DSM-5 – Dimensional Diagnoses – More Conflicts of Interest?

BACKGROUND

On November 20, JAMA Psychiatry (formerly Archives of General Psychiatry) published an interesting letter.  It was headed: Failure to Report Financial Disclosure Information,  and was signed by Robert D. Gibbons PhD, David J Weiss PhD, Paul A. Pilkonis PhD, Ellen Frank, PhD , and David J. Kupfer MD.

The letter is an apology for failing to disclose a financial interest in an article, Development of a Computerized Adaptive Test for Depression, that had appeared in Archives of General Psychiatry a year earlier (November 2012).  The article described a computerized questionnaire for depression (the CAT-DI) and was generally positive with regards to the potential usefulness of the test in clinical settings.  In the article, the authors had clearly stated that they had no conflicts of interest, but that:

“The CAT-DI will ultimately be made available for routine administration, and its development as a commercial product is under consideration.” (p 1)

But they did not disclose that they had already formed a company, Psychiatric Assessments, Inc. (PAI), the apparent purpose of which was to market the test.  According to the Delaware Division of Corporations, PAI was incorporated on November 29, 2011.  The Gibbons et al article was accepted for publication on Jan 4, 2012, and was published in November 2012.  So there was certainly plenty of time for the authors to disclose their financial interest.

The matter came to light earlier this year.  Bernard Carroll, MD, PhD, who incidentally blogs on Health Care Renewal, wrote a letter to JAMA Psychiatry critiquing the Gibbons et al article, and challenging the validity, usefulness, and need for the CAT-DI.  Dr. Carroll’s letter is dated July 2013, and contains a clear conflict of interest disclosure to the effect that he himself receives royalties from depression scales that he has developed.

Dr. Gibbons et al responded to Dr. Carroll’s letter in the same issue. Dr. Carroll was not convinced by this response, did some investigating, and uncovered the existence of PAI and the conflict of interest.  He has documented this matter in a post When Is Disclosure Not Disclosure? on Health Care Renewal.

We’ve seen so many conflicts of interest scandals in this field in recent years, that it might be tempting to shrug this off as just more of the same.  But, there’s a bigger issue.

DSM-5 AND DIMENSIONAL ASSESSMENT

First a little history.  In the Introduction to DSM-IV (1994) it states:

“It was suggested that the DSM-IV Classification be organized following a dimensional model rather than the categorical model used in DSM-III-R.  A dimensional system classifies clinical presentations based on quantification of attributes rather than the assignment of categories and works best in describing phenomena that are distributed continuously and that do not have clear boundaries.  Although dimensional systems increase reliability and communicate more clinical information (because they report clinical attributes that might be subthreshold in a categorical system), they also have serious limitations and thus far have been less useful than categorical systems in clinical practice and in stimulating research.  Numerical dimensional descriptions are much less familiar and vivid than are the categorical names for mental disorders.  Moreover, there is as yet no agreement on the choice of the optimal dimensions to be used for classification purposes.  Nonetheless, it is possible that the increasing research on, and familiarity with, dimensional systems may eventually result in their greater acceptance both as a method of conveying clinical information and as a research tool.” (p xxii)

Under a dimensional system a person might be described as having a certain score on an anxiety scale, rather than having generalized anxiety disorder, or a certain score on a depression scale rather than having major depressive disorder, and so on.  When this notion was floated in 1994, it seemed to me that it would be a big improvement over the traditional DSM “diagnoses,” but in the intervening years I’ve come to the conclusion that psychiatry could compromise and exploit a dimensional diagnosis just as readily as a categorical diagnosis.  But that’s a separate subject.

The central issue here is that one of the authors of the original Gibbons et al study is David J. Kupfer, MD, chairperson of the DSM-5 Task Force.  Given that DSM-IV had floated the notion of dimensional assessment, it was entirely reasonable that the DSM-5 Task Force should give the matter some consideration.  And they did.  Here are some quotes from their Introduction to DSM-5 under the heading Dimensional Approach to Diagnosis (p 12-13)

“Indeed, the once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality… (p 12)

This is a somewhat elaborate way of saying that the “diagnoses,” collected and set out in successive revisions of the manual, have no validity – they don’t “capture” reality!  This is a truly amazing admission, given that it is precisely the alleged ontological reality of these “diagnoses” that has constituted the conceptual underpinning of psychiatry and the legitimization of the drugging for the past 60 years.  The current edition of psychiatry’s diagnostic manual has the unique distinction of denying the validity of its subject matter in its own introduction.  But that’s also a separate subject.

“The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible…” (p 12)

(Just in case there was any doubt as to the meaning of the previous quote.)

“The adjacent placement of ‘internalizing disorders’ characterized by depressed mood, anxiety, and related physiological and cognitive symptoms, should aid in developing new diagnostic approaches, including dimensional approaches, while facilitating the identification of biological markers.” [emphasis added] (p 13)

In other words, we’re introducing a dimensional approach through a back door.  “Internalizing” will become the dimension underlying the various diagnoses in that category.

