The January issue of the widely read e-zine Wired has published an article about Allen Frances’ (pictured left) vocal opposition to the process by which the 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disroders (DSM-5) is being written. There are, or course, many people who are discontented with the ways in which psychiatry goes about its professional business. What makes Frances’ critique so notable is not only that he is himself a psychiatrist, but that he was one of the editors of the last edition of the selfsame book, DSM-IV.
But Frances’ doubts go far beyond the 5th edition. They appear to extend to all of psychiatry, including his own participation in writing its most important and influential reference work. “There is no definition of a mental disorder. It’s bullshit,” he declares at one point. “We made mistakes that had terrible consequences,” he concedes at another.
One of Frances key worries is the dramatic uptick in psychiatric diagnoses that follows the inclusion of new, especially ill-defined, conditions in the DSM. In his own case, it was the extension of bipolar disorder to children, which led to a 40-fold increase in pediatric diagnoses of the condition. According to the article,
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.
Frances sees the influence of pharmaceutical companies in the proposals for the new edition as well. For instance, the editorial committee has suggested adding a condition they call “psychosis risk syndrome.” Although “only about a quarter of its sufferers would go on to develop full-blown psychoses…. [Frances] 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 [the chair of the Psychotic Disorders work group, Will] Carpenter was grievously underestimating.” (When the rough draft of the manual was released 11 months ago “psychosis risk syndrome” had been replaced by “attenuated psychotic symptoms syndrome,” thereby neatly sidestepping the criticism that too many allegedly “at risk” never went on to become psychotic.)
Now Robert Spitzer, a legendary psychiatrist who led the team that edited DSM-III (most notable for having cleared psychiatry of much of its psychoanalytic assumptions and vocabulary), has joined he fight as well. Spitzer is reportedly horrified at the secrecy under which DSM-5 is being written. All members of the editorial team have had to sign a confidentiality agreement. They say that this is to prevent undue influence from outside pressure groups such as pharmaceutical companies (though patients rights groups would, of course, be excluded as well). Spitzer argues that science cannot properly proceed in such a isolation, and that the discussions of the DSM working committees should be available to all psychiatrists, many of who have more specialized expertise than those doing the writing.