Tag Archives: DSM-5

Intermittent Explosive Disorder: The ‘Illness’ That Goes On Growing

According to the APA, intermittent explosive disorder is characterized by angry aggressive outbursts that occur in response to relatively minor provocation.

This particular label has an interesting history in successive editions of the DSM.

DSM I  (1952) 

Intermittent explosive disorder does not appear as such in the first edition of DSM, but the general concept is clearly discernible in “passive-aggressive personality, aggressive type”:

“A persistent reaction to frustration with irritability, temper tantrums, and destructive behavior is the dominant manifestation.” (p 37)

Note the term “reaction” in the definition, implying that the temper tantrums are being conceptualized as a reaction to a frustrating experience, rather than an illness, as such.

DSM-II (1968)

By DSM-II, the diagnosis had acquired free-standing status as a “personality disorder”, and was called “explosive personality (Epileptoid personality disorder)”.  Here’s the definition:

“This behavior pattern is characterized by gross outbursts of rage or of verbal or physical aggressiveness. These outbursts are strikingly different from the patient’s usual behavior, and he may be regretful and repentant for them. These patients are generally considered excitable, aggressive and over-responsive to environmental pressures.  It is the intensity of the outbursts and the individual’s inability to control them which distinguishes this group. Cases diagnosed as ‘aggressive personality’ are classified here. If the patient is amnesic for the outbursts, the diagnosis of Hysterical neurosis, Non-psychotic OBS [Organic Brain Syndrome] with epilepsy or Psychosis with epilepsy should be considered.” (p 42-43)

There are three notable features of this definition.

Firstly, the term “reaction” has been eliminated.  With the benefit of hindsight, it is clear that the term “reaction” which was used extensively in DSM-I became an embarrassment for psychiatry.  In 1952, I believe that many psychiatrists would have acknowledged that the problems they encountered in their work were not illnesses in any biological sense of the term.  By 1960, however, the drugs were beginning to come on stream, and the promise was emerging that psychiatrists, if they made some conceptual adjustments, could ride pharma’s bandwagon and become “real” doctors.  And one of the conceptual adjustments that had to be made was the elimination of the word “reaction” and all that it entailed.  So, eliminate it, they did.  They offered no explanation, but there is this charmingly candid little quote on page ix of DSM-II:

“Consider, for example, the mental disorder labeled in this Manual as ‘schizophrenia,’ which, in the first edition, was labeled ‘schizophrenic reaction.’ The change of label has not changed the nature of the disorder, nor will it discourage continuing debate about its nature or causes. Even if it had tried, the Committee could not establish agreement about what this disorder is; it could only agree on what to call it.”

Secondly, the notion that the person is unable to control the aggressive impulses is introduced as a distinguishing feature of the “diagnosis”.  This is a particularly interesting development, in that it is impossible to determine whether a person is, or is not, unable to control his aggression.  All that can be determined is whether a person did or did not control aggressive impulses on any given occasion.

Thirdly, the definition clearly allows the “diagnosis” to be made on the basis of verbal aggressiveness.

Side note on “epileptoid Personality disorder”:  During the first half of the 1900’s, and even as late as the 70’s, there were frequent references in psychiatric writings to epileptic (or sometimes epileptoid) personality disorder.  It was widely believed that people with epilepsy tended to be generally impulsive, explosive, and egocentric.  The notion was given a good deal of credence and attention.  Psychiatric research purported to identify the traits involved, and causative theories were developed and promoted.  Most epilepsy specialists today consider the research to have been questionable, and the supporting observations to have been cases of people “seeing” what they had been taught to expect:   a lesson that psychiatry generally seems unable to assimilate. 

DSM-III (1980) 

In DSM-III, “intermittent explosive disorder” appears as an entry in the category “Disorders of Impulse Control Not Elsewhere Classified.”  Here are the criteria:

“A. Several discrete episodes of loss of control of aggressive impulses resulting in serious assault or destruction of property.

B.  Behavior that is grossly out of proportion to any precipitating psychosocial stressor.

C.  Absence of Signs of generalized impulsivity or aggressiveness between episodes,

D.  Not due to Schizophrenia, Antisocial Personality Disorder, or Conduct Disorder,” (p 297)

Notice that the criteria are fairly simple, and that, even allowing for the vagueness of language, what’s being described is relatively severe and serious:  “…serious assault or destruction of property.”  In other words, DSM-II’s acceptance of verbal aggressiveness as a criterion item has been eliminated: a rare instance of the APA actually tightening their criteria.  The effect of this, however, was probably minimal, as the “diagnosis” was still described under Prevalence as “very rare”.

The diagnostic criteria in DSM-III-R (1987) were essentially similar to those in DSM-III, though the list of exclusions was expanded to:  “…a psychotic disorder, Organic Personality Syndrome, Antisocial or Borderline Personality Disorder, Conduct Disorder, or intoxication with a psychoactive substance.” (p 322)

Prevalence is still shown as “apparently very rare”.

DSM-IV (1994)

DSM-IV made two changes to the criteria.

1.  Item C from DSM-III-R, which had read: “There are no signs of generalized impulsiveness or aggressiveness between the episodes”, was eliminated. Up till DSM-III-R, the “diagnosis of intermittent explosive disorder” was given only to individuals who were generally even-keeled, but who exhibited episodes of explosive anger that were apparently out of character.  DSM-IV offered no explanation for the removal of this item, stating only:  “The DSM-III-R criterion excluding this diagnosis in the presence of generalized impulsiveness or aggressiveness has been deleted.”  Obviously this deletion widens the scope of the “diagnosis”, and allows a great many more people to be given this label than was formerly the case.

2.  As in DSM-III-R, the “diagnosis” is not to be given if the episodes  “…occur during the course of…intoxication with a psychoactive substance”. DSM-IV added the clarification that this included the effects of “medication” – an implied acknowledgement that psychiatric drugs can precipitate outbursts of violence and destructiveness.

DSM-IV also amended the prevalence from “very rare” to “rare”, though in fact, Kessler et al (2006), using DSM-IV’s criteria, reported a lifetime prevalence rate of 7.3%, and a previous 12-month-rate of 3.9%.  A lifetime prevalence rate of 7.3% is approximately one person in fourteen.  This is hardly rare!

DSM-5 (2013)

In DSM-III and IV, a diagnosis of intermittent explosive disorder required several episodes of serious assaults or serious destruction of property.

But DSM-5 changed all that.  Here’s criterion A:

“A.  Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:

  1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.
  1. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period.” (p 466)

Note the word “either” in the lead in, and the proliferation of “ors” in 1 and 2.  This makes for labored reading, but one thing is crystal clear:  under DSM-5 rules, a person can be assigned this psychiatric label on the grounds of “verbal aggression” occurring twice weekly, on average, for a period of three months.  A person can also be so labeled on the grounds of physical aggression that does not result in property damage or physical injury.

Essentially what this means is that a person who, say, habitually rants aggressively and obnoxiously at other motorists while driving is actually mentally ill.  Prior to DSM-5, he wasn’t mentally ill; he was just rude and vituperative.  But now, thanks to the endlessly inspired creativity of psychiatry, he is mentally ill, and can be cured of this malady by ingesting a few pills every day for the rest of his (probably shortened) life.

The authors of DSM-5 offer no explanation for this change.

“The primary change in Intermittent explosive disorder is in the type of aggressive outbursts that should be considered:  DSM-IV required physical aggression, whereas in DSM-5 verbal aggression and nondestructive/noninjurious physical aggression also meet criteria.” (p 815) [Emphasis added]

Note also the specification:  “twice weekly, on average, for a period of three months.”  These kinds of frequency statements occur occasionally in DSM-5, and were included, presumably in an attempt to rescue the “diagnosis” in question from the charge of vagueness and unreliability.  What’s not usually recognized, however, is that the frequency criteria are entirely arbitrary.  Why not three times weekly for a period of two months?  Or four times weekly for four months? The answer, of course, is because the APA says so.  There is no evidence, nor can there ever be any evidence, supporting one over the other.

AGE OF ONSET

Age of onset has been an interesting issue across the various editions.