“…the…dimensional DSM-5 approach and organization structure can facilitate research across current diagnostic categories by encouraging broad investigations within the proposed chapters and across adjacent chapters.  Such a reformulation of research goals should also keep DSM-5 central to the development of dimensional approaches to diagnosis that will likely supplement or supersede current categorical approaches in coming years.” [emphasis added] (p 13)

It doesn’t take too much reading between the lines here to see that there was clearly some momentum within the Task Force to adopt a dimensional approach.  The categorical approach of the past is subjected to considerable criticism (in fact, I would suggest, total repudiation), and although DSM-5 didn’t adopt the dimensional approach whole-heartedly, it’s clear that the alterations in the manual’s layout and structure were adopted with a view to encouraging a dimensional approach in the future.

“The organizational structure [of the manual] is meant to serve as a bridge to new diagnostic approaches without disrupting current clinical practice or research.” [emphasis added] (p 13)

All of which leads us to wonder where within the DSM-5 Task Force was the momentum towards a dimensional framework centered, and in this regard it is clear that Dr. Kupfer has been a big fan of the dimensional approach.

In an April 2013 article in Nature, Mental health: On the spectrum, writer David Adam stated:

“The problem is that biologists have been unable to find any genetic or neuroscientific evidence to support the breakdown of complex mental disorders into separate categories. Many psychiatrists, meanwhile, already think outside the category boxes, because they see so many patients whose symptoms do not fit neatly into them. Kupfer and others wanted the latest DSM to move away from the category approach and towards one called ‘dimensionality’, in which mental illnesses overlap. According to this view, the disorders are the product of shared risk factors that lead to abnormalities in intersecting drives such as motivation and reward anticipation, which can be measured (hence ‘dimension’) and used to place people on one of several spectra. But the attempt to introduce this approach foundered, as other psychiatrists and psychologists protested that it was premature.” (p 2)

and

” When Kupfer and his DSM-5 task force began work in 2007, they were bullish that they would be able to make the switch to dimensional psychiatry. ‘I thought that if we did not use younger, more-basic science to push as hard as we could, then we would find it very difficult to move beyond the present state,’ Kupfer recalls.” (p 5)

 and

” In the middle of 2011, the DSM-5 task force admitted defeat. In an article in the American Journal of Psychiatry, Kupfer and Darrel Regier, vice-chair of the DSM-5 task force and the APA’s research director, conceded that they had been too optimistic. “We anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred.” The controversial personality-disorder dimensions were voted down by the APA’s board of trustees at the final planning meeting in December 2012.” (p 5)

and

“On the question of dimensionality, most outsiders see it as largely the same as DSM-IV. Kupfer and Regier say that much of the work on dimensionality that did not make the final cut is included in the section of the manual intended to provoke further discussion and research.” (p 6)

and

“Once the evidence base strengthens, he says, perhaps as a direct result of the NIMH project, dimensional approaches can be included in a DSM-5.1 or DSM-5.2” (p 6)

In December 2011, Emily Kuhl, PhD (the Senior Science Writer on the DSM-5 Task Force), Darrell Regier, MD (Task Force Vice-Chair), and Dr. Kupfer co-authored an article for the AMA’s Virtual Mentor.  The article is called Patient-Centered Revisions to the DSM-5.  The word “dimensional” occurs ten times in this article.  Here are some quotes:

“Supplementing binary diagnostic categories (in which the diagnosis is either present or absent) with dimensional quantitative rating scales (in which symptoms are measured along a continuum) will better capture the nuances of mental illnesses, including co-occurring conditions and disease severity, and could result in earlier, more accurate identification of psychiatric illness and provision of care.”

“Theoretically, this would allow psychiatrists to document limitless variations in personality by providing dimensional ratings of personality traits, domains, and facets; this level of specificity should make a designation of personality disorder trait specified more clinically meaningful than the DSM-IV’s personality disorder NOS in terms of better understanding patients’ symptom presentations and treatment needs.”

There is also a reference to the use of scales and questionnaires to implement dimensional assessment:

“A patient who indicates that she has been experiencing moderately depressed mood for the past 2 weeks, for instance, would be given a corresponding assessment for depression…”

“Many of the proposed dimensional assessments for the DSM-5 are drawn from existing tools…”

And, incidentally, Ellen Frank, PhD, one of the co-authors of Gibbons et al, served on the DSM-5 Task Force as Text Coordinator for mood disorders.

DISCUSSION

So we have three main themes:

1.  Dr. Kupfer, during his tenure as DSM-5 Task Force Chair, was heavily invested in the promotion of dimensional assessment, initially as a replacement for the traditional categorical system, and later, when it became clear that this was not achievable, as an ancillary component of the categorical system.  It is also clear that he conceptualizes DSM-5 as a bridge between the categorical “diagnoses” of the past and the dimensional ratings that he visualizes for the future.

2.  At the same time, Dr. Kupfer was a major shareholder in a private company that was designing a computerized assessment tool that would plausibly be much in demand if the dimensional system were implemented.

3.  Dr. Kupfer, along with his co-authors, failed to disclose their conflict of interest in the November 2012 JAMA article, and in fact only did so later when the conflict was exposed by Dr. Carroll.  This, incidentally, was about the same time that Dr. Kupfer was issuing assurances that the ties of 70% of Task Force members to Pharma did not sway their judgment.

