Tag Archives: DSM

Robert Spitzer’s Legacy

Robert Spitzer, MD, the architect of DSM-III (1980), died of heart disease on Christmas Day, 2015, at age 83.

Most major media outlets published obituaries in which Dr. Spitzer was praised on the grounds that he had brought scientific rigor to psychiatry by naming and defining the various psychiatric illnesses.

Here are a few illustrative quotes:

“Dr. Robert L. Spitzer, who gave psychiatry its first set of rigorous standards to describe mental disorders, providing a framework for diagnosis, research and legal judgments — as well as a lingua franca for the endless social debate over where to draw the line between normal and abnormal behavior — died on Friday in Seattle.”  (New York Times, December 26)

“Robert Spitzer, the influential American psychiatrist credited with establishing a modern classification of mental disorders, has died at the age of 83.” (BBC News, December 27)

“Dr. Robert Spitzer – a psychiatrist who played a leading role in establishing agreed-upon standards to describe mental disorders and eliminating homosexuality’s designation as a pathology – died Friday in Seattle. He was 83.” (Independent.co.uk, December 27)

“He [Dr. Spitzer] added dozens of mental disorders to the psychiatric lexicon: anorexia, bipolar disorder, panic disorder, PTSD and many other now-familiar maladies. It’s not that these ailments didn’t exist before the 1970s — but they had no agreed-upon names or definitions until Dr. Spitzer branded them in two new editions of the DSM. The book tripled in size (from a 134-page paperback to a 567-page doorstop) and at least as much in influence under his leadership.” (Washington Post, December 26)

Obviously, I don’t share the various obit writers’ enthusiasm for Dr. Spitzer’s work on the DSM-III.  In fact, I would describe the DSM-III as the turning point that steered psychiatry into the irremediably spurious, expansionist, and destructive situation in which it now finds itself.

I had been planning to write a post on this matter in the near future, but I noticed this morning that Bonnie Burstow has published an article on Mad in America that says everything I had wanted to say on the matter, with her customary skill, sensitivity, and erudition.

Here are two quotes:

“To be clear, it is always sad when someone dies — and I in no way wish to detract from the personal tragedy. Nor do I intend to make any pronouncement about Spitzer the individual. What concerns me in this article is one thing only — how to understand his ‘psychiatric contribution’ to society. Now no one denies that Spitzer was enormously influential. However, it is precisely because his legacy endures and because vulnerable people are forced to live with what was set in motion that I felt compelled to write this article.”

“…they [Dr. Spitzer and his colleagues] set psychiatric diagnosing decisively on a path where it would look scientifically rigorous; where it could claim the authority of medicine on the basis of appearance, while in point of fact being vacuous.”

You can link to Bonnie’s article here.  It’s well worth reading and passing along.

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.

Allen Frances Saving Psychiatry From Itself?

On October 12, 2014, the eminent psychiatrist Allen Frances, MD, participated in a panel discussion at the Mad In America film festival in Gothenburg, Sweden.  After the festival, he wrote an article – Finding a Middle Ground Between Psychiatry and Anti-Psychiatry – for the Huffington Post Blog, summarizing the positions he had discussed at the festival. The article was re-published on MIA on October 26, 2014.

The article is ostensibly an attempt to find common ground between psychiatry and its critics, but the piece contains numerous distortions and omissions which I think need to be identified and discussed.

Here are some quotes from the article, interspersed with my comments.

“There will never be any compromise acceptable to the die-hard defenders of psychiatry or to its most fanatic critics.

Some inflexible psychiatrists are blind biological reductionists who assume that genes are destiny and that there is a pill for every problem.

Some inflexible anti-psychiatrists are blind ideologues who see only the limits and harms of mental-health treatment, not its necessity or any of its benefits.

I have spent a good deal of frustrating time trying to open the minds of extremists at both ends — rarely making much headway.”

This is Dr. Frances’s opening passage.  Essentially what he’s saying here is that there are “extremists” on both sides of this issue.  Although he doesn’t say that these individuals are minorities, I think that this is implied.  Certainly those of us in the anti-psychiatry camp are a minority, but the implication that psychiatrists who are  “blind biological reductionists” represent a minority is, I suggest, simply false.  I have been retired now for 13 years, but in the previous twenty-five years, I doubt if I encountered more than three or four psychiatrists who were not “blind biological reductionists”.  The phrases “chemical imbalance” and “illness just like diabetes” were standard fare in psychiatry’s narrative, and the 15-minute “med check” was the standard “treatment” for all problems.

With regards to “inflexible anti-psychiatrists” being “blind ideologues”, I think I can speak from personal experience.  I am indeed inflexibly anti-psychiatry.  My position in this regard is based entirely on the fact that the various problems listed in the DSM (apart from those indicated as due to a general medical condition) are not illnesses, and that conceptualizing these problems as illnesses has done, and continues to do, vastly more harm than good.  I am – to use Dr. Frances’s term – inflexible on this matter in the same way that I am inflexible on the matter that the Earth is round rather than flat.

But, on the other hand, as I’ve stated many times on my website, if psychiatry will adduce convincing evidence that the various items catalogued in their manual really are illnesses, (i.e., stem from an identified biological pathology), then I will accept this evidence, apologize for my errors, and close the website. At the risk of understatement, this evidence is not to hand, and at present, psychiatry’s contentions, explicit and implicit, that the various problems that they “treat” are illnesses are nothing more than destructive, disempowering, self-serving, unsubstantiated assertions.

And lest there be any perception that psychiatry’s love-affair with biological reductionism is a thing of the past, here’s a quote from Jeffrey Lieberman’s June 19, 2012 video Causes of Depression.  Dr. Lieberman is Psychiatrist-in-Chief at New York Presbyterian/Columbia University Medical Center, and at the time of the video was President-elect of the APA.  The video was made by The University Hospital of Columbia and Cornell.

“…the way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated.  And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate.  So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion.”

And lest there be any perception that Dr. Frances did not contribute to psychiatry’s ardent embrace of biological reductionism, here’s a quote from the Introduction to DSM-IV, of which Dr. Frances was the Task Force chairman:

“The terms mental disorder  and general medical condition are used throughout this manual.  The term mental disorder is explained above.  The term general medical condition is used merely as a convenient shorthand to refer to conditions and disorders that are listed outside the ‘Mental and Behavioral Disorders’ chapter of ICD.  It should be recognized that these are merely terms of convenience and should not be taken to imply that there is any fundamental distinction between mental disorders and general medical conditions… (p xxv) [Boldface added]

. . . . . . . . . . . . . . . . 

“Fortunately, though, there are many reasonable people in both camps who may differ markedly in their overall assessment of psychiatry but still can agree that it is certainly not all good or all bad. With open-mindedness as a starting point, common ground can usually be found;”

At the risk of appearing cynical, I see this as a rather facile attempt at divide-and-conquer.  Psychiatry is the Goliath here, and the anti-psychiatry movement is a very weak and poorly-provisioned David.  What Dr. Frances is doing is marginalizing the more extreme members of the anti-psychiatry camp, and attempting to gather the more moderate members into psychiatry’s fold, under the pretense that most psychiatrists are reasonable people who will welcome their input with “open-mindedness”.  In reality, apart from a truly tiny number of psychiatrists, there is no receptivity within psychiatry to the anti-psychiatry concerns.  In fact, the dominant feature of the present debate is psychiatry’s increased insistence that the problems they “treat” are indeed real illnesses, and that their “treatments” are safe and effective.

In a recent radio interview with Michael Enright on Canadian Broadcasting Corporation’s The Sunday Edition, Jeffrey Lieberman, MD, one of the most eminent and prestigious psychiatrists in the world, characterized Robert Whitaker as “a menace to society” for daring to suggest otherwise!  And there was scarcely a ripple of protest from psychiatry.

. . . . . . . . . . . . . . . .

“And finding common ground has never been more important. We simply can’t afford a civil war among the various advocates of the mentally ill at a time when strong and united advocacy is so desperately needed.”

Note the term “civil war” with its connotations of brother against brother, families torn apart, etc…  The message here is:  that those of us who are “open-minded” basically want the same thing, so why are we engaged in this struggle?  But note also the phrase “the mentally ill”.  The essential core of the anti-psychiatry movement is that the various problems embraced by psychiatry’s catalog are not illnesses.  But Dr. Frances dismisses this entire issue in the guise of being open-minded and conciliatory.

In addition, the phrase “the mentally ill”, with its connotations of amorphousness, homogeneity, and anonymity, is extraordinarily stigmatizing.  I would concede that person-first language is sometimes promoted to an excessive degree, but the phrase “the mentally ill” is not at all helpful.

Ironically, Dr. Frances uses this phrase in the context of advocacy!  “…various advocates of the mentally ill…”  I respectfully suggest that a good first advocacy step for Dr. Frances would be to stop calling the individuals concerned “the mentally ill”.

Incidentally, the phrase “the mentally ill” occurs in Dr. Frances’s paper three times; the phrase “the severely ill” occurs once.

And why is this “strong and united advocacy…so desperately needed”.  Because:

“Mental-health services in the U.S. are a failed mess: underfunded, disorganized, inaccessible, misallocated, dispirited, and driven by commercial interest. The current nonsystem is a shameful disgrace that won’t change unless the various voices who care about the mentally ill can achieve greater harmony.”

But, and Dr. Frances fails to mention this, it is psychiatry itself that has been running this “shameful disgrace” for the past 150 years or so.  And psychiatry was, and still is, a very willing and devoted partner to pharma, the major commercial interest.

Also note the guilt-trip:  if you’re not joining the great Allen-Frances coordinated unification drive, then you just don’t care about “the mentally ill”, (that phrase again).

 

. . . . . . . . . . . . . . . .

“…those who don’t need psychiatric medicine get far too much: We spend $50 billion a year on often-unnecessary and potentially dangerous pills peddled by Big Pharma drug pushers, prescribed by careless doctors, and sought by patients brainwashed by advertising. There are now more deaths in the U.S. from drug overdoses than from car accidents, and most of these come from prescription pills, not street drugs.”

But Dr. Frances neglects to mention that his own DSM-IV had a clearly expansionist agenda, details of which I’ve discussed in an earlier post.  It is the proliferation of “diagnoses” and the progressive relaxing of the criteria that enables the increases in prescribing.  And Dr. Frances has been a major player in this area.

He also neglects to mention his own interest-conflicted collaborative relationship with Janssen Pharmaceutica in the mid-1990’s in the promotion of Janssen’s drug Risperdal (risperidone).  In that regard, Dr. Frances was quoted in a witness report as stating:

“We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.” [Boldface added]

. . . . . . . . . . . . . . . . 

“The mess is deeply entrenched because 1) there are few and fairly powerless advocates for the most disadvantaged; 2) the commercial interests are rich and powerful, control the airwaves and the politicians, and profit from the status quo; and 3) the mental-health community is riven by a longstanding civil war that distracts from a unified advocacy for the severely ill.

The first two factors won’t change easily. Leverage in this David-vs.-Goliath struggle is possible only if we can find a middle ground for unified advocacy.

I think reasonable people can readily agree on four fairly obvious common goals:

1.  We need to work for the freedom of those who have been inappropriately imprisoned.

2.  We need to provide adequate housing to reduce the risks and indignities of homelessness.

3.  We need to provide medication for those who really need it and avoid medicating those who don’t.

4.  We need to provide adequate and easily accessible psychosocial support and treatment in the community.”

There is indeed a David and Goliath aspect to this issue.  Pharma-psychiatry is Goliath; and the struggling anti-psychiatry movement is David.  But note how Dr. Frances has reconfigured this. Goliath is now “the commercial interests” (presumably pharma), and David is psychiatry (without, of course, the few “blind biological reductionists”) plus those “reasonable” members of the anti-psychiatry movement who genuinely care for “the mentally ill”.  Casting pharma and psychiatry as being on opposite sides of this issue, and portraying psychiatry as the powerless, innocent victim, are extraordinary feats of mental gymnastics.

. . . . . . . . . . . . . . . . 

