Saving Normal -- The Diagnosis Game

For readers unencumbered by the facts of the matter or any understanding of them, Allen Frances' book Saving Normal is an entertaining romp through the world of psychiatric diagnosis which will support your deepest held suspicions: that there are a few seriously wacko people out there who are very different from the rest of us, but for the most part, mental illness is a sham and you need to just snap out it.

Not to tip my hand, or anything.

The claims made without benefit of facts will take some time to sort through. And a later post will support part of Frances' agenda. In fact, support it enthusiastically. But not this one.

The APA's Cocktail Party, 2009

This week, let's start where Frances starts, at the fateful cocktail party he attended in May, 2009 that yanked him out of retirement and onto a crusade.

It was the American Psychiatric Association's annual meeting. The committee to revise DSM-V had just been formed, and they were all abuzz with their ideas of needed revisions and additions to that work first published nineteen years ago and tweaked six years later.

Now Frances had once been all abuzz on his own, when he was first appointed editor of DSM-IV. He tells about a walk on the beach, when he spun out his own pet ideas. Most of these never saw the light of day, once he got past the first headiness and down to work.

But alarm bells went off in May, 2009. Somehow he got it into his head that the well-oiled ideas floating around a cocktail party were going to come to fruition and result in an entire nation diagnosed with his peers' favorite mental illnesses.

Note: while DSM-5 did eventually make a few changes in Frances' edition, none of which he approves, many who have actually read it agree with NIMH director Thomas Insel, that it is not a revolutionary document. But that was yet to be seen. Back to the party...

The DSM Diagnosis Game

So he moved from committee member to committee member, collecting their initial enthusiasms. By the end of the evening, he writes, [I] soon discovered that I personally qualified for many of the new disorders that were being suggested by them for inclusion for DSM-5. My gorging on the delectable shrimp and ribs was DSM-5's "binge eating disorder." My forgetting names and faces would be covered by DSM-5 "minor neurocognitive disorder." My worries and sadness were going to be "mixed anxiety/depressive disorder." The grief I felt when my wife died was "major depressive disorder." My well-known hyperactivity and distractibility were clear signs of "adult attention deficit disorder." An hour of amiable chatting with old friends, and I had already acquired five new DSM diagnoses. And let's not forget my six-year-old identical twin grandsons -- their temper tantrums were no longer just annoying; they had "temper dysregulation disorder."

You gotta give him credit. He knows how to tell a story. I have quoted in length, because this is the heart of his criticism of DSM-5, a great story on the theme of over-diagnosis, repeated in innumerable articles and interviews, and the foundation his coming-out-of-retirement career as trasher-in-chief of the DSM-5.

The thing is, Frances is playing a game here. He knows it is a game. He just doesn't cop to knowing the game until page 67.

The game has been around for thirty-three years, since DSM-III made its first appearance, as he recounts on page 67: DSM-III diagnosis quickly replaced psychoanalysis as a topic of cocktail party chatter, and people seemed eager to find a neat fit for their problems (or their boss's problems) in its pages.

Diagnosis for Real

As a game, it is entertaining, often a little mean when directed at bosses and exes, but entertaining. Take the resulting diagnosis outside the cocktail party, and it is disingenuous at best, unethical certainly, and potentially dangerous at worst.

Frances knows very well that the critical issue is not whether one can tick off symptoms, but the extent to which those symptoms are disruptive, disturbing or disabling to the one who suffers from them. Understanding the whole patient was often reduced to filling out a checklist. Lost in the shuffle were the narrative arc of the patient's life and the contextual factors influencing symptom formation -- again, page 67.

And there it is, in Frances' own story -- their temper tantrums were no longer just annoying; they had "temper dysregulation disorder." No, their temper tantrums are not temper dysregulation disorder -- a diagnosis that did not make it into the published book anyhow -- because they were just annoying.

The parents make the first and most crucial differential diagnosis. Can these temper tantrums be managed by the parents' own skills? Or do friends come up with good advice? Or the children's teachers or school counselors? Or Terry Brazleton, Benjamin Spock, Fred Rogers? Or Grandpa, who happens to be a psychiatrist, or Grandma, who has ideas of her own? Or Dear Abby? Failing all, can they be simply endured until the children grow out of them? If so, then these unruly children never make it to a doctor's office and are never diagnosed, because temper tantrums do not a diagnosis make.

The Consequences of a Clever Story

The Diagnosis Game is probably older than DSM-III. I think we can blame Freud, with his notion that there are things in the unconscious mind we would prefer would stay there. But Dr. Freud knows our dirty little secrets. Oh yes, he knows.

And that is what gives the game its power, the suspicion that psychiatry knows, or claims to know us better than we know ourselves. When we put our best foot forward, the shrink sneaks up from behind to pounce on that back foot.

So when Frances trots out his five imaginary diagnoses, he is feeding on his readers' fears, that psychiatrists lurk in the corners of cocktail parties, waiting to discover what is wrong with us. We feel for him, we join him in protest, I am not crazy!!

Which, of course, is not how diagnosis really works. Psychiatrists do not lurk outside funeral homes, or stand in grocery lines watching temper tantrums, or guard the shrimp plate, passing out their business cards. Unfortunately, they also do not go on talk shows to defend themselves and their patients from this fear-mongering. They can't, until they come up with a scarier story to push ratings.

So score one for Allen Frances' communication skills.

Allen Frances' Mission: Saving Normal

Allen Frances wants to turn around the epidemic of mental illness. Having failed to get doctors to stop diagnosing mental illness, he turns to the public with that good old message that so many people in pain have found so helpful, You'd have to be crazy to go to a psychiatrist! To the older fears that they will read your mind and know your dirty little secrets, he adds two new ones, first that they will call you names, turn you into The Other, the Ab-Normal, and then that they will poison you.

This is a frustrating book, and I am struggling to stay fair. The man has a big credential and a story that connects to his audience's deep insecurities about his profession. He does have something legitimate to say about medication, and I will get to that. But I have to sort through his manipulation of fears and facts to do it.

More to come...

book jacket from
photo of Classic Martini by Ken Johnson, used under the Creative Commons license
photo of shrimp by Frank C. Müller, in the public domain
clip art from
portrait of Sigmund Freud in public domain
graphic of Zombie bJean-noël Lafargue, used under the Free Art License


  1. Looking forward to the more to come...

  2. Very astute commentary, Willa! It's a shame that the issue of serious psychiatric illness--often destroyers of life--gets lost in the rhetoric of DSM-and-psychiatry bashing. You and your readers might be interested in a piece I did on the DSM-5, for Medscape. It is viewable at:

    Ron Pies MD

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