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Allen J. Frances, MD (born 1942) is an American psychiatrist best known for chairing the task force that produced the fourth revision of Diagnostic and Statistical Manual (DSM-IV) and for his critique of the current version, DSM-5. He warns that the expanding boundary of psychiatry is causing a diagnostic inflation that is swallowing up normality and that the over-treatment of the "worried well" is distracting attention from the core mission of treating the more severely ill.
Education and career
Frances was born in New York City in 1942. He received his bachelor's degree in pre-med and economics from Columbia College in 1963; his MD from Downstate Medical Center in 1967; completed his psychiatric residency at the Columbia Presbyterian Medical Center and New York State Psychiatric Institute in 1971; and received a certificate in psychoanalytic medicine from the Columbia University Center for Psychoanalytic Training and Research 1978. His early career was spent at Cornell University Medical College where he rose to the rank of professor, headed the outpatient department, saw patients, taught, established a brief therapy program, and developed research specialty clinics for schizophrenia, depression, anxiety disorders, and AIDS. Throughout his academic career, Frances was an active investigator and prolific author in a surprisingly wide range of clinical areas including personality disorders, chronic depression, anxiety disorders, schizophrenia, AIDS, and psychotherapy. His book on Differential Therapeutics tried to bring specificity and evidence to decisions on how best to match patient and treatment. His recognition of therapeutic limits resulted in the 1981 paper No Treatment as the Prescription of Choice. Dr Frances was the founding editor of two journals that have become standards: The Journal of Personality Disorders and the Journal of Psychiatric Practice. And in 1991, he became chairman of the Department of Psychiatry at Duke University School of Medicine where he helped to expand the excellent research, training, and clinical programs that had been initiated by his predecessor as chair, Dr Bernard Carroll.
The Diagnostic Manual of Mental Illnesses
The DSM provides definitions of mental disorders that are widely used to guide clinical practice, research, education, forensics, and eligibility for mental health treatment, school services, and disability benefits. Dr Frances helped to prepare DSM III (published in 1980), DSM III R (published in 1987); and was Chair of the Task Force that published DSM IV in 1994. The earlier DSM revisions had relied on expert opinion to create definitions of disorders. The DSM IV was a more conservative revision requiring that changes be justified by a high threshold of scientific evidence drawn from literature reviews, data reanalyses, and field testing. Of the ninety-four suggestions for new diagnoses, only two were accepted—Asperger's and Bipolar II Disorder. The DSM-IV Sourcebook documents the rationale and scientific support for all the decisions made. Minor updates in the explanatory text were added in 2000 (DSM-IV-TR).
Despite its conservative intent and careful methodology, DSM-IV was not able to prevent diagnostic inflation. Rates of attention deficit disorder tripled as a result of heavy drug company marketing starting in 1997—instigated by the introduction of new on-patent drugs and facilitated by the removal of federal prohibitions against direct-to-consumer advertising. Rates of autism increased by more than twenty fold largely because the loose diagnosis followed its becoming a prerequisite for extra school services. Rates of bipolar disorder doubled largely because of drug company marketing. And rates of bipolar disorder in children increased by forty fold when thought leaders and drug companies convinced practitioners that temperamental kids had bipolar disorder even if they didn't have mood swings—a concept that had been rejected by DSM-IV. Frances later felt that DSM-IV should have fought more vigorously against the risks of diagnostic inflation by tightening diagnostic criteria and providing more specific warnings against over-diagnosis. Frances co-authored Am I Okay?: A Layman's Guide to the Psychiatrist's Bible with psychiatrist Michael First.
The next revision DSM-5 was initiated with a 2002 book (A Research Agenda for DSM-V) questioning the utility of the atheoretical, descriptive paradigm and suggesting a neuroscience research agenda aiming to develop a pathophysiologically based classification. After a series of symposiums, the task force began to work on the manual itself. In June 2008, Dr. Robert Spitzer who chaired the DSM-III and DSM-IIIR revisions had begun to write about the secrecy of the DSM-V Task Force (DSM-V: Open and Transparent?). Frances initially declined to join Spitzer's criticism, but after learning about the changes being considered, he wrote an article in July 2009 (A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences) expressing multiple concerns including the unsupported paradigm shift, a failure to specify the level of empirical support needed for changes, their lack of openness, their ignoring the negative consequences of their proposals, a failure to meet timelines, and anticipate the coming time pressures. The APA/DSM-V Task Force response (Setting the Record Straight: A Response to Frances Commentary on DSM-V) dismissed his complaints.