“Eighty percent of all psychiatric medicine is prescribed by primary-care doctors after very brief visits that are primed for overprescribing by misleading drug-company advertising.”

But not a single one of those prescriptions could have been written if psychiatrists had not invented, and avidly promoted, the “illnesses” for which they are prescribed.

. . . . . . . . . . . . . . . .

 “Many psychiatrists also tend to err by being too quick to write prescriptions.”

But isn’t this an integral part of the medical model:  diagnose the illness, prescribe the treatment; follow-up.  This isn’t some kind of unforeseeable aberration.  Rather, this is psychiatry as psychiatrists – leaders as well as rank and file – have consciously and deliberately sculpted it over the past 50 years.  This spurious and destructive travesty is the inevitable culmination of psychiatry’s efforts to establish itself as a bona fide medical specialty.  The fact that it is such a colossal failure is not a reflection on the efforts of the participants, or the pharma money that fuelled those efforts.  Rather, it reflects the obvious fact that the medical model is not a useful way to conceptualize or approach non-medical problems of thinking, feeling, and/or behaving.   

. . . . . . . . . . . . . . . . 

“I think reasonable people can agree that we need to reeducate doctors and the public that medications have harms, not just benefits…”

Doctors need to be re-educated to the fact that medications have harms, not just benefits!  Don’t they read the PDR?   And note the use of the generic term “doctors” rather than psychiatrists, even though it was psychiatrists who routinely proclaimed the safety and efficacy of the drugs they pushed, and downplayed adverse reactions, when they mentioned them at all.  And it was the pharma-funded psychiatric research mill that churned out, and continues to churn out, the spurious studies that “established” the safety and efficacy of these products.

. . . . . . . . . . . . . . . . . 

“…it is equally ludicrous that anyone should be sent to jail for symptoms that would have responded to medication if the waiting time for an appointment had been one day, not two months.”

First, note the implication that the criminal behavior is a “symptom” that “would have responded to medication.”  But what of the increasing number of very serious criminal acts committed by people who are actually taking psychiatric drugs, particularly SSRI’s?

. . . . . . . . . . . . . . . . 

“When, more than 50 years ago, Tom Szasz began to fight for patient empowerment, freedom, and dignity, the main threat to these was a snake-pit state hospital system that warehoused more than 600,000 patients, usually involuntarily and often inappropriately. That system no longer exists. There are now only about 65,000 psychiatric beds in the entire country, and the problem is finding a way into the hospital, not finding a way out.”

This is not entirely accurate.  The late Thomas Szasz, MD, was indeed concerned about coercive psychiatry, but he was even more concerned about psychiatry’s spurious medicalization of non-medical problems: what Dr. Szasz called the myth of mental illness.  And this latter concern is one that Dr. Frances consistently fails to address, or even acknowledge.  To abuse the late Dr. Szasz’s legacy in this way strikes me as dishonorable.  And to suggest that the concerns so forcefully expressed by Dr. Szasz are now a thing of the past is simply false.

. . . . . . . . . . . . . . . . 

“Anti-psychiatrists are fighting the last war. Psychiatric coercion has become largely a paper tiger: rare, short-term, and usually a well-meaning attempt to help the person avoid the real modern-day coercive threat of imprisonment.”

So psychiatric coercion is rare, short-lived, and is essentially an act of kindness to keep people out of prison.  But on August 28, 2014, Dr. Frances wrote an article on the Huffington Post Blog in which he lionizes D.J. Jaffe, whom he describes as “one of a small group of stalwart defenders of the 5 percent” (people with “severe mental illness”).  Dr. Frances provides an extensive quote from D J. Jaffe in which Mr. Jaffe clearly supports the infamous Tim Murphy bill, which, if implemented, would increase vastly the amount of coerced psychiatric “treatment” in the US.

. . . . . . . . . . . . . . . .

Depression is not an illness.  Childhood inattention is not an illness.  Painful and distressing memories are not illnesses.  Habitual criminality is not an illness.  Psychiatry’s routine medicalization of these and other non-medical problems is a disaster of monumental proportions, and Dr. Frances has been a major contributor to this process.

At the present time, psychiatry is being exposed as the self-serving, disempowering, and destructive charlatanism that it is.  The anti-psychiatry movement, though still the David, is gaining ground and adherents daily.  Psychiatry has no defense, and can see the edifice, so carefully and deceptively constructed over decades, crumbling by the day.

What Dr. Frances is trying to do is co-opt the anti-psychiatry movement, by marginalizing its more extreme members, while gathering the rest under a dubious banner of reasonableness and compromise.  But beneath the thin veneer of amenability, there are still the spurious, self-serving concepts and the destructive, disempowering practices of a system that is intellectually and morally bankrupt, and has no legitimate claim to being a medical specialty.

Allen Frances’ Ties to Johnson & Johnson

INTRODUCTION

I recently came across an article titled Diagnosisgate: Conflict of Interest at the Top of the Psychiatric Apparatus, by Paula Caplan, PhD.  The article was published in Aporia, the University of Ottawa nursing journal, in January 2015.  Aporia is “a peer-reviewed, bilingual, and open access journal dedicated to scholarly debates in nursing and the health sciences.”

Dr, Caplan is a clinical and research psychologist, and an Associate at Harvard’s DuBois Institute.  She worked as a consultant to the DSM-IV task force in the 1980’s, but resigned from this position after two years.    Here’s a quote from her February 2014 post on Mad in America The Great “Crazy” Cover-up: Harm Results from Rewriting the History of DSM:

“In the late 1980s, I was a consultant to two committees appointed by DSM-IV Task Force head Allen Frances to decide what DSM-IV should contain. I resigned from those committees after two years because I was appalled by the way I saw that good scientific research was often being ignored, distorted, or lied about and the way that junk science was being used as though it were of high quality . . . if that suited the aims of those in charge. I also resigned because I was increasingly learning that giving someone a psychiatric label was extremely unlikely to reduce their suffering but carried serious risks of harm, and when I had reported these concerns and examples of harm to those at the top, they had ignored or even publicly misrepresented the facts.”

Dr. Caplan has also written a brief synopsis of the Diagnosisgate article here.

PSYCHIATRISTS FOR HIRE

The central theme of Dr. Caplan’s 2015 article is that in 1995, Allen Frances, MD,  and two other psychiatrists (John Docherty and David Kahn) received grants of about $515,000 from Johnson & Johnson to write “Schizophrenia Practice Guidelines” which specifically promoted Risperdal (a Johnson & Johnson product) as the first line of treatment for schizophrenia.  The guidelines were called the “Tri-University Guidelines” in recognition of the fact that Dr. Frances worked at Duke, Dr. Docherty at Cornell; and Dr. Kahn at Columbia.  Subsequently, the three psychiatrists formed Expert Knowledge Systems, and from that platform, actively assisted Johnson & Johnson in the implementation and marketing of the guidelines.  For these latter services, J & J paid EKS a further $427,659.

The role of the three psychiatrists came to light because in 2004, the State of Texas filed a lawsuit against Janssen Pharmaceutica, a subsidiary of Johnson & Johnson, alleging that  company officials “targeted Texas Medicaid with their sophisticated and fraudulent marketing scheme” (here) to ensure that Risperdal was included in the state’s preferred drug list.

During these proceedings, an expert witness report was presented to the court by David Rothman, PhD, professor of Social Medicine at Columbia University College of Physicians and Surgeons.  The report is titled simply “Expert Witness Report” and is dated October 15, 2010.  The report, which can be found here, runs to 86 pages, and is meticulously detailed.

Here are some quotes from Dr. Caplan’s article:

“Allen Frances, arguably the world’s most powerful psychiatrist, spearheaded a massive, million-dollar project using psychiatric diagnosis to propel sales of a potent and dangerous drug by pharmaceutical giant Johnson & Johnson (J & J). Frances began the initiative in 1995, but his involvement has been little known, despite a court document written in 2010 that revealed what its author [David Rothman, PhD], an ethics specialist, called serious deception and corruption in that project.”

“According to the court document, Frances led the J & J enterprise that involved distortion of scientific evidence, conflicts of interest, and other illegal and unethical practices.”

“Rothman reported that, in 1995, the very year after DSM-IV appeared, Johnson & Johnson had paid more than half a million dollars (USD) to Frances and two of his psychiatrist colleagues to create an official-seeming document as the basis for promotion of one of their drugs. The following year, the drug company paid them almost another half million dollars to continue and expand the marketing campaign.”

“According to the Rothman report, Frances and his colleagues wrote guidelines that were designed specifically to persuade physicians to prescribe J & J’s drug Risperdal as the first line of treatment for schizophrenia.”

Here are some quotes from David Rothman’s report:

“In 1993, GTFH Public Relations echoed what State and Federal Associates [another PR company] had recommended the year before.  It, too, emphasized the need [for J & J]to cultivate state officials along with members of the psychiatric community…GTFH also emphasized that J&J should be convening Expert Task Force Meetings: ‘Formulate position and draft guidelines for consensus…Use: ‘Personalized invitational campaign to maximize participation.’…Finally, it counseled J&J to ‘Form exclusive partnership with growing advocacy group,’ citing NAMI as one case in point. J&J should help establish chapters and co-sponsor educational programs on patient issues…”(pp 13-14) [Emphasis added]

Note that one of GTFH’s recommendations was to “…draft guidelines…”

“As one of its first activities, and in disregard of professional medical ethics and principles of conflict of interest, in 1995 J&J funded a project led by three psychiatrists at three medical centers (Duke, Cornell, and Columbia) to formulate Schizophrenia Practice Guidelines.  From the start, the project subverted scientific integrity, appearing to be a purely scientific venture when it was at its core, a marketing venture for Risperdal.  In fact, the guidelines produced by this project would become the basis for the TMAP [Texas Medication Algorithm Project] algorithms, giving a market edge to the J&J products in Texas.” (p 14)

The production of the practice guidelines involved polling a selected sample of expert psychiatrists, and collating their questionnaire responses.

“The guideline team [Drs. Frances, Docherty, and Kahn] promised wide distribution of its product, including publication in a journal supplement.  The team was prepared to have J&J participate in its work, not keeping the company even at arms length.  With a disregard for conflict of interest and scientific integrity, the group shared its drafts with J&J.  On June 21, 1996, Frances wrote Lloyd [John Lloyd, J&J’s Director of Reimbursement Services]:  ‘We are moving into the back stretch and thought you would be interested in seeing the latest draft  of the guidelines project….Please make comments and suggestions.‘  (Italics added).  So too, the group was eager to cooperate with J&J in marketing activities.  Frances wrote without embarrassment or equivocation:  ‘We also need to get more specific on the size and composition of the target audience and how to integrate the publication and conferences with other marketing efforts”  (Italics added)…Indeed, from the start J&J had made it apparent to the team that this was a marketing venture.  In a letter to Frances, Lloyd set forth what he called an ‘aggressive time line’ for the project, and added:  ‘There are a number of other Treatment and Practice Guidelines for schizophrenia being developed or published during this same period that may well serve our marketing and implementation needs at a substantial lesser cost.’…” (p 15)

“Not only were Frances, Docherty and Kahn ready to violate standards of conflicts of interest in mixing guideline preparation with marketing for J&J, but also in publicizing the guidelines in coordination with J&J.  The three men established Expert Knowledge Systems (EKS).  The purpose of this organization was to use J&J money to market the guidelines and bring financial benefits to Frances, Docherty, and Kahn.” (p 15)

“EKS [i.e., Drs. Frances, Docherty, and Kahn] wrote to Janssen on July 3, 1996 that it was pleased to respond to its request to ‘develop an information solution that will facilitate the implementation of expert guidelines.’…It assured the company:  ‘We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.’  Now that the ‘first phase’ was completed, with the guidelines created, ‘EKS is now ready to move forward in a strategic partnership with Janssen.’…The strategy will allow Janssen to ‘Influence state governments and providers….  Build brand loyalty and commitment with large groups of key providers around the country.’…EKS also promised ‘rapid implementations,’ with particular attention to having an impact on Texas decision making.’It is our intent to work with the State of Texas immediately in implementing this product in a select number of CMHC’s with the assistance of A. John Rush, MD.’…Again EKS emphasized:  ‘It is essential for Janssen to distinguish Risperidone [Risperdal] from other competitors in a timely and creditable way.’…In its Summary of the document, EKS wrote: ‘Your investment in the development of state of the art practice guidelines for schizophrenia is already beginning to pay off in terms of positive exposure in the Texas Implementation project.’…” (p 15-16) [Emphasis added]

Back to Paula Caplan’s article:

“On August 30, 2012, Texas Attorney General Abbott issued a press release to announce that Texas and 36 other states had together reached a settlement in which Janssen was to pay the states a total of $181 million because of its ‘unlawful and deceptive marketing.’  Here there appears another mystery: Interestingly, nowhere in either the filing or the press release did the names of Frances, Docherty, or Kahn appear, although their deceptive guidelines were the foundation for the enterprise, nor did they include the names of the other psychiatrists whom Janssen had hired to carry out the deceptive acts. Furthermore, they did not include information about harm done to the individuals who had been prescribed Risperdal.”

