Psychiatric Times.

Normality Is an Endangered Species: Psychiatric Fads and Overdiagnosis

By Allen Frances, MD | July 6, 2010

Fads in psychiatric diagnosis come and go and have been with us as long as there has been psychiatry. The fads meet a deeply felt need to explain, or at least to label, what would otherwise be unexplainable human suffering and deviance. In recent years the pace has picked up and false “epidemics” have come in bunches involving an ever-increasing proportion of the population. We are now in the midst of at least 3 such epidemics—of autism, attention deficit, and childhood bipolar disorder. And unless it comes to its senses, DSM5 threatens to provoke several more (hypersexuality, binge eating, mixed anxiety depression, minor neurocognitive, and others).

Fads punctuate what has become a basic background of overdiagnosis. Normality is an endangered species. The NIMH estimates that, in any given year, 25 percent of the population (that’s almost 60 million people) has a diagnosable mental disorder. A prospective study found that, by age thirty-two, 50 percent of the general population had qualified for an anxiety disorder, 40 percent for depression, and 30 percent for alcohol(Drug information on alcohol) abuse or dependence. Imagine what the rates will be like by the time these people hit fifty, or sixty-five, or eighty. In this brave new world of psychiatric overdiagnosis, will anyone get through life without a mental disorder?

What accounts for the recent upsurge in diagnosis? I feel quite confident we can’t blame it on our brains. Human physiology and human nature change slowly if at all. Could it be that the surge in mental disorders is caused by our stressful society? I think not. There is no particular reason to believe that life is any harder now than it has always been—more likely we are the most pampered and protected generation ever to face its inevitable challenges. It is also tempting to find environmental (eg toxins) or iatrogenic causes (eg vaccinations), but there is no credible evidence supporting either of these. There is really only one viable environmental candidate to explain the growth of mental disorder—the widespread recreational use of psychotropic substances. But this cannot account for the extent of the “epidemics," particularly since most have centered on children.

No. The “epidemics” in psychiatry are caused by changing diagnostic fashions—the people don’t change, the labels do. There are no objective tests in psychiatry—no X-ray, laboratory, or exam that says definitively that someone does or does not have a mental disorder. What is diagnosed as mental disorder is very sensitive to professional and social contextual forces. Rates of disorder rise easily because mental disorder has such fluid boundaries with normality.

What are the most important contextual forces?

1. DSM-III made psychiatric diagnosis interesting and accessible to the general public. More than a million copies of each edition have been sold—more to ordinary people than to mental health professionals. The widespread appeal of the DSM is in its clear definitions that allow people to diagnose themselves and family members. For the most part, this has been a useful contributor to self-knowledge and to early identification and treatment. But it can also be overdone and inevitably leads to overdiagnosis in the hands of non-clinicians.

2. This interacts with the fact that it is fairly easy to meet criteria for one or another DSM diagnosis. The definitional thresholds may be set too low and the DSM system has included many new diagnoses that are very common in the general population. The experts who establish the DSM criteria always worry more about missing cases than about casting too wide a net and capturing people who do not require a diagnosis or a treatment.

3. The pharmaceutical industry has proven to be fairly unsuccessful in developing new and improved medications. But it is wonderfully effective at marketing existing wares and is an important engine in overdiagnosis and the spread of psychiatric epidemics. The drug companies are skilled at mounting a full-court press that includes “educating” doctors, “supporting” advocacy groups and professional associations, controlling research, and direct-to-consumer advertising.

4. Patient and family advocacy groups have played an important role in calling attention to neglected needs; in lobbying for clinical, school, and research programs; and in reducing stigma and promoting group and community support. There are times, however, when advocating for those with a disorder can spill over and promote the spread of the disorder to others who are mislabeled. The mental disorders all have unclear boundaries among themselves and with normality. Clinical experience and caution are necessary in distinguishing at the boundary who does and who does not meet the criteria for the diagnosis. Well-informed self-diagnosis or family diagnosis can play a screening role and is part of being a wise consumer. But self-diagnosis is usually far too inclusive and needs trimming and validation by a cautious clinician.

