Tag Archives: DSM-5

Autism Prevalence Increase Questioned

BACKGROUND

A couple of days ago (June 12) I posted Autism Prevalence Increasing.  The article drew attention to a post by Kelly Brogan, MD, called See No Evil, Hear No Evil which had appeared on Mad in America on June 9.  Dr. Brogan’s article had cited an alarming increase in the incidence of autism over the past few decades, and mentioned some possible causative factors.

I checked the figures against the DSM and CDC prevalence estimates and found they were broadly in line.  I mentioned the possibility that diagnostic expansion, particularly as embracing milder presentations, might be a confounding factor, but that given the reported increase (1 in 5000 to 100 in 5000) over 38 years, I expressed the view that this was a bit of a stretch.

Subsequently on Twitter, John McGowan of CCCU Applied Psychol wrote:

“Wonder if huge autism increase in 40ish years based on subjective factors really a stretch? 1975 a foreign country.  When I compare my kids’ experience at school to mine in the 70s. So, so much more emphasis on diagnosis now.”

This is an important question that I thought warranted some examination.

AUTISM AND DSM

From a purely logical point of view there are three possibilities.  The incidence of autism is either:  increasing; decreasing; or staying about the same.  On the face of it this looks like an empirical question that could be readily answered by conducting a fairly straightforward retrospective survey.

However, we must first have an unambiguous definition of autism.

DSM defines its so-called “mental disorders” by listing a set of “diagnostic” criteria, and requiring that the individual score positive on a certain percentage of these items (e.g. 2 out of 4; 3 out of 5, etc.).

Here are the DSM-IV criteria for autistic disorder:

A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

(1) qualitative impairment in social interaction, as manifested by at least two of the following:

(a) marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity

(2) qualitative impairments in communication, as manifested by at least one of the following:

(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

(3) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities as manifested by at least one of the following:

(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(b) apparently inflexible adherence to specific, nonfunctional routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting or complex whole-body movements)
(d) persistent preoccupation with parts of objects

B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

C. The disturbance is not better accounted for by Rett’s disorder or childhood disintegrative disorder.

There are two problems with this definition.  Firstly, the individual items are vague.  Consider item A (1)b: ” failure to develop peer relationships appropriate to developmental level.”  The wording of this item presupposes that there exists a clear standard of peer relationships appropriate to the child’s developmental level.

(There is, incidentally, a purely logical problem with this item, in that peer relationships constitute an intrinsic element of developmental level.  It’s a bit like a weather forecaster saying that it will rain today if there are showers.  But let’s be gracious to Allen Frances and his DSM-IV colleagues, and assume that they meant to say “…developmental level in other areas,” or something similar.)

Of course there are such standards, but they’re not as clear cut or precise as the item cited above presumes; nor, I suggest, are they all that well known by people making the “diagnosis.”  The extreme cases are fairly easy to identify, e.g. a child who sits in the corner by himself in a playroom and doesn’t interact at all with the other children. But what if he interacts once in a one-hour observation period?  What about twice?  And so on.  Also, perhaps we should look at the quality of the interaction.  If he gets up once in the hour and bashes another child on the head with a toy, would we rate this the same as approaching the other child and giving him the toy?  Probably not.

Also, we have to ask:  who’s doing the rating?  There’s a good deal of research dating, if I remember right, back to the 60’s that suggests that if a teacher is told that a particular child is very bright, but just needs some extra encouragement, he/she will tend to rate that child as brighter than a teacher who is told that the child isn’t very bright.  (Incidentally, this body of research is almost universally ignored in psychiatric “diagnosis.”)

But even if we ignore all these difficulties, there’s still the fact that the appropriateness of peer relationships, however accurately we might try to define it, is inevitably a continuous variable.  It will never be a question of “yes” or “no,” but rather “how much.”  And an additional complication:  it will be “how much in such and such a situation, at what time of day, in whose company, etc., etc., etc….”  The only way to dichotomize this kind of data is arbitrarily.  But in fact DSM doesn’t even address these kinds of issues.  Practitioners are forced to make a “yes” or “no” determination on each item and then count the items.  Which brings us to an even more serious problem.

The first line of the APA’s definition reads:  ” A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3)”  This is a common feature throughout the DSM, and represents a major weakness, in that it involves assigning the same “diagnosis” to people whose presentations may be quite different.

Take just two examples:

Child 1:  meets only the following items from the DSM list:

1 (b) failure to develop peer relationships appropriate to developmental level
1 (d) lack of social or emotional reciprocity
2 (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
3 (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
3 (b) apparently inflexible adherence to specific, nonfunctional routines or rituals
3 (c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting or complex whole-body movements)

 Child 2:  meets only the following items:

1 (a) marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
1 (b) failure to develop peer relationships appropriate to developmental level
1 (c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
1 (d) lack of social or emotional reciprocity
2 (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
3 (d) persistent preoccupation with parts of objects

Setting aside the reliability issues discussed earlier, it is clear that the presentations of these two children are very different.  Yet they both receive a “diagnosis” of autistic disorder.

In fact, using the APA’s own polythetic formula,  one could identify 2,091 different presentations that meet the DSM criteria for this “diagnosis.”  Even if one allows that many of these presentations will be somewhat similar, it is clear that there is a great deal of heterogeneity built into this diagnosis.

PREVALENCE

So let’s return to the question of prevalence.  The overriding issue here is that the more vagueness in the definition of the phenomena in question, the more suspect are the prevalence estimates.  Here’s the graph that Autism Speaks have generated.

Autism Prevalence Graph

Obviously the graph shows a steepening rise from earlier to later, and it’s tempting to ask the question:  Does this reflect a real rise in prevalence?  But the assumption here is that there is this “entity” called “real autism.”  In fact, the only generally accepted definition of autism is (as far as I know) the one provided by the APA, and that, as we saw, is subject to various intrinsic problems.

The fact is that we can never say with certainty whether there is a real increase in prevalence until we define the problem much more closely.  My guess is that any serious attempt to do this will reveal that in fact there is not one autism, but many.   Or more accurately, that the various problems which today are loosely aggregated under the heading autism would be better conceptualized, and addressed, as several distinct problems.