NIMH FUNDING

The CAT-DI research that was written up in the original Gibbons et al article was funded by a grant from the National Institute of Mental Health (a department of the NIH).  The article cites the following grant number:  R01-MH 66302.  On the NIH’s RePORTER website there are 23 entries under Robert Gibbons’ name since 1990.  Nine (9) of these entries are linked to the 66302 number:

 

Project Year Total Cost
MH066302 2002 $380,713
MH066302 2003 $381,740
MH066302 2004 $375,025
MH066302 2006 $634,030
MH066302 2007 $581,084
MH066302 2008 $554,052
MH066302 2009 $555,007
MH066302 2009 $368,885
MH066302 2010 $1,127,810
Total $4,958,346

 

So since 2002, Dr. Gibbons and his colleagues have drawn down a total of almost $5 million in public money to develop a psychiatric assessment instrument that they now plan to promote for private profit.  This has prompted Dr. Carroll to write:

“…where is NIMH in all of this? Since when are public NIMH funds to be treated as commercial seed money? Who actually owns the algorithms and data bases on which the Gibbons corporation relies for its commercial aspirations? Why are they not publicly accessible? Is Thomas Insel [Director of NIMH] on top of this?”

INTERPRETATION

It is difficult to put a benign interpretation on Dr. Kupfer’s role in this matter.  It is clear that he believed in the merits of the dimensional system, and that, in his role as DSM-5 Task Force Chair, he promoted this system with as much vigor as he could muster.  Even when the APA Board of Trustees voted in December 2012 to retain the categorical approach, he laid the structural groundwork for the introduction of dimensional assessment at a later time, and crafted a numbering system (5.1; 5.2; etc.) whereby the manual can be updated easily and at frequent intervals.

During the DSM-5 deliberations, it was obvious to anyone that if the APA replaced the categorical model with a dimensional model, then there would be a vastly increased market for dimensional rating scales, and that the profit potential was enormous.

Given all of this, and given the lack of transparency in the Gibbons et al article, it is difficult to avoid the conclusion that Dr. Kupfer’s motivation was at least partly financial, and that he used his position as DSM-5 Task Force Chair to further his own financial agenda.

If a more benign interpretation can be put on these events, I would be interested in hearing it.  But it’s clear that psychiatric credibility has taken yet another hit.  Dr. Kupfer is a graduate of Yale’s medical school.  He joined the University of Pittsburgh in 1973, and became chairman of the psychiatry department in 1983.  He continued as department chair until 2009, and is now a professor of psychiatry at that establishment.  He has published more than 800 articles, books, and book chapters, and has served on the editorial boards of various journals.  And, of course, as mentioned earlier, he served in the prestigious position as chair of the DSM-5 Task Force.  He is, in every sense of the term, an eminent psychiatrist.

So I am left with two questions:  Firstly, why hasn’t Dr. Kupfer issued some kind of explanation for the lack of transparency?  The JAMA Psychiatry letter of apology was just a stark statement of fact, which leaves a huge cloud of doubt not only over Dr. Kupfer, but also over DSM-5 and psychiatry generally.  Secondly, why are we not hearing widespread expressions of concern from psychiatry about this matter?  To the best of my knowledge, the only psychiatrists who have spoken out on this are Bernard Carroll, who exposed the matter in the first place, and Mickey Nardo, who has been retired for ten years.

This kind of silence in these kinds of situations has become characteristic of psychiatry, through scandal after scandal, in recent years.  It is very difficult to avoid the impression that neither psychiatry’s leadership nor its general body has any interest in ethical matters.

There is only one agenda item in modern American psychiatry:  the relentless expansion of psychiatric turf and drug sales.  They’ve promoted categorical diagnoses and chemical imbalances strenuously for the past five decades.  Now that these spurious notions are on the point of expiration, psychiatry is developing dimensional diagnoses and neurocircuitry malfunctions as the rallying points of the “new and improved” psychiatry.

But the bottom line is always the same:  turf and money.  Something is truly rotten in the state of psychiatry.

  • Francesca Allan

    Good article as usual, Phil. I’m afraid I’ve slowly become so jaded about the financial motivations within psychiatry that little surprises me anymore.

  • Bernard Carroll

    Thank you for picking up on this story. The more one looks, the more questions arise. In my original post on Health Care Renewal, to which you linked, I was uncertain whether Dr. Kupfer had disclosed his COI with the corporation to the APA. Now I have learned he didn’t disclose it in an APA-authored infomercial published in JAMA, April 24, 2013, Vol 309(16). pp 1691-1692. This infomercial carries the grandiose title DSM-5 – The Future Arrived.

  • Nanu Grewal

    Hello Phil
    Just read your article from my on-call room over here in Queensland, Australia (where it is already a steamy 26C on Christmas morning – season’s greetings to you, by the way)…

    Great piece of work. It is small wonder that professional journalism is withering away and nobody bothers with the lazy rubbish that is regurgitated by the so-called professional Press anymore.

    You have done a fantastic job uncovering this story. In my training as a junior doctor I remember the great fanfare around 1999-2000 about a NEW screening test for depression. It was called the “2-Question Screening Test For Depression” [It was something like – comically – 1. Have you been really sad in the last 7 days 2. Have you been unable to enjoy yourself in the past 2 weeks] And all sorts of complex Chi-squared test data and confidence intervals and specificity and sensitivity charts were with the original article stating how great the “new tool’ was. All nonsense. There are lots of these “pay per tool” questionnaires out there some the psych-businesspeople out there.

  • Phil_Hickey

    Francesca,

    Yes, as they don’t even seem to care when it’s exposed! It’s almost become the norm.

  • Phil_Hickey

    Bernard,

    Thanks for your comment and for the reference. I agree, it’s a tawdry item. A better title might have been Apocalypse Now!

