Tag Archives: DSM

The Kinderman-Pies Debate

BACKGROUND

On May 15, Peter Kinderman, PhD, of the University of Liverpool, posted an article on DxSummit.org.  It was called So…What Happens Next?

The gist of the article was that psychiatric “diagnoses” are conceptually spurious, unhelpful, and even hindersome in practice, and discourage practitioners from pursuing genuine explanations for the problems clients bring to their attention.

It was an excellent piece, and I did a short post in which I recommended it strongly.

ENTER DR. PIES

On May 29, Ronald Pies, MD, posted a response to Dr. Kinderman, also on DxSummit.org.  It was titled When Language Goes on Holiday.

It was standard biopsychiatric spin.

For instance:

“On what basis does Prof. Kinderman come to believe that psychiatric diagnoses imply that people’s difficulties can be understood, or ought to be understood, ‘in the same way as bodily diseases’? Where, in any of the DSMs, is such a claim made? In what psychiatric textbook is this claim made? How does the claim square with the ‘biopsychosocial model’, which has been the predominant paradigm in American academic psychiatry since George Engel introduced the term?”

In this quote Dr. Pies is apparently pleading ignorance of the fact that the great majority of psychiatrists – at least here in America – tell their clients that their problems are real illnesses, just like diabetes, and that the drugs will correct the biological deficiency in the same way that insulin will help a diabetic!

Which, as often happens with spin doctors, forces one to conclude that Dr. Pies is either very deceptive or very much out of touch.

DR. KINDERMAN RESPONDS

Yesterday, June 4, Dr. Kinderman responded.  His article, also on DxSummit.org, is a superb critique of the conceptual and practical failings of biopsychiatry.  Here are some quotes:

“… DSM-IV, DSM-5 and ICD criteria sets actively hinder caring and skilled clinicians as they try to understand and help their clients.”

“They [psychiatric diagnoses] aren’t useful over and above simply focusing on the problems people experience. Two people with the same diagnosis may have two largely (sometimes completely) non-overlapping sets of problems, with no established underlying pathology. Proponents of psychiatric diagnosis argue that a diagnosis is useful for communication, but since the information doesn’t tell you what problems a person is actually experiencing, doesn’t specify what treatment will be effective and doesn’t point towards a specific set of causal agents, I find this claim hard to understand.”

“Dr. Pies is absolutely correct – when I refer to ‘humanity’, I’m making a moral judgment. I fear that the ‘diagnosis-treat’ model leads to inhumane treatment.”

“To my mind, the reduction of this [client’s] narrative from the understandable consequences of rape to the symptoms of schizophrenia is inhumane.”

“And as a result of all these failings, the diagnostic tools that we are currently living with mean a person’s social and interpersonal difficulties are often ignored in the hope that the right medication regimen will achieve the desired return to normal functioning.”

” That is, when we expose psychiatric diagnoses to factor analysis or cluster analysis or other statistical techniques, the wise and careful judgments of committees of experts turn out to be … wrong.”

“We can, we should, work with self-generated problem-lists. The difficulties arise when, completely unnecessarily, scientifically unwisely, we insist upon adding meaningless and misleading committee-generated labels to this useful and valid description of a person’s problems. The labels necessarily obscure the real nature of the person’s difficulties. My question to Dr. Pies would be: since clearly describing a person’s problems seems so helpful, what additional benefit is offered by a diagnosis?”

As I said earlier, Dr. Kinderman’s critique is superb.  It is cogent, scholarly, and meticulous.  In the few quotes given above I cannot begin to do the article justice.

Please read it, and pass it on.

Live Video Chat: DSM-5

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

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

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

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

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

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

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

The Problem with DSM

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

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

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

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

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

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

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

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

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

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

Dr. Insel Changes His Mind

Well, as I guess everybody knows by now, Dr. Insel has changed his mind.  On April 29, he stated that the weakness of DSM “…is its lack of validity.”  He went on to express the view that his agency, NIMH, (the US government’s mental health research arm) “…cannot succeed if we use DSM categories…”  You can see his full statement here.