SIGNIFICANCE OF PREVALENCE ESTIMATES

So what does Autism Speaks’ graph mean?  Does it mean that there really has been a huge increase in the number of children with these problems, or does it simply reflect that more children are being assigned this particular label?  People like Dr. Brogan say the former, and they blame vaccines and various environmental toxins.  But it could also be argued that the increase is due to various forms of diagnostic creep, including extending the diagnostic net to include less severe cases.  John McGowan’s point is that there is “much more emphasis on diagnosis now,” and this is undoubtedly true.  We’ve certainly seen this phenomenon with the other mental health “diagnoses.”

I’m not aware of any study that has attempted to clarify this.  In fact, I’m not even sure that such a study would be feasible.  The past is gone forever.

According to Webster’s dictionary, the word “autism” was not in use prior to the 1940’s.  Autism was not included as a separate entity in DSM-II (1968), but was mentioned simply as one of the characteristics of childhood schizophrenia.  It certainly would not be possible to obtain prevalence estimates for that period.

Most of the steepness of the graph, however, occurs after 1995.  And it really climbs after 2010!  As I’ve mentioned earlier, the DSM criteria have a good measure of built-in vagueness, but has the vagueness increased that much since 1995?

It is a central theme of this website that the putative increase in “mental illness” prevalence generally is driven by disease-mongering and pharma-psychiatric marketing.  And it is certainly possible the considerations of this sort underpin the autism figures.  Some support for this position can be drawn from the report that “…approximately 45% of children and adolescents and up to 75% of adults with ASDs [autism spectrum disorders] are treated with psychotropic medications.”  (Management of Children With Autism Spectrum Disorders.  The American Academy of Pediatrics 2007)  The drugs most commonly used are SSRI’s, neuroleptics, and stimulants.

So we’re still left with the question:  is there really an increase in the numbers of children with these problems, or is the reported increase artifactual?  With the information I’ve been able to find, I have to say:  I don’t know.

Dr. Brogan says clearly that the increase is real, and is due to environmental toxin and vaccines.

Judith Mill, PhD, of the Center for Autism Research at Children’s Hospital, Philadelphia, says it’s both:  “…contributing to the increased number of diagnoses is heightened awareness of subtle forms of ASD and broader application of the diagnostic criteria,…” and “…new data suggesting that 15 percent to 30 percent of autism cases may be due to the increasing average age of new fathers.”  (Autism prevalence and the DSM, APA 2012)

Joel Paris, MD, expresses the view that the increase reflects the “…pathologizing of subclinical symptoms,” i.e. diagnostic creep.  [The Intelligent Clinician’s Guide To the DSM-5, (2013), p 142]

With regards to Dr. Brogan’s contention that the APA’s revision of their criteria is a pharma-APA conspiracy to conceal the increasing prevalence, I have to say again that I don’t know.  It’s a strong claim.  I have no qualms asserting that psychiatry and the psycho-pharma industry routinely collaborate in disease-mongering, and in the marketing of drugs.  But the assertion that they would collaborate to cover up the harmful effects of mass vaccination takes us to a different level.  I’m not saying that it couldn’t happen.  I just have no information to support the claim.  In fact, I hardly know where to look.  If anyone has any information or leads, I’d be glad to take a look.

There is, incidentally, a general expectation that the implementation of DSM-5 will indeed result in fewer diagnoses of autism.  The APA has created a lesser “diagnosis” – social communication disorder – to accommodate the less severe presentations.  How all this will work out in practice remains to be seen.  It is unusual, I think, to see the APA making one of their “diagnoses” more restrictive.  Their agenda since the first DSM has always been expansion.

Autism Prevalence Increasing

On two occasions in the past week or so, I have been involved in discussions on the increasing prevalence of autism.  In the more recent of these, the individual with whom I was talking expressed the concern that the recent DSM enlargement of autism disorder to autism spectrum disorder might be an APA-pharma designed artifact to draw attention away from the steady increase in the incidence of autism in recent decades.

Of course, I have no direct knowledge of any such conspiracy, but given the history of the last few decades, I had to concede that the notion was within the realm of possibility.

And then on Sunday (June 9) I came across an article on Mad in America.  It’s called See No Evil, Hear No Evil, and was written by Kelly Brogan, MD.  Dr. Brogan is a member of the American Board of Integrated Holistic Medicine, and her article is forthright and outspoken.

Dr. Brogan points out that the incidence of autism in 1978 was 1 in 10,000, and is now 1 in 50.

This increase seems almost unbelievable, so I did some checking.  Here’s what I found.

Autism Speaks is an organization dedicated to funding research into the causes, prevention, treatments, and cure for autism.  They confirm that autism has increased from 1 in 5000 (in 1975) to 1 in 110 (in 2009).  (1 in 110 is about 45 in 5000).

Autism Prevalence Graph

These figures are generally consistent with the prevalence numbers from DSM-III and DSM-IV, and from the CDC.  Autism Speak’s graph stops at 2009, but the CDC’s figure for 2013 is 1 in 50.  One in fifty is equivalent to 100 in 5000.  So the reported prevalence has risen from 1 case in 5000 to 100 cases in 5000 in 38 years.

But these figures can’t be taken at face value.  The APA’s definition of autism consists entirely of subjectively assessed behaviors (e.g. “lack of social or emotional reciprocity;” “failure to develop peer relationships appropriate to developmental level;” etc…)  Because of this definitional vagueness and subjectivity, a measure of discrepancy is to be expected in prevalence estimates across time and from place to place.

An additional complication arises from the fact that the APA’s definition of autism changed considerably from DSM III to IV, and has changed again with the publication of DSM-5.

On the other hand, autism is not a trivial matter, and even allowing for a generous measure of diagnostic imprecision and expansion of the diagnostic criteria to include milder presentations, the idea that more than 90% of cases were simply being missed as recently ago as 1975 is a bit of a stretch.  It’s not as if the condition is particularly latent.

Dr. Brogan’s article is strongly worded but nevertheless interesting and worth sharing.

I’m sure we all remember the APA’s inexplicable rush to publish the DSM-5.  Was this motivated, as Dr. Brogan suggests, by a pharma-APA conspiracy to expand the concept of autism as a way to obscure an alarming increase in the prevalence of autism?