5. It is no accident that the recent “epidemics” have all occurred in the childhood disorders. There are two contributing factors. The first is the push by drug companies into this new market. The second is that the provision of special educational services often requires that there be a DSM diagnosis.

6. The internet is a wonderful communication tool that provides a wealth of information and creates a social network of informed consumers. But it can also contribute to the spread of “epidemics”. Disorder-focused Web sites (often run by patients and families) provide a powerfully attractive forum and support system that draws people who may inaccurately self–overdiagnose in order to be part of the internet community.

7. The media feeds off and feeds the public interest in mental disorders. This happens in two ways. Periodically, the media becomes obsessed with one or another celebrity whose public meltdown seems related to a real or imagined mental disorder. The mental disorder is then endlessly commented on and dissected by the media. The latest example is the Tiger Woods media frenzy which will likely lead to an “epidemic” of “sexual addiction.” Popular movies can also be contagious. Sybil helped cause a fad in multiple-personality disorder.

8. We live in a society that is perfectionistic in its expectations and intolerant of what were previously considered to be normal and expectable distress and individual difference. What was once accepted as the aches and pains of everyday life is now frequently labeled a mental disorder and treated with a pill. Eccentrics who would have been accepted on their own terms are now labeled as sick (with Asperger's) and in need of therapeutic intervention. Mental disorder labels can provide cover for societal problems. Criminal behavior has been medicalized (eg, rape as a psychiatric disorder) because prison sentences are too short and such labeling allows for indefinite psychiatric commitment.

All the above factors interact to produce follow-the-leader diagnostic fads that punctuate a general pattern of overdiagnosis. The definition of fad is “a temporary fashion, notion, manner of conduct especially one followed enthusiastically by a group.” What makes something a psychiatric fad is that a psychiatric label seems to explain some common, nonspecific, problematic symptom or behavior, and that label is suddenly given to everyone. The fact that everyone is doing it reduces the stigma of the diagnosis and leads to more people getting the diagnosis. Then, like the old adage that if you have a hammer, everything looks like a nail, the new label gets twisted to fit cases which really don’t fit it simply because the label itself is popular and accepted.

There is no objective way to determine what should be the proper rate of mental disorder in the general population. My view is that DSM-IV is almost certainly overinclusive, but I would not recommend tightening the criteria until we have clear evidence this would do more good than harm. The DSM-5 bias to thrust open the diagnostic floodgates is supported only by flimsy evidence that does not come close to warranting its great risks of harmful unintended consequences. It is too bad that there is no advocacy group for normality that could effectively push back against all the forces aligned to expand the reach of mental disorders.

by Robert Peers | December 25, 2010 9:47 PM EST

Because Allen Frances, like any psychiatrist, is unaware of nutritional effects on the developing and adult brain, he cannot imagine what might explain the apparent rise in ADHD, autism and "childhood bipolar", which may be, not bipolar, but Temper Dysregulation with Dysphoria (TDD). Take autism: the child may be obviously autistic, yet the affected parent may be only mildly eccentric or obsessional--but able to function and work: in these cases, I have noticed that the mother's diet has been fatty in pregnancy, and such a diet causes anxiety in the offspring, simply by letting maternal cortisol leak across the placenta. I have cured co-morbid anxiety in an autistic child, by giving Inositol, which cures adults likewise. As for ADHD, I did a large case/control study in 1995, showing that almost all cases came from pregnancies in which the mother consumed refined seed oils (which are known to cause Alzheimer's in adults). ADHD incidence has risen recently in the US. As for childhood bipolar, the genes are only for Benign Unipolar Hypomania, not for bipolar itself, so a child with BUH will be calm, creative and quick-witted, but could be turned into TDD by adding ADHD, from refined oils in the mother's diet, with further exposure during childhood itself. Similarly, a fatty maternal diet will add co-morbid anxiety to the picture, and an anxious child with BUH is likely to become moody and irritable--like Winston Churchill at school--but will not develop serious mood swings until adolescence, unless fortuitously exposed to refined seed oils. Finally, more common than aggravated BUH is straight TDD, which may be the result of maternal diet rich in both fats and refined oils, causing a co-morbidly anxious ADHD kid, further aggravated by current exposure to the same fats and refined oils. Prevention is obvious, while ADHD requires a switch to olive oil, plus fish oil for brain repair, and anxiety responds superbly to Inositol, a seed sugar found in grains, nuts, legumes, and citrus. I have no trouble reversing these disorders in my general family practice.

