On May 3, 2013, David Kupfer MD (DSM-5 Task Force Chair) responded to Thomas Insel’s April 29th unequivocal attack on the validity and usefulness of DSM. You can see Dr. Kupfer’s response here. Essentially Dr. Insel said that the categories set out in the DSM did not correspond to anything in the real world, and that NIMH would no longer be using these categories as the basis for their research program. This statement did not, however, represent any significant movement away from the biomedical model on the part of NIMH. In fact, if anything, it was a movement towards an even more deeply entrenched medical model. But it was a huge hit on DSM and on the APA, who tout the catalog as the basis to their claim to scientific credibility.
There was nothing particularly new in Dr. Insel’s article. Those of us on this side of the debate have been saying the same things for years. But it did represent a very serious rift in what up till then had seemed a coherent and unified front.
THE APA’S RESPONSE
I have contended for many years that psychiatry is based on marketing rather than science, and spin rather than truth. Dr. Kupfer’s response to the NIMH paper is a good example.
Although Dr. Kupfer’s article is clearly a response to the NIMH piece, Dr. Kupfer makes no mention of the latter until the last paragraph but one. Even then he does not attack Dr. Insel’s position – but actually praises it!
This is spin of a very high order. If he had attacked the NIMH article, there would have been onus on him to refute the charge that the DSM “diagnoses” have no validity. By sidestepping the issue, he doesn’t have to go out on that limb, which has always been shaky, but has been made more so by Dr. Insel’s attack.
Instead, he opens on a very upbeat note: “The promise of the science of medical disorders is great.” This really doesn’t mean anything, but it sure sounds good. These guys could give lessons to the politicians.
It gets better.
“In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”
This almost sounds like an honest confession. But let’s take a closer look.
“We’ve been telling patients for several decades that we are waiting for biomarkers.”
I suggest that this is simply not the case. Psychiatrists have been telling their ‘patients’ for decades that they have chemical imbalances in their brains, that the chemicals involved are known, that the pills correct these imbalances, and that the pills are safe. All of these statements are patently false and extremely destructive. I have never heard (or even heard of) a psychiatrist who said to his ‘patients’ or to anyone else that “we are waiting for biomarkers.” The entire house of cards has been built on the illusion of scientific certainty, which the psychiatric profession promoted shamelessly.
After this bogus confession, Dr. Kupfer continues:
“In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia.”
Note the phrase: “… clinical experience and evidence, as well as growing empirical research…” In other words: we may not have the chemistry nailed down precisely, but our work is still underpinned by clinical experience, evidence, and empirical research.
What he omits to mention is that most of the research that supports the DSM concepts has long been hijacked by pharma and amounts to little more than pharma advertizing, and that the genuine research in this field demonstrates that psychiatric practice in America is not only ineffective, but in a great many cases also destructive.
Clinical practice that is based on spurious research is called quackery.
In his second paragraph, Dr. Kupfer has this to say:
“This progress will soon be recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The new manual, due for release later this month, represents the strongest system currently available for classifying disorders. It reflects the progress that we have made in several important areas.”
Remember that Dr. Insel had said, in effect: DSM is rubbish. We won’t be using it any more.
Dr. Kupfer makes no rebuttal; he simply refers to DSM-5 as “progress” and as the strongest system currently available for classifying disorders. But Dr. Insel’s precise point was that the DSM has no validity. In other words, the only thing that it is classifying is the collective prejudice of the APA!
To demonstrate the “value” of DSM-5, Dr. Kupfer lists four features of the new manual which collectively don’t amount to a hill of beans, but serve merely to distract the reader from the fundamental criticism that the categories have no validity.
If you drill an oil well and it turns up dry, you don’t have an oil well. You have an expensive hole in the ground. If you construct a classification system that has no validity, you don’t have a classification system, you have a pile of rubbish – and in this case – dangerous and destructive rubbish. And if the APA keep insisting that their rubbish is valuable, and if they keep selling it to people and using it to justify their actions – then the word that comes to mind, at least to my mind, is charlatan.
Dr. Kupfer continues. DSM, he tells us, “… provides clinicians with a common language to deliver the best patient care possible.” Once again, he’s dodging the point. The APA field trials of DSM-5 demonstrated clearly that the categories in the manual have very poor inter-rater reliability. So it isn’t even a common language.
And the notion of delivering the “best patient care possible,” is a little hard to reconcile with the well-established fact that psychiatric “treatment” of depression, for instance, is not only ineffective in the short run, but actually increases the chance of a chronic deteriorating course in the long run.
Now we get to the NIMH. There’s no response to the validity challenge, just a statement to the effect that the institute’s new research framework, which they will use instead of DSM, is “vital to the continued progress of our collective understanding of mental disorders.” The use of the word “collective” suggests that the APA and NIMH are still good buddies. Don’t show the rift.
But – and clearly Dr. Kupfer perceives this as his trump card – the institute’s proposed domain criteria “… cannot serve us in the here and now, and they cannot supplant DSM-5.” In other words, we’ve got the only football, so if you want to stay in the game, you’d better get on board with us.
He goes on to characterize the NIMH’s research framework as “…a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field.” (emphasis added)
What he’s doing here is marginalizing the NIMH’s position: They will be out there in left field doing their thing and someday they may have something that will warrant us accepting them back into our field.
And here’s where it gets really good. “In the meantime, should we merely hand patients another promissory note that something may happen sometime?” Promissory note evidently is a euphemism for blatant lie.
“Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.”
There is a great deal of evidence that their ‘patients’ would be a lot better off if the psychiatrists packed in their spurious and destructive practices and found honest work.
Then he plays the “we’re-doctors, you-can-trust-us” card:
“The American Psychiatric Association is a national medical specialty society whose physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org.”
This is very high quality spin. Dr. Kupfer never actually addresses a single serious issue. He simply strings together a series of inane platitudes. He insults his clients, and he insults the general public.
If the Director of the NIH had published a paper criticizing some of the fundamental concepts underlying urology, say, I think the response from the American Urological Association would have been based on facts and science, rather than rhetoric and spin.