Psychiatric Times Blog / Fads in Diagnosis

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Normality Is an Endangered Species: Psychiatric Fads and Over Diagnosis

July 06, 2010 | On DSM-5, Addiction, Alcohol Abuse, Bipolar Disorder, Sexual Addiction

By Allen Frances, MD

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, DSM-5 threatens to provoke several more (hyper sexuality, binge eating, mixed anxiety depression, minor neurocognitive, and others).

Fads punctuate what has become a basic background of over diagnosis. 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 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 over diagnosis, 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?



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