“Papers impelled by J & J were published in scholarly journals and, as Rothman reports, ghost-written by individuals selected by J & J, with high-profile names affixed as first authors after the articles had been written. These papers helped promote use of Risperdal to treat not only Schizophrenia but also Childhood Onset Schizophrenia, Schizo-affective Disorder, Bipolar Disorder in Children and Adults, Mania, Autism, Pervasive Developmental Disorder other than Autism, Conduct Disorder, Oppositional Defiant Disorder, Psychosis, Aggression Agitation, Dementia, below average IQ, and disruptive behavior. Subsequent to the production and marketing of the Tri-University Guidelines came the FDA approval of Risperdal to treat adults and then children diagnosed with Bipolar Disorder, and finally children diagnosed with Autism.”

And another quote from David Rothman:

“J&J turned the guidelines into a powerful marketing tool.  The slides presented at a CNS National Sales Meeting in March 1997, instructed employees to use the guidelines to convince its ‘Primary customers: P & T members [Pharmacy and Therapeutics committees], Formulary Decision Makers and Psychopharmacologists’ – those who made purchasing and reimbursement decisions – that they should use the guidelines to justify making Risperdal the drug of choice.…J&J also wanted the guidelines to promote the product’s use among ‘Secondary Customers,’ namely ‘Physicians who are not convinced of RISPERDAL’s 1st line status.’  So although the front piece for the guidelines described them as ‘suggestions for clinical practice,’ from J&J’s perspective, they provide ‘credibility; Reinforces RISPERDAL’s 1st line status; Differentiates RISPERDAL from convention[al] APS [antipsychotics] and other atypical APS.’  To make certain the customers got the message, the ‘Full Supplement [of the guidelines publication] should be left behind.’  J&J also funded CME offerings to publicize the guidelines, including a ‘Free ½ Day Seminars, Earn Up to 8 Hours of CE/CME.’  The panel of experts included Frances, Docherty, and Kahn, and also John Rush (who would play a key role in TMAP).  http://web.archive.org/web/19961106071503/www.ibh.com/expert1.htm” (p 17)

. . . . . . . . . . . . . . . . 

What’s particularly noteworthy in all of this is that since about 2010, Dr. Frances has been critiquing the obviously expansionist agenda of DSM-5, and the corruptive role of pharma in disease-mongering, and in the increasing over-use of psychiatric drugs.

In this context, he presents himself as the defender of moderation and scientific integrity, but, to the best of my knowledge, he has never publicly acknowledged his marketing role  with J & J in the creation of the Tri-University Guidelines.

ALLEN FRANCES REPLIES

On March 5, 2015, Dr. Frances did respond to Paula Caplan’s “Diagnosisgate” article.  Here are some quotes from this response, which appeared on the Huffington Post blog.  The quotes are interspersed with my comments.

“…in her usual dramatic and distorted way, Dr. Caplan feels she can score points and gain public attention by exposing a supposed, creatively named, ‘Diagnosisgate.'”

It is my general perception that when people respond to criticism with this kind of personal attack, they have something to hide.

. . . . . . . . . . . . . . . .

“Dr. Caplan, as always, is careless with facts, quick with misinterpretations, and filled with wild accusations. I will first debunk what is simple nonsense in her claims and then discuss the issues that do have a factual basis.”

“It is nonsense to state that my participation in guideline development was in any way a conflict of interest with DSM IV or affected in any way its preparation. The guideline project occurred several years after DSM IV was already in print. The term ‘Diagnosisgate’ is no more than Dr Caplan’s misleading attempt to attract an audience and has no connection to reality.”

There is no suggestion in Dr. Caplan’s article that Dr. Frances’s participation in the guideline development was a conflict of interest with DSM-IV.  In fact, Dr. Caplan notes that J & J’s first payment to Drs. Frances, Docherty, and Kahn occurred the year after DSM-IV was published.  What’s stressed in both Paula Caplan’s and David Rothman’s reports is the fact that Dr. Frances and his two co-founders of EKS actively collaborated with Johnson & Johnson in the marketing of Risperdal, and that the guidelines that they created were clearly designed for this purpose.

. . . . . . . . . . . . . . . .

“It is nonsense to imply that I made a great deal of money from DSM IV sales, which Dr. Caplan states totalled $100 million.”

There is no reference, or even implication, in Dr. Caplan’s article, that Dr. Frances made a great deal of money from DSM-IV sales.  Dr. Caplan mentions the fact that sales of the manual “earned more then $100 million”, but there is no suggestion that Dr. Frances shared in these profits.  Again, what’s stressed in both Paula Caplan’s and David Rothman’s articles is that Dr. Frances and his colleagues made about $900,000 from J & J for producing and marketing the Tri-University Guidelines.

. . . . . . . . . . . . . . . .

“It is nonsense for Dr. Caplan to claim there was ‘data distortion’ in either DSM IV or in the guidelines. Both efforts were the result of completely transparent and forthright processes. Both efforts had very clear and published methodological rules of the road that were conscientiously followed every step of the way.”

The phrase “data distortion” occurs in a sub-heading in Dr. Caplan’s synopsis article, but the phrase does not occur in her main article in Aporia.  So I’m not sure exactly what she had in mind.  But the notion that following one’s own “clear and published methodological rules of the road” guarantees validity and lack of bias is a little naïve.  All that Drs. Frances, Docherty, and Kahn would have to do to skew the results is, firstly, select questionnaire recipients whom they knew favored risperidone, and secondly, word the questions in a way that would tend to elicit the kind of responses that would promote risperidone.  In the published guideline document, the authors state that questionnaire participants were selected from several sources:

“…recent research publications and funded grants, the DSM-IV advisers for psychotic disorders, the Task Force for the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Schizophrenia, and those who have worked on other schizophrenia guidelines.” (p 2)

From this – obviously very large group – Dr. Frances and his partners selected 99 psychiatrists, 87 of whom responded to the questionnaire.  I can find no information as to how the 99 psychiatrists were selected.

. . . . . . . . . . . . . . . .

“She enjoys being the center of controversy and will always do her best to stir a tempest in a thimble.”

Ah!  That explains everything.

. . . . . . . . . . . . . . . .

But then, Dr. Frances acknowledges some retrospective misgivings:

“But in retrospect, there are two things about the project I much regret. Firstly, it was very unwise to do guidelines with drug industry funding. Even though they were fairly done, accurately reported, and contained built in methodological protections against industry-favorable bias, the industry sponsorship by itself created an understandable appearance of possible bias that might reduce faith in the sound advice and useful method contained in them. It was an error in judgment on my part that I apologize for. I have learned from my mistake and hope others do as well.”

So, there was absolutely nothing wrong with the guidelines, but the acceptance of pharma money may have created an appearance of bias.  And although no such bias existed, Dr. Frances is apologizing for creating this appearance.  But remember the EKS commitment quoted earlier:  “We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.”  This is a clear statement of  bias.  It’s not an appearance of bias; it’s not possible bias.  It is out and out, unmitigated bias.  They express commitment, not to some improvement in client outcomes or welfare, but to increasing Janssen’s market share.  Drs. Frances, Docherty, and Kahn were hired to market Risperdal.  They were well paid, and they delivered what their employer expected of them.

And incidentally, despite his misgivings, there’s no indication that Dr. Frances has refunded his share of the $900,000 from J & J.  “May one be pardon’d and retain the offence?” (Hamlet, Act 3, Scene 3)

. . . . . . . . . . . . . . . .

“Secondly, I did not at the time anticipate, nor did the experts, that the atypical antipsychotics would be so frequent a cause of obesity and of the serious complications that follow from it. The considerable risks involved in using these new medications, and ways of avoiding these, were then unknown and not covered in the guideline.”

So, he assumed without evidence that the drug was safe unless proven dangerous, when in fact, good practice would be the opposite:  assume that the drug is dangerous, until it’s proven safe!  But, in any event, it wasn’t Dr. Frances’s fault.  After all, who could have known?

PUBLICATION OF THE GUIDLELINES

In 1996, the EKS’s Treatment of Schizophrenia guidelines were published as a 58-page supplement in The Journal of Clinical Psychiatry.  It’s an interesting document, and it certainly does promote the use of Risperdal (risperidone).  But of even more interest is this statement in the preface to the supplement .  It was written by Alan Gelenberg, MD, Editor in Chief of the journal.  Dr. Gelenberg begins the Preface with some words of praise for the guidelines, but also advocates caution with regards to pharma-funded projects:

“…in conditions such as bipolar disorder and schizophrenia, where the primary treatments are medications, industry is a looming presence.  Pharmaceutical companies devote enormous sums to academic departments and individual faculty members who consult, conduct research, and teach under the auspices of the company.  These then are the experts who create consensus guidelines.  While few of us sell our opinions to the highest bidder, fewer still are immune from financial influence.” [Emphasis added]

So Dr. Gelenberg could see these issues very clearly in 1996, when the guidelines were published; but Dr. Frances, despite his mea culpa in the Huffington Post last March, still hasn’t grasped the issue.  In that document, from which I quoted earlier, Dr. Frances contends that the guidelines “…contained built in methodological protections against industry-favorable bias…”.  But as Dr. Gelenberg so clearly points out, the expert consultants on whose opinions the guidelines were based were already subject to industry influence by the very fact of their status within the psychiatric community.  So, in fact, industry-favorable bias was actually built in.

Page 2 of the supplement lists the 87 expert psychiatrists on whose questionnaire responses the guidelines were based.  The list is in alphabetical order, and I checked the first fifteen names for links to pharma.  Two of the fifteen are deceased.  Of the remaining thirteen, nine have disclosed that they have received payments from pharmaceutical companies, and eight of these have received payments from Janssen Pharmaceutica/J & J.

I have no way of checking if these financial links were present in 1995/96 when the guidelines were produced, but the extent of these individuals’ involvement with pharma today suggest that Dr. Gelenberg’s concerns were probably well founded.

. . . . . . . . . . . . . . . .

On the supplement’s sub-cover there is a brief acknowledgement of Janssen’s funding:

“This project was supported by an unrestricted educational grant from Janssen Pharmaceutica.”

The term “unrestricted” has a very specific meaning in this context.  It means that the recipients of the grant are not required to produce any particular result.  Essentially there is an expectation that both grantor and recipient will take steps to keep one another at arms’ length.  The term “unrestricted” is, in a sense, a warranty to the reader that the document in question is free from funder bias.

In the light of the material quoted above, it strikes me that the description “unrestricted” in this case was at best misleading, and possibly a blatant deception.

A CHALLENGE TO DR. FRANCES

If Dr. Frances really wants to put this matter to rest, he needs to answer these questions publicly and unambiguously:

  1. Are the allegations against him and his EKS partners that are set out in detail in the David Rothman report accurate?
  1. Are the quotations in that report that are attributed to Dr. Frances accurate?

If the answer to both of these questions is No, then I suggest that Dr. Frances start devoting his time and energy to addressing these matters, and clearing his name, because the allegations are very serious.

