Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274)

by Frances, Allen

  There was a brief resurgence of multiple personality in the mid-1950s suggested by the popular book and movie The Three Faces of Eve.10 It didn’t last long because most therapists were analytically trained and uninterested in multiple personality disorder. There was no cadre of therapists ready, willing, and able to create a cadre of new MPD patients. A more enduring fad followed after Sybil in the 1970s. The volume of MPD cases began rising dramatically; the fad fed on itself, peaked in the early 1990s, and then disappeared as suddenly as it had emerged. The revival of MPD was fueled by a renewed therapeutic interest in hypnosis and other regressive and suggestive treatments aimed at bringing out “alters.” An industry of therapists was born during weekend workshops where they learned how best to uncover new personalities. This poorly trained army of enthusiastic newly branded MPD “experts” created new personalities at an alarming clip, and MPD became the default “diagnosis du jour” for every patient seen in their practice.

  MPD is probably no more than a metaphor that has taken on a life of its own. Most (if not all) of the MPD cases were induced by the efforts of these well-meaning but misguided therapists who were as clueless about what was going on as were the patients. It is not hard for a suggestible therapist treating a suggestible patient to turn any run-of-the-mill psychiatric problem into MPD. The individual and the doctor conjure up and name the “alter(s)” to give coherence to fragmentary and unacceptable impulses and behaviors that are in conflict with self-expectations. It is not a far step to assume they have an independent existence.11

  For a while it seemed that every third or fourth patient was claiming to have multiple personalities. The fad was also fed by the Internet’s (then emerging) ability to provide instant information and support. As the number of people with MPD grew, so did the number of personalities per person, and a competition developed to determine who could achieve the most “alters.” The record in my experience was set by a woman who claimed to have unearthed 162 distinct personalities (mostly female but including a couple of dozen males), of widely varying ages and dispositions, and each with a name. The whole thing got even sillier when some patients (and even, believe it or not, some therapists) began to assert that the multiple personalities were somehow related to demonic possession and satanic rituals.

  The demand for MPD treatment dropped dramatically when insurance stopped paying for it and when therapists grew fatigued and disillusioned. MPD enthusiasts came to realize they were opening a Pandora’s box by inducing more and more personalities. The patients usually got progressively worse, sometimes much worse, and were difficult to handle in treatment and in life. I have seen at least a hundred people who claimed to harbor multiple personalities. Almost all of them presented in a flock during the heyday of the epidemic in the late 1980s and early 1990s. In every case, I discovered that the emerging personalities had taken on a life of their own only after the patient had entered treatment with a psychotherapist interested in the topic, or after joining an Internet chat group, or after meeting someone else with the problem, or after seeing a movie that portrayed it. I wonder if MPD ever occurs as a spontaneous clinical entity—if so, it cannot be very often.

  MPD presented a dilemma for me in my work as chair of the DSM-IV Task Force. I felt it was a hoax (or more kindly a collective temporary contagion of therapist and patient suggestibility) and certainly not a legitimate mental disorder. For better and worse, I chose not to impose my view on DSM-IV. We continue to include MPD in the manual and we took scrupulous pains to present both sides of the controversy as fairly and effectively as possible—even though I believed one side was complete bunk. I was hoisted on my own conservative petard—not to make changes based only on my own opinion. Thankfully, the world has taken a break and for now has moved away from MPD, but I would expect other outbreaks in the future. Multiple personality seems to have an enduring appeal to suggestible patients and suggestible therapists and lies dormant, ready to make a comeback. We are always just a blockbuster movie and some weekend therapist’s workshops away from a new fad. Look for another epidemic beginning in a decade or two as a new generation of therapists forgets the lessons of the past.

  Witch Hunts: The Day Care Sex Abuse Scandal (Circa 1980 to 2000)

  The day care sex scandals (occurring contemporaneously with, and sometimes related to, the MPD fad) were a close replay of the Salem witch trials. Separated by exactly three hundred years, both epidemics reflect the worst in human nature and were fueled by the same ingredients of fear, vitriolic accusation, prurient puritanism, suggestion, projection, group contagion, and the credulous acceptance of the obviously fantastic testimony of children. The Salem witch hunts of the 1690s were propagated by righteous (but misguided and destructive) Puritan ministers. In the United States in the 1990s, the epidemic was fostered by well-meaning (but misguided and destructive) therapists—admittedly ably assisted by misguided parents, police, prosecutors, judges, and juries. This is a discouraging tale, an outrageous miscarriage of justice, and a discouraging breakdown in our civil society.

  The cases all followed the same depressing script. The fad began in Kern County, California, in 1982 and, within ten years, had spread like wildfire across the country (and to a lesser degree around the world). There were allegations that day care workers were sexually abusing their charges, often in the most shocking and bizarre ways. In every case, the evidence was based on wild and fantastic accusations made by very young children, unsupported by physical evidence or credible corroborative testimony. The initial charge would usually be made by a vindictive or deranged accuser—usually a parent, stepparent, or grandparent. The panic would soon spread to other parents and the community at large.