In March 2010, Frances began a weekly blog in Psychology Today, DSM-5 in Distress: The DSM's impact on mental health practice and research, often cross-posted in the Psychiatric Times and the Huffington Post. While many of his blog posts were about the DSM-5 Task Force lowering the thresholds for diagnosing existing disorders (attention deficit disorder, autism, addictions, personality disorders, bipolar II disorder), he was also disturbed by the addition of new speculative disorders (Attenuated Psychosis Syndrome, Disruptive Mood Dysregulation Disorder, Somatic Symptom Disorder). He has argued that the diagnosis attenuated psychosis syndrome promoted by advocates of early intervention for psychosis, such as Australian psychiatrist Patrick McGorry, is risky because of a high rate of inaccuracy, the potential to stigmatize young people given this label, the lack of any effective treatment, and the risk of children and adolescents being given dangerous antipsychotic medication. The elimination of the bereavement exclusion from the diagnosis of major depressive disorder was another particular concern, threatening to label normal grief as a mental illness. So while the task force was focusing on early detection and treatment, Frances cautioned about diagnostic inflation, overmedication, and crossing the boundary of normality. Besides the original complaint that the DSM-5 Task Force was a closed process, Frances pointed out that they were behind schedule and even with a one year postponement, they had to drop a follow-up quality control step. He recommended further postponement and advocated asking an outside body to review their work to make suggestions. While the American Psychiatric Association did have an internal review, they rejected his suggestion of an external consultation. When the field testing for inter-rater reliability was released in May 2012, several of the more contested disorders were eliminated as unreliable (attenuated psychosis syndrome, mixed anxiety depression) and the reliabilities were generally disappointing. The APA Board of Trustees eliminated a complex "Cross-Cutting" Dimensional System, but many of the contested areas remained when the document was approved for printing in December 2012 for a scheduled release in May 2013. There were widespread threats of boycott.
Frances's writings were joined by a general criticism of the DSM-5 revision, ultimately resulting in a petition calling for outside review signed by 14,000 and sponsored by 56 mental health organizations. In the course of almost three years of blogging, Frances became a voice for more than just the specifics of the DSM-5 Diagnostic Manual. He spoke out against the overuse of psychiatric medications—particularly in children; a general trend towards global diagnostic inflation—pathologizing normality; the intrusion of the pharmaceutical industry into psychiatric practice; and a premature attempt to move psychiatry to an exclusively biological paradigm without scientific justification. Along the way, he wrote two books: "Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life" and "Essentials of Psychiatric Diagnosis" meant to guide clinicians and to help curb unwarranted diagnostic exuberance. He has decided to continue writing on a new Psychology Today blog called Saving Normal.
In 2013, Allen Frances wrote a paper entitled "The New Crisis of Confidence in Psychiatric Diagnosis", which said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests". Frances was also concerned about "unpredictable overdiagnosis".
- Frances, Allen (1984). Differential Therapeutics. Bruner Meisel U. p. 440. ISBN 0876303602.
- Frances, Allen; Clarkin,JF (May 1981). "No Treatment as the Prescription of Choice.". Arch Gen Psychiatry 38 (5): 542–545. doi:10.1001/archpsyc.1980.01780300054006. PMID 7235855. Retrieved 2012-03-26.
- DSM-IV® Sourcebook DSM-IV® Sourcebook. Arlington, VA: American Psychiatric Publishing. 1997. p. 1085. ISBN 978-0-89042-073-7.
- Frances A, First MB (2000). Am I Okay?: A Layman's Guide to the Psychiatrist's Bible. Simon and Schuster, ISBN 978-0-684-85961-3
- Edited by David J. Kupfer, M.D., Michael B. First, M.D., and Darrel A. Regier, M.D., M.P.H. (2002). A Research Agenda For DSM V A Research Agenda For DSM V. Arlington, VA: American Psychiatric Publishing. p. 336. ISBN 978-0-89042-292-2.
- Spitzer, Robert (June 18, 2008). "DSM-V: Open and Transparent?". Psychiatric News. Retrieved 2013-03-26.
- Greenberg, Gary. "Inside the Battle to Define Mental Illness". Wired. Retrieved 2013-03-26.
- Frances, Allen (June 26, 2009). "A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences". Psychiatric Times. Retrieved 2013-03-26.
- Schatzberg AF, Scully JH, Kupfer DJ, Regier DA (July 1, 2009). "Setting the Record Straight: A Response to Frances Commentary on DSM-V". Psychiatric Times. Retrieved 2013-03-26.
- Frances, Allen. "DSM5 in Distress: The DSM's impact on mental health practice and research". Psychology Today. Retrieved 2013-03-26.
- Frances, Allen. "Blog". Psychiatric Times. Retrieved 2013-03-26.
- Frances, Allen. "Blog". The Huffington Post. Retrieved 2013-03-26.
- "Frances A. Psychosis risk syndrome—far too risky". Aust N Z J Psychiatry. 2011 Oct;45(10):803-4.
- Carey, Benedict (May 8, 2012). "Psychiatry Manual Drafters Back Down on Diagnoses". New York Times. Retrieved 2013-03-27.
- Frances, Allen (2013). Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. William Morrow. p. 336. ISBN 978-0062229250.
- Frances, Allen (2013). Essentials of Psychiatric Diagnosis. The Guilford Press. ISBN 978-1462510498.
- Frances, Allen. "Saving Normal: Mental health and what is normal". Psychology Today. Retrieved 2013-03-26.
- Allen Frances (17 May 2013). "The New Crisis in Confidence in Psychiatric Diagnosis". Annals of Internal Medicine.