This statement was widely interpreted as a significant rift between NIMH and the APA.  But apparently they’ve made up their differences and are pals again.  On May 13, just two weeks after his divorce statement, Dr. Insel and Dr. Lieberman, APA president elect, have issued a joint statement in which they express the belief that the DSM “…represents the best information currently available for clinical diagnosis of mental disorders.”  Patients, families and insurers, we are told, “…can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care.”  It’s hard to believe that this is the same DSM that he earlier criticized as lacking validity!

A number of people have asked me what in the world is going on.  So here’s my theory.

Dr. Insel is an honorable and learned man.  After all, he was appointed by the government to a prestigious position, and as everybody knows, Washington only appoints honorable and learned men to prestigious positions.  So Dr. Insel had been studying this matter for years – poring over learned journals, discussing with learned colleagues, etc., and finally came to the conclusion that DSM had no validity.  He struggled with this because of the enormous implications, but finally honor prevailed, and he went public.

But a day or two later one of his faithful retainers came to him with some additional research findings that Dr. Insel had overlooked.  He reviewed the new material and realized that he had made a terrible mistake.  So he called Dr. Lieberman, and together they drafted the recantation.  And as far as I am concerned, this raises him in my estimation.  It takes a big man to admit he’s wrong.  Well, he doesn’t actually admit he was wrong, but he comes as close to it as a man in a prestigious D.C. position can.

There are, of course, other theories.  My friend Clive from Chicago, who is very knowledgeable about the ways of the world, expresses the belief that two heavy-set guys in big overcoats came into Dr. Insel’s office and said:  “Do youse people want to work wid us or not?”  Dr. Insel said “Uh?”  Whereupon the heavy-set guys put a paper on his desk and told him that they would have his signature on the paper or his brains.  This, for Dr. Insel was, if you’ll pardon the observation, a no-brainer.

My great Aunt Molly, who will be 104 next week, has been divorced four times.  Her theory is that the marriage between APA and NIMH is in trouble.  “You always see these little spat and make up patterns when things are starting to go south,” she observed.  “Often there’s alcohol involved,” she added wisely.

I don’t associate much with psychiatrists, but there is one whom I encounter occasionally – Dr. I. Mapusher.  I asked Dr. Mapusher what he thought of Dr. Insel’s recantation, and he confidently expressed the view that Dr. Insel has a brain illness.  “Really?” I asked.  “Oh, yes,  definitely bipolar disorder.  He made the first statement in a depressive phase, and the recantation when he was manic.  Or perhaps the other way around.  But definitely a brain illness. After all, according to the NIMH, the lifetime prevalence is 50%!”

So there it is.  I still believe that Dr. Insel is an honorable and learned man who discovered his error and did the right thing.

But whatever the reason, the whole business looks more like political wrangling than professional/scientific debate.

Psychiatry has never been about science.  It’s about marketing and spin.  Dr. Insel opened a breach when he said – correctly – that the DSM categories are invalid.  No one from the APA has honestly addressed this issue.  Instead they’re churning out spin.  The Insel-Lieberman statement is more of the same.  For instance:

“By continuing to work together, our two organizations are committed to improving outcomes for people with some of the most disabling disorders in all of medicine.”

Now doesn’t that just make you feel good all over?

The Empire Strikes Back: APA Responds to NIMH

BACKGROUND

On May 3, 2013, David Kupfer MD (DSM-5 Task Force Chair) responded to Thomas Insel’s April 29th unequivocal attack on the validity and usefulness of DSM.  You can see Dr. Kupfer’s response here.  Essentially Dr. Insel said that the categories set out in the DSM did not correspond to anything in the real world, and that NIMH would no longer be using these categories as the basis for their research program.  This statement did not, however, represent any significant movement away from the biomedical model on the part of NIMH.  In fact, if anything, it was a movement towards an even more deeply entrenched medical model.  But it was a huge hit on DSM and on the APA, who tout the catalog as the basis to their claim to scientific credibility.