  The testimony of the children was a confabulation derived from long, repeated, and grueling inquisitions conducted by an unholy alliance of therapists, police officers, and prosecutors—egged on by parents and press. The tone of the interrogators was leading, suggestive, and at times even coercive. They already knew what terrible things had happened—it was just a question of having the child victims fill in the gory details. The kids were told what the other kids were saying and great pressure was applied to get them to conform and confirm. The stories offered by the different child witnesses naturally fed on one another and gradually converged into a seemingly consistent and damning picture. Salem redux.

  There was no shortage of lurid, ready-made details to fill in any holes in the child’s imagination or recollection of events. The possible limitations of creativity of a given interviewer or child were supplemented by wide and wild media reporting of the charges that had been made in other cases. The press and TV were having a field day and providing a circus. That the charges were ridiculous, fantastic, and physically impossible did not matter. One would assume that no reasonable person could possibly grant them any credibility, but people had stopped being reasonable. The weirdest accusations gained a crazy authority if they were repeated enough in any given case. And they seemed to confirm what had been reported so often and so loudly and with such vivid detail in so many different cases in so many different states and countries. There had to be fire, since there was so much smoke. The judicial system could cop a plea to its own temporary insanity.

  The cases played different variations on two themes of abuse—sexual and satanic. The sexual part consisted of every imaginable sex act (and some that are not imaginable or even possible) and of orgies, pornography, prostitution, and torture. The satanic rites consisted of devil worship, killing or torturing animals, drinking blood or urine, eating feces, and demonic possession. Some of the stories contained obviously fantastic elements—alien contact, abuse by robots, knife stabbings that left no wounds, and so on. The patent absurdity of some of these claims somehow failed to alert the eager pursuers to the likely absurdity of all of them.

  All these horrible goings-on would purportedly occur at the day care center during its regularly appointed hours with no one noticing—not parents, or neighbors, or delivery men, no one
. It went unexplained how, up to the point of exposure of the foul deeds, the children could leave the center each day smiling and normal. Things got worse as the methods of grand inquisition ground into gear. The suspicion and blame spread. Clearly the primary perpetrator could not have gone undetected in his corrupting acts without the conspiratorial connivance or active participation of the entire staff of the day care center. These poor innocent souls would be subjected to the righteous wrath and brutal interrogation techniques of naive (but often ambitious) public servants determined to protect our children and to punish severely all those responsible for their lost innocence. The coworkers faced the usual horrible choice of those who have been accused unfairly—lose honor or lose freedom. Confess to false charges that they had participated in the absurd activities alleged by their child accusers, thus betraying their friends who will be found guilty based on their false testimony. Or face a long prison term for the crime of having been innocently in the wrong place at the wrong time.

  In a panicked and frenzied desire to protect their children from an imagined loss of innocence, the parents subjected them to damaging interrogation, fantastic concepts about sex and Satan, the need to lie and bear false witness, public exposure, and later guilt for being part of this mess. Certainly they caused their children to have a real loss of innocence. The “therapists” involved in the cases had developed an instant expertise on day care sex and would soon acquire celebrity for their heroic efforts to root it out. The interviewers were remarkably blind to the effect of their biases and the role of suggestion and positive reinforcement in helping to get the children to parrot their preconceptions. The therapists furthered the process by using anatomically correct dolls, presumably for an evidentiary purpose to determine what had actually occurred. But it degenerated instead into a mutual play therapy that elicited ever more fantastic fantasies from the collaborative sexual imaginations of the children and the therapists.12

  Why did the epidemic of day care hysteria happen just when and where it did? Why in 1982? Why in the United States? It is never possible to be precise in evaluating the causes of any event that has so many different and interacting influences. But some things stand out as likely contributors. You can’t have a panic about day care centers unless you have day care centers. These had become a necessary fixture of American life as more mothers entered the workforce, families traveled far distances to chase available jobs, and there were fewer available grandmothers to help babysit. Undoubtedly parental guilt in turning over parental responsibility played a role. Among therapists, there was concern over previously not taking seriously enough the statements of kids who had actually experienced sexual abuse. There were also too many therapists with too little expertise who were able nonetheless to self-promote and gain authority as fake “experts.” This sad episode is the clearest caution imaginable to any therapist feeling the impulse to jump onto a current or future fad bandwagon.

  Following the Pack

  We should not be surprised that psychiatric diagnosis has always been, and still is, so faddish. Fashion influences every aspect of our behavior, and following the pack is part of human nature. The good news is that fashions come and fashions go. A century ago, the world was awash in neurasthenia, conversion hysteria, and multiple personality disorder. Then all three suddenly and mysteriously disappeared. The psychiatric fads that now seem so entrenched are less robust than meets the eye and will likely also wilt with time and as people come to understand their risks. But there’s also bad news. Most epidemics in the past were isolated, local, and self-limited. Our new fads are globalized, monetized, and becoming part of the societal infrastructure.