DSM-I and II made no reference to age of onset.

DSM-III:  “The disorder may begin at any state of life, but more commonly begins in the second or third decade” (p 296) [Emphasis added]

DSM-III-R:  The same as DSM-III.

DSM-IV:  “Limited data are available on the age at onset of Intermittent Explosive Disorder, but it appears to be from late adolescence to the third decade of life.” (p 611) [Emphasis added]

DSM-5:  “The onset of recurrent, problematic, impulsive aggressive behavior is most common in late childhood or adolescence and rarely begins for the first time after age 40 years.” (p 467) [Emphasis added].  Also, Criterion E states:  “Chronological age is at least 6 years old.”  [Emphasis added]

So the usual age of onset has progressed from “second or third decade”, to “late adolescence”, to “late childhood”, and as young as 6 years old!

DISCUSSION

What’s particularly noteworthy in all of this is the progressive loosening of the criteria across time, especially the elimination in DSM-5 of the requirement for serious damage or serious assault.  The lowering of the age of onset is also telling, and DSM-5’s criterion that “chronological age is at least 6 years” is chillingly consistent with psychiatry’s present promotion of the need for “early intervention”.  Here’s a quote from Kessler et al 2006:

“Intermittent explosive disorder is a much more common condition than previously recognized.  The early age at onset, significant associations with comorbid mental disorders that have later ages at onset, and low proportion of cases in treatment all make IED a promising target for early detection, outreach, and treatment.” [Emphasis added]

Promising, one is tempted to ask, for whom?

At the risk of stating the obvious, what psychiatrists call “intermittent explosive disorder” is not an illness in any ordinary sense of the term.  There are rare instances where brain damage can precipitate episodes of extreme anger, and these should indeed be considered illnesses.  But in the vast majority of temper tantrums, there is no neural pathology, but rather the simple fact that the individual hasn’t acquired the habit of controlling his/her temper.

To previous generations, the need to train/school children in this regard was considered a self-evident part of normal child-rearing.

But psychiatry needs illnesses to legitimize medical intervention.  And where no illnesses exist, they have no hesitation in inventing them.  And since they invented them in the first place, they have no difficulty in altering them to suit their purposes.  Of course, almost all the alterations are in the direction of lowering the thresholds, and thereby increasing the prevalence.

The idea of medical professionals arbitrarily inventing, and changing, the criteria for the “illnesses” that they treat sounds so preposterous that most people find it hard to believe.  It is widely assumed that psychiatrists have valid, scientifically-based reasons for making these changes.  But in fact, intermittent explosive disorder is nothing more, and nothing less, than what the APA says it is.  And over the years, in successive revisions of the catalog, they have made these changes, culminating in the sea-change of DSM-5.

And remember, DSM-5 was also the birthplace of “disruptive mood dysregulation disorder” – a pathologizing label for children (aged 6 and over) who are persistently bad-tempered.  In intermittent explosive disorder, the psychiatrists also have an “illness” for children (aged 6 and over) who are intermittently bad-tempered.  In psychiatry, as in fishing:  the bigger the net, the bigger the catch.

The great “breakthrough” for psychiatry in this regard was DSM-III’s definition of a mental disorder:

“…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability).”  (p 6)

DSM-III-R expanded this to:

“…a clinically significant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress (a painful symptom) or disability (impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” (p xxii)

If you strip away the verbiage, and note the frequent use of the word “or”, what this actually means is:  any significant problem of thinking, feeling, and/or behaving.  This was Robert Spitzer’s “great” achievement:  defining mental disorder/illness in such a way that it could include virtually any and all problems.  It was this simple contrivance that made it possible to expand the psychiatric net more or less indefinitely.  And Dr. Spitzer’s definition has been dutifully retained, with only minor verbal changes, by both DSM-IV and DSM-5.  After all:  “if it ain’t broke, don’t fix it.”  Though it should be noted that DSM-5 did manage to relax Dr. Spitzer’s definition even further by the ingenious use of the word “usually”:  “…usually associated with significant distress…”  “Usually” means not necessarily.

It might be asked:  how can they do this?  How can they just invent illnesses for themselves to treat?  And the answer is simple:  they did it gradually and imperceptibly; and nobody stopped them.  Protesters were marginalized and ridiculed as unscientific blamers and stigmatizers, while the psychiatric juggernaut inched forward year by year, decade by decade, increasing its territory, expanding its scope, selling ever more drugs for pharma and – in the process – destroying people’s brains, and undermining our cultural resilience.

In this regard, here are some interesting quotes:

Intermittent explosive disorder:  Treatment and drugs, at Mayo Clinic:

“Different types of drugs may help in the treatment of intermittent explosive disorder. These medications include:

  • Antidepressants, such as fluoxetine (Prozac) and others
  • Anticonvulsants, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), phenytoin (Dilantin), topiramate (Topamax) and lamotrigine (Lamictal)
  • Anti-anxiety agents in the benzodiazepine family, such as lorazepam (Ativan) and clonazepam (Klonopin)
  • Mood stabilizers, such as lithium (Lithobid)”

Treating intermittent explosive disorder, from Harvard Medical School:

“A number of medications are known to reduce aggression and prevent rage outbursts, including antidepressants (namely selective serotonin reuptake inhibitors, or SSRIs), mood stabilizers (lithium and anticonvulsants), and antipsychotic drugs.”

Intermittent Explosive Disorder, Child Mind Institute, under the subheading “Treatment”:

“…a variety of medications have been used to help people with IED, including antidepressants and anti-anxiety medications, as well as anticonvulsants and other mood regulators.  After a careful evaluation, a psychiatrist will prescribe the appropriate type of medication for an individual case.”

This is not the practice of medicine; this is drug-pushing in the guise of medicine.  Whatever effectiveness the drugs might have in reducing aggression, is far outweighed by the spurious message to the individual, that he is incapable of controlling his aggression without “meds”, and to parents, that their 6-year-old’s temper tantrums are symptoms of a serious lifelong illness that needs prompt psychiatric attention.

This is not the practice of medicine.  This is a hoax.

Justina Pelletier: The Case Continues

On March 25, Joseph Johnston, Juvenile Court Justice in Boston, Massachusetts, issued a disposition order in the case: Care and protection of Justina Pelletier.  The background to the case is well-known.  Justina is 15 years old.

Judge Johnston did not return Justina to the care of her parents, but instead granted permanent custody to the Massachusetts Department of Children and Families (DCF), with a right to review in June.

In paragraph 4, the disposition order states: 

“At trial there was extensive psychiatric and medical testimony.  Voluminous psychiatric and medical records were entered in evidence.  Based on credible psychiatric and medical evidence this court has found that Justina suffers from a persistent and severe Somatic Symptom Disorder.  On December 20, 2013, this court found the MA DCF sustained its burden by clear and convincing evidence that Justina Pelletier is a child in need of care and protection pursuant to G.L c. 119, §§ 24-26 due to the conduct and inability of her parents, Linda Pelletier and Lou Pelletier, to provide for Justina’s necessary and proper physical, mental, and emotional development.”

This is the substantial finding of the court, and it is noteworthy that there is no mention of the mitochondrial disease which had been Justina’s earlier diagnosis and for which she had been receiving treatment at Tufts Medical Center, Boston. 

The disposition order is somewhat terse and sparing in its tone, but reading between the lines, it seems clear that the court has determined that Justina either does not have mitochondrial disease or that, even if she does have mitochondrial disease, her concern about this matter is inappropriate and excessive.  There is also the suggestion that her parents, Linda and Lou Pelletier, have contributed to Justina’s preoccupations in this regard, and that for this reason, Justina needs to be protected from them.  As in all cases of this kind, a great deal of the information is kept confidential.  So we are inevitably working with incomplete information.

Obviously there are many issues that might be raised, and these are being addressed by others, but I would like to focus here on the “diagnosis” of somatic symptom disorder.

DSM-5 describes somatic symptom disorder as:  “…distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms.”  A “diagnosis” of somatic symptom disorder can be assigned even if the person really does have an actual illness, provided that the person’s response to the symptoms of the illness is excessively distressing and disruptive.