  • Phil_Hickey

    Nanu,

    Thanks for coming in. Happy holidays to you too.

    I think one of the big barriers in this field is that the general public just can’t get their heads around the fact that psychiatry is a fraud. Medicine is held in high esteem – deservedly, as attested by the fact that I am still alive! – that people just can’t accept that a “bona fide” medical specialty is based on complete nonsense. And, of course, psychiatrists keep playing the “we’re-real-doctors” card.

    So, there will be lots to do in the new year.

    Best wishes.

  • cannotsay

    You are very right that for many, including my former self, it is very hard to accept that there is a whole branch of medicine that is built on complete nonsense. Once I began to read about serious anti psychiatry literature, one of the fears that I had is that I would become something akin to an AIDS denialist.

    As you said in your other comment though, the more you investigate, the more you realize that psychiatry is built on a gigantic lie. There is nothing to deny. At least in the case of AIDS, the denialists deny a causal link HIV/AIDS. And those people infected with the HIV virus who live by that denial, pay dearly with their lives.

    What is exactly that those of us in this side of the debate are denying? Unlike what happens with AIDS, psychiatry postulates that so called “mental illness”, however you define it, is caused by “biology” but unlike the case of AIDS they don’t know what that biology that causes “mental illness” looks like (a virus, genetics, a “chemical imbalance” ?). The virus is no joke, I think that Torrey at some point claimed that schizophrenia’s cause was viral! This nonsense does not prevent them from prescribing poisonous drugs to treat whatever thing they think that they are treating. On the other side, rejecting whatever it is that psychiatry sells as “mental illness” is in most cases a sure path towards a very fulfilling life.

    We need to keep working to make sure that psychiatry stops destroying people’s lives.

  • Bernard Carroll

    Don’t we need a little moderation here? I for one would not
    go so far as to say psychiatry is a fraud or that it is based on complete
    nonsense or that it is a gigantic lie. There has always been room for
    improvement in psychiatric practice and theory, and that applies to the rest of
    medicine. There has been corruption in the field and that needs to be
    publicized, but demonizing psychiatry is not called for. Here is a link to a
    commentary on Health Care Renewal from a while back about these issues: http://tinyurl.com/d9g5hba Another good place for a
    consistently balanced perspective is the blog http://1boringoldman.com/ (Dr.
    John M. (Mickey) Nardo).

  • cannotsay

    I am assuming you refer to yours truly :-). Well, I am all ears. Tell me about the deep theory that justifies drugging people who behave in ways not approved by DSM guidelines, by force if necessary, until they do. Mickey is a true believer in psychiatry. He banned me not for being rude, but for pointing out that his outrage at big pharma abuses was misplaced, ie, that the reason big pharma scandals affect psychiatry way more than other areas of medicine is psychiatry’s lack pseudoscientific foundations. He couldn’t take it.

  • Bernard Carroll

    Yes, I was referring to you, cannotsay. Listen up.

    Psychiatry is a branch of medicine and a clinical science. It is not a basic science per se, and any theories in our field are just theories. The legitimacy of psychiatry doesn’t come from those theories, but from the clinical disciplines of descriptive nosology, diagnosis, and therapeutics. As Thomas Kuhn conceptualized for us, the basic sciences of neurobiology, pharmacology, and psychology bear a discipline-antidiscipline relationship to psychiatry. That boundary is like a tectonic plate junction, with the more basic sciences pushing to absorb the clinical sciences like
    psychiatry and medicine. But psychiatry is not one of those related disciplines in its own right, so your kind of deep theory challenge is not relevant.

    Second, 95+ percent of those who come to psychiatrists for help do so spontaneously, not under duress. And most of them are darned grateful for the real help they get. That was my experience of 30 years in practice.

    It was psychiatrists who mapped the territory of mental illness. It was psychiatrists who refined diagnostic interviewing and interpersonal techniques for managing distressed, psychotic, and out of control behavior, with coercion as a last resort. It was psychiatrists above all who alertly recognized the potential of chance drug discoveries (lithium for bipolar disorder, the early antidepressant, anti-anxiety, and antipsychotic drugs). And it was psychiatrists who did more than any other specialists to refine the design of clinical trials from the 1950s through the 1960s. The validity of psychiatry does not rest on the proof of some theory about what causes the major psychiatric disorders or about how the treatments actually work. The validity of psychiatry is ecological validity – as when the British psychiatrists Ball and Kiloh in 1959 remarked that they were doing a lot less ECT in their outpatient clinic now that this new drug imipramine (Tofranil) had come along. Or as when catatonia responds to barbiturates and, nowadays, to benzodiazepines, so the patients can resume eating and communicating. Or as when Joshua Logan stopped experiencing his manic-depressive cycling after being placed on long term preventive lithium treatment… and lest you say that is just one anecdote, look at the classic Schou-Amdisen trials of the 1960s. Or as when Aaron Beck and others opened up a new option of focused and time-limited interpersonal help through cognitive therapy. So yes, there are things we can measure in the clinical science of psychiatry – things like number of relapses, food intake and verbal output, return to occupational functioning, reduction of hospital admissions, validated patient self-reports of symptoms and functioning.

    I can readily agree with you that the psychiatry of today has been corrupted in many ways, not least by the influence of commerce. But is psychiatry a fraud? No.