I don’t know.  Dr. Brogan has strong views.  She describes DSM-5 as:

“The culminating shame of a profession marked by hack-science, placebo-driven assertions of medication efficacy, manipulation of data and a total absence of objective diagnostic markers.”

And on psychiatric “diagnoses” generally:

“So, at once, we continue to pathologize normative human experience to better sanction mass prescribing to a populace convinced they need these magic pills, but we stop the hemorrhaging on the pediatric statistics that directly implicate the medical-industrial complex and the consequences of reckless obstetrical and pediatric interventions.”

Dr. Brogan, if I understand her article correctly, seems to attribute the increase in autism prevalence to a wide range of environmental factors, including pesticides, processed food, plastic diapers, vaccines, “endocrine disruptors,” etc…

I don’t know much about these matters, but the increase in prevalence estimates warrants some consideration.

 

 

Psychiatry Is Not Based On Science

On May 27, David Brooks, a New York Times columnist, wrote a piece on psychiatry called Heroes of Uncertainty.

It’s an interesting and somewhat contradictory article.  Here are some quotes:

“As the handbook’s [DSM-5] many critics have noted, psychiatrists use terms like ‘mental disorder’ and ‘normal behavior,’ but there is no agreement on what these concepts mean.”

“What psychiatrists call a disease is usually just a label for a group of symptoms.”

This is beginning to look like an anti-psychiatry article.  But then:

“Psychiatrists are not heroes of science. They are heroes of uncertainty, using improvisation, knowledge and artistry to improve people’s lives.”

“They certainly are not inventing new diseases in order to medicalize the moderate ailments of the worried well.”

So what we’ve got is a kind of middle of the road article.  Psychiatrists are basically good guys (heroes, actually), but their subject isn’t as scientific as they claim.

If I were a psychiatrist, I think I would have just left it alone.  But the not-scientific jab had to be addressed, and psychiatrists Jeffrey Lieberman and Jack Drescher weighed in with comments.

Dr. Lieberman is president of the APA and a professor of psychiatry at Columbia University.

He opens his rebuttal with this paragraph:

“While I share David Brooks’s frustration over the slow progress in finding the biological causes of mental disorders, I am concerned about his opinions on the scientific basis of psychiatry and the clinical care that it provides to millions of people. The brain has proved to be infinitely more complex than any other organ in the human body, and the functions that mediate behavior are the most highly evolved in the animal kingdom.”

There’s a lot of spin in here.  Firstly, David Brooks, in his article, never expressed any “frustration over the slow progress in finding the biological causes of mental disorders.”  What he said was:

“Furthermore, psychiatric phenomena are notoriously protean in nature. Medicines seem to work but then stop. Because the mind is an irregular cosmos, psychiatry hasn’t been able to make the rapid progress that has become normal in physics and biology.”

What he’s saying here is that mental phenomena are inherently too complicated, irregular, and changing to ever yield the kind of scientific certainty that one finds in physics and biology.  And that’s what Dr. Lieberman can’t let go of, because that is their Holy Grail – that “one day” we’ll know the underlying biological causes of “mental illnesses,” and psychiatrists will finally be real doctors.

Back to Dr. Lieberman’s quote:

“I am concerned about his opinions on the scientific basis of psychiatry and the clinical care that it provides to millions of people.”

This is the spin mechanism known as juxtaposition.  The “scientific basis of psychiatry” is juxtaposed (irrelevantly) with “clinical care…to millions of people”.  We’re good guys toiling in the trenches of human suffering; therefore our work must be scientifically based!  It’s not real logic.  It’s Madison Avenue logic, and psychiatrists are getting better at it every day.  It’s the equivalent of politicians arranging to have themselves photographed kissing babies or shaking hands with soldiers in wartime.

“The brain has proved to be infinitely more complex than any other organ in the human body…”

Note the phrase “has proved to be” – like this is something that psychiatrists have just discovered.  They went looking for their neurochemical causes of complex human behavior, and guess what – the brain is more complex than they had thought!  For decades they and their psycho-pharma allies have been telling us that they had it all figured out.  But now the beans are spilled.  So will they come clean and say: “Guys, we’re a bunch of shysters who have been deceiving you for decades?”  No.  The brain was just more complex than they had thought.  The scale of complexity of the brain has been known for at least 100 years.  But perhaps they didn’t teach that in psychiatry school!

Here’s more spin from Dr. Lieberman:

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.”

There it is again:  the “biology of the brain and mental illness.”  Still the Holy Grail.

Jack Drescher, MD, is a psychiatrist, and served on one of the DSM-5 work groups.  Here are two quotes:

“Like the rest of humanistic medicine, a science of the mind should never lose its heart.”

This sounds good, but says nothing.

“In comparing psychiatry with astronomy, however, Mr. Brooks should remember that in 2006, the International Astronomical Union voted on whether Pluto is a planet. Even astronomy, the hardest of sciences dealing with the most irrefutable of facts, is dependent on its human practitioners’ subjectivity and interpretation of data.”

This is very high order spin.  The message that a casual reader would take from this paragraph is that psychiatry is just as scientific as astronomy – “the hardest of sciences.”

The International Astronomical Union voted to designate Pluto a dwarf planet instead of a planet, but no astronomer ever imagined that this had any significance other than administrative.  NASA called the shuttle a “vehicle.”  They could have called it a “spaceship.”  It wouldn’t have made the slightest difference.  A botanist can call a plant by its Latin name or its English name.  It doesn’t affect anything in the world of botany.  But when psychiatrists vote, for instance, to expand their “diagnosis” of depression to routinely include bereavement, this is an entirely different matter, and highlights that the entire taxonomic system is arbitrary and subjective.

A biological analogy of the DSM voting system would be if biologists voted that henceforth geese would be swans.  They could vote all they liked, but that will not make geese swans.  Biological classification is based on reality, whereas psychiatric classification is based on the subjective perceptions and votes of psychiatrists.

An analogy from astronomy would be if the astronomers had voted to make Pluto a star.

As we often find when we analyze the psychiatric spin, Dr. Drescher is either not too bright or very deceptive.