But if the answer to one or both of these questions is Yes, then I respectfully suggest that Dr. Frances exit the stage with whatever dignity he can muster, and resume his well-earned retirement.

AND INCIDENTALLY

Mickey Nardo, MD, has also posted David Rothman’s report on his website, 1 Boring Old Man.  Dr. Nardo has also written a post on this topic.  The post is titled detestable.

. . . . . . . . . . . . . . . .

I have quoted from David Rothman’s report in this post, but I’ve confined my attention to material concerning Dr. Frances and EKS.  In fact, the report covers a lot more ground, and gives a great deal of detail on the pharma-psychiatry corruption that has marred the landscape in this field for so long.  It’s well worth reading.

For instance, here’s an insightful little gem from page 21:

“Shon [Steven Shon MD, Medical Director of the Texas Department of Mental Health and Mental Retardation] was also considered a pivotal figure by another J&J employee, Percy Coard…After thanking his colleagues for attending a Shon presentation, he listed all the reasons why J&J wanted a ‘strategic alliance’ with him.  As Coard explained, Shon was a KOL [key opinion leader], influential in the public sector, where ’85 Percent of all anti-psychotic dollars come from;’ he has influenced and supported the use of new drugs in TMAP [Texas Medication Algorithm Project], and a proactive approach to him ‘to support/partner with his current and future projects in the public sector arena will continue to position Janssen as a true partner in public mental health initiatives.'”

Such a sense of civic responsibility!

. . . . . . . . . . . . . . . .

Robert Whitaker discusses EKS and the Tri-University Guidelines in his latest book, Psychiatry Under the Influence, p 149-150.

FINALLY

And for anyone who has any doubts concerning the effectiveness of pharma-psychiatry’s marketing machine, here’s a graph produced by the Agency for Healthcare Research and Quality (AHRQ), a division of the US Department of Health and Human Services.

AHRQ fig 1 on antipsychotics

So between 1997 and 2007, total expenses for neuroleptic drugs in the US went from $1.7 billion (corrected to 2007 value) to $7.4 billion.  This is an increase of $5.7 billion over and above any increase due to inflation.

The cost of these extra sales in terms of reduced life expectancy and quality of life is psychiatry’s legacy to humanity.

Allen Frances and the Spurious Medicalization of Everyday Problems

On April 5, Allen Frances MD, published an article on the Huffington Post blog.  The title is Can We Replace Misleading Terms Like ‘Mental Illness,’ ‘Patient,’ and ‘Schizophrenia’  It’s an interesting piece, and it raises some fundamental issues.

Here are some quotes from the article, interspersed with my comments.

“Those of us who worked on DSM IV learned first-hand and painfully the limitations of the written word and how it can be tortured and twisted in damaging daily usage, especially when there is a profit to be had.”

The fact that words can acquire multiple, and even contradictory, meanings is well known to most high school graduates.  People of all walks of life are generally sensitive to this reality, and take steps to clarify their meanings, especially with regards to words that are known to be ambiguous.

In the above quote, Dr. Frances is, I believe, implying that he and the other members of the DSM-IV work group chose their words carefully, but that their meanings were corrupted in “damaging daily use”.  Additionally, he appears to ascribe blame for this process to the drive for profits, presumably on the part of pharma.

But this is not consistent with the fact that ambiguity and a general lack of verbal precision are primary characteristics of successive revisions of the DSM, including DSM-IV.  In DSM-IV’s criteria for attention deficit hyperactivity disorder, for instance, the term “often” occurs in every criterion item, even though its lack of clarity, and its potential for abuse, are obvious.

. . . . . . . . . . . . . . . .

“This did not stop the widespread misuse of the terms Attention Deficit Disorder, Asperger’s Disorder, Bipolar Disorder, PTSD, Paraphilia and others. The lesson: If some wording in DSM can possibly be misused for any purpose, it almost certainly will be.”  [Emphasis added]

Here again, the impression being given is that Dr. Frances and his team defined these various terms judiciously and with precision, but that others came along afterwards and “misused” these carefully crafted definitions for their unstated, but presumably venal, purposes, while the injured innocents of the DSM-IV work groups could only watch in dismay from the sidelines.

The reality, of course, is quite different.  All of the definitions, in every edition of the DSM, are notoriously vague, and are subject to diverse interpretation.  This vagueness has consistently served the interests of psychiatry in expanding its scope and influence.  DSM-IV was simply one of the steps in this process, and the notion that Dr. Frances and/or other members of the work group were naïve to this dynamic is simply not credible.

. . . . . . . . . . . . . . . . 

“‘Mental illness’ is terribly misleading because the ‘mental disorders’ we diagnose are no more than descriptions of what clinicians observe people do or say, not at all well established diseases. For example, the term ‘schizophrenia’ just describes a heterogeneous set of experiences and behaviors; it doesn’t at all explain them and eventually there will be hundreds of different causes and dozens of different treatments. ‘Schizophrenia’ is certainly is not one illness.”

This is in marked contrast to what Dr. Frances and his task force wrote in the DSM-IV section on schizophrenia:

 “The essential features of Schizophrenia are a mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period (or for a shorter time if successfully treated), with some signs of the disorder persisting for at least 6 months (Criteria A and C).” (p 274)

The clear implication here is that “Schizophrenia” (with a capital S!) is a single unified entity that can be recognized by its characteristic signs and symptoms.

In addition there are numerous phrases and sentences that imply clearly that, as far as the authors were concerned, schizophrenia is a unified condition.  These include “The individual with Schizophrenia…”; “Individuals with Schizophrenia…”; “The onset of Schizophrenia…”; “…the symptoms of Schizophrenia…”; ”…prevalence of Schizophrenia…”; “…age of onset for the first psychotic episode in Schizophrenia…”; “…course and outcome in Schizophrenia…”; etc…  In no part of the DSM-IV entry is there the slightest intimation that “schizophrenia” is anything other than a single unified “disorder”.

So again, it seems reasonable to ask:  what has changed?  Is there some new science that has debunked the old unified illness notion?  Or is it simply the case, as many of us on this side of the issue have maintained for years, that the unified illness notion was never more than a convenient psychiatric fiction, devoid of any scientific underpinning, which Dr. Frances is now disavowing.

Note particularly in the above quote from Dr. Frances’ current paper, the phrase:  “…it [schizophrenia] doesn’t at all explain them [the problematic experiences and behaviors]…”

Here again, this represents a marked departure from DSM-IV, where schizophrenia (the unified disorder) is clearly presented as the cause of the so-called symptoms.  In the section on schizophrenia (p 277) it states:

“Although quite ubiquitous in Schizophrenia, negative symptoms are difficult to evaluate because they occur on a continuum with normality, are nonspecific, and may be due to a variety of other factors (e.g., as a consequence of positive symptoms, medication side effects, a Mood Disorder, environmental understimulation, or demoralization).”

The statement that negative symptoms may be due to “other factors” clearly implies that in other cases, they are due to (i.e. caused by) schizophrenia.  Note, incidentally, that one of the other factors that is given as causative of negative symptoms is “a Mood Disorder”, again clearly implying that those “disorders” also are being conceptualized and presented as the causes of the “negative symptoms”.

. . . . . . . . . . . . . . . . 

“The ‘mental illness’ term also lends itself to a simple-minded biological reductionism that pays insufficient attention to the psychological and social factors that are crucial in understanding anyone’s problems. Everyone complains about ‘mental illness,’ but nobody has come up with a better substitute.”

The DSM-IV entry on Schizophrenia runs to 16 pages – p 274-290.  In all of that text, there is only one reference to environmental factors:

“Although much evidence suggests the importance of genetic factors in the etiology of Schizophrenia, the existence of a substantial discordance rate in monozygotic twins also indicates the importance of environmental factors.” (p 283)

and there is no specific reference to “…psychological and social factors that are crucial in understanding anyone’s problems.”  Additionally, on page 275, DSM-IV states:

“…positive symptoms may comprise two distinct dimensions, which may in turn be related to different underlying neural mechanisms…”

which at the very least suggests a “simple-minded biological reductionism”.  So, again, what we have is Dr. Frances lamenting a situation of which he and his colleagues were some of the primary architects.

And the old chestnut —we all hate the term “mental illness, but alas, nobody has come up with a better substitute.”  This, I suggest, is less than candid.  There are lots of better (i.e. more accurate) terms, e.g., problems of thinking, feeling, and/or behaving.  It is difficult to avoid the conclusion that psychiatrists cling to the term “mental illness”, not because they can’t come up with anything better, but rather because it serves as an integral part of the spurious medicalization of these problems.  If the concept of “mental illness” were to be eliminated, as it should be, then psychiatry’s justification for its role in this area would also go.  The notion that the APA, with all its talent and its prestigious PR company, couldn’t come up with a better term if they wanted to, is simply not remotely credible.

Note also that Dr. Frances’ concern about the term “mental illness” is because “…it lends itself to a simple-minded biological reductionism that pays insufficient attention to the psychological and social factors…”.  And this, of course, is a valid concern.  But it is not the core concern.  The core concern with the term “mental illness” is that the problems it purports to delineate are not illnesses at all.  The spurious medicalization of these problems is the fundamental error from which all of psychiatry’s excesses and venality flow.  It is also the issue that they simply refuse to address.

. . . . . . . . . . . . . . . .

Dr. Frances expresses some reservations about the use of the term “patient”, because it implies  “…participation in a hierarchical relationship that brings with it little responsibility for shared decision making.”  Then he continues:

“But I have also never been comfortable with cold, market-sounding terms like ‘client,’ ‘consumer,’ ‘customer’ or ‘service user.’ These are business terms and lack the connotation of caring and responsibility associated with helping a ‘patient.’…Unless someone comes up with a better term, I think it would be better to rehabilitate the connotation of ‘patient’ rather than replace it, making clear that it implies full partnership in a therapeutic relationship.”

Here again, I suggest that Dr. Frances is being less than candid.  Social workers refer to the people they serve as “clients”, and the word has never suggested connotations of coldness or market place values in that context.  In fact, in my experience, social workers, other than those who have been co-opted by psychiatry, are arguably the most compassionate and client-centered professional group in this field.  And there are lots of other words, e.g. – and this is pretty radical –”person”.  And in fact, Dr. Frances’ own DSM-IV routinely uses the word “individual”.

If, as appears to be the case, Dr. Frances is arguing that psychiatrists cling to the term “patient” because it reflects their values of caring and warmth, all I can say is that I find this difficult to reconcile with the fact that the 15-minute med check has become psychiatry’s standard practice, and that the psychiatric falsehood – “a chemical imbalance just like diabetes” has been, and continues to be told to countless millions of psychiatric “patients”.

Dr. Frances expresses the belief that the word “patient” should be rehabilitated to make it clear that the term implies “full partnership in a therapeutic relationship”.  But he’s neglecting the fact that the term “patient” already has a perfectly valid and generally accepted meaning:  a person who is sick and who goes to a physician for assessment and/or healing.  And this, I suggest, is precisely why psychiatrists, including Dr. Frances, cling to the term – because when used in the psychiatric context, it embodies within its meaning the fiction that the problems “treated” by psychiatrists are illnesses requiring medical intervention.

. . . . . . . . . . . . . . . .

 Dr. Frances then quotes from a debate that he had with Anne Cooke PhD, editor of the BPS report Understanding Psychosis.  He notes that they are in agreement on some issues.

“We certainly join forces in worrying that loose usage and commercial gain have extended the terminology of mental ‘illness’ to many expectable problems of everyday living that are much better explained by psychological factors and social context and better described using everyday language.”

But:

“…we part company when you suggest that all diagnostic labels can be easily and safely. Your suggestion would have disastrous consequences for those who have severe psychiatric problems.”

There’s an obvious typo here, but it seems clear that Dr. Frances is stating that there would be disastrous consequences if diagnostic labels were dispensed with in the case of people with “severe psychiatric problems”.