by Michele Renaud | December 24, 2010 1:38 AM EST

I am normally abnormal, at times abnormally normal...

The reality of epidemic proportion is that labels exist, the extensive DSM diagnostic criteria, Psychiatric fads, overdiagnosis, underdiagnosis, misdiagnosis or otherwise, are all tentacles of the field of the wide variations of society today where many are stressed moreso now than ever. Lets not forget about the extreme state of must have technology, tech gadgets, and oh yes, the internet where patients can become educated about their own health, conditions as well as options for treatments with and without the pharmaceutical companies.
The statistics are not a surprise, for times most certainly have changed, and if we as a people are not stressed nor concerned about the world we live in, the health and priority of health, then well we simply exist as gunea pigs for getting labeled, medicated, and thus join in the overall judgements being made by those who can make those judgement calls aka diagnoses. Find me a sane person in this insane world and I would have to comment that they are just as crazy or abnormal as ever other person including theyre therapists. Psychiatry and the DSM are subjective to the clinicians assessment, patient history, patient input, clinicians opinion, and or speciality, as well as, criteria that requires a fine tooth comb when deciphering and or diagnosing. Take a pill....any pill, pick a pill, match the diagnose and then pick a pill....which by the way very well could put you over the top to a new DSM equivalent labeled as abnormality.

by Peter Olsson | November 22, 2010 2:15 PM EST

IN SEARCH OF "NORMAL".*

Peter Alan Olsson MD

*Prepared at the request of The Swedish Psychiatry association for their magazine's "Guest Editor"column. (Tidskriften for Svensk Psykiatri #4 November 2009 pp46-48).

Introduction

Some classic textbooks in psychiatry and psychology simply avoid discussion

of normality. Others discuss the vexing topic of normality from several possible

theoretical perspectives (Cameron, 1963):

(1)Normality is an idealized internal integration or homeostasis of an

individual personality; a kind of search for a psychoanalytic utopia.

(2)Normality is a conformity with or successful performance within social,

religious, or cultural expectations or norms.

(3)Normality is the process of attempting to satisfy the inner needs of the

Individual, without disrupting or violating conventions of group living.

No easy or final definitions for any of the above have been reached.

EXTRAPOLATION from CLINICAL OBSERVATIONS of ABNORMAL GROUPS and

LEADERS to ILLUMINATE NORMAL GROUPS and LEADERS.

I have studied destructive-exploitive cults and terror cult groups from a psychodynamic perspective for over thirty years. (Olsson 2005, 2007). I conclude that during rapid social and economic change and stress, utopias are often sought and promoted. Most utopian dreams emerge out of the psychological cesspools of malignant individual and group narcissism. When merged with fundamentalist mentality, they are destined for tragedy and destruction. It does not matter if the doomed utopia is formulated in terms of religious metaphor and precepts, or political ideology and propaganda. Jim Jones's "Socialist Heaven" for his People's Temple; Luc Jouret's pollution-free and spiritually liberating suicidal journey for his Solar Temple; Hitler's fascist utopia; Osama bin Laden's terror-paved islamofascist caliphate, and Stalin's communist state, were/ are --all headed for tragic failure.

I have concluded that one way to help prevent future apocalyptic events such as a Jonestown or Waco; perhaps even a 9/11 type event , is to carefully compare destructive cults and terror groups to NORMAL religious groups. It is also helpful to examine relatively NORMAL religious and political leaders; again, as compared and contrasted with destructive leaders. These carefully studied comparisons between NORMAL and ABNORMAL lead to some important observations and conclusions.