There was nothing particularly new in Dr. Insel’s article.  Those of us on this side of the debate have been saying the same things for years.  But it did represent a very serious rift in what up till then had seemed a coherent and unified front.

THE APA’S RESPONSE

I have contended for many years that psychiatry is based on marketing rather than science, and spin rather than truth.  Dr. Kupfer’s response to the NIMH paper is a good example.

Although Dr. Kupfer’s article is clearly a response to the NIMH piece, Dr. Kupfer makes no mention of the latter until the last paragraph but one.  Even then he does not attack Dr. Insel’s position – but actually praises it!

This is spin of a very high order.  If he had attacked the NIMH article, there would have been onus on him to refute the charge that the DSM “diagnoses” have no validity.  By sidestepping the issue, he doesn’t have to go out on that limb, which has always been shaky, but has been made more so by Dr. Insel’s attack.

Instead, he opens on a very upbeat note:  “The promise of the science of medical disorders is great.”  This really doesn’t mean anything, but it sure sounds good.  These guys could give lessons to the politicians.

It gets better.

“In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”

This almost sounds like an honest confession.  But let’s take a closer look.

“We’ve been telling patients for several decades that we are waiting for biomarkers.”

I suggest that this is simply not the case.  Psychiatrists have been telling their ‘patients’ for decades that they have chemical imbalances in their brains, that the chemicals involved are known, that the pills correct these imbalances, and that the pills are safe.  All of these statements are patently false and extremely destructive.  I have never heard (or even heard of) a psychiatrist who said to his ‘patients’ or to anyone else that “we are waiting for biomarkers.”  The entire house of cards has been built on the illusion of scientific certainty, which the psychiatric profession promoted shamelessly.

After this bogus confession, Dr. Kupfer continues:

“In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia.”

Note the phrase:  “… clinical experience and evidence, as well as growing empirical research…”  In other words: we may not have the chemistry nailed down precisely, but our work is still underpinned by clinical experience, evidence, and empirical research.

What he omits to mention is that most of the research that supports the DSM concepts has long been hijacked by pharma and amounts to little more than pharma advertizing, and that the genuine research in this field demonstrates that psychiatric practice in America is not only ineffective, but in a great many cases also destructive.

Clinical practice that is based on spurious research is called quackery.

In his second paragraph, Dr. Kupfer has this to say:

“This progress will soon be recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The new manual, due for release later this month, represents the strongest system currently available for classifying disorders. It reflects the progress that we have made in several important areas.”

Remember that Dr. Insel had said, in effect:  DSM is rubbish. We won’t be using it any more.

Dr. Kupfer makes no rebuttal; he simply refers to DSM-5 as “progress” and as the strongest system currently available for classifying disorders.  But Dr. Insel’s precise point was that the DSM has no validity.  In other words, the only thing that it is classifying is the collective prejudice of the APA!

To demonstrate the “value” of DSM-5, Dr. Kupfer lists four features of the new manual which collectively don’t amount to a hill of beans, but serve merely to distract the reader from the fundamental criticism that the categories have no validity.

If you drill an oil well and it turns up dry, you don’t have an oil well.  You have an expensive hole in the ground.  If you construct a classification system that has no validity, you don’t have a classification system, you have a pile of rubbish – and in this case – dangerous and destructive rubbish.  And if the APA keep insisting that their rubbish is valuable, and if they keep selling it to people and using it to justify their actions – then the word that comes to mind, at least to my mind, is charlatan.

Dr. Kupfer continues.  DSM, he tells us, “… provides clinicians with a common language to deliver the best patient care possible.”  Once again, he’s dodging the point.  The APA field trials of DSM-5 demonstrated clearly that the categories in the manual have very poor inter-rater reliability.  So it isn’t even a common language.

And the notion of delivering the “best patient care possible,” is a little hard to reconcile with the well-established fact that psychiatric “treatment” of depression, for instance, is not only ineffective in the short run, but actually increases the chance of a chronic deteriorating course in the long run.