  CHAPTER 5

  Fads of the Present

  “When I use a word,” Humpty Dumpty said, in a rather scornful tone, “it means just what I choose it to mean—neither more nor less.”

  “The question is,” said Alice, “whether you can make words mean so many different things.”

  “The question is,” said Humpty Dumpty, “which is to be master—that’s all.”

  LEWIS CARROLL, Alice’s Adventures in Wonderland

  HUMPTY DUMPTY BRAGS unrealistically about his ability to master words and control their definition. His pride qualifies him for the well-deserved great fall he is about to have. One of the things Alice is constantly discovering in Wonderland is that words can fly out of control and have different and confusing meanings, very dependent on context. It is not so much what you “choose to mean” as it is what others take you to mean. And that can be much more or much less than you intended.

  We were unaware how much we were in Humpty’s precarious position when DSM-IV was published in 1994. We shared his complacent belief in the power of carefully chosen words and were surprised when ours also flew out of control. Our goal was to prevent diagnostic inflation from growing and our conceit was to think we had succeeded in holding the line.1 We were wrong.2 It turns out that the impact of the diagnostic system is not in the words as written, it’s in the way words come to be used. DSM-IV was meant to be a careful and conservative diagnostic manual, but once out of our hands, it was not always used carefully and conservatively. We thought we shot down every new suggestion that might be a giveaway to the drug industry. But we greatly underestimated their power to convince practitioners and patients to apply our words in the loosest possible way. A colorful TV commercial has much more dramatic impact than the fine print of a dry DSM-IV criteria set. The constant blitz of misleading marketing easily overwhelmed the barriers to overdiagnosis we thought were built into our definitions. As it turned out, DSM-IV unwittingly contributed to three new false epidemics in psychiatry—the overdiagnosis of attention deficit, autism, and adult bipolar disorder. Rule of thumb—if anything in a DSM can possibly be misused, it will be misused.

  We should have known better. Conflicts between the written and oral tradition are as old as the Bible and as current as the Supreme Court’s interpretation of the Constitution. The written words themselves generally don’t rule—it is all in their later interpretation. Alternate productions of the same play can each convey very different meanings without ever changing one single word. The lesson of the last fifteen years is that the DSM alone does not establish standards. Physicians, other mental health workers, drug companies, advocacy groups, school systems, the courts, the Internet, and cable TV all get to vote on how the written word will actually be used and misused. There are false prophets and false epidemics. You get to exert control over the diagnostic manual only up to the moment you publish it. Once it is out in the public domain, people use it (and often misuse it) as they damn well please.

  Below is a rogues’ gallery of the current false epidemics in psychiatry—the mental disorders most likely to be overdiagnosed and overtreated. Describing them will hopefully reduce their spread. But first, one important caveat—a fad diagnosis is a useful diagnosis gone wild. Many, perhaps most of the people who currently have the diagnosis have gotten it for good reason. These are “fads” only because they have become too fashionable and are often loosely and inappropriately applied—particularly in primary care. Each, in its right place and accurately diagnosed, is absolutely essential to understanding and treating psychiatric symptoms. Anyone at the margins who has already received one of these diagnoses should get a second opinion. Always be skeptical, but not too skeptical.

  Attention Deficit Disorder Runs Wild

  It is 6:00 A.M., dark and rainy, and I am driving to the airport. I can’t put up the top to my convertible because it has been broken for months, but I keep forgetting to get it fixed. I arrive, double-park to check my bags, leaving the lights on and the radio blaring golden oldies from the 1960s, 1970s, and 1980s. On returning a week later, I can’t find my car in the garage. This is surprising to me, but shouldn’t be, because I never parked it there. I forgot it altogether, just checked the bags and blithely boarded the plane. Good-humored security officers call in all their buddies to enjoy a hearty laugh at my expense. I am enor
mously grateful to them for towing my car to a safe place, charging my battery, and refusing any money because the rare experience of meeting anyone so silly has been more than enough reward.

  My secretary, Tammy, has similarly found her life enriched by the delectation of my magical ability to lose papers going the ten feet from her office to mine, my repeated inability to find my office in a hospital maze I have worked in for years, and my capacity to forget meetings and appointments. My wife is much less connoisseur than critic. She unempathically claims that my lack of attention to the needs and errands of everyday life reflects willful avoidance rather than diagnosable mental disorder. My life has been a kind of sheltered workshop. The kindness of friends and strangers has protected me from any serious impairment.

  Am I an absentminded professor or psychiatrically sick? Should I start taking stimulants or muddle through after my fashion? In the old days I was a normal, if sometimes ridiculous, person. But things are different now. ADHD is spreading like wildfire. It used to be confined to a small percentage of kids who had clear-cut problems that started at a very early age and caused them unmistakable difficulties in many situations. Then all manner of classroom disruption was medicalized and ADHD was applied so promiscuously that an amazing 10 percent of kids now qualify. Every classroom now has at least one or two kids on medication. And increasingly, ADHD is becoming an explain-all for all sorts of performance problems in adults as well.