One psychiatrist’s rebellion against the pathologisation of everyday life.

Saving normal in a world gone mad 

by Helene Guldberg

Saving normal and saving psychiatry are mammoth tasks. For ‘normal’ to be saved, it is not going to be sufficient to change the wording of a manual. We need a cultural and political sea-change, too, a transformation in how human beings are understood and talked about today.

Many human behaviours, quirks, eccentricities and woes which in the past would have been seen as parts of the rich tapestry of life are now branded mental disorders

In the early 1990s, American psychiatrist Allen Frances was chair of the taskforce that created the American Psychiatric Association’s Diagnostic and Statistical Manual-IV (DSM-IV) (published in 1994). The DSM is the book used by psychiatrists to track and describe mental disorders and conditions. He had previously been part of the team – led by a former teacher, Bob Spitzer – that created DSM-III (published in 1980) and DSM-IIIR (published in 1987). Now he is one of the most prominent critics of DSM-5 (published in 2013).

Frances describes his book Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life as ‘part mea culpa, part j’accuse, part cri de coeur’.

Frances’ arguments about the dangers of inflating psychiatric conditions and psychiatric diagnosis are persuasive – maybe more so because he honestly admits to his own role in developing such an inflation. He is keenly aware of the risks of diagnostic inflation ‘because of painful firsthand experience’, he writes. ‘Despite our efforts to tame excessive diagnostic exuberance, DSM-IV had since been misused to blow up the diagnostic bubble’. He is particularly concerned about the exponential increase in the diagnosis of psychiatric conditions in children, writing: ‘We failed to predict or prevent three new false epidemics of mental disorder in children – autism, attention deficit, and childhood bipolar disorder. And we did nothing to contain the rampant diagnostic inflation that was already expanding the boundary of psychiatry far beyond its competence.’

Take Attention Deficit Hyperactivity Disorder (ADHD), which is ‘spreading like wildfire’. This diagnosis is applied so promiscuously that ‘an amazing 10 per cent of kids now qualify’, Frances writes. In the US, boys born in December are 70 per cent more likely to be diagnosed with ADHD than boys born in January. The reason diagnosing ADHD is so problematic is that it essentially is a description of immaturity, including symptoms such as ‘lack of impulse control’, ‘hyperactivity’ or ‘inattention’. Boys born in December tend to be the youngest in their school year group (in the US) and thus they are more likely to be immature. In the UK, the youngest children in a school classroom are born in August, and so here, August-born kids are more likely to be diagnosed with ADHD. We have medicalised immaturity.

Until his colleagues started working on DSM-5, Frances had been ‘pretty much a dropout from psychiatry’ for almost a decade. But on hearing that DSM-5 was moving in ‘the wrong direction, adding new diagnoses that would turn everyday anxiety, eccentricity, forgetting and bad eating habits into mental disorders’, he felt compelled to get stuck in to the debate. ‘If a cautious and generally well-doneDSM-IV had probably resulted in more harm than good, what were the likely negative effects of a carelessly done DSM-5?’, he wondered.


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