There are two noteworthy points here.  Firstly, Dr. Frances has started referring to the DSM “diagnoses” as “diagnostic labels“, which is interesting.  Secondly, his use of the term “severe psychiatric problems” implies the existence of a discreet, identifiable set of problems, in the same way as the phrases “severe cardiac problems” or “severe kidney problems”.  In fact, this is not the case.  The DSM-IV definition of a mental disorder embraces all significant problems of thinking, feeling, and/or behaving, including expectable problems of everyday living.  If an expectable problem of everyday living, e.g., bereavement, crosses a  vaguely defined threshold of significance, then it is, by Dr. Frances’ own DSM-IV definition, a psychiatric problem.  And if it crosses an equally vaguely defined threshold of severity, then it becomes a severe psychiatric problem.

But even if we set that issue aside, the question still remains as to why dispensing with psychiatric “diagnoses” would result in disastrous consequences.  Dr, Frances tells us why.

“Here’s why: An adequate differential diagnosis of delusions and hallucinations requires full consideration of whether the problems are best described as: ‘Substance Induced Psychotic Disorder’, ‘Psychotic Disorder Due To A General Medical Condition’, “Delirium’, ‘Dementia’, ‘Schizophrenia’, Brief Psychosis’, Delusional Disorder’, ‘Bipolar Disorder’, ‘Major Depressive Disorder’, ‘Catatonia’, Obsessive Compulsive Disorder’, or ‘Sleep Disorder’. Each of this has different implications and calls for different actions. Only when all have been ruled out, can one conclude before that the experiences have no clinical significance and can be described adequately with everyday language.”

So in plain “everyday language”, what Dr. Frances is saying is this:  If a person is expressing delusional beliefs and hallucinating, we need to explore the nature and causes of the delusions and hallucinations if we want to adequately define and identify the problem.  So we have to compare the precise details of the individual’s presentation with the various DSM entities mentioned in order to get the correct “diagnosis”.  But he’s already told us that one of the “diagnoses” (schizophrenia) is merely a heterogeneous set of experiences and behaviors.  So it’s difficult to imagine what benefits would accrue from this kind of “differential diagnosis”, over and above a description of the problem in plain language.  Is Dr. Frances suggesting that the statement:  John is hallucinating and paranoid because he has been using PCP, is less informative than the statement:  John has Substance-Induced Psychotic Disorder?  It’s also difficult to imagine what “disastrous consequences” might result from the observation that Mary is expressing delusional beliefs because of a brain tumor, that would be averted by the formula Mary has Psychotic Disorder due to a general medical condition.

In fact, it is a general contention on this side of the issue that psychiatric “diagnoses” militate against the exploration of the nature and causes of the presenting problems, in that psychiatrists routinely terminate this kind of enquiry once they have determined the “diagnosis”.  And these are the very “diagnoses” that Dr. Frances earlier conceded are purely descriptive with no explanatory significance.

. . . . . . . . . . . . . . . . 

“Labels can help a great deal. They can hurt a great deal. They can provide clarity, but they can also badly mislead. The words we use in mental health all carry the heavy baggage of misleading and potentially stigmatizing connotation. They are vastly overused to describe mild problems of everyday life better described with everyday language. But we need diagnostic labels for the ‘severely ill’ and all suggested replacements are much more harmful than helpful.”

So Dr. Frances concedes that the words used in mental health are vastly over-used to describe “mild problems of everyday life”, but once again, he doesn’t seem to be acknowledging that his own DSM-IV was one of the great contributors to this process.  Psychiatric proliferation and expansion were both well under way by the time he convened his work force, but his final product endorsed every single aspect of DSM-III that had enabled and facilitated the expansion, e.g.:

  • the adoption, with only minor, inconsequential changes, of DSM-III’s all-embracing definition of a mental disorder;
  • the use of inherently vague language in the criteria sets;
  • the use of polythetic (two out of five, six out of nine, etc.) criteria sets;
  • the decision not to revert to DSM-I’s widespread use of the term “reaction”, which recognized that the problems being addressed were reactions of the individual to psychological, social, and biological factors;
  • the insistence, in the definition of a mental disorder, that the problems reside “in an individual”, as opposed to the person’s circumstances or environment;
  • the extensive use of the “not otherwise specified” (NOS) category, which essentially enabled psychiatrists to expand the so-called nosology more or less as they wished.

In addition to this, DSM-IV introduced specific innovations that also facilitated expansion of psychiatric turf into “the problems of everyday life.”

Firstly, it was DSM-IV that made it possible for an individual to be labeled “bipolar” without ever having displayed a manic episode.

Secondly, there occurred in DSM-IV a general liberalizing of the criteria for many of the so-called diagnoses.  “ADHD” is a good example.  DSM-III listed 14 criteria items for this label; DSM-IV listed 18.  One DSM-III item was dropped.  The additional five items in DSM-IV are:

“1 (a)  often fails to give close attention to details or makes careless mistakes in  schoolwork, work, or other activities.” (p 83)

This is almost a defining feature of early childhood.

    “1 (e)  often has difficulty organizing tasks and activities”

Again, a fairly common attribute of young children.

    “1 (f)  often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such  as schoolwork or homework)”

Note the use of the word “or”.  So if the child avoids, dislikes or is reluctant to do his/her homework, this criterion is endorsed.  I suggest that very few children actually like doing homework!

    “1 (i)  is often forgetful in daily activities” (p 84)

Again, the pathologizing of the normal.

         “2 (c)  is often ‘on the go’ or often acts as if driven ‘by a motor'”

The use of colloquialisms here is especially interesting, in that expressions like “always on the go” and “like he’s driven by a motor” are things that parents often say about their young children without any pathologizing connotations or intent.  By including these expressions in this list of “symptoms”, Dr. Frances and his team have effectively pathologized these descriptors, and brought psychiatric scrutiny to bear on children so characterized.

In addition, the following fairly extreme item in DSM-III

    “(14)  often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking” (p 53) [Emphasis added]

was liberalized in DSM-IV to the much more banal

     “2 (c)  often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)” (p 84)

In DSM-III, the “age of onset” had to be before the age of seven.  In DSM-IV, this requirement has been eased to “Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.” [Emphasis added] (p 84)

And, perhaps most significantly of all, in DSM-III the label ADHD is clearly conceptualized as pertaining to childhood.  DSM-IV, however, states:

“In most individuals, symptoms attenuate during late adolescence and adulthood, although a minority experience the full complement of symptoms of Attention-Deficit/Hyperactivity Disorder into mid-adulthood.  Other adults may retain only some of the symptoms, in which case the diagnosis of Attention-Deficit/Hyperactivity Disorder, In Partial Remission, should be used.  This diagnosis applies to individuals who no longer have the full disorder but still retain some symptoms that cause functional impairment.” (p 82)

In the light of all this, it is difficult to accept Dr. Frances’ contention that the proliferation and expansion of psychiatric “diagnoses” was not an integral part of his, and psychiatry’s overall plan.

And incidentally, psychiatry’s usual response to this particular criticism is that they must update the criteria, as more knowledge is gained about the “illnesses”. But this is untenable.  The only definition of the “illness” is the one given in the DSM.  There is no deeper entity to which the criteria refer.  What psychiatrists call ADHD is nothing more than a loose clustering of vaguely described habitual behaviors and omissions.  Psychiatry can add to, or modify, the list at will.  In stark contrast to real medicine, there is no reality to which these additions or modifications must conform.  If the APA decides that  “…is often forgetful in daily activities” is a “symptom” of the “illness” known as ADHD, then that decision makes it so.  And if the decision represents a liberalization of the criteria, then, literally overnight, more people will now “have” the “illness”.  And given that this process has been going on for the past fifty years, it is difficult to avoid the conclusion that it is intentional.

. . . . . . . . . . . . . . . .

Dr. Frances’ position in this and other recent papers appears to be that in general, psychiatric “diagnoses” and “treatment” are OK, but that they are being overused by unscrupulous practitioners with the encouragement of pharma, and perhaps other monied interests.

And of course the expansion of psychiatric “treatment” is indeed a huge problem.  But it is a problem of Dr. Frances’ own making – a fact which, to the best of my knowledge, he has never conceded.

But, even more importantly, the expansion is not the critical issue.  The central issue is the spurious medicalization of non-medical problems in the first place.  There are no more grounds for considering severe depression an illness than there are for mild depression.  Severe and persistent inattentiveness is no more an illness than mild or transient inattentiveness.

It is from this spurious medicalization that all of psychiatry’s excesses flow.  Once psychiatry recognized that they could create illnesses by fiat, then the door was opened, and remains open, for unlimited expansion and pathologizing.  And Dr. Frances’ DSM-IV was a major – and perhaps the major – step in this process.

Psychiatric Diagnoses:  Labels, Not Explanations

On March 16, Ronald Pies, MD, published an article in the Psychiatric Times.  The article is titled The War on Psychiatric Diagnosis, and the sub-title synopsis on the pdf version reads:  “A recent report that argues against descriptive diagnosis in medicine is historically ill-informed and medically naive, in the opinion of this psychiatrist.”

Dr. Pies is a very prestigious and eminent psychiatrist.  He is a professor of psychiatry at both Syracuse and Tufts.  He was the first editor of Psychiatric Times, which, by its own account, provides “News, Special Reports, and clinical content related to psychiatry” for “…psychiatrists and allied mental health professionals who treat mental disorders…Circulation of the monthly print publication is approximately 40,000.”

The report that Dr. Pies considers “historically ill-informed and medically naïve”, is the BPS November 2014 paper Understanding Psychosis and Schizophrenia, which has been widely discussed in recent weeks.

. . . . . . . . . . . . . . . . 

There is much in Dr. Pies’ paper that warrants critical examination, but I would like to focus here on just one topic:  the explanatory value of diagnoses.

Dr. Pies himself acknowledges the centrality of this matter, and writes:

“But there is a larger issue raised in the BPS report that goes to the very heart of psychiatric diagnosis, which the report tries to discredit with the following argument:

We normally expect medical diagnoses to tell us something about what has caused a certain problem, what the person can expect in future (‘prognosis’) and what is likely to help. However, this is not the case with mental health ‘diagnoses,’ which rather than being explanations are just ways of categorizing experiences based on what people tell clinicians. . . . For example, someone who says that they are hearing voices might be given a diagnosis of schizophrenia. Since this says nothing about cause, it makes little sense to say that the person hears the voices ‘because of ‘ the schizophrenia.

Actually, it makes a good deal of sense, in precisely the same way it makes sense to say, ‘Mr Jones has severe facial pain because he has tic douloureux;’ or ‘Smith has severe left-sided head pain and nausea because he has migraines.’ We still do not know the precise causes of these conditions; moreover, the diagnosis of  tic douloureux (literally, ‘painful tic’) or migraine headache (etymologically, headache ‘in half the cranium’) is made almost entirely on the basis of ‘what people tell clinicians’—not on the basis of an abnormal laboratory value, x-ray film, or anatomical finding. (Of course, certain tests, such as a CT scan of the head, can help rule out other diagnostic possibilities, such as a brain tumor.)”

The essence of Dr. Pies’ contention here is that psychiatric diagnoses are just as valid as diagnoses in general medicine, and that, in particular, the absence of knowledge concerning causes does not diminish their status or usefulness.

It has long been my contention that psychiatric “diagnoses” have no explanatory value, and in fact constitute nothing more than vague, unreliable re-labeling of the presenting problems.

This is clearly demonstrated in the hypothetical conversation:

Client’s parent:  Why is my son so paranoid?  Why does he just sit in his room all day?  Why won’t he do anything?

Psychiatrist:  Because he has an illness called schizophrenia.

Parent:  How do you know he has this illness?

Psychiatrist:  Because he is so paranoid, sits in his room all day, and won’t do anything.

The only evidence, and I stress the only evidence, for the so-called illness is the very behavior that it purports to explain.  The psychiatric explanation essentially comes down to:  he is paranoid, sits in his room all day, and won’t do anything, because he’s paranoid, sits in his room all day, and won’t do anything.  There is nothing more to it than that.

I realize that I’ve labored this matter to the point of tedium. But I’ve done so for two reasons.  Firstly, because it is one of the core flaws in psychiatry.  Its diagnoses have no explanatory value.  They are nothing more than labels.  Secondly, because psychiatry consistently fails to respond to this particular criticism, and with equal consistency presents these labels as if they did have explanatory value.

