conservatism, we learned some pretty tough lessons. We learned overall that even if you make minimal changes to the
DSM
, the way the world uses the manual is not always the way you intended it to be used.”

Letting his questionable claim of conservatism stand for a moment,
I asked Frances to elaborate on what he meant by his learning some pretty tough lessons.

“We added a Bipolar II [this is for individuals who have manic episodes, who also might have a bipolar tendency]. We also added Asperger's disorder [this was to cover people who didn't have full-blown autism but who had considerable problems with autistic-like symptoms] and finally we added ADHD [for people who had attention issues coupled with hyperactivity]. And, well, these decisions helped promote three false epidemics in psychiatry.”

Trying to sound unfazed, I asked Frances to clarify what he meant by
three false epidemics
.

“We now have a rate of autism that is twenty times what it was fifteen years ago. By adding Bipolar II, we also doubled the ratio of bipolar verses unipolar depression, and that's resulted in lots more use of antipsychotic and mood-stabilizer drugs. We also have rates of ADHD that have tripled, partly because new drug treatments were released that were aggressively marketed. So every decision you make has a tradeoff, and you can't assume the way you write the
DSM
will be the way it'll be used. There will be so many pressures to use it in ways that will increase drug sales, increase school services, increase disability services, and so forth.”

At this point in our interview I could not help but recall young Dominic and the Canadian schoolchildren, all of whom had been diagnosed with ADHD. Was the creator of the modern ADHD category now admitting that potentially millions of children just like them (not to mention the adults) were being wrongly diagnosed with this and other mental health conditions?

I put the question to him directly: “Are you saying that the way the
DSM
is being used has led to the medicalization of a number of people who really don't warrant their diagnoses?”

“Exactly.”

“Can you put a figure on how many people have been wrongly medicalized?”

“There is no right answer to who should be diagnosed. There is no gold standard for psychiatric diagnosis. So it's impossible to know for sure, but when the diagnosis rates triple over the course of fifteen years, my assumption is that medicalization is going on.”

Once in a while when conducting interviews, you hear a confession that hits like a thunderclap. And this for me was one of those moments. Here was the creator of
DSM-IV
admitting that many new disorders they included actually helped trigger the unnecessary medicalization and medication of potentially millions of people.

But is this the whole story? Could the story actually be even worse than this? Frances's admission only relates to the
new
disorders he included, but what about all the
old
disorders (around 292) that Frances actually imported directly into his
DSM-IV
? After all, Frances's team only significantly reformulated four of the 292 disorders inherited from Spitzer. In other words, while Frances's “conservatism” meant many new disorders were placed in the appendix rather than in the main text, did it not also allow the continued existence of countless disorders that frankly had woeful scientific support?

For example, some of the more eccentric disorders Frances's taskforce incorporated into
DSM-IV
, and which also, incidentally, are contained in the ICD, included
:
Stuttering (disturbance in normal fluency and time patterning of speech);
Premature Ejaculation
(which requires no explanation);
Caffeine-Related Disorders
(caffeine withdrawal and dependency);
Expressive Language Disorder
(below average language skills);
Social Phobia
(shyness and/or fear of public speaking);
Sexual Aversion Disorder
(absence of desire for sexual activity);
Reading Disorder
(falling substantially below the reading standard for your age, intelligence, and age-appropriate education);
Female Orgasmic Disorder
(persistent or recurrent delay in or absence of orgasm);
Noncompliance with Treatment
(a diagnosis that can be given when the patient resists treatment);
Conduct Disorder
(repetitive or persistent violation of societal norms or others' rights);
Transsexualism
(identifying with a gender not of your sex);
Oppositional Defiant Disorder
(for children with irritable mood swings, and who overly defy authority), to name a few.

Notwithstanding that most critics find indefensible the idea that the above problems are psychiatric disorders, I asked Frances why he carried these and the other disorders from Spitzer's
DSM
into
DSM-IV
. Why didn't he, as chair of DSM-IV,
simply remove them on the grounds they were eccentric and enjoyed remarkably weak scientific support?

“If we were going to either add new diagnoses or eliminate existing ones,” Frances explained, “there had to be substantial scientific evidence to support that decision. And there simply wasn't. So by following our own conservative rules we couldn't reduce the system any more than we could increase it. Now, you could argue that is a questionable approach, but we felt it was important to stabilize the system and not make arbitrary decisions in either direction.”