  • cannotsay

    Hi Bernard,

    First of all, I want to thank you, unlike our friends Mickey and Joel (http://cantmedicatelife.com/2013/12/11/so-if-the-issue-is-respecting-choice-when-do-we-hold-peoples-feet-to-the-fire/ ) for your willingness to have an open, uncensored debate about this matter.

    Before I refute your statement, I have to explain a little bit where I am coming from. I have a PhD in hard science from one of America’s best universities. I am not disclosing which field and which university for confidentiality reasons. I make a living out of making accurate predictions based on accurate modeling (and more importantly accurate understanding) of the underlying mechanisms. In my field there is no room for wishy-washy predictions. If the systems we create do not behave in predictable ways, really bad things could happen. In short, in my field there is no room for the type of pseudo science that Richard Feynman denounces here https://www.youtube.com/watch?v=IaO69CF5mbY .

    This takes me to your points. They sound great as propaganda points, but they do not address the following,

    1- What is the so called “disease model” of psychiatry? You see, other areas of medicine have theirs: viruses, bacteria, cell replication gone rogue (case of cancer). What is the “theory” that psychiatry presupposes to back that the behavioral patterns that they so much dislike via DSM labels have to be “diseases”? I hope that you see that voting DSM labels is very different from articulating a clear somatic model that explains what is going wrong in the brain. Over the years psychiatry has come up with increasingly nonsensical theories (humor theory, psychoanalysis, chemical imbalances, etc) that have been debunked one after the other. Each time psychiatry reacts the same way: first demonizing those who criticize the flaws of “the model du jour”, then admitting the criticism and finally moving to the next chimera, as it is happening now with the NIMH and the Research Domain Criteria now that the chemical imbalance model has been duly discredited. Not having a clear disease model is the main reason psychiatry is not a scientific endeavor. Falsifiability and predictability are the hallmarks of science, the kind of science that sends probes to Pluto or that makes air travel possible. This is the SCIENCE that enjoys the prestige and regard in the public discourse. This is the type of science behind all areas of medicine except psychiatry. Then there is a different type of science, pseudo science, if you will, of the kind Feynman denounces. The best representative of this junk science is economics. Economics gets its predictions right as often as they get them wrong. While there are economics departments in all major academic centers and economics gets a great deal of research funding, we do not hold economist in the same high esteem, as scientists, as we hold physicists, chemists or mathematicians. The reason again is clear: while hard scientists get their stuff right all the time, the predictions of economists are for the most part worthless.

    2- We do know after the works of the Irving Kirsch and EH Turner (who has extended recently his meta analyses to areas outside SSRIs/depression) that not only the disease model is non existent, but that even the alleged “benefits” of psychiatry’s treatment of choice for their invented diseases are no better than those of a placebo. And this is a expected result from psychiatry dealing with subjective realities. While it is perfectly possible to define a “healthy brain” in the sense a “healthy liver” is well defined, a so called “healthy mind” is a very subjective value judgement. This is why meta analyses consistently show that there is no real benefit for any of psychiatry’s interventions. Meta analyses average out the subjectivity giving a net zero effect.

    3- Which takes me to my final point, and the only one that I really care about. One would expect that a discipline that doesn’t have any scientific foundation whatsoever and whose average net effect is zero (this being generous to psychiatry because the drugs do have side effects which are fatal in many cases) would be an entirely voluntary endeavor such as astrology or homeopathy are. Wrong!! Psychiatry is an exception in the usual practice of medicine is that it can be imposed onto unwilling victims.

    See, you cannot have it both ways. If psychiatry is really “just another branch of medicine” is should be treated as such and all psychiatric coercion should be banned. If psychiatry is not really like the rest of medicine in order to justify its coercive status, then there should be a higher intellectual standard for accepting its validity and its imposition should be carefully watched. Instead we have an unscientific discipline that can be imposed onto people more easily than the NSA can spy on Americans.

    You work on a bankrupt field on every level, and I haven’t heard anything from you, Mickey or Joel to refute the above other than what the NSA says to justify itself “trust us, we are good people”.

  • cannotsay

    And one more thing.

    I am pretty sure that astrologers and homeopathists are sincerely and genuinely convinced that their respective pseudo sciences have helped a lot of people who have voluntarily come to them for help. Many astrologers surely would be disgusted at the suggestion that explaining the life issues that some people experiment in terms of planets/houses is a form of abuse. The subjective validation of “patients” is orthogonal to the scientific status of either discipline.

    Yet, with a scientific foundation that is not better than astrology or homeopathy, psychiatry not only is offended to be called out for the pseudo science it is, but it feels it has a prerogative that not other area of medicine or CAM enjoys at imposing itself onto people who don’t want anything to do with psychiatry. This aspect of psychiatry is what makes it so contemptible from my point of view.

    I would not have cared less about psychiatric chimeras about their belief of how helpful SSRIs or TCA are to treat so called “OCD” if they had not been imposed onto me by the force of a detention and a court order. Not only I got a humiliation and a stigma that will last for the rest of my life but, if I had not stopped the charade in time, thanks to the American laws that allowed me to do it, I might be now worrying more about applying for a liver or kidney transplant than fighting psychiatric nonsense.

  • Bernard Carroll

    Nice to hear back from you, cannotsay.

