The Balance of Allen Frances

How The Creator of DSM-IV Ended Up Being A Staunch Critic of DSM-V

For the last few weeks, I have been dissecting the history of the DSM from the 1970s onwards. So far, the main character in our stories has been Robert Spitzer and his shady legacy and methods in the creation of DSM-III. This week, I want to take the story forward and talk about how the future revisions of the DSM looked back on his work. The new main character in our story today is Dr Allen Frances who was the chairman of the DSM-IV Task Force. The position had been held by Robert Spitzer in the previous edition and for the fourth revision, Frances took on the role from him.

DSM-III had been created with one idea, to remove psychoanalysis from the mainstream psychological and psychiatric practice and follow other evidence-based techniques and methods to help patients in the clinic. This chase for evidence and scientific disorders and their treatments may not always have been up to the scientific standards though, as I wrote last week here. Still, one thing was clear, psychoanalysis had no place in psychiatry and psychology. It needed to be banished from the realm. That was Dr Robert Spitzer’s dream.

Frances: The Creator of DSM-IV

After the DSM-III was released in 1980, the flaws in its systems became obvious. It was not as reliable as the creators claimed it to be. The diagnostic criteria were not clear cut and it was not certain whether some disorders grouped together really belonged with each other. This led to the revision of DSM-III in 1987 but that was not enough.

The DSM needed to be overhauled once again. This time with a bigger pool of professionals to contribute to it. This required a new task force and a new chairman.

The man of choice was Dr Allen Frances

Dr Allen Frances

Ironically, Spitzer’s successor was, despite being a psychiatrist, a big fan of Freud and the psychoanalytic school of thought.

He thought it was a tragedy the way in which Freud’s work and his legacy was being tarnished for the sake of some reductive ‘biologicalism’. When he took over the DSM-IV task force, he just had one idea in mind: We don’t need more disorders.

DSM-III had added nearly 70 disorders to the list of recognized mental disorders. Frances believed we did not need more.

If DSM-III was the revolution of psychiatry, DSM-IV was the consolidation of power. It was based on more research than the previous edition and only ended up adding 8 new disorders.

DSM-IV was released in 1994 after six years of research, consultations and evidence gathering.

But that is not where the story of Allen Frances ends.

Allen Frances: The Critic

In 2007, another task force was set up. This was to create another new edition of the DSM. DSM-V was eventually published in 2013 and this time Allen Frances emerged as a vehement critic of the new edition.

He believed that the new edition had too many disorders. To the point that everyday life events were being pathologized as well. Frances called this ‘diagnosis inflation’. He hints this is due to the influence of pharmaceutical companies on the creators of the DSM but doesn’t dive deep into the extent of this influence.

I fear that too many psychiatrists are now reduced to pill pushing, with far too little time to really know their patients well……I despair the diagnostic inflation that results from a too loose diagnostic system, aggressive drug company marketing, careless assessment, and insurance company pressure to rush to judgement

Allen Frances in an interview in 2019

If that was not enough, in 2022, DSM-V was revised again to create DSM-V-TR, this time with even more disorders.

And is this not what most of our experiences with psychiatrists have been? You go to a psychiatrist, tell them what is troubling you and within the first session, you have a prescription for anti-depressants, anti-anxiety medication or sleep medicines or any combination of all three. There is hardly ever an attempt to understand what the patient is experiencing and a hurry to prescribe any pill possible.

That said, Frances does not think that psychiatry should be abolished, as some of his more excitable psychiatry critics feel. He feels that psychiatry needs to be reformed and the patient and their experiences need to be put back at the centre of the psychiatric practice.

Balance is what Frances advocates for. Not every problem is a mental illness, and neither are all mental illnesses simply money-making gambits.

I have previously talked of anti-psychiatrists like Szasz who believe that mental illnesses are not real at all and thus don’t need to be treated. Frances disagrees. For Frances, the suffering that his patients undergo is a genuine experience and denying that, or the idea that the practice of psychiatry can alleviate this suffering is incorrect.

Today, Allen Frances, the man who created the DSM-IV actively discourages psychiatrists from buying the latest editions of the DSM without prior research. He asks his peers to exercise caution while using what is called ‘the bible of psychiatry’ by many.

If the DSM truly is the bible of psychiatry, it is natural that it is going to have its own Luther and Dawkins as well, men who were born into the tradition of the Bible but then turned away from it.

Question of the Week.

What do you think about Frances assertion that modern psychiatry has too many diagnoses focused on selling drugs instead of helping individuals? Do you agree with him?

You can let me know in the comments :)

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And that is it for the week! (Or is it?)

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