The present article by Dr. Pies is a perfect example of the second point, because although Dr. Pies appears to address the issue, he actually side-steps it.

Let’s go back to the quote from the BPS article.

We normally expect medical diagnoses to tell us something about what has caused a certain problem…

This is absolutely accurate.  When a person consults a physician concerning a medical problem or concern, there is a general expectation that the diagnosis, if forthcoming, will provide an explanation of the problem.  And in practice, this is normally the case.  If a person reports exhaustion, pulmonary congestion, elevated temperature, pain in the chest, and nasty-looking phlegm, his diagnosis might be pneumonia.  Pneumonia is a viral or bacterial infection of the lung tissue.

What is noteworthy here, in the present context, is that we have two distinct elements:  the symptoms and the cause of the symptoms.  The person consults a physician because of the symptoms, and, from the physician, he learns the cause of these symptoms.  This is what diagnosis means:  determining the cause and nature of a pathological condition.  Wikipedia gives the following definition:

“Medical diagnosis…is the process of determining which disease or condition explains a person’s symptoms and signs.” [Emphasis added]

Another critical factor in this issue is that there has to be a clear logical link between the symptoms and the diagnosis.  If, for instance, the physician’s diagnosis in the above scenario were “incorrect curvature of the spine”, there would, I suggest, be an enormous burden of proof as to how this particular pathology could cause these particular symptoms.  But with a diagnosis of pneumonia, the logical link is clear:  the infection causes exudation of blood and other fluid into the lung tissue; the immune system triggers an increase in temperature, etc..

So let’s see how our consultation conversation might run in this case.

Patient:  Why am I so tired; why did my temperature spike; why am I spitting up such dreadful-looking phlegm?

Physician:  Because you have pneumonia.

Patient:  How do you know I have pneumonia?

Physician:  Because I can hear characteristic sounds through the stethoscope; your chest X-ray shows large quantities of fluid in both lungs; your sputum labs are positive for pneumococcus; and because everything you have told me is consistent with this diagnosis.  I can show you the X-rays if you like.

The difference between this kind of conversation and the psychiatric conversation is obvious.  In the pneumonia case, the physician has progressed from the symptoms to the essential underlying nature of the illness.  In psychiatry, no such progress has occurred or can occur.  In psychiatry, the so-called symptoms are the essence of the problem.  There is no underlying reality to which the symptoms point.  The “symptoms” and the “illness” are identical.

Back to the BPS quote:

“For example, someone who says that they are hearing voices might be given a diagnosis of schizophrenia. Since this says nothing about cause, it makes little sense to say that the person hears the voices ‘because of ‘ the schizophrenia.”

Again, this is accurate.  “Schizophrenia” is a label, not an underlying explanatory entity that enables us to understand the symptoms.  The phrase  “…because he has schizophrenia” is a form of words that looks like an explanation, but in fact isn’t.

To illustrate this, let’s consider another example.  Imagine a small child running tearfully to his mother with the complaint that another child has been hitting him.  Mother gathers the victim to her arms and soothes him.

Mother:  It’s OK.  I’ve got you.  It’s OK. etc.

Child:  Why does he keep hitting me?

Mother:  Because he’s a bully.  Don’t mind him.

The phrase “because he’s bully” looks like an explanation, and will be accepted by the child as an explanation, but in fact it has no explanatory value.  All we have to do to see this is ask the question:  “How do you know he’s a bully?”, and the only possible answer is “because he keeps hitting you”.

The statement “he beats you because he is a bully” is logically equivalent to the statement:  “He beats you because he beats you.”  It contains no explanatory insights into the aggressor’s action.  And psychiatric explanations are exactly of this kind.

Now, please don’t misunderstand me.  This is not a logical critique of mothers who try to comfort their children.  As parents, we do what we can to comfort our children, and there is no great onus with regards to logic or science.  But psychiatric concepts and assertions do need to pass the tests of logic and science.

The statement:  “Your son hears voices because he has schizophrenia” is logically equivalent to “Your son hears voices because he hears voices.”  Schizophrenia is nothing more than the label that psychiatry gives to that loose cluster of vaguely defined thoughts, feelings, and/or behaviors that are listed on page 99 of DSM-5.  These are:

  1. Delusions
  2. Hallucinations.
  3. Disorganized speech (e.g., frequent derailment or incoherence).
  4. Grossly disorganized or catatonic behavior.
  5. Negative symptoms (i.e., diminished emotional expression or avolition)

The simple fact of the matter is that the reasons underlying these thoughts, feelings, and behaviors are as varied as the individuals who experience them.  But psychiatrists make no attempt to explore these reasons.  Instead, they rely on the medical-sounding, but facile,  “because-he-has-schizophrenia” form of words.  As in so many areas, psychiatry has become intoxicated by its own rhetoric, and individual practitioners seem to believe that this form of words actually has some explanatory value.

Back to Dr. Pies:

“Actually, it makes a good deal of sense, in precisely the same way it makes sense to say, ‘Mr Jones has severe facial pain because he has tic douloureux;’ or ‘Smith has severe left-sided head pain and nausea because he has migraines.’  We still do not know the precise causes of these conditions; moreover, the diagnosis of  tic douloureux (literally, ‘painful tic’) or migraine headache (etymologically, headache ‘in half the cranium’) is made almost entirely on the basis of ‘what people tell clinicians’—not on the basis of an abnormal laboratory value, x-ray film, or anatomical finding.”

So there is a fairly profound disagreement.  The BPS say that the explanation “because he has schizophrenia” makes little sense.  Dr. Pies says it makes a good deal of sense. Let’s take a closer look.  First, let’s go back to the BPS statement which Dr. Pies quoted and which I reproduced above.  Although there are no quotation marks around this passage, it is actually a verbatim quote from the BPS paper, but a crucial piece of the quote has been omitted.  (The omission is indicated by an ellipsis in the regular online version, but there is no ellipsis in the pdf version.)

The omitted passage is:

“The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) explicitly states that its categories say nothing about cause – in its own words it is ‘neutral with respect to theories of aetiology’.”

So a summary of the BPS passage might look something like this:

  1. medical diagnoses give us the cause or explanation of a problem
  2. psychiatric diagnoses, by contrast, do not give causes or explanations
  3. psychiatric diagnoses are just ways of categorizing clients’ reports
  4. the APA acknowledges that its diagnoses say nothing about cause
  5. therefore the label schizophrenia has no explanatory value
  6. so, to say that a person hears voices because he has schizophrenia makes little sense

What Dr. Pies has omitted is item 4 arguably the most important part of the passage.  So Dr. Pies is accusing the BPS of leaping from

psychiatric diagnoses are just ways of categorizing clients’ reports

to

therefore the label schizophrenia has no explanatory value

and ignores the interim premise which is crucial to the issue.  Dr. Pies then uses this distortion to make the point that some diagnoses in general medicine are based entirely on patient report but are nevertheless considered valid and useful.  This, of course, is non-contentious.  There are, indeed, genuine medical conditions which are diagnosed largely on the basis of patient report. Dr. Pies mentions tic douloureux as an example, and states that the precise cause of this illness is unknown. But he is, I suggest, being less than candid, because a great deal is known, and has been known for decades, about the cause of tic douloureux, which, incidentally, is now usually called trigeminal neuralgia.  Here’s the entry for this illness in the 1963 edition of Taber’s Cyclopedic Medical Dictionary:

“Degeneration of or pressure on the trigeminal nerve, resulting in neuralgia of that nerve…The pain is excruciating.  Usually occurs after forty.  Pain is paroxysmal, radiating from angle of the jaw along one of the involved branches.  If the first branch, a shocklike pain is felt along the eye and back over the forehead.  If it is the middle fiber, the upper lip, nose, and cheek under the eye are affected.  If it is the third branch, pain is in the lower lip and outer border of tongue on affected side.  Pain is momentary but returns again and again.” (p T-30)

More up-to-date information is provided by drugs.com, a service of Harvard Health Publications:

“In some cases, the cause of trigeminal neuralgia is unknown. In many people, however, something seems to be irritating the trigeminal nerve, usually in the area of the nerve’s origin deep within the skull. In most cases, the irritation is believed to be caused by an abnormal blood vessel pressing on the nerve. Less often, the nerve is being irritated by a tumor in the brain or nerves. Sometimes, the problem is related to a rare type of stroke. In addition, up to 8% of patients who have multiple sclerosis (MS) eventually develop trigeminal neuralgia as a result of MS-related nerve damage.”

So, if a patient were to ask his physician why he is experiencing excruciating stabbing pains in his face, the response “because you have tic douloureux” is a perfectly logical explanation.  It might, or might not, be correct – that is not the issue.  But it is a coherent, valid explanation, and is not simply a relabeling of the presenting problems, which is  the essential status of all psychiatric diagnoses, other than those specified as being “due to a general medical condition”.

What’s particularly interesting here is that the BPS document is in fact very clear on this matter.  The sentence following the passage quoted by Dr. Pies reads:

“An analogy with physical medicine might be a label such as ‘idiopathic pain’, which merely means that a person is reporting pain, but a cause of that pain cannot be identified.”

Idiopathic means “of unknown cause, as a disease.”  (Random House Webster’s College Dictionary, 1992).  So if a patient were to ask a physician why he was experiencing severe facial pain, the response “because you have idiopathic pain” would simply be a restatement of the presenting problem, and would have no explanatory value.  The point being made in the BPS report is that a relabeling of the presenting problem that entails no understanding of cause has no explanatory value.  The phrase “because you have schizophrenia” is precisely on a par, logically, with “because you have idiopathic pain.”  Dr. Pies’ introduction of, and comparison to, “because you have tic douloureux” is an enormous red herring.  His use of the etymological annotation “painful tic” is also a red herring, in that etymology is a poor guide to current meaning.  The etymology of the word “mortgage”, for instance, is “death pledge”, because the original meaning of a mortgage was a pledge that a debt would be repaid from one’s estate after one’s death.  This is interesting, of course, but has no relevance to the current meaning of the term.

Certainly there are disease entities that general medicine has named, and can identify with reasonable accuracy, prior to establishing the etiology or cause of these illnesses.  But this is fundamentally different to the situation that prevails in psychiatry.  Firstly, in general medicine there are always prima facie reasons for believing that the condition is an organic pathology.  Secondly, the quest of general medicine for explanations and causes has been remarkably successful.

Neither of these conditions exists in psychiatry.  In fact, despite an enormous amount of highly motivated research in this area, no psychiatric “illness” has ever been reliably established to be the result of a specific neural pathology.  Even Thomas Insel, MD, Director of NIMH, wrote on April 29, 2013:

“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

Whilst I don’t agree with Dr. Insel in all areas, on this matter he has hit the nail squarely on the head.

The bottom line is this:  if one doesn’t know the cause of something, then one can’t explain it.  Explanation is the presentation of causes.  And despite their frequent claims to the contrary, psychiatrists do not know the cause of the loose collection of thoughts, feelings, and/or behaviors that they call schizophrenia.  They assume that any decade now they will discover this cause in the form of some neural pathology.  Meanwhile, they go on telling their clients the falsehood that they have chemical imbalances, or neural circuitry anomalies or whatever is the latest fashion, and that these putative illnesses can be corrected by drugs or electric shocks to the brain.  And they ignore the reality:  that the best (indeed only) way to understand people is to talk to them patiently, compassionately, and with humility, and without the assumption that one already knows the source of their troubles.  It is only in this way that we discover that people’s so-called symptoms are understandable within the context of each person’s unique history and current circumstances, and that the facile labels cataloged so conveniently by the APA are an irrelevant travesty.