Now we get to the NIMH.  There’s no response to the validity challenge, just a statement to the effect that the institute’s new research framework, which they will use instead of DSM, is “vital to the continued progress of our collective understanding of mental disorders.”  The use of the word “collective” suggests that the APA and NIMH are still good buddies.  Don’t show the rift.

But – and clearly Dr. Kupfer perceives this as his trump card – the institute’s proposed domain criteria “… cannot serve us in the here and now, and they cannot supplant DSM-5.”  In other words, we’ve got the only football, so if you want to stay in the game, you’d better get on board with us.

He goes on to characterize the NIMH’s research framework as “…a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field.” (emphasis added)

What he’s doing here is marginalizing the NIMH’s position:  They will be out there in left field doing their thing and someday they may have something that will warrant us accepting them back into our field.

And here’s where it gets really good.  “In the meantime, should we merely hand patients another promissory note that something may happen sometime?”  Promissory note evidently is a euphemism for blatant lie.

“Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.”

There is a great deal of evidence that their ‘patients’ would be a lot better off if the psychiatrists packed in their spurious and destructive practices and found honest work.

Then he plays the “we’re-doctors, you-can-trust-us” card:

“The American Psychiatric Association is a national medical specialty society whose physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org.”

SUMMARY

This is very high quality spin.  Dr. Kupfer never actually addresses a single serious issue.  He simply strings together a series of inane platitudes.  He insults his clients, and he insults the general public.

If the Director of the NIH had published a paper criticizing some of the fundamental concepts underlying urology, say, I think the response from the American Urological Association would have been based on facts and science, rather than rhetoric and spin.

 

 

 

Mental Distress Is Not An Illness

BACKGROUND

Sam Thompson (University of Liverpool) posted the following tweet on April 27:

Can anyone point me to a good, succinct summary of the case for equating mental distress with illness?  (serious, non-sarcastic question)

On the face of it, this looks like a straightforward question, and one might think that a straightforward answer could be found.  But this is not the case, because ultimately it boils down to a matter of definition.  And psychiatry is a field where definitions are notoriously fuzzy.

MENTAL DISORDER

Contrary to widespread belief, the APA’s Diagnostic and Statistical Manual is not a listing of “mental illnesses,” but rather of “mental disorders.”  However, for the last 20 years or so, almost all psychiatrists have conceptualized the problems they treat as illnesses (specifically, chemical imbalances in the brain) and have routinely expounded this untruth to their clients.

It is noteworthy that the APA has never issued any kind of clarificatory statement on this matter, and in practice the terms are used interchangeably.  But the confusion is no accident.  By interchanging these terms, the psychiatrists have allowed the medicalization of the identified problems by implication rather than by fiat, which makes it easier for them to extricate themselves should the medical model ever come under serious scrutiny – which, incidentally, is what’s happening at present.

The protest against the spurious medicalization of virtually every life problem is loud, focused, and growing.  And, predictably, the psychiatrists are beginning their extrication process.

Ronald Pies, MD, is a well-known US psychiatrist who blogs on Psychiatric Times.  On the illness terminology, he had this to say on July 11, 2011:

“In truth, the ‘chemical imbalance’ notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists.” (link)

And on April 18, 2013:

“But on the whole, I believe the medicalization narrative is philosophically naive and clinically unhelpful.” (link)

He blames the “chemical imbalance” notion on pharma:

“And, yes—the ‘chemical imbalance’ image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding.” (link) ( 7/11/2011)

So the spurious medicalization of clients’ problems is in no way the responsibility of psychiatrists.  It’s the fault of pharma.

But like most psychiatrists, Dr. Pies is experiencing some inner conflict in this general area.  Here’s another quote from the April 18 paper:

“So long as the patient is experiencing a substantial or enduring state of suffering and incapacity, the patient has disease…”

And there you have it.  For Dr. Pies, suffering + incapacity = disease, which presumably is synonymous with illness.  Dr. Pies quotes a reference in support of this position.  It’s an essay he wrote in January 2013.  You can see Part 1 here, and Part 2 here.  In these papers he doesn’t actually produce arguments in support of this position, but simply asserts it to be so.  For instance:

“Regardless of context, once a certain threshold of suffering and incapacity is crossed, physicians justifiably apply the term ‘disease’ (or ‘disorder’) to the person’s condition. (For purposes of this discussion, I am using the terms ‘disease’ and ‘disorder’ more or less synonymously, although the medical literature is remarkably inconsistent in how these terms are applied.

