Allen Frances
Allen J. Frances, born 1942, is an American psychiatrist. Frances' early career was spent at Cornell University Medical College where he rose to the rank of professor. In 1991, he became chairman of the Department of Psychiatry at Duke University School of Medicine. Frances was the founding editor of two well-known journals: the Journal of Personality Disorders and the Journal of Psychiatric Practice.
Frances chaired the task force that produced the fourth revision of Diagnostic and Statistical Manual of Mental Disorders and became critical of the current version, DSM-5. He warned 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. In 2013, Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests".
Frances is the author or co-author of multiple books within the fields of psychiatry and psychology, including: Differential Therapeutics, Your Mental Health, Saving Normal, Essentials of Psychiatric Diagnosis, and Twilight of American Sanity.
Education and career
Education
Frances was born and raised in New York City, US. He received his bachelor's degree from Columbia College in 1963 and his medical degree in 1967 from SUNY Downstate College of Medicine. His research in the fields of psychiatry and behavioral sciences focused on schizophrenia, personality disorders, anxiety disorders, mood disorders, and clinical treatment of psychiatric patients.Career
Frances' 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. And in 1991, he became chairman of the Department of Psychiatry at Duke University School of Medicine where he helped to expand the research, training, and clinical programs that had been initiated by his predecessor as chair, Dr. Bernard Carroll.Publications
Frances' 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. Frances was the founding editor of two journals that have become standards: The Journal of Personality Disorders and the Journal of Psychiatric Practice.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".
The ''Diagnostic and Statistical Manual of Mental Disorders''
DSM-IV
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 twentyfold 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 fortyfold 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 Your Mental Health: A Layman's Guide to the Psychiatrist's Bible with psychiatrist Michael First.DSM-5
The next revision DSM-5 was initiated with a 2002 book 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. Frances initially declined to join Spitzer's criticism, but after learning about the changes being considered, he wrote an article in July 2009 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 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, he was also disturbed by the addition of new speculative disorders. 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 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 a 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. 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.
Book and statements on [Donald Trump]
Frances wrote a 2017 book, titled, Twilight of American Sanity, in which he asserts that Trump himself does not suffer from a mental disease, but rather that the problem lies with the American people for selecting him as U.S. President. Frances writes in the book: "Calling Trump crazy allows us to avoid confronting the craziness in our society." The Washington Post gave a book review of Twilight of American Sanity and found the arguments by Frances to stray from medical to political in nature. The book review by Carlos Lozada in The Washington Post concluded: "America is delusional not just because it elected Trump, but because it doesn’t conform to Frances’s views on climate change, population growth, technology, privacy, war, economics and guns." Publishers Weekly concluded in a book review that Twilight of American Sanity contained factual errors and exaggeration. A book review by Kirkus Reviews was positive, calling the work a "cogent analysis". Kirkus Reviews concluded its book review: "This welcome and insightful book joins a small shelf of essential titles... that help explain why and how the Trump presidency happened."On August 25, 2019, in an interview on CNN, Frances stated that Trump is responsible for millions of deaths and may have killed more people than Adolf Hitler, Joseph Stalin and Mao Zedong. Frances was quoted as saying, "Trump is as destructive a person in this century, as Hitler, Stalin, and Mao were in the last century. He may be responsible for many more million deaths than they were. He needs to be contained, but he needs to be contained by attacking his policies, not his person."
Politifact noted that Frances posted a follow-up to Twitter in which he asserted his comments referred to the potential future impact of climate change. Politifact brought forth multiple referenced sources in order to analyze the comments by Frances. Politifact reported that according to Timothy Snyder, Yale University history professor in a 2011 calculation, Adolf Hitler killed over eleven million people during the Holocaust. Politifact noted that the U.S. Holocaust Memorial Museum estimated about 17 million deaths attributed to Hitler during World War II. Politifact cited the book The Souls of China: The Return of Religion After Mao by author Ian Johnson, which found Mao Zedong responsible for approximately 42.5 million fatalities.
Politifact wrote in their analysis: "Not only does Frances’ comparison exaggerate the predicted climate change death toll compared to that of the dictators, he also lays the blame for potential future deaths at Trump’s feet alone, which even experts critical of Trump consider wrongheaded." Politifact concluded, "We rate the statement Pants on Fire.
Snopes analyzed the assertions by Frances and received a follow-up comment from him, in response to social media backlash to his statements. Frances clarified in his comment to Snopes, that he was referring to the potential future impact of climate change. Frances said in his email to Snopes: "I think it is no exaggeration to worry that the policies that follow from Trump’s reckless climate denial may wind up causing the death of hundreds of millions of people. Our species appears to be on a path to self-destruction, and Trump is enthusiastically leading the way."