CONCLUSION

Psychiatry is under attack for its spurious concepts and its destructive, disempowering practices.  It presents no defense based on logic or facts, because it has none.  It’s a sandcastle, and the tide has turned.

An Attempt to Defend DSM-5

BACKGROUND

On 19 April, The Conversation ran an article titled Mental disorders: debunking some myths of the DSM-5, by Perminder Sachdev, MD.  Dr. Sachdev is a psychiatrist, and was a member of the DSM-5’s Neurocognitive Disorders Work Group.  He works at the School of Psychiatry, University of New South Wales, Australia.  (Thanks to Dave Traxson on Twitter for the link.)

ANALYSIS

Let’s start with the title.  “…debunking some myths of the DSM-5.”  This sounds good.  You might get the impression that he’s going to address the myth of mental illness – the myth that all human problems are illnesses and are best treated by drugs.  But – alas – you would be mistaken.  Dr. Sachdev lists four myths that he plans to debunk.  He refers to these as the “…four key criticisms about DSM-5…”  Let’s examine what he says about these one by one.

1. It’s impossible to classify mental disorders

This, remember, is one of the “key criticisms” that is leveled against DSM-5.  I think it would be fair to say that I’m reasonably familiar with the criticisms that are being directed against the DSM, but I don’t think I’ve ever heard this one.  I have heard numerous critics express the criticism that the concept of mental disorder has no validity, or explanatory value, and is not a helpful way to conceptualize human problems.  But I’ve never heard anyone say that these putative entities can’t be classified.  Indeed, for most of us on this side of the argument, saying that mental disorders can’t be classified would invalidate our central position, in that we would be acknowledging the ontological reality of these purely fictitious psychiatric inventions.  How can you classify something that doesn’t exist in the first place?

People have problems.  That is not in dispute, but the notion that these problems stem from, or are best explained as manifestations of, mental disorders is nonsensical and destructive.  Moreover, it is probably the issue on which the anti-DSM movement is most united.  It is the central criticism.

It would have been honest and interesting if Dr. Sachdev had made this his first myth:

There are no mental disorders/illnesses.

He might have marshaled some ideas, and we could have had some serious debate.  Instead, he does what we’ve been seeing a lot of lately – the old psychiatric side shuffle:  don’t address the issue; address something tangential.  Politicians have been doing this for years.

Imagine if the scientists at CERN had been asked:  “Well, did you find the Higgs boson?”  And they replied, “We have some really nice quarks to show you.”

Incidentally, you’ll find exactly the same side shuffle in DSM-IV (1994).  On page xvi you’ll find this gem:  “The need for a classification of mental disorders has been clear throughout the history of medicine, but there has been little agreement on which disorders should be included, and the optimal method for their organization.”  Here again, we glide right over the much more critical question:  has the concept of mental disorder any validity in itself? – and go straight to the problem of classifying these fictitious entities.  Classifying mental disorders, incidentally, is on a par with classifying witches!

Anyway – back to Dr. Sachdev.

“The primary purpose of the DSM-5 is to enable physicians and other clinicians to reliably diagnose patients who present with a mental disorder.”

Note the word “reliably.”  DSM-5’s own field trials showed unequivocally that the manual is extremely unreliable.  Different psychiatrists routinely assign different diagnoses to clients presenting the same problems

Dr. Sachdev must be aware of the results of the field trials, and so he might reasonably have been expected to point out that DSM-5 is a failure with regard to what he describes as its “primary purpose.”  Again, there’s a similarity to politics:  Say something often enough and people start to believe it.

Dr. Sachdev acknowledges that some diagnostic discrepancies can occur, but he assures us:  “…using the DSM, two clinicians working remotely from each other should reach the same diagnosis for a particular patient.”

Maybe he doesn’t know about the field trials?  Maybe be doesn’t care?  Maybe it’s just spin.

2. The DSM is just a money maker

Certainly some critics have commented on the financial aspect, but it’s never been a major part of the anti-DSM movement.

But note how Dr. Sachdev deals with this.

“Considering that about US$25 million has already been spent on the fifth revision process, as estimated by the chair of the task force, it does not appear to be a great investment if book royalties were the primary objective.”

He tells us what the APA has spent, but doesn’t tell us what the projected income is.  Fortunately, however, Dan Gorenstein of Marketplace Health Desk has done a cost revenue analysis, How much is the DSM-5 worth?  Here’s a quote:

“And he [Dr. James Scully, CEO of APA] says with 150,000 pre-orders the DSM-5 is a hot seller.  ‘We may do a second printing more quickly than we originally thought,’ says Scully.  At $199 dollars for the hardcover, $149 for paperback — that’s more than $20 million in sales right there.”

Actually at paperback price, it’s nearly $22.4 million.  So assuming that they sell even a modest number of hard cover copies, they have recouped their initial investment already.  And remember, up till last week, DSM-IV was still bringing in $4-5 million a year.  So projecting a 20-year lifetime, the DSM-5 will likely prove very profitable.

So let’s go back to Dr. Sachdev.  He tells us that he’s going to debunk the myth that the “…DSM is just a money maker.”  Then he tells us that $25 million has been spent, but says nothing about projected earnings.  There are three possibilities.  Either:

1.  He’s not very bright.
2.  He’s being deliberately deceptive.
3.  He thinks we’re not very bright.  Does he imagine that we will say something like: “Oh, gosh, $25 million.  That’s such a lot of money.  Thanks, Dr. Sachdev, for debunking the cash cow myth!”

And this guy was a member of the DSM-5 Neurocognitive Disorders Work Group.  So he must be really bright, right?

3. Under the DSM-5, more people will be diagnosed with a mental disorder

Here it gets even worse:

“The process of revising the DSM is extremely rigorous, and any proposal for a new disorder or a major revision of existing criteria needs to come on the back of strong scientific evidence.”

The twin pillars of scientific evidence are reliability and validity.  The APA’s own reliability figures for DSM-5 were embarrassingly dismal, and Dr. Thomas Insel of NIMH stated publicly on April 29 that the diagnoses had no validity whatsoever; a statement, incidentally, he has not recanted despite some suggestions to the contrary.

From Dr. Sachdev:

“Any new proposal must be accepted by other members of the advisory group, all of whom are experts in their field.”