NORMAL RELIGIOUS GROUPS COMPARED TO DESTRUCTIVE CULT GROUPS.

Characteristics of NORMAL Religious Groups

A NORMAL Religious Group has central shared experiences of worship, wonder, reverence, and meaningful community service. The NORMAL spiritual leader shares leadership with group members. The NORMAL religious group gives positive support for life-long loving connection and support for and from, families of origin. A NORMAL religious group promotes respect and support for the sanctity, fidelity and self-respecting boundaries of couples` freely chosen marital and sexual commitments. NORMAL spiritual groups do not tolerate priests, imams, rabbis or ministers who berate or flagellate their congregations with words of derision or hate toward anyone.

The NORMAL religious congregation embraces projects that contribute to the betterment of the community at large and not just their group narcissism or the narcissism of their leader. Such altruism is regarded as evidence of spiritual growth and value. Monies raised over and above parish staff salaries and building expenses, are normally used for projects to help the broader community or society. Normal religious congregations seek sacred music that promotes joy, wonder, reverence and worship.

Characteristics of a Destructive Cult Group

Exploitive-Destructive Cults concentrate a large percentage of their efforts on recruiting new members and controlling the financial, social, familial, and sexual or aggressive lives of their members---"For their own good". These cults promote isolation from the ferment of ideas abounding in the broader society and culture. They actively seek to alienate all their members from potential moderating influences found in healthy families, communities, and churches of origin. In fact, the cult group itself is often inserted as a member's new and by implication, "Superior family". The destructive cult leader becomes a Father / God / Prophet Himself. Fund raising is a high priority and a source of status for cult leader. First Amendment protection and tax-exempt status in America and democratic countries can obviously aid and abet destructive-exploitive and terror cults. Freedom of religion and speech in America and "Western" democracies can unfortunately allow safe havens for subtly, incrementally constructed 'Trojan Horse' cults & terror cells, masquerading as old or new religious forms of expression.

CHARACTERISTICS of A NORMAL POLITICAL OR RELIGIOUS LEADER.

It is helpful to outline what personality characteristics are often possessed by those who become "good" leaders. They are capable of making "good" decisions even under adverse circumstances. A NORMAL religious group leader has similar traits. Kernberg (1984) writes that first a "good" leader should be rational and have high intelligence. Intelligence is necessary for strategic conceptual thinking and decision-making. I would add that a NORMAL religious leader must also be intelligent and knowledgeable but wise and discerning enough to avoid rigidity and fundamentalist mentality. Second, the leader must have incorruptible honesty. (No mean characteristic to possess!) Third, the leader's personality organization needs to be capable of establishing and maintaining good human relationships in depth. Such an ability is essential for evaluating others realistically. Fourth, the leader requires healthy narcissism, making him or her self-assertive rather than self-effacing. (All the exploitive cult leaders I studied had malignant narcissism) Fifth the leader must have a sense of caution and alertness to the world for the sake of himself and his people. The NORMAL leader does not use speeches to enflame his people toward hate and destructive action.

CHARACTERISTICS of DESTRUCTIVE (ABNORMAL) LEADERS

Let me describe the core thesis of my observations about exploitive and

destructive cult leaders, whom I call Malignant Pied

Pipers. They develop a relentless quest to become strong

parents or father/mother figures to enhance their self-esteem. This lifelong search,

of course, requires a ready supply of child-admirers, who are found

in the cult followers. Malignant Pied Pipers give psychological birth

to followers through an array of indoctrination and seduction techniques.

Apocalyptic-destructive cult leaders have experienced harsh

disappointments in their own parents and often their home

community via neglect, abandonment, shame, or humiliation during

their childhood. As the years go by, their loneliness and their

memories of empathy-starved and shame-dominated childhoods

become magnified, as if these lonely, humiliating years had become

a psychological deformity.