    I like and respect Richard Feynman as much as you seem to
    like him. But what is your point with that video? I already said clinical
    sciences aren’t comparable to basic sciences. They have their own protocols and traditions, and they are very pragmatic disciplines. No surgeon doing a CABG procedure would dream of asserting your claim of complete reliability, though he may aspire to it. No psychiatrist treating a patient with psychotic depression would dream of comparing that task to a shot at Pluto. You may think you are very good as a mathematical modeler or systems theorist but I wonder
    about your grasp of clinical uncertainty. All the more reason for you not to hector us on clinical issues.

    To your Question 1: the issue of a disease model is a red
    herring. The foundations of pragmatic psychiatry are descriptive nosology, diagnosis, and therapeutics. You want Popperian falsifiability? Fine, just look at all the negative clinical trials of candidate psychotropic drugs. They are legion. You tell us all areas of medicine except psychiatry have achieved the precision of air travel or of rockets to Pluto? Dream on. When was the last
    time you checked on standards for blood pressure control or fasting plasma glucose or Number Needed to Treat for mammography screening? Hint: it’s over 2000.

    To your Question 2: you cannot be serious. Are you seriously
    trying to tell us that the disease model is nonexistent and that the benefits of psychiatric treatments for their invented diseases are no better than those of a placebo? Try telling that to a patient recovered from catatonia through IV lorazepam or ECT. Try telling that to a manic-depressive who has been stabilized on lithium. Try telling that to a patient who recovers from obsessive-compulsive disorder with cognitive-behavioral therapy. Try telling that to a patient with panic disorder whose panics attacks abruptly cease with use of a tricyclic antidepressant drug. You cannot be serious.

    To your Question 3: your premises are simply wrong. There is
    plenty of scientific foundation for clinical psychiatry, and the average net effect is a long way from zero, as I have outlined above.

    I am happy that you think I may be a good person. I would
    prefer that I can persuade you with my logic.

  • cannotsay

    Hi Bernard,

    Thanks for replying. To the point of the video. Even being generous with psychiatry, it is at least an order of magnitude less precise than other areas of what you call “clinical science”. A cholesterol level can be measured with a number. It represents a biological reality and you can alter it with this drug treatment or that nutritional regime. A biopsy can tell you if a cell has cancer. A blood test can tell you if there is HIV infection.

    How do you measure “depression”. You just can’t because obviously something like the HRSD is highly subjective, which is why meta analyses with large samples find no difference between placebo, active placebos, SSRIs or I would assume even a regime of 3 daily hamburgers. Same thing with OCD/Y-BOCS. That is not to say that certain areas of brain activity cannot be measured accurately. Certainly IQ tests measure something that is quantifiable, namely, the ability of your mind to do a specific set of tasks of linguistic and mathematical nature fast. What what do HRSD or Y-BOCS measure? Absolute nonsense.

    With respect to my point 1-. I didn’t say that the rest of medicine as a whole has achieved the type of precision required to send a probe to Pluto (although some areas like HIV science do have that precision when it comes to measuring the efficacy of HAART). What that means is that even though some areas of non psychiatric medicine might be more precise than others there is a huge gap between what these areas achieve and what psychiatry achieves, to the point that no other than Jeffrey Lieberman called psychiatry a step child of medicine here http://www.npr.org/2013/05/31/187534467/bad-diagnosis-for-new-psychiatry-bible . I do not think though that psychiatry is presented by psychiatrists this way to patients (willing or unwilling). I am of the opinion of Greenberg. Maybe there is value in psychiatry and psychiatric drugging (just as probably there is value in astrology and homeopathy) but it should be presented to patients for what it is, not for what people like you would like it to be.

    To point 2-. I hope you realize that you are just provided anecdotal evidence. And as anecdotal evidence goes, yours is as good as this http://openparadigmproject.com/ (or my own) . These people all claimed to have gotten better ONLY after they abandoned psychiatry’s prescriptions. This is coupled with point 1-. You cannot measure what is exactly that psychiatry is improving and when you try modest attempts like HRSD or Y-BOCS, when you have enough samples it turns out that on average psychiatry’s prescriptions have zero efficacy. You don’t seem to have a problem with the fact that every single serious (ie, not corrupted by Big Pharma) meta analysis performed using psychiatry’s own measures of efficacy has shown no benefit on psychiatric interventions. I do because drugs and ECT have side effects that might worsen people’s lives more than if no psychiatric intervention was performed. In the worst case, we do know that SSRIs increase the risk of suicide. ECT is known for affecting memory, etc.

    To point 3-, you didn’t address the point what is so special about psychiatry as to warrant to be the only so called area of medicine that can be imposed on innocent victims by force. If anything, the things that you mention about psychiatry (lack of disease model, only anecdotal evidence to justify its treatments) should make individual freedom trump any attempt at imposing psychiatry on unwilling victims.

    You might be a nice guy, but untold suffering has been caused though human history by people who were acting with good intentions.

    I for one have had my life destroyed by colleagues of yours who restrained and drugged me against my will. I have no reason to believe other than they were acting on “good intentions”. Fast forward a few years and the end result is that I am divorced, estranged from my parents and stigmatized for life. The latter is the worst of all for me. Many people can recover from a failed marriage and from abusive parents.

    Now, in an environment in which the disease mongering that those of your profession regularly engage in to justify your salaries results in stigma it is very difficult to recover from the stigma of having been involuntarily committed in a psychiatric institution. I have already accepted that my social life has become toxic and I will never again have anything remotely close to the type of social life that I had before my commitment. In my case your profession won an activist that will spend every single bit of his intelligence and influence for the rest of his life in seeking the delegitimization and destruction of psychiatry. Nothing against you personally, but a lot against a quackery that has destroyed more lives than we can count, including my own.