“But one of the problems with proceeding in that way,” I pressed, “is that it assumes the
DSM
system you inherited from Spitzer was fit for its purpose. For example, it assumes that the disorders Spitzer included and the diagnostic thresholds Spitzer's team set [i.e., the number of symptoms you need to warrant any diagnosis] were themselves scientifically established.”

“We did not assume that at all,” asserted Frances. “We knew that everything that came before was arbitrary [Frances quickly corrects himself]; we knew that
most
decisions that came before were arbitrary. I had been involved in
DSM-III
. I understood their limitations probably more than most people did. But the most important value at that time was to stabilize the system, not change it arbitrarily.”

I pressed harder now. “So you are essentially saying that you set out to stabilize the arbitrary decisions that were made during the construction of
DSM-III
?”

“In other words,” corrected Frances, “it felt better to stabilize the existing arbitrary decisions than to create a whole assortment of new ones.”

At this point I simply did not know what else to say. Frances, it seemed, had said it all. While his “conservatism” had stopped his taskforce from including excessive numbers of new disorders (if we exclude the appendix inclusions and subdivisions), it had also led him to import Spitzer's mistakes into the DSM that has now been in medical use for eighteen years and is still in use today as I write. Not only did the eccentric and non-scientifically established disorders remain, but so too did many of the low thresholds people had to meet in order to warrant receiving a diagnosis. This meant that the dramatic medicalization of normal human reactions to the problems of everyday life was allowed to proceed unchecked.

5

Toward the end of my interview with Allen Frances, I asked him whether he felt that the problem of medicalization would be solved someday soon. I asked this question because, as I write, a new edition of the
DSM
(called
DSM-5
) is being prepared for publication in May 2013. Would this new
DSM
, many years in the making, rectify the problems of the past?

“That question is crucial,” responded Frances passionately, “because the situation I think is only going to get worse.
DSM-5
is proposing changes that will dramatically expand the realm of psychiatry and narrow the realm of normality—resulting in the conversion of millions more patients, millions more people from currently being without mental disorders to being psychiatrically sick. What concerns me about this reckless expansion of the diagnostic boundaries,” continued Frances, “is that it will have many unintended consequences which will be very harmful. The ones I am most particularly concerned about are those that will lead to the excessive use of medication, and most particularly antipsychotic medication because it leads to excessive weight gain.”

Frances was particularly disturbed by
DSM-5
's proposal to make ordinary grief a mental disorder. While previous editions of the
DSM
highlighted the need to consider excluding people who are bereaved from being diagnosed with a major depressive disorder, in the draft version of
DSM-5
that exclusion for bereavement has been removed. This means that feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and low appetite, which continue for more than two weeks after the death of a loved one, could actually soon warrant the diagnosis of depression, even though these reactions are simply the natural outcome of sustaining a significant loss.
35

“Reclassifying bereavement as a symptom of depression will not only increase the rate of unnecessary medication,” said Frances angrily, “but also reduce the sanctity of bereavement as a mammalian and human condition. It will substitute a medical ritual for a much more important time-honored one. It seems to me there are cultural rituals—powerful and protective—that we shouldn't be meddling with. But by turning a normal painful human experience into a medical illness we are doing precisely that.”

“Are there any other new inclusions in
DSM-5
that worry you?”

“Yes, sure—there is the new Generalized Anxiety Disorder which threatens to turn the aches and pains and disappointments of everyday life into mental illness. There is Minor Neurocognitive Disorder that will likely turn the normal forgetfulness of aging into a mental illness. There is Disruptive Mood Dysregulation Disorder which will see children's temper tantrums become symptoms of disorder. These changes will expand the definition of mental illnesses to include more people, exposing more to potentially dangerous psychiatric medications.”
36

“So where do we go from here?” I asked Frances, feeling rather bleak. “What will happen when this version goes forward?”

“I am worried that the already existing diagnostic inflation will be made much worse,” responded Frances, “and excessive medication treatment will increase. This will also lead to a misallocation of resources away from the more severely ill, who really need help, and towards people who don't need a diagnosis at all and will receive unnecessary and harmful treatment.”