Where Have All the Normals Gone?

Click here to read an original op-ed from the TED speaker who inspired this post and watch the TEDTalk below.

Jon Ronson claims to have a dozen DSM mental disorders. Clearly, he has me beat by very far -- I can diagnose myself with only a handful.

We are both joking, of course, but the joke is not the slightest bit funny and it touches on a problem that has deadly serious consequences.

The boundary between psychiatry and normal is fuzzy and elastic, with no bright line to say who is sick and who is well.

Loose definitions of mental disorders and misleading drug company marketing have combined to shift the playing field.

Psychiatry is rapidly expanding and normal is shrinking.

Grief is now Major Depressive Disorder; medical illness is Somatic Symptom Disorder; everyday worries are Generalized Anxiety Disorder; the forgetting of old age is Mild Neurocognitive Disorder; being geeky smart makes you an Aspie; gorging is Binge Eating Disorder; having temper tantrums is Childhood Bipolar Disorder; and all of us have Attention Deficit Disorder (ADD).

And things can get even worse if the concept of Behavioral Addictions is ever taken seriously. Our interests and passions will be turned into Internet Addiction; Work Addiction; Sex Addiction; Shopping Addiction; Golf Addiction; Jogging Addiction; and my personal favorite Sun Worship Addiction.

Grief is now Major Depressive Disorder; medical illness is Somatic Symptom Disorder; everyday worries are Generalized Anxiety Disorder; the forgetting of old age is Mild Neurocognitive Disorder; being geeky smart makes you an Aspie; gorging is Binge Eating Disorder. -- Allen Frances

Here is the cruel paradox. We are spending tens of billions of dollars plying the worried well with unnecessary and expensive drugs, while at the very same time ignoring the desperate needs of those who really could benefit from psychiatric diagnosis and treatment.

Because of sharp cuts in state mental health budgets, more than one million mentally ill people are behind prison bars for nuisance crimes that could have been avoided if they had access to care and decent housing. This is inhumane and economically irrational.

I am partly to blame for the topsy-turvey misallocation of resources. I have been involved in the preparation of DSM's that set too low a threshold for diagnosing mental disorder. The decisions we made seemed appropriate at the time, but we never anticipated the awesome power of drug company advertising to sell psychiatric ills as a way of encouraging people to buy their over-priced and over-sold pills.

Attention Deficit Disorder is a good illustration that what is written in the diagnostic manual doesn't always determine how the diagnoses are actually made in real life. In DSM IV, we made some small changes in the definition of ADD to recognize the fact that girls are more likely to have problems with inattentiveness than with hyperactivity. Our field trials predicted an increase in rate of ADD of only 15 percent.

Instead, ADD rates have tripled in the last 15 years because of factors we didn't and couldn't predict. Three years after DSM IV was published, pharma lobbyists persuaded the government to give them an unprecedented right (unique in the world) to advertise directly to consumers. At the same time, new and expensive ADD drugs gave the companies the incentive and the resources to mount an all media/all the time marketing campaign to convince parents teachers, and doctors that ADD was common, under-diagnosed, and easily treated with a pill. The revenue from ADD drugs increased 100 fold and 4 percent of our kids are on medication. Some need and do well on meds, but for many they do more harm than good.

For a different reason, rates of autism have increased 40 fold. Some of the growth is due to better recognition and reduced stigma. But much of the explosive growth comes from the fact that having a diagnosis of autism provides eligibility for much smaller class size and additional school services. The DSM definition of autism was developed for clinical purposes and is not a sure guide to what is best educationally. Educational decisions should be based on educational need, not an unreliable clinical diagnosis.

Diagnostic inflation and misallocation of resources are bad enough now and will be made worse by DSM V -- the new diagnostic system to be published in two months. DSM V is a travesty of careless suggestions that will likely turn our current diagnostic inflation into hyperinflation. Let the buyer beware.

We need to rein in psychiatry and rein in the drug companies. We should get back to treating the really ill who need us badly and let people with everyday problems solve them with their own resources and resiliency -- and not with a potentially harmful pill.

Hippocrates -- the father of medicine -- said it best 2,500 years ago -- First, do no harm.

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM IV task force.

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