Here are the actual diagnostic criteria as set out on page 311 of DSM-5:

Somatic Symptom Disorder 300.82 Diagnostic Criteria

A.  One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B.  Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

1.  Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2.  Persistently high level of anxiety about health or symptoms.
3.  Excessive time and energy devoted to these symptoms or health concerns.

C.  Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Specify if:

With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.

Specify if:

Persistent:  A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).

Specify current severity:

Mild:  Only one of the symptoms specified in Criterion B is fulfilled.
Moderate:  Two or more of the symptoms specified in Criterion B are fulfilled.
Severe:  Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

CRITERION A

DSM-5 (p 830) defines a symptom as:  “A subjective manifestation of a pathological condition.  Symptoms are reported by the affected individual rather than observed by the examiner.  Compare with SIGN.”  On page 829 they define a sign as:  “An objective manifestation of a pathological condition.  Signs are observed by the examiner rather than reported by the affected individual.  Compare with SYMPTOM.”  This kind of terminology has become standard in general medicine.  A symptom is something reported by the patient (e.g. abdominal pain); a sign is something observed by the examiner (e.g. distended abdomen).  Symptoms and signs are the twin pillars of medical diagnosis.

“Somatic” means bodily or physical, as opposed to mental.

So criterion A requires that the individual reports at least one physical symptom, and that this symptom is distressing and results in significant disruption of daily life.  Distress and significant disruption are vague concepts, the assessment of which is clearly dependent on the psychiatrist’s subjective judgment.

CRITERION B

Here again, we have a great deal of subjectivity.  Words like “excessive” and “disproportionate” are open to individual interpretation, and there are no objective standards by which the accuracy of the diagnostic decision can be assessed.

Ultimately, a person will meet the requirements of criteria A and B if, and because, a psychiatrist says so.  There is no objective reality against which the psychiatrist’s assessment can be checked.  The psychiatrist’s subjective assessment is the only test for a “diagnosis” of somatic symptom disorder.

So when a psychiatrist says that a person “suffers from somatic symptom disorder,” all that this means is:  “In my opinion this individual is excessively preoccupied with physical symptoms and that, also in my opinion, this preoccupation is causing significant disruption in his/her life.”

The APA, by including this “diagnosis” in their diagnostic manual, assigning it a name and number, and listing the diagnostic criteria, create the impression that this is a real illness, and distract attention from the central fact:  that the only reality here is a psychiatrist’s opinion.

The only justification for the assertion that Justina Pelletier “suffers from a persistent and severe Somatic Symptom Disorder” is a psychiatrist’s subjective opinion.  In fact, the statement “Justina suffers from somatic symptom disorder” means:  “A psychiatrist believes that Justina’s concern about her symptoms is excessive.”  These two statements are absolutely equivalent.  The first statement, despite its appearance of objectivity, contains no additional substance over the second.

CONFLICTS OF INTEREST

This deception is the foundation of modern psychiatry.  But it doesn’t just occur at the point of individual assessment.  It also applies to the invention of these illnesses in the first place.  Somatic symptom disorder, like all psychiatric diagnoses, is considered to be an illness because the APA say so.  And individuals are considered to have a particular psychiatric “illness” because an individual psychiatrist says so.  It’s all based on subjective opinion.  And subjective opinion is notoriously unreliable.

But it is particularly unreliable when there are conflicts of interest.  The notion that all significant problems of thinking, feeling, and/or behaving are illnesses is central to the APA’s survival.  When the day comes – as it surely will – that it is recognized that these problems are not illnesses, then psychiatry will go the way of astrology and phrenology.  It will cease to exist.  Psychiatry’s foundation is an enormous deception, and in my view psychiatrists know this.  But they are fighting for their very existence.  The conflict of interest isn’t just about money; it’s also a matter of their professional identity.  As a group, they are so invested in the notion of psychiatric illness that they have rendered themselves incapable of honestly and objectively addressing the question:  are these problems really illnesses?

In this context, psychiatrists frequently point out that diagnoses in general medicine sometimes involve a physician’s opinion.  This is true, but misses the point.  When a real doctor says: In my opinion, this person’s diagnosis is X, what he’s saying is that he’s not 100% sure what the actual physical etiology is, but his best assessment at that point in time is X.  In psychiatric “diagnosis” there is no reality against which the “diagnosis” can be checked.  There is nothing but the psychiatrist’s opinion.

At the present time, small numbers of individual psychiatrists are seeing the light, and are courageously struggling with these conceptual issues.  But organized psychiatry in the form of the APA is actually doubling down and fighting harder than ever to prop up the deception that is crumbling like a sandcastle in a flowing tide.

And, of course, there is a huge conflict of interest for individual psychiatrists during their initial evaluations.  The psychiatrist’s bill, whether it’s sent to a private insurance carrier, or Medicare, or other reimbursing entity, depends for its legitimacy on the diagnosis.  Without a diagnosis, the psychiatrist doesn’t get paid!

So the situation is this:  the “diagnosis” is based entirely on the psychiatrist’s subjective opinion; and the psychiatrist’s paycheck depends entirely on the diagnosis.  Not surprisingly, psychiatrists manage to “uncover” a great many diagnoses.  In fact, the psychiatric leadership routinely and confidently claim that at any given time about ¼ of the US population has a mental disorder/illness, and that the lifetime prevalence is a staggering 50%.  They remain blind to the fact that these figures are driven by their own interest-invested need to create more “diagnoses” with progressively lower thresholds, and by their members’ equally self-serving need to assign more “diagnoses” in individual cases.

And this is the background against which Judge Johnston felt confident enough to write:

“Based on credible psychiatric and medical evidence this court has found that Justina suffers from a persistent and severe Somatic Symptom Disorder.”

I truly cannot think of any significant field of human endeavor in which such far-reaching decisions would be made on the basis of such poor evidence.  And bear in mind, Justina’s is by no means an isolated case.

If parents are abusing or neglecting their children – and obviously these things do happen – then some kind of intervention is appropriate.  But interventions of this sort should always be based on clear evidence and with due regard to the rights of the parents and the rights of the child.  But a “diagnosis” of somatic symptom disorder, by its very definition can never reach the standard of clear evidence.  

DSM-5: Dimensionality: Conflicts of Interest

In DSM-5 – Dimensional Diagnoses – More Conflicts of Interest? which I posted on December 23, 2013, I drew attention to the fact that David Kupfer, MD, in his position as head of the DSM-5 Task Force, was vigorously promoting a dimensional model of assessment while at the same time was positioning himself to benefit financially if such a system were to be adopted by psychiatry generally.

Dr. Kupfer’s potential conflict of interest was exposed by Bernard Carroll, MD PhD, and has been investigated and publicized by Mickey Nardo, MD.

The APA investigated Dr. Kupfer’s activities, and in their report they acknowledged that he should have disclosed his interests, but they assured us all that no harm had been done.

Psychiatry has had its share of scandals in the past few years, and the response from the profession’s leadership has been remarkably consistent:  inconsequential censoring of the culprits, followed by a speedy return to business as usual.  The general attitude seems to be that the public memory is short; that the storm will blow over; and that all will be well.  And above all – there must be no admission of fundamental systemic problems within psychiatry itself.

And there was a time when those kinds of tactics worked.  But not any more.  Because now we have the Internet – and we have Mickey Nardo – who blogs as 1 boring old man.

Dr. Nardo is not letting this thing go.  On January 21, he posted open letter to the APA.  The opening paragraph is compelling:

“It has been a dark time for psychiatry. Since the investigations of Senator Grassley exposed significant corruption and unseated three chairs of Psychiatry in 2008, there has been a series of disturbing exposures involving widespread ghost writing, guest authoring, and questionable clinical trial reporting; escalating widely publicized settlements by pharmaceutical companies involving psychoactive drugs and implicating prominent psychiatrists; charges of overmedication and entrepreneurialism; the drying up of the pharmaceutical pipeline; recurrent charges of ubiquitous Conflicts of Interest in high places; and an ongoing and divisive process that spanned the DSM-5 Revision process. Besides the gravity and frequency of the problems, their handling by the administrative levels in our specialty have played poorly in the eyes of the public and our currency is at an all time low.”

