It was difficult to approach the book “Saving Normal” dispassionately after having just read “The Book of Woe” by Gary Greenberg, in which Frances’s points were often countered and in which Frances displayed a tendency to ramble, to denounce antipsychiatry, and to use possibly weak analogies. Overall, Frances agrees with Greenberg in attacking the DSM, the “Diagnostic and Statistical Manual of Mental Disorders,” the so–called bible of psychiatry. Both books are about equally comprehensive. Yet Frances takes a much more conservative standpoint about psychiatry and his writing is often humdrum, lacking the intellectual depth of Greenberg’s writing.
Allen Frances is the psychiatrist who was chair of the DSM–IV Task Force in 1994.
His main points
(1) The DSM–5, the latest edition, is fatally flawed, for many scientific and practical reasons.
(2) The DSM has been, and continues to be, abused by the pharmaceutical industry and by other institutions.
(3) The DSM pathologizes too many people as mentally ill. The standard of mental normality needs to be saved. Most people are normal and these “worried well” people (page XV) are overtreated, while the truly mentally sick people are undertreated.
(4) Despite the prior points, psychiatry is a noble and essential field. “Saving normal” and “saving psychiatry” are interdependent, “are really one and the same” (283).
The first point is better argued by Gary Greenberg. Gary Greenberg would probably take issue with the third point, arguing against a clear distinction between normal and mentally ill people. Gary Greenberg likely totally disagrees with the fourth point.
He talks about “disease mongering” (29). He notes:
Disease mongering cannot occur in a vacuum—it requires that the drug companies engage the active collaboration of the doctors who write the prescriptions, the patients who ask for them, the researchers who invent the new mental disorders, the consumer groups that advocate for more treatment, and the media and Internet that spread the word. A persistent, pervasive, and well–financed “disease awareness” campaign can create disease where none existed before.
He admits that more than half of the DSM–IV experts had financial conflicts of interest with pharmaceutical firms. He says, “I apologize for this but don’t agree that financial conflict of interest compromised any of our decisions” (75). He does admit that drug companies “exploited” the DSM–IV, “but this happened in ways we could not have predicted or prevented” (76).
He criticizes the competence of primary care physicians in psychiatric treatment. He says, “Primary care physicians are prescribing potentially dangerous medications, outside their competence, for people who should not be taking them” (89).
Like other psychiatric dissidents, he (rightfully) challenges the theory that most or many mental disorders are caused by a chemical imbalance (93).
He is skeptical of defining many criminals as mentally ill and the use of the insanity defense (110). In particular, he gives a lengthy argument against classifying rape as a symptom of mental disorder, instead of merely as a crime (164).
He has a section on how medical illnesses are often misdiagnosed as mental illnesses and vice versa (193).
Where the writing gets weak
The book is about the DSM, but in Chapter 4 he writes a lengthy and unneeded history of cultural beliefs about the causes of mental disorder. It goes from beliefs in demonic possession—to dance manias—to vampire hysteria—to Goethe’s novel that inspired suicides. These very old historical events have almost no relationship to the DSM and shouldn’t be in a book about the DSM.
An unsettling issue is how he wants to continue drawing a line between the “normal” people with everyday problems and the “sick” people with severe mental illnesses, while continuing to classify himself as normal. Why should he only question the psychiatric definition of normality now that he finds himself eligible to be diagnosed with serious mental illnesses? On page 179, he admits that he and his wife are aging and starting to experience geriatric forgetfulness. He now realizes that he is eligible for the diagnosis of mild neurocognitive disorder or MNCD. Ironically, in his section on the disorder and in his denial of having it, he alters the acronym from MND (180) to MNCD (181) to MCND (181–182).
Allen Frances also admits that he has a problem with gluttony. “Never have I gone for more than week without a monster binge,” he writes (182). This makes him eligible for a diagnosis of binge eating disorder. It is honorable that he wants to shield people from this diagnosis. Perhaps it should not be classified as a mental illness. Yet binge eating is not normal. Why can’t he just admit that he is abnormal, not merely eccentric? Why must he continue placing a dividing line between himself and the people who are unfortunate enough to have a serious diagnosis?
Furthermore on the same point, he denies personal responsibility over his binge eating problem, blaming general human nature and society instead (183):
Why do I binge eat? Why does anyone? Nature made it so. Our appetites are perfectly designed to ride out famine, but they make us terribly vulnerable to feast. […] But even more to the point, BED distracts attention from what could provide a real cure for the obesity epidemic. We need a dramatic change in public policy. Our society is getting way too fat not because of an epidemic of this newly devised mental disorder, but rather through the ever present and always tempting availability of cheap, delicious, convenient, caloric, and horribly unhealthy fast food, snacks, and sodas.
He’s partly right about that, but it’s wrong that he grant himself excuses against being diagnosed, while some other people are not afforded such excuses, despite environmental factors that have driven their mental disorders much more than intrapersonal factors.
And then here are some of the awkward parts, even though they’re taken out of context (201, 204):
Sex with an underage, pubescent teenager is a despicable crime deserving imprisonment, not a mental disorder treatable in a hospital. There is nothing inherently psychiatric about being sexually attracted to budding teenagers. Numerous studies have proven the opposite—such attraction is common and completely within the range of normal male lust.
Sexual excess is often misguided but rarely indicative of mental disorder. Humans, especially males, cheat so often it might almost be considered normative behavior, not sickness.
Obviously, this reviewer favors Gary Greenberg’s book on the DSM over that of Allen Frances. However, the one thing that Frances does prominently better is to offer solutions. In Chapter 7, page 212, he lists several specific ways to remediate the abuse by the pharmaceutical industry. The chapter also has sundry other ideas about how to fix psychiatry and the DSM.
Author: Allen Frances. Book: Saving Normal: An Insider’s Revolt Against Out–of–Control Psychiatric Diagnosis, DSM–5, Big Pharma, and the Medicalization of Ordinary Life. Edition: First. Place of publication: New York, New York. Publisher: HarperCollins Publishers. Imprint: William Morrow. Date: 2013.