And, indeed, Dr. Pies himself, even though he clings tenaciously to the need for psychiatric “diagnoses”, acknowledges the additional need to take the time to get to know clients:

“Finally, while diagnosis is a necessary first step in helping the patient with emotional, cognitive, or behavioral problems, it is far from sufficient. We must enter empathically into the patient’s ‘inner world,’ and provide a safe, trustworthy environment for the exploration of the patient’s troubles. This takes time—it can’t be done in 15 minutes!—and it requires what psychoanalyst Theodor Reik eloquently called, ‘listening with the third ear.’ “

But what Dr. Pies neglects to add is that the 15-minute med check has become standard practice in psychiatric care.  Douglas Mossman, MD, Professor of Psychiatry at the University of Cincinnati, has written unambiguously:

“Even psychiatrists who deplore 15-minute med checks recognize that they have become standard care in psychiatry.”

Glen Gabbard, MD, a widely published professor of psychiatry at Baylor and Syracuse, has written on Psychiatric Times:

“There can be little doubt in our current era that the brief ‘med check’ is becoming standard practice in psychiatry.”

Dr. Pies himself, in an earlier paper (Psychiatrists, Physicians, and the Prescriptive Bond) has written:

“Unfortunately, many prescriptions for psychotropics are written in haste—often after the infamous ’15-minute med check’ – and without any real understanding of the patient’s inner life or psychopathology.”

Dr. Pies, incidentally, also failed to mention that Theodor Reik (1888-1969) was a psychologist, not a psychiatrist, and in fact, had to fight a lawsuit against the medical community in order to establish the principle that psychoanalysis could be practiced by non-physicians.

Nor does Dr. Pies seem to recognize that psychiatry’s contention, that the DSM entities are bona fide illnesses, is, in fact, the primary driving force behind the cursory treatment which he decries so ardently.  After all, if people’s problems are caused by brain malfunctions, and if psychiatric drugs correct these malfunctions, what need is there for dialogue or understanding?

There is no factual or logical evidence that the loose collection of vaguely defined thoughts, feelings, and/or behaviors that psychiatrists call schizophrenia is a coherent entity, much less an illness.  Nevertheless, psychiatrists continue, not only to make this groundless assertion, but also to prescribe neurotoxic chemicals to “treat” this pseudo-illness, often against the vehemently expressed wishes of the victims.  This is not the practice of medicine.  It is a travesty which no amount of Dr. Pies’ sophistry can mitigate.

. . . . . . . . . . . . . . . . .

With regards to the title of his piece –  The War on Psychiatric Diagnosis – Dr. Pies has this to say:

“If ‘war’ seems a somewhat overheated term in the title of this piece, I would recommend perusal of some of the anti-psychiatry Web sites, on which the ritual evisceration of psychiatry and psychiatrists is unapologetic and unrelenting.*”

The asterisk refers to a footnote:

“*In my view, the Web site of ‘Mad in America’ is particularly abusive toward psychiatrists, though it is far from the worst of the bunch”

Well, of course, there’s anger and vitriol on both sides of this issue, though I must say that MIA has always struck me as the epitome of civility and restraint.  But it’s important in this, as in any human endeavor, to rise above the rhetoric, and deal honestly and squarely with the issues.  And the issue on the table here is that psychiatric diagnoses – other than those clearly identified as “due to a general medical condition” – have no explanatory value, but are routinely and deceptively presented by psychiatrists as if they did.

And, Dr. Pies has not addressed that issue. 

Psychiatry is under criticism because its concepts are spurious, and its treatments are destructive.  The problems that psychiatry guards tenaciously as its turf are not medical in nature, but for the sake of that turf, are shoe-horned shamelessly into psychiatry’s bogus nomenclature, and are “treated” with neurotoxic drugs and electric shocks to the brain.  Petulant complaining about the “ritual evisceration of psychiatry and psychiatrists”, is no substitute for rational, honest, and informed debate.

Psychiatry Is Not Based On Valid Science

BACKGROUND

On December 23, I wrote a post called DSM-5 – Dimensional Diagnoses – More Conflicts of Interest?  In the article I sketched out the role of David Kupfer, MD, in promoting the concept of dimensional assessment in DSM-5, and I speculated that at least part of his motivation in this regard might have stemmed from the fact that he is a major shareholder in a company that is developing a computerized assessment instrument.  I ended the piece with a general criticism of psychiatry:

“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 article precipitated a fairly lengthy debate in the comments section.  The discussion was wide ranging, and some of the issues addressed were fundamental to the entire psychiatric debate, in particular:  whether or not psychiatry is based on valid science.

My own position is that the foundations of psychiatry are spurious, and the purpose of this post is to set out my position on this matter.

PSYCHIATRY’S USE OF THE TERM “ILLNESS”

Psychiatry’s most fundamental tenet is that virtually all significant problems of thinking, feeling, and/or behaving are illnesses that need to be studied and treated from a medical perspective.  What’s not usually acknowledged, however, is that this is an arbitrary assumption.

In common speech and within the medical profession, the word “illness” indicates the presence of organic pathology: i.e. damage or malfunction in an organ.  Historically, mental illnesses came into being, not because some scientist or group of scientists had recognized and established that problems of thinking, feeling, and/or behaving are caused by an organic malfunction, but rather because the APA had simply decided to extend the concept of illness to embrace these kinds of problems.  For the record, some problems of thinking, feeling, and/or behaving are known to be caused by organic pathology, and I exclude those from the present discussion.

It is not superficially obvious that other problems of thinking, feeling, and/or behaving are actually illnesses, and there is a strong burden of proof on those who adopt this position.  Psychiatry, however, has never proved this assertion, but nevertheless continues to expand its diagnostic net in the same way that it started – by fiat.  A particular pattern of thinking, feeling and/or behaving becomes a mental illness/disorder because the APA says so!

Obviously I can’t dictate to psychiatrists how they should and should not use words.  If they choose to call problems of this sort illnesses, then that’s their business.  But they should also acknowledge that they are using the word illness in a distorted and misleading sense of the term.

They are also deviating from the ordinary standards and procedures of medical science.  In the 1930’s, a German pathologist named Friederich Wegener discovered a “new” disease, which is now called Wegener’s Granulomatosis.  He discovered this disease the old-fashioned way – by years of diligent post-mortem examinations and hundreds (thousands?) of microscope hours.  The history of medical progress is the history of these kinds of discoveries.

By contrast, psychiatry produces their “diagnoses,” (e.g. ADHD, disruptive mood dysregulation disorder, conduct disorder, etc., etc.), simply by voting.  They cling to the unacknowledged extended use of the term illness in these kinds of deliberations and decisions, whilst maintaining the pretense in their practices and promotional literature that the word is being used in its classical sense of organic pathology.

The reason that several psychoactive drugs have become blockbusters in recent years is that psychiatry has the advantage, unique in the medical field, that it can invent illnesses, and relax the criteria for these illnesses, more or less at will.  Psychiatry, unlike other medical specialties, has no natural limits to its growth potential.  They can continue to expand the diagnostic net until everybody in the world has a diagnosis.  But it doesn’t even have to stop there.  They can go for everybody having two, three, four, etc., diagnoses.  If organized psychiatry votes an illness into being, there is no reality that can act as a brake or a check on this activity.

PSYCHIATRY AND SCIENCE

Despite this confusion in terminology, psychiatry routinely contends that its diagnoses are based on science.  In the Introduction to DSM-IV, the APA wrote:

“More than any other nomenclature of mental disorders, DSM-IV is grounded in empirical evidence.” (p xvi)

And, of course, an enormous number of studies had been done.  But, to the best of my knowledge, there wasn’t a single study on any “diagnosis” that addressed the fundamental question:  is there any logical reason why this particular problem of thinking, feeling, and/or behaving should be conceptualized as an illness?  This, in every case, was simply assumed, despite the fact that there are better, more productive, more parsimonious, and more logically sound ways to conceptualize these problems.

As a companion to DSM-IV, the APA published a five-volume sourcebook of references.  There were prevalence studies, correlation studies, data re-analyses, field trials, etc… All of which was wonderful.  But on the fundamental question:  is there any rational reason for conceptualizing these conditions as illnesses? –  there was nothing.  Which was not surprising, because there had been nothing along those lines in the earlier manuals.

THE CHANGE FROM DSM-I TO DSM-II

And speaking of the earlier manuals, it needs to be noted that a major shift in underlying theory occurred between DSM-I and DSM-II.  In DSM-I, most of the diagnostic terms contained the word “reaction” (e.g. schizophrenic reaction), the implication being that the problem in question was to be conceptualized as a reaction to something.  In DSM-II, the word reaction was dropped.  In the Foreword to DSM-II the drafting committee stated that the purpose of this change was to avoid terms that implied any particular causal theory.  This notion was repeated in the Introduction to DSM-III-R:

“The use of the term reaction throughout the classification [in DSM-I] reflected the influence of Adolf Meyer’s psychobiologic view that mental disorders represented reactions of the personality to psychological, social, and biological factors.”  (Adolf Meyer was an eminent Swiss-American psychiatrist, 1866-1950)

And

“The DSM-II classification did not use the term reaction, and except for the use of the term neuroses, used the diagnostic terms that, by and large, did not imply a particular theoretical framework for understanding the nonorganic mental disorders.” (p xviii)

All of this sounds fairly reasonable, but ignores the fact that the omission of the term “reaction” inevitably conveys the impression that the categories listed are to be conceptualized as primary illness entities.  Despite their proffered justification for the claim, it is more plausible that the term was dropped in a deliberate attempt to oust Adolf Meyer’s notion of mental disorders as reactions to biopsychosocial stressors, especially his reformulation of schizophrenia as a cluster of maladaptive habits acquired in response to such stressors.  It is also plausible that it was an attempt to return psychiatry to a Kraepelinian nosology of biologically-specifiable illnesses.  In any event, that is exactly what has happened.

PSYCHIATRY’S “NOSOLOGY”

Many eminent psychiatrists today refer to the DSM as a psychiatric nosology.  These include:

The word nosology (from the Greek word nosos, meaning disease) means classification of illnesses, and by using this term in this context, psychiatrists are implying, without valid reason, that all significant problems of thinking, feeling, and/or behaving are illnesses, even though there is no evidence that this is a valid or helpful stance.  In fact, as we’ve seen above, an alternative perspective (Adolf Meyer’s “reactions”) actually constituted psychiatric orthodoxy from 1952 to 1968.  What is also clear and noteworthy in this matter is that Adolf Meyer’s theoretical/explanatory concepts were not abandoned on the grounds that they had been scientifically discredited or disproven.  They were abandoned as part of an arbitrary decision by the DSM-II committee  to medicalize problems of thinking, feeling, and/or behaving.

DSM-II’s decision to drop the word “reaction” was not, as claimed, a move to an atheoretical classification.  Rather, it replaced a genuinely biopsychosocial causal framework with one that was purely biological:  i.e. that all problems of thinking, feeling, and/or behaving are by definition primary disease entities.  Under the present DSM system, psychiatry doesn’t have to prove that a problem is an illness, because that assertion is built into their definitions.  If the DSM is a nosology, then every item listed must be an illness.  This is not science.  It is intellectual chicanery.

Having demonstrated that they could do this without much opposition in DSM-II, the APA solidified the arrangement in DSM-III, and expanded it to the point of travesty in DSM-IV and 5.  In fact, in DSM-5, the disease notion is injected even more explicitly and more clearly than in the earlier manuals.  In the Introduction chapter, following a discussion on the value of dimensional assessment, the APA states:

“These findings mean that DSM, like other medical disease-classifications, should accommodate ways to introduce dimensional approaches…” (p 5) [emphasis added]

EXPLANATORY VALUE OF PSYCHIATRIC DIAGNOSES

The notion that all problems of thinking, feeling, and/or behaving are illnesses has no explanatory value.  Consider the following conversation.

Client’s daughter:  “Why is my mother so depressed?”
Psychiatrist:  “Because she has an illness called major depression.”
Client’s daughter:  “How do you know she has this illness?
Psychiatrist:  “Because she is so depressed.”

The only evidence for the illness is the very behavior it purports to explain.  Unlike diagnoses in real medicine, there is no actual illness behind the DSM symptom lists to provide genuine explanatory value.  Those of us on this side of the debate have been pointing out this kind of circular reasoning for decades, but I have never seen or heard a convincing response from psychiatry.  Instead, they continue to promote their “diagnoses” to their clients, the media, and the general public as if they had explanatory value – when in fact they have none.