Dr. Nardo challenges the thoroughness of the APA’s investigation, which, he notes, is being widely perceived as a “whitewash.”  He continues:

“Our specialty is in a steady decline, much of it our own making, and we don’t need to help it along by ignoring this obvious issue of integrity.”

The foundation of psychiatry is the notion that virtually all problems of thinking, feeling, and/or behaving are in fact illnesses that need to be treated by medically trained practitioners primarily through the use of psycho-pharmaceutical drugs.  The DSM is the document that lists and codifies these putative illnesses, and as such must be regarded as the main cornerstone of this foundation.

Even the possibility that the revision of this document has been corrupted by financial considerations should be sending Richter 9 shock waves through the entire profession.  But instead, there’s barely a murmur.

In the article mentioned above, Dr. Nardo has created a time line of the major events in this affair.  It makes interesting reading.

There is an urgent need for Dr. Kupfer to meet the press, and to provide complete and candid answers to the various questions that are being asked.  Riding out the storm, and waiting till it blows over, is no longer a viable strategy for public figures in any walk of life.

 

Evaluating DSM-5: A Debate at Harvard

There’s a debate on this topic scheduled for 12:00 p.m., March 11, 2014, at Wasserstein Hall, Cambridge, Massachusetts.  The event is free, and open to the public.

The debate is sponsored by the Petrie-Flom Center For Health Law Policy, Biotechnology, and Bioethics at Harvard Law School.  This is the same group that produced the recent symposium on Institutional Corruption and Pharmaceutical Policy.

The debate will be moderated by I. Glen Cohen, Professor Law at Harvard and Co-Director of the Petri-Flom Center.

Panelists:

  • Steven E. Hyman, Director of the Stanley Center for Psychiatric Research at the Broad Institute and Harvard University Distinguished Service Professor of Stem Cell and Regenerative Biology 
  • Anne Becker, Maude and Lillian Presley Professor of Global Health and Medicine, Harvard Medical School 
  • Nita Farahany, Professor of Law, Professor of Genome Sciences & Policy, and Professor of Philosophy at Duke University 

It is encouraging that these kinds of issues are being discussed.  Readers living in the Cambridge area might like to attend, but I imagine that the Petri-Flom Center will publish transcripts/summaries after the event, for general release.

Thanks to Dustin Salzedo on Twitter for the link to the  debate.

Affluenza: A New Mental Illness?

A short editorial piece by James Bradshaw in the current issue (Jan/Feb) of the National Psychologist discusses the trial of a 16-year-old male who killed four people and severely injured two others while driving under the influence of Valium (diazepam) and alcohol.  He had stolen the alcohol from a store earlier, and his blood alcohol level was three times the legal adult limit.  He was driving 70 mph in a 40 mph zone at the time of the incident.

Prosecutors had asked for 20 years imprisonment (the maximum sentence), but instead the sentence was 10 years’ probation.

What’s interesting is the defense:

“Great furor stemmed from a defense psychologist’s describing the youth as a victim of affluenza – being cushioned by the money of wealthy parents to the point he never understood the consequences of his actions.

G. Dick Miller, PhD, a private practice clinical psychologist in Bedford, Texas, has since said he regrets using the term because of the uproar it created.”

It’s tempting to say:  But there’s no such diagnosis in DSM-5!  Think again.

On page 708, you’ll find:

“Other Specified Mental Disorder 300.9

This category applies to presentations in which symptoms characteristic of a mental disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any specific mental disorder.  The other specified mental disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific mental disorder.  This is done by recording ‘other specified mental disorder’ followed by the specific reason.”

There it is:  “make up your own diagnosis.”  The only requirement being that the problem causes “…clinically significant distress or impairment in social, occupational, or other important areas of functioning…” [emphases added]

And as everyone knows, having parents throw buckets of money at one during one’s formative years stunts social development, and saps occupational motivation.

Voila!  It’s like pulling rabbits from hats.

A Compelling Critique of Psychiatric ‘Diagnosis’

I have just read a very interesting and insightful article on this topic.  It’s called After DSM-5: A Critical Mental Health Research Agenda for the 21st Century.  It was written by Jeffrey Lacasse, PhD, and is a guest editorial published in Research on Social Work Practice.

Here are some quotes:

“At times, it has seemed that the APA has behaved very much like a corporation seeking profit and influence rather than a scientific organization charged with the crucially important task of defining mental disorders.”

[DSM-5]”… is vague and provides no clarity regarding the boundaries between what is normal and what is mentally disordered.”

“All problems defined in the DSM-5, from adjustment disorder to sexual problems to shyness, are just claimed to be medical…”

“The DSM-IV-TR mentions that brain changes in schizophrenia may be related to treatment with antipsychotic medication and notes that antidepressants may cause akathisia (a dangerous adverse effect associated with suicidal behavior…).   Despite the increasing body of literature demonstrating the clinical importance of these issues…references to both were deleted from DSM-5.”

“The DSM-5 field trial data demonstrate that DSM-5 categories are unreliable…a crucially important issue that should be addressed in both research and practice.”

“Thus the unreliability of psychiatric diagnosis can confound both the defining of client problems and the application of research evidence to clients.”

“…they sometimes explain that depression is caused by serotonin deficiency…  Clients are likely to absorb such messages as scientific facts…This should disturb those who think clinical practice and informed consent should be based on evidence, as serotonin deficiency as a cause of depression is known to be a myth…”

“Using the language of ‘mental disorder’ and presumed underlying brain disease or defect could have important effects on how clients view their problems and negatively impact their capacity to recover from them…”

Dr. Lacasse’s article is cogent and articulate, and cites a great many references.  It draws together succinctly, yet thoroughly, many of the critical issues in the present debate.

It has long been my position that psychiatry is scientifically empty and morally bankrupt.  It is time for the other helping professions to disassociate themselves from psychiatry and its spurious, money-driven “nosology,” and to develop their own person-centered conceptual framework for the services they provide.

It has also been my belief that social workers are ideally poised to provide a leadership role in developments of this sort.

Dr. Lacasse is by no means the first social worker to critique psychiatry, but his paper draws together many of the critical threads of this debate, and would serve as an excellent springboard from which the social work profession could re-appraise their ties to psychiatry.

Thanks to Mad in America for the link to Dr. Lacasse’s paper.

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.

The Allen Frances – Lucy Johnstone Debate

On October 28, Allen Frances, MD, Chairperson of the DSM-IV task force, published an article on Psychology Today.  It is titled Does It Make Sense To Scrap Psychiatric Diagnosis? and is essentially a response to the British Psychological Society’s Division of Clinical Psychology’s (DCP) call to abandon the medical model in situations where it is not appropriate, and to embrace a psychosocial approach.  You can see a copy of the DCP’s May 13, 2013, statement here.

Dr. Frances identifies Dr. Lucy Johnstone, PhD as the “most articulate and energetic supporter” of the DCP position, and most of his article is directed towards material Dr. Johnstone has recently written on these matters.  For ease of reference, Dr. Frances reproduces Dr. Johnstone’s material in his own article.

Dr. Frances sets the tone in the first sentence:

“I am always sceptical of suggested new ‘paradigm shifts’ and worry that ambitiously striving for them will wind up causing more harm than good.”

Dr. Frances lists three examples of proposed paradigm shifts that, in his view, have caused, or will likely cause, more harm than good.

Firstly:

“DSM 5 failed so badly precisely because it promised a ‘paradigm shift’ in psychiatric diagnosis.”

In support of this position, he suggests that the revised manual:

“…may mislabel as mentally ill millions of normal enough people who would do better left alone.”

This, of course, is an interesting perspective, though in my view DSM-5 is failing, not particularly because it sought a paradigm shift or because it continued the APA’s long-standing expansionist agenda, but because psychiatric concepts and practices generally are being exposed as spurious and destructive.  The publicity surrounding the release of DSM-5 gave impetus to this movement, but the general anti-psychiatry sentiment was already well established when the manual was printed.  It is also arguable that DSM-IV, of which Dr. Frances was the architect, widened the diagnostic net at least as much as DSM-5 is likely to do.