There it is:  we’re experts, we’re doctors; you can trust us.

Now he debunks the proliferation-of-diagnoses myth – brace yourself.

“…the total number of disorders will not be more than in the DSM-IV: 297.”

I hate to repeat myself, but here again, he demonstrates that either: he’s not very bright; he’s being deliberately deceptive; or he thinks we’re not very bright

A ten-year-old child could tell you that there are two broad ways to catch more people in the “diagnostic” maw:

1. Invent more “diagnoses.”
2.  Lower the threshold on existing “diagnoses.”

So to tell us that the total number of diagnoses will be the same doesn’t debunk the “myth.”  One of the major criticisms directed at DSM-5 over the past year has been the lowering of the thresholds.  Could it be that Dr. Sachdev is not aware of this?

He then goes on to talk in general terms about thresholds, but seems blithely unaware of the fact that this is the central issue in the “myth” that he has not debunked.

4. The DSM is trying to redefine what’s normal

This is a complicated issue.  It is my contention that the behaviors and feelings cataloged in the DSM are, for the most part, normal reactions on the part of individuals to abnormal situations.  They emphatically are not illnesses or manifestations of illnesses residing in the individualIn a very small number of cases there may be some neural malfunction, but in the vast majority of cases the behaviors and feelings can best be understood in well-established psycho-social terms, and to assume a neural pathology in every case is unwarranted and dangerous.

So by calling all these loosely clustered syndromes mental disorders/illnesses, the APA is indeed pathologizing normality and doing so to an increasing extent with each edition of the DSM.  And this is not to say that the behaviors/feelings in question are not unusual or troublesome or even downright devastating.  They can be, and frequently are.  But they’re not illnesses!

Dr. Sachdev clearly believes that this last paragraph that I’ve written is a myth.  And if he wants to debunk this myth, all he has to do is adduce clear and convincing evidence that all of the troublesome behaviors/feelings listed in the DSM are caused by physiological pathology.  At which point I will fold my tent, retract what I’ve written, apologize profusely to all concerned, and go back to my vegetable garden.

But up until now all I’ve seen from psychiatry in this regard is a long string of discredited theories.

And from Dr. Sachdev, we don’t even get a theory – just more patronizingly pathetic spin.

“The DSM-5, and any other classification of mental disorders, is not an attempt to define what is normal. Being normal is not the same as “not having a DSM-5 diagnosis”, and having such a diagnosis is not the same as being “insane”, as some have wrongly argued about the DSM.”

And that’s it.  The “myth” is debunked because Dr. Sachdev says so!  So with that “myth” out of the way, Dr. Sachdev treats us to a couple of gems of irrelevancy:

“Many individuals, including physicians, find it difficult to accept that mental illness…is common…”

“The DSM-5 must simply be regarded as psychiatry’s next faltering step. It’s not above criticism, but is probably the best manual of mental disorders that we are likely to have for some time.”

I’m sorry that this is so lengthy, but it is so offensive to see these people using this kind of self-serving drivel to justify and bolster their spurious, destructive, and disempowering practices, while dismissing and discounting the cries of their victims.

 

 

The Psychiatric Side-shuffle Continues

Joel Paris, MD, is an eminent psychiatrist, and is also a Professor of Psychiatry at McGill University in Montréal.  He has recently written a very timely book titled: The Intelligent Clinician’s Guide to the DSM-5, published by Oxford University Press.

I have placed an order for this book through our local inter-library loan system, and when it comes in, I’ll publish a review.  But in the meantime, Dr. Paris has posted on Oxford University Press’s website a brief essay to promote the book.  The essay has lots of interesting aspects, and I thought it might be helpful to examine it in some detail.

The opening sentence in the essay is:

“The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification of all diagnoses given to patients by mental health professionals.”

Note that Dr. Paris did not say that the DSM is a classification of mental disorders, which is what its name would imply.  Rather, he’s saying it’s just a sort of catalog of psychiatric activity.  What Dr. Paris is doing here is distancing himself from the notion that the DSM is a classification of conditions existing in clients. But the essential point that the APA and psychiatric thought leaders have been pushing for decades is that the DSM is such a classification.  But now the cat is out of the bag:  DSM is a pile of rubbish and, everyone wants to get off the ship.  We’ve seen a great deal of this psychiatric side-shuffle recently.

In his second paragraph Dr. Paris begins:

“DSM-5 is not, as sometimes claimed, “the bible of psychiatry”. It is not based on a thorough understanding of the causes of mental disorder, which remain largely unknown.”

Bearing in mind that “mental disorder” is simply the name that the APA gives to human actions or feelings that entail a significant level of stress or incapacity or pain or risk of incarceration, it is difficult to understand Dr. Paris’s contention that the causes of these problems are “largely unknown.”

In my experience, if you ask a person who is depressed, for instance, why he is depressed, he can usually give a pretty coherent answer.  He can tell you the cause of his depression.  Similarly with the condition known as PTSD, the individual can recount the precipitating traumatic incident, which common sense suggests is the proximate cause of the disturbing memories.

So when Dr. Paris says that the causes of mental disorders are largely unknown, he means the putative biological causes, though he doesn’t make this explicit.  Once again, it’s a case of psychiatry discounting and even disregarding what clients say about their problems, and imposing a bio-psychiatric perspective.

Dr. Paris continues:

“What DSM does is to allow mental health professionals to communicate with each other by listing criteria by which diagnoses can be made reliable.”

This is a frequently heard theme.  But given the poor reliability figures from the DSM-5 field trials, it simply isn’t true!  A more accurate analogy would be that when psychiatrists communicate, some speak in English, others in German, others in Spanish, others in various mixtures of various languages, etc…  The common language argument is an attempt on the part of psychiatry to salvage something from the DSM, but the fact remains – it isn’t even a common language.

To continue:

“Unfortunately, the use of certain diagnoses is so widespread that people get the impression that categories in psychiatry are as real as hepatitis or multiple sclerosis. They are not.”

With which, of course, I wholeheartedly agree.  Dr. Paris, however, makes no mention of the fact that for the past two or three decades psychiatrists have been saying otherwise.  It would have been nice if he’d acknowledged this widespread and persistent deception.

