Is Anybody Still “Normal?”

When I introduce the psychological disorders unit in both intro psych and biopsych, I spend quite a bit of time discussing what we mean in psychology by the term “abnormal.” This sometimes seemed like overkill–the students were always anxious to get into the meat of the material. After reading Allen Frances’ commentary on DSM V in the Los Angeles Times, though, I am more than ever convinced that the time spent in the discussion of “abnormal” is time well spent.

If you’re not familiar with Professor Frances, he is an emeritus professor and former department chair in psychiatry at Duke University, and he headed up the DSM IV task force in 1994. Those credentials suggest to me that when he has something to say about DSM V, we should all listen carefully.

I am not a clinician, and I have often been troubled by the DSM’s couching what seems to be very typical behavior to me in terms of disorder. Here are a few of my favorites:

1. “Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)” from the criteria for Attention Deficit Hyperactivity Disorder. Do we know anybody who doesn’t do this?
2. “Often leaves seat in classroom or in other situations in which remaining seated is expected.” Another gem from the ADHD criteria. Instead of making this a symptom of a mental disorder, why don’t we consider our expectations for young children remaining seated? After all, with current rates of childhood obesity, maybe we shouldn’t let them sit down at all.
3. “Often initiates physical fights” from the DSM criteria for Conduct Disorder, which is the psychologists’ equivalent of juvenile delinquency. I’m not saying physical fights are ideal behavior, but this is what boys do. I attended a very prissy school system, and most of my classmates are college graduates and successful professionals, and I distinctly recall the boys getting about a block away from our elementary school and starting to punch each other. And what about “mean girl” behavior that doesn’t involve physical fighting? There aren’t too many more vicious creatures on the planet than a pack of 7th grade girls, yet the DSM seems to think that relational aggression is just dandy….

But let’s get back to Dr. Frances, who has some stern things to say about the upcoming DSM V. Here are some of my favorite quotes from his article:

1. Our panel tried hard to be conservative and careful but inadvertently contributed to three false “epidemics” — attention deficit disorder, autism and childhood bipolar disorder.
2. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day — despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
3. …many misidentified teenagers would receive medications that can cause enormous weight gain, diabetes and shortened life expectancy.
4. Defining the elusive line between mental disorder and normality is not simply a scientific question that can be left in the hands of the experts.
5. This is a societal issue that transcends psychiatry. It is not too late to save normality from DSM-V if the greater public interest is factored into the necessary risk/benefit analyses.

The last two points Dr. Frances makes are consistent with continuing to emphasize a general education at the university level, not just career training. We need citizens educated in history, philosophy, ethics, and social sciences to help make wise decisions for how the science we produce is used. I hope the current DSM task force pays attention to Dr. Frances’ comments, or we soon won’t have any normal people left on the planet.