Secondly:

“The National Institute of Mental Health has neglected the current needs of the mentally ill because of its preoccupation with producing a ‘paradigm shift’ in understanding the neural networks that cause psychiatric problems.”

And:

“Dreams of the future potential of a neuroscience ‘paradigm shift’ have blinded NIMH to the crying needs of patients in the present.”

I could quibble with some of Dr. Frances’s terminology here, but at a more substantive level, I think it is inaccurate to describe the NIMH’s RDoC program as a paradigm shift.  It’s actually just an extension of what psychiatry has been promoting for decades:  that human problems are best conceptualized as brain illnesses and are best treated with drugs, ECT, and lately, other biological interventions.  Dr. Insel and the NIMH may like to think of RDoC as a paradigm shift, but it isn’t.

Thirdly:

“… the Division of Clinical Psychology (a sub-section of the British Psychological Society) has issued a statement announcing its own opposite brand of radical ‘paradigm shift.’ While paying superficial lip service to the role of brain in generating mind, the DCP suggests abandoning altogether what it regards as an overly restrictive biomedical model- it would eliminate any role for psychiatric diagnosis and instead focus on the role of external stressors in generating symptoms.”

Somewhat by way of an aside, there is a confusion here that needs to be clarified.  Under the present psychiatric system, the primary objective of the initial interview is the assignment of a “diagnosis.”  This “diagnosis” then becomes the basis of “treatment.”  If the “diagnosis” is, say, depression, then the “treatment” will be an antidepressant; if schizophrenia, the treatment will be a neuroleptic, and so on.  Then as treatment progresses, the drugs are changed, doses adjusted, etc., in response to client feedback.  The presenting problem(s) are conceptualized (spuriously) as caused by the diagnosis, and little or no attention is paid to other matters such as personal history, social supports, lifestyle, economic issues, etc…  This is what’s meant by the medical model.  What’s particularly noteworthy about this model is that in medical matters, it is very effective.  If a person has complete kidney failure, for instance, his likely diagnosis will be end-stage renal disease (ESRD), and this diagnosis gives the nephrologist a great deal of the information he needs to provide excellent care.  The nephrologist will, of course, gather additional data in order to tailor make the treatment to the patient, but an accurate diagnosis constitutes the bulk of what he needs to know in order to design good and effective treatment.

But, and this is a crucial point, problems of thinking, feeling, and/or behaving that are not biologically caused, are so varied and individualized as to their source and presentation, that they simply are not amenable to this kind of approach.  A DSM diagnosis, which is nothing more than a notoriously unreliable label, provides very little of the information that a helping professional needs in order to provide good and effective help, and often presents no useful information at all.  In fact, it is frequently a hindrance.

So when Dr. Frances characterizes the DCP’s position as calling for the elimination of “…any role for psychiatric diagnosis and instead focus on the role of external stressors in generating symptoms…,” he is simplifying the DCP’s position to the point of caricature, as even a cursory reading of the DCP’s paper will attest.

The charge of “paying lip-service to the role of brain in generating mind” reflects a misunderstanding of the DCP paper.  The paper clearly acknowledges the role of the brain in the production of thoughts, feelings, and behaviors, and specifically recognizes the value of the DSM’s system in “conditions with an identified biological aetiology.” [emphasis added]  What the DCP paper challenges is the assignment of “an unevidenced role for biology as a primary cause” [again, emphasis added]  in mental problems generally.

But to get back to the main thread, essentially what Dr. Frances is saying is that what’s needed is a middle way.  Those who see mental problems as purely biological, he tells us, are in error, as are those who see these problems as purely psychosocial.  He advocates a biopsychosocial approach, and he develops this theme for the rest of the article.

Dr. Frances begins this discussion by listing the areas in which he is in agreement with Dr. Johnstone and the DCP.

  • Biomedical reductionism is simplistic and misleading.
  • Mental distress must be understood in its context.
  • There are many ways of dealing with emotional difficulties, and excessive professional competition is unhelpful.
  • Limitations in current knowledge of the brain and behavior call for humility.

Then he turns to areas of disagreement.

“But then there are our areas of continuing disagreement. I fear that you [Dr. Johnstone] would replace biological reductionism with a psychosocial reductionism that is equally incomplete, and potentially harmful to patients. Human nature encompasses the complex interaction of biological, psychological, and social factors and understanding and treating psychiatric symptoms requires adequate recognition of each. The biological model has been greatly oversold and medication has been greatly overused- but both remain essential if kept in their proper place.”

It should be noted that psychosocial reductionism is a kind of contradiction in terms – at least as the term is being used here.  This has already been pointed out by Duncan Double in a recent post.  But I think it is reasonably clear that Dr. Frances means focusing on psychosocial factors to the exclusion of biological factors.

“Human nature encompasses the complex interaction of biological, psychological, and social factors…”

This part of the sentence is true, but doesn’t say very much.  All it says is that we humans are made up of biological tissue; and that we can think, feel, learn, etc.; and that we interact a good deal with one another.  But Dr. Frances uses this obvious truism as a springboard for the second part of the sentence:

“… and understanding and treating psychiatric symptoms requires adequate recognition of each.”

This assertion is the central issue of the entire debate, but Dr. Frances has just tucked it in under the biopsychosocial platitude as if it followed logically therefrom, which it does not.

Let’s consider the analogy of Mr. Jones, a businessman, who is in financial difficulty.  He goes to his banker to negotiate an extension to his line of credit.  Imagine if the banker said something like this:

“Mr. Jones, you are a biopsychosocial organism, and for that reason, I need to factor all of these perspectives into your loan application.  So let’s start with your childhood illnesses.”

Or take the case of a person who consults a lawyer to sue his employer for false dismissal.  Would it be reasonable for the lawyer to begin the interview by reviewing the individual’s medical and social history, purely on the grounds that the client is a biopsychosocial organism?

Or if a person went to see a surgeon to have a hernia repaired, how appropriate would it seem for the surgeon to perform a detailed survey of the person’s psychosocial history, again on the grounds that the patient is a biopsychosocial organism.

One can readily think of hundreds of similar examples.  The central point is:  yes, we humans are indeed a complex composite of biological, psychological, and social factors.  We can also be conceptualized from political, economic, historical, evolutionary, artistic, ethnic, linguistic, etc., perspectives.  But this doesn’t mean that all of these factors have to be addressed every time a person seeks help.  To the surgeon, I am primarily a biological entity; to the lawyer, I am primarily a citizen with certain statutorily-defined responsibilities and rights; to Wal-Mart, I’m a consumer with money in my wallet; to a teacher, I’m someone seeking knowledge; etc…

The essential point here is that each practitioner focuses on those aspects of my human nature that are appropriate to the situation.  Of course a certain amount of spillover is warranted in certain cases.  For instance, a surgeon working with a frail, elderly person might want to ensure that the person will have adequate post-surgical care at home, but these kinds of matters, though often important, are usually incidental rather than central.

From this perspective, let’s take another look at “…understanding and treating psychiatric symptoms requires adequate recognition of each.”

My position is simple:  if a problem of thinking, feeling, and/or behaving stems from a biological illness or malfunction, then it should be treated biologically.  Some “spillover” into the psychosocial area might be warranted, but it would be incidental and secondary.  The problem is a genuine medical matter, and a medical model is appropriate.

On the other hand, if the problem is a function of psychosocial factors, which, I contend, the vast majority of these problems are, then it is along those lines that the problem should be conceptualized and addressed.  Here again, spillover will occur.  For instance, if a person has been neglecting his health because of a psychosocially-induced problem, then some medical care might be needed.  But the problem itself is not medical in nature.  The medical model is not an appropriate conceptual framework, and medical interventions are not called for.

At the present time (with the exception of the due-to-a-general-medical-condition category and some of the substance abuse categories), no DSM “diagnosis” has been definitively linked to an identifiable biological illness or malfunction.  No psychiatric drug in current use fixes or resolves any biological malfunction, and there is growing evidence that the drugs are doing a great deal of harm.