  • Bernard Carroll

    Cannotsay, I am not going to keep this exchange going forever, but I am not going to let you get away with bs and hand waving, either.

    To your first response, I already gave you examples of quantifiable metrics for clinical improvement. You might say that clinimetric measures like quality of life and social functioning deserve precedence over HRSD scores, and I might agree with that, but HRSD is not absolute nonsense. I should know. Max Hamilton was a good friend of mine, and a straight shooter. Plus, there are plenty of hard end points, as I described earlier. And please do not try to claim that clinical hypotheses are nonfalsifiable or that clinical science is not a
    science. As for measuring brain activity, don’t get carried away with fMRI pictures that can be measured accurately but that have a tenuous relationship to the clinical phenomena.

    On your earlier point 1, now you are back pedaling. I think you really don’t grasp the uncertainty that clinicians in general medicine and psychiatry deal with every day.

    On your earlier point 2, please don’t play rhetorical games and please don’t be disingenuous. You must know perfectly well that my examples were not single case anecdotes. I expected better from you as a serious interlocutor. And please quit the hand waving about no benefit from psychiatric interventions. Remember lithium? Remember benzodiazepines for catatonia? Remember the original antidepressant drugs? They had a NNT of 3 compared to 10 for the commercially favored newer agents.

    On your earlier point 3, you have utterly misrepresented what I said. That is not what I expect of a logical interlocutor. It is obvious from what you say that you have had some tragic experiences. I wish you well in your efforts to recover from those, but I don’t think “the destruction of psychiatry” is part of an effective plan.

    I won’t come back to this thread. I hope for you that your
    smarts can finally get you to a good place. Ave
    atque vale.

  • cannotsay

    Hi Bernard,

    I am sorry you have decided to invoke cloture but sadly, it has been my experience with every psychiatrist that I have corresponded with that conversations end the same way. When the objections to psychiatry are detailed my psychiatrist debate opponent always ends the game the same way, without refuting the criticism in any substantive way, cloture is invoked with accusations of me being “heartless” and “not caring” for those who claim to have benefited from the psychiatric quackery. What that means is, of course, that my basic criticism of psychiatry is spot on: psychiatry is a pseudo scientific endeavor that is bankrupt intellectually.

    Now to briefly correct your misrepresentation of my points,

    1- Not backpedaling, the exchange is here for everybody to see. People can make up their own minds. The HRSD doesn’t measure anything that can be considered “objective” and that’s a problem because science requires objective realities, even your so called “clinical science”. We might agree or disagree what the best range for the level of cholesterol in blood is or the best way to alter it, but we all understand what a level of 200 mg/dL is. It’s the same for everybody. On the other hand, a HRSD score of say 20 is meaningless, which is why, again, when you average the raw scores of large sample, HRSD can be altered by almost anything. As I said, I bet that a regime of 3 daily hamburgers would have the same effect on a randomized clinical trial than the SSRI of your choice. Also, on the fMRI, you are again confusing correlation with causation. In 2008 somebody published this study about the different fMRI correlates between heterosexual men and gay men http://www.ajnr.org/content/29/10/1890.long . How is that relevant to the status of homosexuality as a disease? Not relevant at all.

    2- Yes, your examples were mere anecdotes. Again. psychiatry doesn’t any so called “objective metric” like the HRSD which hasn’t been shown to be meaningless in analyses of large sample sets. The NNT is not such a metric, sorry. Similarly “quality of life” and “social functioning” do not measure any objective reality, it is subjective.

    3- You still have not addressed what is your position of the coercive status of psychiatry, not even here. I suppose that, as every psychiatrist I have met in my life, that you find coercive psychiatry acceptable at least in “some cases”, whichever those “some cases might be”, which again, begs the question of how somebody who is on record agreeing that psychiatry doesn’t have a scientifically valid disease model and that doesn’t have good indicators to measure the “effectiveness” of its so called “treatments” is so arrogant as to believe that the psychiatric quackery can be imposed onto unwilling and innocent victims. Sadly, again, your mindset is very representative of the average psychiatrist, at least in my experience.

    With regard to the destruction of psychiatry, I see it more likely now than one year ago. 2013 has been particularly lethal for psychiatry (as I am sure you already know). Some said that it would be impossible to fight Big Tobacco effectively. Boy they were wrong. I am under no illusions about how hard it is going to be (as the Murphy bill shows) and about the weight of Big Pharma making 80 billion dollars a year out of a quackery plus 50000 psychiatrists making a salary in the US out of the same quackery. But I think that psychiatry pushed the envelope too far with DSM-5 and that its greed will be its undoing. Now that the genie is out of the bottle, with Tom Insel and Allen Frances on record saying things that a few years ago they themselves would have considered anti psychiatry nonsense. I don’t see how psychiatry can regain legitimacy any time soon.

    I wish you a Happy and Prosperous 2014.

  • Phil_Hickey

    cannotsay,

    Torrey’s virus is toxoplasma gondii. (You can get it from handling cat litter.) Here’s a reference to an article he wrote.

  • cannotsay

    Oh dear! When I learned about it, I considered the hypothesis so nonsensical that I didn’t even bother keeping track of the actual virus he blamed :D.