Then he makes a particularly interesting point:

“They [DSM diagnoses] are simply convenient ways of describing what clinicians see in practice.”

This sounds very simple and innocent, but it ignores the well-studied and widely known fact that preconceived ideas influence perceptions.  To put it simply: if you’re looking for the things listed and described in the DSM, then there is a very high likelihood that you will find these things and – more importantly – that you will miss or discount other things.  If all a psychiatrist is seeking in the initial interview is a “diagnosis,” then that’s what he’ll find.  What he won’t find is the complexity, individuality, and uniqueness of the person.  And if he believes that these “diagnoses” are brain illnesses, he will also “see” a need for drugs.

DSM is, and was designed to be, normative.  It is not simply a record of what psychiatrists see.  It is their professional manual that tells them what to find.  And for the past 60 years, that’s exactly what they have been doing: reducing people to DSM codes and using these codes to justify pouring toxic chemicals into their brains.

Back to Dr. Paris:

“The DSM system has led to an inflated prevalence of certain disorders, sometimes producing diagnostic epidemics. These problems affect some of the most common disorders in practice. Thus “major depression” is a very disparate collection of signs and symptoms that cannot be used to determine the correct treatment. Bipolar disorder is being diagnosed in patients who do not have its classical features, and has even been applied to young children. Attention deficit hyperactivity disorder (ADHD) has no definite boundaries, and is being greatly over-diagnosed, both in children and adults. Autism spectrum disorders, once considered rare, are now being seen as among the most common of all conditions that professionals see.”

This is all very true, of course, and you might even be wondering which side Dr. Paris is on.  But his final paragraph raises some concerns:

“The DSM system can be described as flawed but necessary. Clinicians need to communicate to each other, and even a wrong diagnosis allows them to do so. However it will require many decades before we know enough about mental illness to produce a truly scientific classification.”

Note the phrase in the second sentence: “…even a wrong diagnosis allows them to do so” (i.e. communicate).  He’s clinging desperately to the DSM, even though it’s invalid.  A great many psychiatrists today are stuck on this particular cusp.  They have seen their treasured manual pounded, even by their very own thought leaders.  But it still feels safe.  It still offers them the hope that they are real doctors, making real diagnoses, and providing real medical treatment.

I must confess to having significant misgivings in picking on Dr. Paris’s work.  He is by no means a dyed-in-the-wool bio-psychiatrist.  For instance, he has long advocated talk-therapy rather than drugs for the behaviors known as borderline personality disorder, and in a recent paper on overuse of drugs he had this to say:

“Many antidepressants are said to work by fixing “chemical imbalances” in the brain. But no consistent chemical abnormality has ever been found in the brains of patients with mental disorders…”

And

“…doctors should stop all contact with the drug industry and refuse to attend industry-sponsored ‘continuing medical education’ events.”

My guess is he’s struggling with what’s going on in his chosen profession – what decent person wouldn’t – and is trying to salvage what he can.  But there were some subtleties in his paper that I felt warranted elucidation.

Thanks to Peter KindermanSam Thompson, and Helen Haskell on Twitter for the links.

The Empire Still Fighting Back: Dr. Lieberman

Jeffrey Lieberman, MD, is president-elect of the APA, and is scheduled to take over the reins from Dr. Dilip Jeste this month.  Never in its history has the APA been subject to such scrutiny or criticism from such diverse sources, and one might reasonably have expected Dr. Lieberman to open on a conciliatory note, promising investigations, reforms, etc….

But no!  He’s in the ring slugging furiously from the opening bell.  Two days ago (May 20) he published an article in Scientific American titled DSM-5: Caught between Mental Illness Stigma and Anti-Psychiatry Prejudice.

Readers may remember Dr. Lieberman as a joint author (with Thomas Insel, Director of NIMH) of a May 13 statement of reconciliation between the APA and NIMH.  At the time, I expressed the view that the statement was more spin than science.  In the Scientific American piece, Dr. Lieberman continues in the same vein.

Dr. Lieberman opens by announcing that he was “amazed” by the debates surrounding DSM-5.  “Never before has a thick medical text of diagnostic nomenclature been the subject of so much attention.”

When the guys (and gals) on Madison Avenue want you to buy more of a particular soft drink, say, they show you pictures of beautiful people in fabulous cars wearing fabulous clothes and, of course, drinking this particular drink.

What Dr. Lieberman is doing in the above quote is connecting the DSM with the image of a “thick medical text of diagnostic nomenclatures,” i.e. a genuine medical textbook.  You know that drinking that brand of soft drink isn’t going to get you the car, but advertisers know that juxtaposing these images creates an enhanced perception of the value of the product.  Bio-psychiatry has always been more about advertizing and spin than science, and apparently Dr. Lieberman believes that Madison Avenue techniques may serve his purpose here – especially since he hasn’t any science to pitch at us.

Dr. Lieberman goes on to state that DSM-5 “…offers an up-to-the-minute diagnostic GPS…”  I kid you not: an up-to-the-minute diagnostic GPS!  This is the same DSM that Thomas Insel described as having no validity, and whose field trials, conducted by the APA themselves, were so abysmal.  And yet it’s an up-to-the-minute GPS.  Note again, the juxtaposition of something positive (GPS) with the object being promoted (DSM).  This guy thinks we’re not too bright.

Dr. Lieberman goes on to tell us that he was “…alarmed at the harsh criticism of the field of psychiatry and the APA.”  Consequently, he wants to educate his readers concerning:

“…the difference between thoughtful, legitimate debate, and the inevitable outcry from a small group of critics –made louder by social media and support from dubious sources —who have relentlessly sought to undermine the credibility of psychiatric medicine and question the validity of mental illness…”

Why, I wonder, does he describe our outcry as “inevitable”?  Wouldn’t an outcry only be inevitable if indeed there was something terribly amiss with the object under discussion?  And who are the “dubious sources”?  Sinister men lurking in dark corners with sharp knives “… who have relentlessly sought to undermine the credibility of psychiatric medicine…”?  There it is again – we’re real doctors – really!  Honestly!  And here he goes over the top:  “… question the validity of mental illness…”  There it is!  How dare we!  Such cads.  But hang on – isn’t questioning an essential (perhaps the essential) component of science?  Anyway, we’re obviously a dissolute pack of rogues and villains, and we need to be given a good talking to and put to bed hungry.