Dr. Frances mentions other areas of disagreement and discusses them briefly.  He cautions against over-reliance on psychiatric diagnosis, but warns also against abandoning it altogether.  He agrees that psychiatric drugs are over-used, but stresses that sometimes they are needed.

He concludes his piece with a very reasonable-sounding summary:

“The integrated bio/psycho/social model has a long tradition and remains the best guide to clinical practice. It has always been threatened by reductionisms that would privilege one component over the others- but this interacting tripod of bio/psycho/social approaches is unstable and incomplete without the firm support of all three of its legs. In my view, it is equally mistaken to call for a premature ‘paradigm shift’ tilting toward biology (as was suggested by DSM and NIMH) or a ‘paradigm shift’ tilting toward the psychosocial (as was suggested by the DCP). An integrated bio/psycho/social model is essential to understanding each patient and also to unite the mental health professions.

And we certainly need to be united. Mental health care is terribly disorganized and grossly underfunded, especially (but not exclusively) in the US. I think we should find a unified voice to advocate for better care, not be distracted by debates about paradigm supremacy—especially since all three paradigms are absolutely necessary.”

All of this sounds very reasonable, but let’s take a look at the details.  Firstly, the “integrated bio/psycho/social model” does not have a long tradition – at least not here in the US.  In this regard, the only mental health tradition that I am aware of is the inexorable expansion of the diagnostic net through successive revisions of DSM, and the corresponding medicalization of an increasing array of human problems.  Lip service is paid to psychosocial factors, but in practice they are trivialized or ignored.

“An integrated bio/psycho/social model is essential to understanding each patient and also to unite the mental health professions.”

Here again, this sounds very good, but I suggest that it simply isn’t true.  If a person is going “crazy” because of late-stage syphilis, then, I suggest, psychosocial factors have little or no relevance.  On the other hand, if a person is depressed because his wife has left him, his daughter is in jail, and he hates his job, then, I suggest, biological factors are largely irrelevant.  There might, of course, be “spillover” in each case as discussed earlier, but this is incidental to the general position.

“…to unite the mental health professions.”

This is a complex issue, but I don’t think there will be any significant easing of tension between psychiatry and the other mental health professions until psychiatry abandons what has clearly been its mission for the past 50 years:  the medicalization and commandeering of an ever-increasing range of human problems.  Some problems of thinking, feeling, and/or behaving are indeed medical matters.  Others (probably most) are not.  At the present time, psychiatry is giving no indication that they appreciate this distinction.  In fact, I would argue that the very act of putting a problem in the DSM medicalizes the matter.

Dr. Frances himself acknowledges that “…the biological model has been greatly oversold and medication has been greatly over-used…,” but he doesn’t seem to take on board just how damaging and destructive these developments have been and continue to be, both to individuals and to society in general.  Against this background, his notion that an “integrated bio-psycho-social model” will unite the mental health professions strikes me as fanciful, if for no other reason than the fact that psychiatry appears to be moving further and further from such a model with each passing year.  On September 29, Jeffrey Lieberman, MD, President of the APA, was interviewed on 60 Minutes.  The reporter asked him:

“This [schizophrenia] is really a disease of the brain.  Not a disease of the mind?”

To which Dr. Lieberman replied:

“Absolutely.”

Dr. Frances suggests that we find “…a unified voice to advocate for better care, not be distracted by debates about paradigm supremacy…”

Here again, in my view, he’s missing the point.  This is not some kind of turf war, where we all need to just stop squabbling and sit down and work together.  It is precisely because we “advocate for better care” that we challenge the psychiatric orthodoxy, and call for a paradigm shift.  Decades ago, psychiatry formed a destructive and corrupting relationship with pharma, the results of which persist to this day.  The expansion of the “diagnostic” net was not an accident – it was policy.  The prescribing of drugs for an ever-increasing range of human problems (even to the point of giving neuroleptics to 2-year-olds!) was also policy.  The rift between psychiatry and the other mental health professions is of psychiatry’s making, and it emphatically is not a matter of perceptions, professional rivalry, or turf wars.  It is a real rift.  There is a fundamental incompatibility between the bio-reductionist approach that psychiatry has so avidly embraced, (and shows no sign of relinquishing),  and the approach of most other helping professions.  Most of the non-psychiatric professionals I encountered during my career saw the DSM diagnosis as an inane procedure mandated by psychiatry, for its own self-aggrandizing purposes, to which all must conform if they wish to have a seat at the table.

It is obvious (or at least obvious to me) that the medical paradigm is supreme in medical matters, and the psychosocial paradigm is supreme in psychosocial matters.  The only professional group that disagrees with this position are the psychiatrists, who insist that the medical paradigm is supreme in all matters.

What has changed in recent years is simply this:  psychiatry has pushed its spurious and destructive practices so far that survivors and non-psychiatric mental health workers are no longer willing to just go along.

Sometimes a paradigm shift – meaning a sea-change in concepts and practices – is what’s needed.  When the oxygen theory of combustion supplanted the old phlogiston theory, there was no question of a compromise.  There was no possibility of the two sides sitting down, recognizing the value of each other’s contribution, and agreeing to respect each other’s position.  There was no oxy-phlogistonic approach, nor should there have been.  The simple fact is that some explanatory concepts are better than others.  And psychosocial concepts provide a better framework for understanding and responding to psychosocial matters than do medical concepts.

Psychiatry’s medicalization agenda should have died a natural death (from lack of evidence) decades ago, but has been kept alive through pharma money and psychiatric lobbying and hegemony.  It is truly time for a paradigm shift, and the DCP’s paper is a very good starting point.  Dr. Frances makes the point that the DCP’s approach is untried and unproven, and for that reason should be treated with caution.  I suggest that he talk to social workers, counselors, psychologists, case managers, job coaches, and other non-psychiatric professionals working in the mental health field.  I believe he will find that few if any of them rely on psychiatry’s medical model as a conceptual basis for their work.  They pay lip service to it, of course, because in the end of the day, they need their jobs.  But the concepts and practices that drive their day-to-day interactions with their clients are emphatically psychosocial.  And if Dr. Frances will listen very carefully, I think he will find that these concepts and practices are very similar, though perhaps not as formally stated, as the DCP proposals.

Far from being untried and unproven, the DCP’s paradigm is the unspoken philosophy of the non-psychiatric mental health workers.  These are the dedicated backbone of the mental health system, who for decades have watched with consternation as increasing numbers of their clients have been sucked into the insatiable maw of pharma-psychiatry.

I don’t doubt Dr. Frances’s sincerity.  He appears to believe that the widening rift between psychiatry and the other helping professions can be resolved through dialogue and mutual respect.  Perhaps, in this regard, he sees himself in a mediator role.  But no amount of discussion, however amiable or well-intentioned, will alter the fact that problems that are psychosocial in their origin and in their nature are not amenable to medical intervention.  In fact, medical intervention has proven disastrous for many of psychiatry’s clients, and psychiatric survivors are speaking out with increasing frequency and vigor against the stigmatizing and destructive treatment that they received at the hands of psychiatrists.  To the best of my knowledge, psychiatry is the only medical profession that has a survivor movement.

But again, Dr. Frances doesn’t seem to get it.  In his October 21, 2013, dialogue with Patrick Bracken, an Irish psychiatrist and a founding member of the Critical Psychiatry Network, Dr. Frances expressed the belief:

“Psychiatry is still by far the most human and humane of the medical specialities.”

In response to which I can only shake my  head in disbelief.

 

DSM-5: How to Salvage a Shipwreck

DSM-5 was published on May 18, 2013, amidst great criticism.  The fundamental criticism was, and is, that the problems listed in the manual are not illnesses in any ordinary sense of the term.  Other critics focused on the pathologizing of normality, the expansion of the diagnostic net by the lowering of thresholds, and the lack of reliability of the so-called diagnoses.