These poignant experiences of neglect, shame, psychological

abandonment, and fear of being alone lead them toward dramatic

action. Actions provide a sense, however spurious, of inner

restitution and parallel revenge. The evolving dynamic in the cult

family group is a two-way street between the members' passive or

masochistic narcissism and the active, aberrant behavior advocated

and orchestrated by the leader. This time the leaders feel empowered,

rather than powerless as they were in childhood. In essence, the cult

leaders gain a sense of power and mastery over their own early

childhood feelings of insignificance by becoming overwhelmingly

significant and powerful in the lives of their cult followers. The

followers feel fused and merged with a power they coauthor with the

leader. These followers feel special and as if they have transcended

the mediocrity, ordinariness and boredom of their families of origin.

But, beneath the outward confidence and swagger is an

unconscious sense of shame and a fear of humiliation ready to

surface when the group or leader's progressively fragile narcissism is

punctured. Thus the cult-family honeymoon is eventually over; and

because of the leader's own malignant narcissism, he recapitulates

the neglect, abuse, and ultimate loneliness and victimization he once

experienced as a child. But, this time, the cult leader is the neglecter,

abandoner, and victimizer. The grand finale as the world saw in Jonestown

, 9/11, and Waco, is group suicide or homicide.

In summary, the leader is crucial to any group; the group to a

leader. When a NORMAL group has an ethical, rational, and

caring leader, it functions smoothly. A NORMAL and effective

spiritual leader helps facilitate rational decision-making

within the group; exhibits incorruptible honesty; makes decisions

with empathy and realism; shares leadership; and cultivates it in

younger members of the group; encourages individual freedom and

dignity; respects members' families; and helps the group with

positive projects that help the community at large. In times of great

stress, healthy leadership matters even more. Think of New York

City on 9/11 when leaders and people pulled together to help victims

of the terrorist attacks.

SUMMARY

NORMAL individual and group action and freedom, require genuine responsibility, wisdom, independent judgment, and altruism. I hope the above effort to compare characteristics of Normal leaders and groups with ABNORMAL leaders and groups, will stimulate thought and discussion of this important topic for contemporary psychiatry.

References

Cameron, N. 1963, Personality Development and Psychopathology: A Dynamic Approach, Houghton Mifflin Company, Boston (pp 8-14).

Kernberg, O. 1984, "The Couch at Sea: Psychoanalytic Studies of Group and Organizational Leadership". The International Journal of Group Psychotherapy, Vol. 34, pp1-17.

Olsson, P. 2005, Malignant Pied Pipers of Our Time: A Psychological Study of Destructive Cult Leaders from Rev. Jim Jones to Osama bin Laden. Publish America, Baltimore ISBN # 1-4489-0973-2

Olsson, P. 2007, The Cult of Osama: Psychoanalyzing Bin Laden and His Magnetism for Muslim Youths. Praeger Security International, Westport Connecticut. London ISBN #978-0-275-99989-6.

by Sara Hartley | November 22, 2010 12:04 PM EST

Dr. Frances has been concerned with the "unintended consequences" he sees associated with DSM V. His role in forming DSM lll gives him real expertise. Categorizing people by checklists of symptoms has been a double edged sword and, over time, has contributed to mindless diagnosis and medicating with neurotoxic substances. Children who suffer may have symptom reduction with medication but- just as Steven Rose pointed out- this is not a clinical 'proff' of etiology. A patient feel better with morphine after a fracture, but this does not mean he has a morphine-deficiency disorder. The dimensional approach to psychiatric diagnosis may have flaws, but at least it tries to look at the individual's constellation of characteristics. Big Pharma will always try to corrupt medicine. All we can do is keep revising as we learn from experience.

by A Gilchrist | November 17, 2010 4:49 PM EST

I notice that the author of this and many similar articles, does not share his email address for comment. I guess his mind is made up already.

Angi G.

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Normality Is an Endangered Species: Psychiatric Fads and Overdiagnosis

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