Dr. Lieberman briefly alludes to “meaningful discourse” and contrasts this starkly with criticism that comes from “…groups who are actually proud to identify themselves as ‘anti-psychiatry’.”  These dreadful people “…don’t want to improve mental healthcare, unlike the dozens of psychiatrists, psychologists, social workers and patient advocates who have labored for years to revise the DSM, rigorously and responsibly.”  (He doesn’t mention that 70% of these ardent toilers were on pharma payrolls!)  He goes on to point out:

“Instead…[these uncouth villains]… are against the diagnosis and treatment of mental illnesses – which improves, and in some cases, saves, millions of lives every year – and ‘against’ the very idea of psychiatry, and its practices of psychotherapy and psychopharmacology.”

We are, to Dr Lieberman’s mind, “…misguided and misleading ideologues and self-promoters who are spreading scientific anarchy.”  There goes my self-esteem.

Dr. Lieberman goes on to liken being against psychiatry as akin to being against cardiology or other medical specialties.  He then laments the fact that “No other medical specialty is targeted by such an ‘anti’ movement.”  And this, of course, is true.  It would have been fruitful at this point if Dr. Lieberman had devoted some energy towards finding out why his profession is taking such a beating.  But no.  His strategy is to beat up his critics, and he will not be deflected.

Up till this point it’s been the straightforward ad hominem nonsense that we’ve come to expect from defensive psychiatry.  But here he crosses a truly unbelievable line:

“This relatively small ‘anti-psychiatry’ movement fuels the much larger segment of the world that is prejudiced against people with disorders of the brain and mind and the professions that treat them. Like most prejudice, this one is largely based on ignorance or fear–no different than racism, or society’s initial reactions to illnesses from leprosy to AIDS. And many people made uncomfortable by mental illness and psychiatry, don’t recognize their feelings as prejudice. But that is what they are.”

What he is saying here is that those of us who criticize psychiatry are fuelling prejudice against the clients.

And note the last but one sentence – “…many people made uncomfortable by mental illness and psychiatry, don’t recognize their feelings as prejudice.”  So when I, and other writers, say there are no mental illnesses or that the concept of mental illness is spurious and circular, or that the concept of mental illness has no explanatory value, we are actually expressing prejudice against clients and we don’t even realize that we’re prejudiced!  How pathetically we wallow in our own ignorance!

And Dr. Lieberman goes on to help us understand our deeply rooted prejudices against clients.  There is “historical fear” of mental illness, he tells us, which stems from the bad old days when “these diseases” were considered manifestations of demonic possession and later as moral defects.

So we critics of psychiatry are on a par with the witch hunters of bygone days.  I need to discard my copy of Malleus Maleficarum (a fifteenth century witch hunters’ manual) and pick up the DSM, for therein is righteousness and, of course, a GPS!

He then takes a swipe at primary care doctors who have criticized the DSM, suggesting that they’re trying to muscle in on psychiatric turf!  He wants them to come back into the fold, however, pointing out that the “anti-psychiatry forces” are “against them too.”

The first rule of spin is deny; second is deflect; third is attack.  We’ve been seeing a lot of it from psychiatry lately.  Dr. Lieberman is not particularly good at it, but what he lacks in finesse, he makes up for in vigor and enthusiasm.  I, and those like me, who critique psychiatry know that we’re opening ourselves up to attack, and we accept this because we believe that psychiatry is destructive and that the evidence supports us.  His article is just one more piece of spin in a long series of similar articles.

But in his last three paragraphs, I suggest, Dr. Lieberman goes too far:

“Only recently, I was at a meeting of medical school leadership at my university, where we discussed how to counsel medical students about choosing which specialty to pursue. One senior faculty member quipped ‘tell all students who get low scores on their board exams not to worry, they just need to change their career plans and go into psychiatry.’

A few months later, the same faculty member called me late one night, asking if I would see his wife, who was having a ‘psychiatric problem.’

The urgency of his request belied any awareness that the joke he made at psychiatry’s expense in that meeting undermined our ability to deliver the kind of quality care that his wife now needed. But it can, and it does.”

So, to score a vengeful point on a colleague, he has breached the confidentiality of the colleague’s spouse!  Everyone who attended that meeting now knows that the senior faculty member’s wife is receiving mental health care.

And this is the person that the APA membership has elected to be their president!  These are sorry times!

Live Video Chat: DSM-5

Today I received the following email from Emily Underwood, a reporter with Science Magazine.

I am a reporter with Science magazine — after reading your Twitter feed and blog I thought you might be interested in a live video chat I’m hosting this week on the controversy surrounding the DSM V. My guests are Allen Frances of Duke University, William Eaton of Johns Hopkins University, and Frank Farley of Temple University; given their different takes on the subject it promises to be a lively conversation!

We’re hoping to have as many audience members as possible tuning in and asking great questions of our guests – would you be willing to promote the chat on your blog or Twitter feed? The chat will run from 3-4pm EST on Thursday, May 23rd, at this website:

http://news.sciencemag.org/sciencelive/

Allen Frances (psychiatrist) was the head of DSM-IV, but has been a vocal critic of DSM-5, whilst insisting that DSM-IV was OK.

William Eaton (psychologist) argues for the retention of what he calls “mild cases” in the DSM on the grounds that “…treatment of mild cases might prevent a substantial proportion of future serious cases.”

Frank Farley (psychologist) has critiqued DSM-5 on the grounds of reliability, and has expressed the view that “…we need to go back to the drawing board.”

DSM-5 Still Under Fire

Mental Health Europe (MHE) is a non-governmental organization “… committed to the promotion of positive mental health and well-being, the prevention of mental health problems, the improvement of care, advocacy for social inclusion and the protection of the human rights of (ex)users of mental health services and their families and carers.”  It is composed of associations, organizations, and individuals who are active in the mental health field, including users and ex-users of services, volunteers, and professionals.  MHE subscribes to the following values: dignity and respect; equal opportunities; freedom of choice; non-discrimination, social inclusion, democracy and participation.  You can read more about them here.