Psychiatry sometimes counters this particular criticism by denying that they ever promoted mental illnesses as causes or explanations of the symptoms.  But in fact, causative language permeates DSM-III, IV, and 5.  In almost every section of DSM-5, one can find exclusion clauses like:  “The disturbance is not better explained by another mental disorder,” the clear implication being that mental disorders are being presented as explanations of the problems listed in the criteria sets.  Additionally, the notion of a disorder/illness as the cause of its symptoms is standard in general medicine.  For instance, the illness pneumonia causes the symptoms of coughing, weakness, etc.,.  By using this kind of language in DSM, the APA is promoting the notion that their putative illnesses are indeed the causes of the symptoms.  For instance, the behavior of running around the classroom and failing to pay attention to the teacher is routinely presented by psychiatry as being caused by the “illness” ADHD, and this is precisely how the notion of “mental illness” is perceived by clients, the media, and the general public.  If it is not psychiatry’s intention to create this impression, then they need to make a concerted effort to correct the misunderstanding.  I am not aware of any moves in this direction by the APA or by psychiatric opinion leaders.

THE IMPORTANCE OF VALID THEORIES

Organized psychiatry tends to dismiss this entire issue of the ontological status of the “mental illnesses” as academic or philosophical, and as having no real bearing on practice.  But imagine how different psychiatry would be today if it had retained Adolf Meyer’s formulations.  Research would probably not have been hijacked by pharma, and would be focused on social and environmental factors rather than on drug responses.  Psychiatrists would take detailed histories in an attempt to understand their clients, rather than gathering just enough information to clinch the “diagnosis.”  There would be no fifteen-minute med checks, and social skills training would be the dominant treatment modality.

Causal theories are not ivory tower abstractions.  In any systematic human activity, they are the pillars that support and drive practice.  And when they are spurious, as in the case of psychiatry, practices and procedures inevitably drift into error.  The legitimacy of a profession depends on the validity and adequacy of its underlying causal theories.  Indeed, the theories are the formal expression of the knowledge accumulated by the science at a given point in time.  This applies particularly to those concepts that are very basic and fundamental. A shipping industry, for instance, that was working on the assumption that the Earth is flat, other things being equal, would probably not be noted for excellence of service.  Similarly, a geo-centered astronomy would be a shaky foundation for the development of space travel.  Human endeavors that are based on valid theories are more likely to yield success than those based on invalid theories.

To guard against misunderstanding, I’m not saying that good theories are sufficient.  One also needs techniques, tools, skills, etc…  But working without valid theories, or worse, working with invalid theories, inevitably leads practitioners astray.  Which is exactly what has happened in the case of psychiatry.  By assuming that all significant problems of thinking, feeling, and/or behaving are illnesses, they have, very naturally, been drawn into seeing these problems as entities that they (the physicians) have to fix by means of medical-type techniques, and seeing the owners of the problems as “patients” – i.e. people who have to be fixed.  The illness theory also, because it conveys the false impression that the matter has been explained, has a dampening effect on practitioners’ curiosity as to genuine explanations.

Modern psychiatry has been plugging away at its so-called nosology for more than a hundred years, and the APA, in their successive revisions of the DSM, assure us that the classifications are scientific.  Thought leaders and individual psychiatrists, with few exceptions, assure us that the “illnesses” listed in the manuals are scientifically established, ontologically valid entities that provide the framework for understanding and ameliorating problems of thinking, feeling, and/or behaving.  But seldom is it acknowledged that this stance is nothing more than an assumption, the purpose of which was to establish psychiatric turf in a non-medical field.

“PSYCHIATRY IS VALID BECAUSE ITS TREATMENTS WORK”

It is sometimes argued that psychiatry derives validity and legitimacy from the fact that its treatments (i.e. drugs) work.  In rebuttal, many writers on this side of the debate have pointed out that small quantities of alcohol help a person overcome shyness, but that nobody would conclude from this either that shyness is an illness, or that alcohol is a medicine.  Drugs, whether they’re of the street, liquor store, or pharmaceutical variety, alter people’s thoughts, feelings, and/or behaviors.  In some cases, the users of these products and their families express themselves pleased with the alteration.

I have known a good many marijuana users who maintained, with, I think, good credibility, that pot helped them control their anger – made them mellow.  Over the years I have worked with several women who always kept a twelve-pack of beer in the refrigerator in case their husbands became angry or upset.  In these cases, the pot and the alcohol “worked” in the sense that they forestalled the anger and rage.  And psychopharmaceutical products sometimes “work” in this same pragmatic use of the term.  But there is no evidence that any psychopharmaceutical product fixes or alleviates any pathological process.  Indeed, what seems to be the case is that these drugs “work” by producing abnormal neurological states.  From a pragmatic point of view the abnormal state may seem better to the client, and/or his family, and/or the authorities.  But this does not establish that the original condition was an illness or that the drug is a medicine.  

CLARIFICATION

Obviously the problems listed in the DSM are real.  That’s not the issue.  What’s being challenged here is the contention that the clusters of problems set out in the manual can be validly conceptualized as symptoms of medical disease entities.  It is my position that such a conceptualization does violence to the subject matter, and has led psychiatry seriously astray.

For instance, at the present time there is a great deal of concern in professional and official circles about the rapidly increasing use of neuroleptic drugs to “treat” childhood temper tantrums and aggression.  What’s not usually acknowledged, however, is that these practices are a direct consequence of the spurious notion that all problems of thinking, feeling, and/or behaving are illnesses that warrant medical intervention.  In the “old days” parents who brought a child to a physician for temper tantrums or aggression would have been told that this, in the absence of some very obvious and compelling indications to the contrary, was not a medical problem.  Today it is a medical problem, not because there has been some breakthrough medical discovery, but simply because the APA says so, and because psychiatrists prescribe neurotoxic drugs that act as chemical strait-jackets and dampen the problem behavior.  Contrary to the congratulatory self-talk of Dr. Lieberman and his like-minded “opinion leaders,” this is not medical progress.

A SECOND CLARIFICATION

Again, to guard against misunderstanding, let me state very clearly that if psychiatry could produce convincing evidence that the myriad problems of thinking, feeling, and/or behaving listed in the DSM are in fact caused by specific illnesses/diseases of the brain or other organs, then my objections are moot.  And if that day comes, as I’ve said many times, I will fold my tent, apologize to all concerned, and end my days writing poetry, growing vegetables, and playing with my grandchildren.  In the meantime, I will continue to state as vigorously and as frequently as I can, that psychiatry’s most fundamental tenet is nothing more than a self-serving assumption which despite decades of highly motivated research, numerous premature, yet confidently asserted, eurekas, and virtually endless promises that the definitive evidence is just around the proverbial corner, remains nothing more than a false and destructive assumption.

 

Invalidity: The Nature of Psychiatry

There’s an interesting post from Duncan Double, MD titled Why does the APA need new editions of DSM?

Dr. Double is a psychiatrist and a member of the Critical Psychiatry Network.  In his current article, Dr. Double expresses the hope that there won’t be a DSM-6, essentially on the grounds that none of the revisions up to this time has resulted in any increase in validity.  So each revision, in effect, replaces an invalid old manual with an invalid new one.

Dr. Double’s final two sentences express the matter very well:

“However, despite all the DSM revisions, there’s no getting away from the poor validity and reliability of psychiatric diagnosis. That’s its nature and psychiatry’s wishful failed ambition needs to be recognised for what it is.”

In other words, psychiatric diagnosis is intrinsically (in its nature) invalid.

 

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.

An Alternative to DSM

Last month (May 31), National Public Radio (NPR) ran an interview on Science Friday with Thomas Insel, MD, Director of NIMH, Jeffrey Lieberman, MD, President of the APA, and Gary Greenberg, PhD, practicing psychotherapist.

I didn’t hear the interview, but I have read the transcript.  Doctors Insel and Lieberman were spinning the barrage of criticism directed at psychiatry in recent months, while at the same time clinging desperately to the notion that the problems that psychiatrists “treat” are real illnesses.  It’s become a familiar theme, and there was nothing new.

What interested me, however, was a remark by Dr. Greenberg.  Here’s the quote:

“I think, you know, one of the things to consider here is we’re dealing with the clinical reality of a need to be able to understand what people bring to us and to make clinical decisions. Some of us are old enough to remember what psychiatry was like or what clinical care was like for mental illness before we had a DSM-III, before there was a dictionary, and it was chaos. And I don’t think anybody wants to go back to that. I don’t think anybody right now has an alternative for clinical use…”

I was surprised to read these words, because I had always had the impression that Dr. Greenberg was opposed to the widespread spurious medicalization of human problems.

Let’s take a closer look at what he said.

“…the clinical reality of a need to be able to understand what people bring to us and to make clinical decisions.”

As an example here, let’s consider the case of a young man who goes to a therapist and says: “I worry a lot about germs, and I wash my hands about 100 times a day.”

To my way of thinking, this is perfectly clear and perfectly understandable.  Gary seems to be suggesting that assigning this man a “diagnosis” of obsessive compulsive disorder somehow enables the therapist to understand the presenting problem.  In other words, the preoccupation with germs and the frequent hand-washing are explained by the “diagnosis” of obsessive compulsive disorder.  The reality, however, is that the “diagnosis” (unlike real medical diagnoses) has no explanatory content.

Let’s apply the acid test:

Client: Why do I worry about germs and wash my hands so much?
Therapist:  Because you have a mental illness called obsessive compulsive disorder.
Client:  How do you know I have obsessive compulsive disorder?
Therapist:  Because you worry about germs and wash your hands so much.

The “diagnosis” explains nothing.

Back to Dr. Greenberg:

“…And to make clinical decisions.”

I can’t even imagine how replacing the client’s very clear, very specific problem statement with a more general statement, which has no explanatory value, can help in making clinical decisions.

Dr. Greenberg continues:

“Some of us are old enough to remember what psychiatry was like or what clinical care was like for mental illness before we had a DSM-III, before there was a dictionary, and it was chaos.”

Well I can remember back then, and it didn’t seem like chaos to me.  We asked the client what was troubling him or her; sought clarification and details as necessary; listened as carefully as we could for nuances; and worked collaboratively with the client towards solutions.  In the hypothetical case mentioned above, the help provided would be along the general lines of stimuli identification, and graduated exposure adapted creatively to the individual needs and concerns of the client.

Also, we didn’t call these kinds of problems mental illnesses.

“I don’t think anybody right now has an alternative for clinical use beyond what the DSM is providing.”

Behavior therapy since at least the 60’s has used the client’s own statement as the treatment “target,” not as a result of any great insight or study, but simply because it made sense.

In addition, Peter Kinderman, PhD, on May 15 posted So…What happens next? on DxSummit.org.  In this article he proposes the use of a client problem list and psychosocial formulations as a rational substitute for a DSM “diagnosis.”

Psychiatric “diagnoses” were invented by psychiatrists to promote the pretense that they are real doctors, and to legitimize the prescribing of mood and behavior altering drugs.  These “diagnoses” not only don’t help, they are a hindrance.  They have no advantage over the client’s own statement.

I know the advantage to psychiatrists:  without a “diagnosis” they can’t prescribe their drugs.  But why would a therapist find these spurious “diagnoses” useful?

Dr. Greenberg continues:

“So it’s easy to criticize this and to say it’s not a perfect document.”

We have been hearing this a lot from psychiatrists lately.  They say, in effect:  we know the DSM isn’t perfect, but it’s the best we’ve got and we’re working hard to improve it.  This whole line of reasoning misses the point of what the anti-DSM contingent is saying.  We’re not saying that the DSM is an imperfect document in need of tweaking.  We’re saying that it’s rubbish!  It has no validity and serves no useful purpose.  And, in that it legitimizes the pushing of dangerous pharmaceutical products for an increasingly wide range of human problems, it is very destructive rubbish.

The purpose of this post is not to attack Gary Greenberg.  But I have commented favorably on Gary’s writing in the past, and I didn’t want there to be any perception that I was in harmony with some of the positions he took on the NPR interview.