The response from the psychiatric community has been mixed.  Some, probably most, psychiatrists are keeping their heads down, getting on with the business of selling pills, and hoping that the gravy train won’t derail.  Others are busy at damage control

Jeffrey Lieberman, MD, President of the APA (in a letter to the New York Times) says that:

DSM- 5 “… reflects the current state of our knowledge, limited as it may be. This does not negate its value in helping clinicians evaluate and treat patients, as well as the fact that it can and will continue to be improved as subsequent research enables us to better understand the biology of the brain and mental illness.”

Allen Frances, MD, architect of DSM-IV, is saying that everything was OK when he was at the wheel, but that DSM-5 has just gone too far!

In this context, Joel Paris, MD, has published a book:  The Intelligent Clinician’s Guide to the DSM-5.  I’ve just read it, and it is interesting.  Dr. Paris’ essential position is that DSM-5 is an improvement over DSM-IV, but he concedes that there are problems.  Here are some quotes:

“DSM-III made diagnosis more reliable, but reliability is not validity.  Over the last 33 years, constant use of the DSM manuals has given clinicians the impression that the categories they describe must be valid.  That is not true.  DSM-5 lacks the data to define mental disorders in the way that physicians conceptualize medical illnesses.  Some diagnoses in medicine are also vague, but psychiatry is far behind other specialties in grounding categories in measurements independent of clinical observation.” (pp x-xi)

and

“No biological markers or tests exist for any diagnosis in psychiatry.  For this reason, any claim that DSM-5 is more scientific than its predecessors is little but hype.” (p xi)

and

“It is understandable that psychiatry – so long the Cinderella of medicine – and desperate for respectability, wanted to plant its flag on the terrain of neuroscience.  But the promise of the 1990’s (‘the decade of the brain’) for research on mental disorders has not been fulfilled.” (p xii)

and

[Many patients] “…now receive a 15-minute check-up in which medications are reviewed and ‘adjusted.’  This kind of practice does not allow psychiatrists enough time to find out what is going on in a patient’s life…” p 184)

and

“DSM-5’s ideology supports all these trends.  The practice that follows from a reductionistic view of psychiatry presents itself as a clinical application of neuroscience. In other words, drugs and more drugs.” (p 184)

and

“DSM-5, by expanding the definition of most disorders in the manual, encourages over-treatment.” (p 185)

and

“We are told, without solid evidence, that millions of people with mental symptoms are tragically undertreated.  …The thrust of these arguments…is that drugs should be prescribed to an even larger percentage of the population than is already the case.  The pharmaceutical industry can only rejoice at such conclusions. The rest of us are left to weep.” (p 185)

One can certainly respect and admire Dr. Paris’ honesty.  It is a pity, however, that he hasn’t been voicing these concerns vigorously over the past three or four decades while his colleagues and their pharmaceutical allies were blatantly and confidently promoting the lie that the various problems they were treating were “real illnesses – just like diabetes,” and that psychotropic drugs were real medications which corrected chemical imbalances in the brain and other putative etiologies.

In fairness to Dr. Paris, he hasn’t been a dyed-in-the-wool bio-psychiatrist, but criticizing the excesses of his colleagues after the profession’s venality and invalidities have been outed might justifiably be considered a little late.

In addition, his depiction of psychiatry as “desperate for respectability” is presented almost as a legitimate excuse for the widespread promotion of a spurious philosophy and the destructive “treatments” that this philosophy entailed and legitimized.

All of which leads to the interesting question:  How can Dr. Paris reconcile the very negative things he says about psychiatry with his continued membership of this profession?  How can any psychiatrists continue to practice, when the document which legitimizes their professional activity is acknowledged to be fundamentally and essentially flawed?  Dr. Paris’ approach to this question is two-fold.  Firstly he’s still a believer.

“To address the issue, I hope that bio-markers will eventually be found to make more valid diagnoses.” (p 188)

Secondly he’s distancing himself from DMS:

“For decades, we have treated DSM as if it contained scientific truth, rather than what it really is – a rough draft based on expert consensus.  The manual remains the main guide to psychiatry for medical students and residents.  But its mechanical approach to diagnosis and treatment is not appropriate for sophisticated medical specialists.  Psychiatry has a richer diagnostic tradition that should trump constructs that are little but political compromises.” (p 187)

To which I can only respond that if psychiatry does indeed have “a richer diagnostic tradition” than that which is embodied in DSM, then they’ve been keeping it well hidden for the past 30-40 years.

But having said all that, I do believe that Dr. Paris is to be commended for his honesty.  He says that DSM is rubbish, and it is.

We need to keep in mind, however, that DSM is not the central issue.  The central issue is the spurious medicalization of all problematic behaviors and emotions.  The DSM is just the visible symbol.  We should definitely be glad to see the manual going down in flames, but we should remember that the bigger problem still confronts us.  Even Dr. Paris, one of psychiatry’s more outspoken critics of DSM, still clings to the medicalization myth.  And although DSM is being consigned to the trash cans, psychiatrists world-wide are still selling pills with unabated zeal and enthusiasm.  At this time, antidepressants are the second most prescribed class of drugs in America: second only to antibiotics!

 

Psychiatry Still Doesn’t Get It

BACKGROUND

On 3-4 June, the Institute of Psychiatry in London hosted an international conference to mark the publication of DSM-5.  On June 10, Sir Simon Wessely, a department head at the Institute, published a paper called DSM-5 at the IoP.  The paper is a summary of the conference proceedings, and also, in many respects, a defense of DSM-5.  The article touches on many issues that are central to the current anti-psychiatry debate, and for this reason, I thought it might be helpful to take a close look at the piece.

WHY IS DSM-5 CONTROVERSIAL?

Sir Simon expresses surprise that DSM-5 has been so controversial.  He discusses this matter from various perspectives, but in my view he misses the essential point.

He writes:  “The DSM is nothing more than a list of psychiatric disorders, accompanied by descriptions of disorders and explicit criteria for their diagnosis.”

It might be argued that this statement is true in the literal sense of the term, but it ignores the fact that the DSM is also (and perhaps more importantly) the primary source of legitimacy for the unproven assumption that all serious human problems are in fact illnesses, and are best “treated” by medical methods.

The contention that the DSM is nothing more than a list of psychiatric disorders is a bit like saying that Malleus Maleficarum (1487) is nothing more than a list of signs by which witches can be identified, and ignoring the fact that it was also the authoritative confirmation that witches really did exist and really did cause a great deal of mischief.  For almost three centuries, Malleus Maleficarum served as the justification for murdering eccentric and otherwise unpopular women.  In the same way, today DSM is used throughout America and other countries to justify and legitimize the drugging (sometimes forcibly) of millions of people, frequently with horrendous side effects.

But Sir Simon doesn’t seem to be aware of any of that.

Nor is this aspect of the DSM’s identity an accident.  In 1952, when the first DSM was published, I don’t think it would be an exaggeration to say that psychiatry was a laughing stock among medical specialties.  As the latter increasingly aligned themselves conceptually and practically with science, psychiatry wallowed in the decidedly unscientific notions of psychoanalytic theory and the brutal unvalidated “treatments” of the asylums.

Psychiatry desperately needed to get its act together and establish that it was a real medical specialty.  It is arguable that this may have been a secondary agenda in 1952, but by 1968 – the year DSM-II was published – this aspect had become more urgent.  There were two reasons for this.  Firstly, the pharmaceuticals were coming on stream, and psychiatrists needed bona fide illnesses for which to prescribe these products.  Secondly, behavior therapy was experiencing a great deal of success in the mental hospitals, especially with the more “challenging” cases, and was beginning to pose a significant challenge to psychiatric hegemony.  By unequivocally medicalizing the presenting problems, psychiatry legitimized the widespread drugging of its clients, re-established its supremacy, and at the same time marginalized and subordinated behavior therapy.

The notion that all problem behaviors and emotions are illnesses is a spurious and unproven assumption, but it is an assumption that has served psychiatry (and incidentally their pharmaceutical allies) well for over four decades.

And that is why there has been so much controversy surrounding the publication of DSM-5.  The negative press has arisen, not because there is anything strikingly new or different about DSM-5.  The criticism stems rather from the fact that it is just more of the same.  It’s the same lie being trotted out:  that depression, misbehavior, mania, disruptiveness, temper tantrums, anxiety, etc., are real illnesses – just like diabetes.  And that this lie is still being promoted despite four decades of failed research looking for the biological etiologies that would save this sorry theory.