On May 17, MHE published a brief article on their website.  It’s called “More harm than good – DSM-5 and exclusively biological psychiatry must be completely rethought.”  You can see it here.  (Thanks to Lucy Johnstone on Twitter for the link.)

Here are some quotes:

“…DSM 5 represents another step in the increasing dominance of a wholly biological approach to mental health problems…”

“There are many tried and tested psychosocial approaches to treating and supporting people with mental health problems, which have been neglected by the powerful political and commercial interests which dominate western psychiatry.”

“The biomedical approach in the DSM 5 is thus restrictive and harmful, and should definitely be rethought…”

So we have another prestigious organization denouncing the DSM and the bio-medical approach.

The Problem with DSM

There’s an interesting article in the NY Times Sunday review.  You can see it here.  It was written by Sally Satel MD, a psychiatrist, currently a resident scholar at the American Enterprise Institute.

The article is called:  “Why the Fuss Over the DSM-5?”  Dr. Satel’s central point is that psychiatrists only treat symptoms anyway and pay little attention to the DSM.  She expresses the belief that the manual’s diagnoses are “…passports to insurance coverage, the keys to special education and behavioral services in school and the tickets to disability benefits.”

Dr. Satel acknowledges that “…the DSM generally affords physicians enough leeway to shoehorn patients into some kind of diagnostic cubby for billing purposes…,” but insists that the manual has little bearing on actual psychiatric practice.  She laments the fact that DSM has created an environment in which a great many people are consigned to disability status, but attributes the responsibility for this state of affairs to “…insurance companies, state and government agencies, and even the courts….,” all of whom will, she tells us, “…continue to imbue the DSM with a precision and an authority it does not have.”

The article is interesting in its own right, and many of Dr. Satel’s criticisms of DSM are familiar to those of us on this side of the debate.

But the real dynamic here, in my view, is a strong desire in many psychiatric quarters to distance themselves from the DSM.  The run-up to DSM-5 has seen an unprecedented torrent of protest from survivors and from other helping professions.  And then, just when the APA perhaps thought that things couldn’t get any worse, Thomas Insel, Director of NIMH, came out and stated that the diagnoses had no validity (here), and the Division of Clinical Psychology (part of the British Psychological Society) issued a statement calling for a rejection of the DSM and of psychiatry’s persistent medicalization of human problems (here).  (Dr. Insel has since patched up his quarrel with the APA, but has not recanted the substance of his earlier criticism.)

The fact is that the DSM is an extraordinarily destructive book.  Its fundamental premise, – that human problems are caused by illnesses – is meaningless.  But its real damage stems from the fact that it is used to legitimize the widespread distribution of ineffective and damaging drugs, and the routine disempowerment and stigmatization of psychiatry’s customers.

Psychiatrists might not refer to it in their day-to-day work, but as a profession, they rely on its concepts to legitimize the medicalization of human problems, to establish and retain their dominance in the mental health system, and to encourage dependence and customer-for-life status among their clients.

Now the DSM is fast becoming a liability, and there’s a rush for the life-boats.

On this side of the debate, we need to recognize that, as damaging as DSM is, it is ultimately only the written codification of psychiatric destructiveness.  And this destructiveness will continue unabated even as DSM is shuffled quietly to the sidelines.

We’ve won a victory, but the war continues, and people are still being destroyed.

Separation Anxiety Disorder: Now Also for Adults

BACKGROUND

The “diagnosis” of separation anxiety disorder has been around since DSM-III.  In DSM-IV it is defined as “…excessive anxiety concerning separation from the home or from those to whom the person is attached.”  (DSM-IV-TR p 121).  The APA’s prevalence estimate is 4%.

This “diagnosis” is listed under the heading: “Other Disorders of Infancy, Childhood, or Adolescence.”  One of the criteria is that the problem must begin before age 18, and in practice the “diagnosis” was generally confined to children under the age of 10 or so.

The “diagnosis” of separation anxiety disorder can be critiqued along essentially the same lines as most of the other DSM labels, e.g. lack of identifiable pathology, arbitrariness, fallacious circularity, vagueness in definition and criteria, etc… It can also be pointed out that there are more valid, and incidentally more helpful, ways to conceptualize fears and anxieties.  In addition, giving a child (and his parent) the message that his fear is an illness for which he must take pills rather than a life hurdle to be overcome by effort and encouragement is stigmatizing and disempowering.  Back in the fifties there were always a few kindergarteners who cried and carried on when being dropped off at school, but they were all “cured” (or apparently so) within the first week.

“TREATMENT” OF SEPARATION ANXIETY DISORDER

The University of Rochester Health Encyclopedia (here) has this to say on the “treatment” of separation anxiety disorder.

“Treatment recommendations may include cognitive behavioral therapy for the child, with the focus being to help the child or adolescent learn skills to manage his or her anxiety and to help him or her master the situations that contribute to the anxiety. Some children may also benefit from treatment with antidepressant or antianxiety medication to help them feel calmer.”

In practice, of course, the cognitive behavioral therapy recommendation is ignored and the child eats pills.  The Wikipedia article specifically mentions SSRIs.

DSM-5

All of this is bad enough, but coming shortly in DSM-5 we will have separation anxiety disorder for adults!

So adults who are excessively anxious on being separated from their children or from other significant figures are now mentally ill.  And this change is based, not on some recent scientific discovery or insight, but simply because the APA say so.  And who, you might wonder, decides how much anxiety is excessive?  The psychiatrists.

It’s business as usual.  More “diagnostic” creep; more stigmatization; more disempowerment; and of course, more drugs!  If you were thinking that the psychiatrists might be having second thoughts concerning their marriage to pharma, you were wrong.  The marriage is thriving.

DISEMPOWERMENT

Gone is the notion that fears are to be conquered through application, effort, and social support.  Gone is the notion of families and friends rallying around a member in trouble and helping him through a rough patch.  Because today there are no rough patches.  What we, naively, used to think of as rough patches have been transformed by the wisdom of psychiatry into mental illnesses.

And so it goes.  These people will never stop until everybody has a “diagnosis” and everybody is taking drugs.  Psychiatry, with its pathetically naïve and simplistic handbook of human problems and its pill-for-every-problem philosophy is a destroyer of people.  Please speak out.  Stop the madness.