Editor’s Note: The controversial fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5 (a.k.a. the manual formerly known as “DSM-V”) is being released tomorrow – after a 14-year revision process to update its criteria for defining mental disorders. This opinion is from the former taskforce chairman and leader of previous DSM editions.
Nature takes the long view, mankind the short. Nature picks diversity; we pick standardization. We are homogenizing our crops and homogenizing our people. And Big Pharma seems intent on pursuing a parallel attempt to create its own brand of human monoculture.
With an assist from an overly ambitious psychiatry, all human difference is being transmuted into chemical imbalance meant to be treated with a handy pill. Turning difference into illness was among the great strokes of marketing genius accomplished in our time.
All the great characters in myths, novels, and plays have endured the test of time precisely because they drift so colorfully away from the mean. Do we really want to put Oedipus on the couch, give Hamlet a quick course of behavior therapy, start Lear on antipsychotics?
I think not. Human diversity has its purposes or it would not have survived the evolutionary rat race. Our ancestors made it because the tribe combined a wide variety of talents and inclinations. There were leaders high on their own narcissism and followers content enough to be dependent on them; people who were paranoid enough to sniff out hidden threats, compulsive enough to get the job done, and exhibitionistic enough to attract mates. Perhaps the healthiest individuals were those who best balanced all these traits somewhere near the golden mean, but the best bet for the group was to have outliers always ready to step up to the plate as the particular occasion demanded.
Allen Frances is professor emeritus and former chair of the Department of Psychiatry and Behavioral Science at Duke University School of Medicine. The Chairman of the DSM-IV Task Force and part of the leadership group for previous editions, Frances’ book Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life was released this week.
I like eccentricity and eccentrics. The word eccentric comes from Greek geometry meaning “out of center.” It entered English as an astronomical description of the rotational paths of the heavenly bodies. Now it is used to describe people who are different — mostly with pejorative connotations, not often enough with admiration for their particular genius.
Nature abhors homogeneity and simply adores eccentric diversity. We should celebrate the fact that most humans are at least somewhat eccentric and accept ourselves as we are, warts and all. Human difference was never meant to be reducible to an exhaustive list of diagnoses drawn carelessly from a psychiatric manual.
It takes all types to make a successful tribe and a full palette of emotions to make a fully lived life. We shouldn’t medicalize difference and attempt to treat it away by taking the modern-day equivalent of Huxley’s somapills.
So how do we save normal, preserve diversity, and achieve a more rational allocation of scarce resources?
Our professionals should act professionally and within their proper competence. Psychiatrists should stick to what they do best — treating people who have real psychiatric problems — and not expand the field to include the normal worried well, who will do just fine on their own. Primary care doctors should stick to what they do best and stop being amateur psychiatrists. Drug companies should stop acting like drug cartels, irresponsibly pushing product where it will do more harm than good. Consumer advocacy groups should advocate for their consumers, not for the group. The media should expose excessive medical claims, rather than mindlessly trumpeting them.
Do we have a realistic chance to reverse diagnostic inflation, or is the die already cast in favor of a never-ending parade of false epidemics? My rational self tells me that diagnostic inflation will win and that saving normal will lose.
But never give up on an underdog, no matter how long the odds. Every once in a while, scrawny David does pull off the seemingly impossible, and invincible Goliath does bite the dust. Who would have thought that Big Tobacco, once so seemingly invincible, could be taken down so quickly? Big Pharma is clearly riding for the same kind of fall — this emperor really does have no clothes.
People and policymakers may eventually wake up to the fact that we are not a bunch of sick individuals, each of us having a bunch of psychiatric diagnoses, cumulatively constituting a sick society. This is a myth generated by an overly ambitious psychiatry and a remarkably greedy pharmaceutical industry.
Most of us are normal enough and would like to stay that way. We can “save normal” only by “saving psychiatry,” and we can save psychiatry only by containing it within its proper boundaries. The legacy of Hippocrates rings as true today as it did 2,500 years ago — be modest, know your limitations, and first do no harm.
Excerpted from Saving Normal by Allen Frances, copyright 2013, published by William Morrow.