Allen J. Frances (born 2 October 1942) is an American psychiatrist. He is currently Professor and Chairman Emeritus of the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine. He is best known for serving as chair of the American Psychiatric Association task force overseeing the development and revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Frances is the founding editor of two well-known psychiatric journals: the Journal of Personality Disorders and the Journal of Psychiatric Practice.
During the development of the current diagnostic manual, DSM-5, Frances became critical of the expanding boundaries of psychiatry and the medicalization of normal human behavior, problems he contends are leading to the overdiagnosis and overtreatment of the "worried well" and the gross undertreatment of the severely ill. In recent years, Frances has become a vocal advocate for improved treatment and societal conditions for the seriously mentally ill, the appropriate use of electroconvulsive therapy in severe cases of mental disorder, and an integrated, biopsychosocial approach to psychiatry.
Frances is the author or co-author of multiple books within the fields of psychiatry and psychology, including: Differential Therapeutics (1984), Your Mental Health (1999), Saving Normal (2013), Essentials of Psychiatric Diagnosis (2013), and Twilight of American Sanity (2017).
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. He graduated from the psychiatry residency training program at the New York State Psychiatric Institute in 1971 and received a certificate in psychoanalytic medicine from Columbia University Center for Psychoanalytic Training and Research in 1978. 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 began his professional journey at Cornell University Medical College, where he advanced to the position of professor. During his tenure, headed the outpatient department, provided patient care, delivered lectures, established a brief therapy program, and developed research specialty clinics for schizophrenia, depression, anxiety disorders, and AIDS. Throughout his academic tenure, Frances was an engaged researcher and prolific writer, contributing significantly in various clinical fields, including personality disorders, chronic depression, anxiety disorders, schizophrenia, AIDS, and psychotherapy. In 1991, he assumed the role of Chairman of the Department of Psychiatry at Duke University School of Medicine, where he played a key role in expanding the research, training, and clinical initiatives established by his predecessor, Dr. Bernard Carroll.
Research Frances had originally viewed himself as a teacher and clinician but his administrative posts—as director of an outpatient department, chair of a psychiatry department, and chair of the DSM-IV Task Force—thrust him into more of a research role. He was an early organizer of outpatient services based on a given psychiatric disorder, providing expert clinical services and enriched research environments. In all, Frances received a dozen research grants as principal or co-principal investigator, most from the National Institute of Mental Health and published extensively on personality disorders, chronic depression, schizophrenia, anxiety disorders, the psychiatric aspects of AIDS, and various aspects of psychiatric diagnosis. He also mentored the careers of many other researchers.
Publications Frances' book on Differential Therapeutics (1984) 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-III Robert Spitzer, later the major force behind DSM-III, was one of Frances' teachers during his psychiatric residency at Columbia University and attempted to recruit him to participate in his research developing standardized criteria for mental disorders and interviewing instruments for diagnostic assessment. Frances declined the offer because he felt psychiatric treatment was much more interesting than psychiatric classification. Ten years later, in 1977, Spitzer attempted to recruit Frances again, this time to join his work on DSM-III. Frances accepted and was given three roles. He wrote the final draft of the personality disorders section of DSM-III; served as DSM-III liaison to the American Psychoanalytic Association and the Academy of Psychoanalysts; and he was a member of the team that delivered DSM-III educational conferences across the country. He wrote a number of papers on the uses and misuses of DSM-III and predicted DSM would eventually adopt a dimensional model of personality disorder diagnosis.
DSM-IV
Frances was appointed Chair of the DSM-IV Task Force in 1987. His selection followed his role as one of the major advisors for DSM-IIIR and reflected concerns within the American Psychiatric Association that new disorders were being added without sufficient evidence and that definitions of existing disorders were too loose. Frances was known as a diagnostic conservative who would promote stability in the system and discourage its rapid expansion across the fuzzy boundary into normality. He introduced a thorough three-stage vetting system to discourage diagnostic exuberance in DSM-IV: 1.) a thorough review of the existing literature had to produce compelling evidence in support of the suggested change; 2.) funding from the MacArthur Foundation allowed dozens of reanalyses of unpublished data sets to help answer questions pertinent to DSM-IV changes; and 3.) NIMH funding allowed for 11 field trials assessing how proposed changes would translate into clinical practice. The conservatism seemed to work. Of the 94 new diagnoses suggested for DSM-IV, only two were accepted: Asperger's syndrome and bipolar II disorder. Both had good supporting literature and both had performed well in field trials. However, Frances argued that any change in DSM-IV that could be misused, would be misused, and both changes led to unfortunate fads of wild overdiagnosis. Frances argues that there was also a fad of attention deficit/hyperactivity disorder partly due to loosened diagnostic criteria but mostly due to pharmaceutical company marketing.
DSM-5 The next revision DSM-5 was initiated with a 2002 book (A Research Agenda for DSM-V) 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 (DSM-V: Open and Transparent?). Frances initially declined to join Spitzer's criticism, but after learning about the changes being considered, he wrote an article in July 2009 (A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences) 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 (attention deficit disorder, autism, addictions, personality disorders, bipolar II disorder), he was also disturbed by the addition of new speculative disorders (Attenuated Psychosis Syndrome, Disruptive Mood Dysregulation Disorder, Somatic Symptom Disorder). 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."Frances A. Psychosis risk syndrome—far too risky". Aust N Z J Psychiatry. 2011 Oct;45(10):803-4. 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 (attenuated psychosis syndrome, mixed anxiety depression) 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 (2013), and Essentials of Psychiatric Diagnosis (2013), 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.
Major contentions
Neglecting severe mental illness