In the meantime, the concept of mental illness is just another spurious assumption which would have been scrapped long ago but for the fact that it serves the interests of psychiatrists and their pharmaceutical allies.

The IoP conference could have addressed this – the central issue of the debate.  And Sir Simon could have written about this.  But instead, the matter was ignored.

EXPANSION OF DIAGNOSTIC ACTIVITY

Instead, Sir Simon wrote about the fact that the number of diagnoses has been quietly increasing, but that thankfully DSM-5 has reversed this trend.  Does he seriously imagine that fewer people will be assigned psychiatric “diagnoses” under DSM-5 than under DSM-IV?

Sir Simon also concedes that there has occurred what he calls “psychiatric mission creep” – “the medicalization of the normal, the eccentric and the odd.”  Bravo!  But it’s still not the main issue.  Medicalizing severe problems is just as spurious as medicalizing trivial problems.

Sir Simon goes on to reassure us that:  “Concerns that the DSM-5 would continue in the inexorable march of medicalization by adding grief and bereavement to the list of human emotions that now required treatment were misplaced.”  I find myself at a loss as to how he can possibly know that.  Grief and bereavement are already being widely medicalized under DSM-IV, and this trend is almost certain to expand, given the specific easing of criteria in DSM-5.

Continuing on the topic of diagnostic expansion, Sir Simon writes:

“For most psychiatrists, claims that we are embarked on emotional world domination, seeking to extend our boundaries, populations and wallets further and further sounds hollow and frankly laughable when most face the most stringent cuts to services in a lifetime.”

This quote warrants some scrutiny.  What Sir Simon is saying here is:

1.  Our critics contend that we are pursuing emotional world domination.  Ha, ha.

This is essentially an attempt to ridicule the opposition.  Addressing our concerns openly and honestly would have been more productive.

2.  The opposition say that we are seeking to extend our boundaries, populations, and wallets.

Psychiatrists have been, are, and apparently plan to continue extending their boundaries, populations, and wallets.  And, with the help of pharma dollars, have been remarkably successful in these areas.  Juxtaposing this statement with the world domination quip is a standard spin doctor trick, well-known to politicians.

3.  The contentions of our opponents are hollow and laughable, because … get this … because our budgets are being cut due to governmental finance restrictions.

The fiscal restraints or otherwise of governments have no bearing on whether or not psychiatry has been pursuing an expansionist agenda.  In fact, the psychiatry-pharma alliance has been consistently and successfully pursuing an expansionist agenda for the past 40 years, regardless of the state of the public coffers.

MARGINALIZING THE CRITICS

Sir Simon laments the fact that the media, “fired up” by DSM-5, are “dominated by a radical critique, questioning the legitimacy of psychiatry.”

Note the terms “fired up” and “radical”.  Instead of responding in a rational and considered way to our criticisms, he’s attempting to portray us as revolutionary hotheads.  And we have the audacity to question the legitimacy of psychiatry!  Imagine!

Sir Simon also laments the fact that a UK psychologist used the occasion of the DSM-5 launch to say that all psychiatric diagnosis is wrong, and – listen to this – was not “shouted down,” but was actually allowed to air her views on a radio program!  Can you imagine that?  Daring to criticize psychiatry!  And actually given air time!

COMMANDEERING THE CRITICISM

One of the basic tactics in political spin is commandeer-the-criticism.  What’s involved is taking the opponent’s point, accepting it as if it were one’s own idea, but altering it just enough to work to one’s own advantage.

Here’s a nice example that comes near the end of Sir Simon’s article:

“No one can, and no one does, deny that the need to be kind, empathetic and understanding, to see all illness in its social context, to understand all illness as to how it affects the person. Far from being a “radical critique” let alone a mandate for the inevitable “paradigm shift” that our critics are calling for, that is merely a description of good psychiatry.”

The first sentence doesn’t close – but the meaning of the quote is clear:  we’re good guys; we’re kind, empathetic, and understanding.  We see all illness in its social context and in the effect it has on the person.  This isn’t a radical critique.  This doesn’t warrant the paradigm shift that these bounders are demanding.  This is just good psychiatry.

So all the criticisms which we mental illness deniers direct at psychiatry are just nonsense; just so much wasted effort because … psychiatry is already there!  Psychiatry doesn’t need to change!

But notice how the word “illness” got sneaked in twice.  And that, as Sir Simon should know, is where the paradigm shift is needed:  the recognition that the problems psychiatry is “diagnosing” and drugging are not illnessesIf he has proof to the contrary, this might have been a good place to set it out.

FINALE

Sir Simon’s final paragraph is a gem of irrelevance.  I must quote it in full:

“The reception afforded DSM-5 has reminded us how we sometimes look to the outside world and it is not always pretty. The charge that DSM itself is a Big Pharma fuelled exercise to open new markets for the sale of drugs is not helped when it becomes clear that some of the biggest names in psychiatry have been less than transparent in their financial dealings.  Sadly the APA only gives further ammunition to the critics when it charges an exorbitant price for an almost unreadable book of marginal relevance to the mental health challenges facing most of the world. But the public relations disaster could still be turned into a triumph if the APA joined the open access movement sweeping across the world of scientific publishing and agreed to make if not DSM-5, then at least DSM 6, free to all. But I am not holding my breath.”

He mentions the accusation that the DSM is essentially a pharmaceutical instrument to sell more drugs.  Now there’s an interesting thought that might have warranted some debate.  But no, we move on.

Then he mentions that some of the “biggest names” in psychiatry have been “less than transparent” in their financial dealings.  Some of us might have said “corrupt.”

And while we’re on the subject of corruption coupled with big names in psychiatry, let us remember the Sir Simon’s own Institute of Psychiatry honored Charles Nemeroff, MD by inviting him to speak at the opening of their new Centre for Affective Disorders on June 17.  In case you’re not familiar with Dr. Nemeroff’s history, here’s an extract from Wikipedia.

“Nemeroff’s undisclosed ties to drugmakers and under-reported incomes from them have raised questions about conflict of interest.  Following a Congressional Investigation led by Senator Charles Grassley of the Senate Finance Committee, Nemeroff was found to be in violation of federal and university regulations and resigned as chair of the psychiatry department at Emory University.  He was also forbidden by Emory to act as an investigator or co-investigator on National Institutes of Health grants for at least two years. Nemeroff has moved to Florida and become the chair of psychiatry at the University of Miami.

According to the Annals of Neurology, the court documents released as a result of one of the lawsuits against GSK in October 2008 indicated that GSK ‘and/or researchers may have suppressed or obscured suicide risk data during clinical trials’ of paroxetine. ‘Charles Nemeroff, former Chairman of the Department of Psychiatry at Emory University, was the first big name ‘outed’ … In early October, Nemeroff stepped down as department chair amid revelations that he had received over $960,000 from GSK in 2006, yet reported less than $35,000 to the school. Subsequent investigations revealed payments totaling more than $2.5 million from drug companies between 2000 and 2006, yet only a fraction was disclosed’.”

Any reputable profession, I suggest, would have ostracized, and probably disbarred, Dr. Nemeroff.  But not psychiatry.  In psychiatry, that kind of corruption draws honors and accolades.  Sir Simon might have written about that.

He might also have explained to us why his institute hosted a conference to mark the publication of DSM-5 if it is – as he claims – “…a book of marginal relevance…”

Then the insult to end all insults.  The APA, Sir Simon writes, has given ammunition to psychiatry’s opponents by over-charging for DSM-5. 

Does he seriously imagine that whether DSM-5 costs $10 or $200 makes a nickel’s worth of difference?  Does he imagine that if DSM-5 had been less expensive that these protests would not have happened?  Is he so out of touch with the fundamental flaws in his chosen profession that he believes that the cost of this book is even on our radar?

And – he tells us – the public relations disaster could have been turned around if the APA had distributed the book free!

And remember, dear readers, Sir Simon is an eminent psychiatrist.