    I hope you followed my debate with Bernard above which as ended as all my debates with other psychiatrists have ended: them calling me something that amounts to me being heartless about the alleged benefits of psychiatry but the psychiatrist in question not refuting in any meaningful way the actual intellectual arguments.

    Bernard (like Mickey Nardo or Allen Frances) are in my opinion the worst type of critic of psychiatry and psychiatric practices.

    Those of use who hold anti psychiatry views are basically following the scientific method: you claim there is something called “mental illness” caused by biology, please show me the money. People like Torrey are akin religious zealots. The way they argue about psychiatry is no different than the way religious people argue about their respective faiths.

    Somebody like Bernard, as you see above, is very creepy. He acknowledges that psychiatry doesn’t have a scientifically valid model for so called “mental illness”. He even acknowledges that psychiatry doesn’t have good metrics to measure efficacy of whatever it is that they are treating (he even said that he favors even more shaky ones like “social functioning” and “quality of life”). So intellectually speaking, I think we are not very far apart. Yet, he defends psychiatry for some obscure reason that he has not been able to elaborate in a compelling matter other than “trust us, we are nice guys drugging people, not your average street drug dealer”.

  • Phil_Hickey

    cannotsay,

    By the way, back in the 60’s, Dr. Torrey was actually on our side of the debate. In his article Is Schizophrenia universal? An open question ( Schiz Bulletin 1973, 7: 53-59) he states:

    “In fact, however, there is no evidence upon which to base a belief in the universality of schizophrenia. The studies which have been used to support this belief are found, on careful examination, not necessarily to point in this direction at all. If anything, they may lead to the opposite conclusion. Schizophrenia may not be a universal disorder.”

    Figure that out.

    I did follow the debate with Dr. Carroll. I was sorry that he bailed. I’m writing a post to pick up some of the main themes.

  • cannotsay

    Yes, he even wrote a book titled “The Death of Psychiatry” if I am not mistaken. I read somewhere that the money he got from Theodore Stanley is what made him turn to the dark side but I find that claim suspicious. For one, according to Wikipedia, Theodore Stanley contacted Torrey only after reading “Surviving Schizophrenia”. By that time it seems that Torrey had already became the Darth Vader of psychiatry, me thinks.

    Good that you are writing a post on the matter. Hopefully he will come back to defend his position. Even though I asked 3 times, I didn’t get a statement from him about why in his view psychiatry deserves the coercion prerogative that no other branch of medicine or CAM enjoys. Your writing is usually crystal clear, so I am really looking forward to it!

  • Bernard Carroll

    There is further discussion of the matters Phil Hickey reviewed here, up today on Dr. Nardo’s blog 1Boringoldman.com [http://1boringoldman.com/index.php/2013/12/29/insider-trading/]

  • cannotsay

    For starters, Mickey banned me from his blog for questioning psychiatry as a legitimate branch of medicine. To me, he, you, Allen Frances and the like belong to the group of most dangerous group of so called “critics” of psychiatry. You understand that it is a rotten endeavor intellectually speaking (or empty if you will) and you understand that the out of control psychiatric diagnosis can kill it. You long for the days in which you ruined only the lives of at most 10% of the population. The days in which thousands of psychiatrists could make a living out of a quackery, in many cases paid for by the tax payer, but nobody paid attention to the abuses those like you perpetrated. Abuses such as this http://video.foxnews.com/v/2965033619001/122313justina1137/ . A 15 year old child kidnapped by a psychiatrist trying to sell her own pet diagnosis. How evil!

  • braindead/washedfuckingretard

    He was hoping a conflict of interest might develop from his investment, but at the time, he had no assurance his investment would yield a dime.

  • braindead/washedfuckingretard

    A true scholar, Torrey kept learning with an open mind and insatiable thirst for knowledge.

    Psychiatry didn’t destroy “cannot say”. She bellyaches about everything, as long as she can suck someone in to debate her. That’s her life’s ambition. To argue endlessly, needlessly, continuously, to try to win a point about something, it doesn’t matter what.

    She’s been permanently stigmatized for having her fanny locked up? Good point. Every one who attains a psych diagnosis and is held against her will is ruined for life. Absolutely. Happens every day.

    I find great joy that no one calls her out.

    “The Moving Finger writes; and, having writ,
    Moves on: nor all thy Piety nor Wit
    Shall lure it back to cancel half a Line,
    Nor all thy Tears wash out a Word of it.” Omar Khayyam

  • braindead/washedfuckingretard

    “From the studies done to
    date, it can be concluded only that “process”
    schizophrenia apparently is found in all cultures
    which have been exposed to Western technology.” Torrey

    Indeed, he found that various cultures from around the world that were exposed to and impacted by modern, western technologies had significant numbers of people with schizophrenia.

  • all too easy

    What is the so called “disease model” of psychiatry? You see, other areas of medicine have theirs: viruses, bacteria, cell replication gone rogue (case of cancer). What is the “theory” that psychiatry presupposes to back that the behavioral patterns that they so much dislike via DSM labels have to be “diseases”?

    Delighted you asked.

    “neurochemical distractibility/impulsivity (NDI)” is the new “name” to describe ADHD, according to Dr. Saul and for which he prescribes stimulants. “NDI is caused by irregular neurotransmitter activity, specifically low levels of whole-blood serotonin or high levels of epinephrine/norepinephrine. The symptoms are classic deficits in attention and executive functioning, as the name suggests, and NDI is treated with stimulants, just like ADHD.”

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