There it is:  once a “…certain threshold of suffering and incapacity is crossed…” a sub-optimal behavior or feeling becomes a disease/illness.  And also notice that “disorder” and “disease” have become synonymous.

I mention Dr. Pies’ work in this context not because of any intrinsic value, but because he managed to put into words many of the unspoken assumptions inherent in modern psychiatry.  What’s particularly striking in Dr. Pies’ writing is the notion that one can consider a condition an illness even in the absence of any demonstrable physical pathology.

This is echoed in the APA’s definition of a mental illness/disorder:

“…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress… or disability … or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” (DSM-IV-TR, p xxxi)

There are a number of noteworthy features to this definition.

–  a behavioral or psychological pattern (i.e. any kind of human activity)
–  that occurs in an individual (as opposed, say, to in a family or in society)
–  that is associated with (not necessarily causally associated)
–  distress or disability or significantly increased risk
–  of death or pain or disability or loss of freedom

Note the multiplicity of “ors”, so only one of the factors listed is needed for a condition to be a mental illness/disorder.

It is truly difficult to think of any sub-optimal human activity that would not be embraced by this definition.  Habitually wearing shoes that are too tight, for instance, is a behavior pattern; it occurs in an individual; and is associated with pain.  Playing one’s car radio too loud is associated with disability (hearing loss).  Any kind of criminal activity is clearly embraced by the definition on the grounds that it entails the risk of incarceration.  Mountain climbing is associated with increased risk of death.  Etc., etc., etc…  The definition is so broad that it can embrace any activity that the APA chooses to include in the DSM.

As with Dr. Pies’ writing, there is no requirement of physical pathology for a condition to be called a mental disorder/illness.

Over the past 30 years or so, various attempts have been made to prove that the conditions listed in DSM are illnesses. These proofs usually involve showing that the activity in question has a characteristic neural underpinning, and “therefore” the activity is an illness.  Most of the attempts have foundered under scrutiny.  For instance, the brain damage theory of “schizophrenia” collapsed when it was demonstrated that the characteristic damage was actually caused by neuroleptics.  But even if characteristic neural or hormonal or genetic correlates were accurately and reliably identified, this will never be the full story.

Consider the case of violent behavior.  Let’s say person X kicks person Y in the head quite viciously, and the question arises:  why did X kick Y?  An explanation might be offered along the following lines:

The muscle fibers in X’s thigh contracted and rapidly released; this muscular activity was caused by the organized firing of various neurons, coupled with the presence of adequate reserves of potassium ions in the blood stream.  The neuronal activity was initiated by synaptic activity in the cerebral cortex which in turn was influenced by sensory input signals.  And all of this activity was made possible by the fact that the digestive tract was primed and functioning and was providing energy to various bodily systems via the blood stream.  The adrenal glands had secreted adrenaline … etc..

This kind of account if developed in detail might easily run to a million words; could be 100% true, and would indeed constitute an explanation of the act of kicking.  Behavioral patterns are indeed underpinned and driven by corresponding physiological patterns.  This is true whether the behavior is functional or dysfunctional; productive or counterproductive, helpful or unhelpful.  The fact that a behavior can be explained in physiological terms does not make the behavior an illness.    All behavior can be explained in physiological terms.  One could, for instance, conduct a physiological analysis (similar to the one above) for the activity of riding a bicycle.  This would not prove that bike-riding is an illness.  Nor would it be the full story or even the main story.

Another way of explaining the kicking incident, for instance, might go like this:

X grew up in very violent surroundings, and he acquired the habit of responding violently to anything or anybody who seemed threatening.  Y was speaking loudly and aggressively and had begun to assault X, so X knocked him down and kicked him in the head.

I suggest that while the physiological explanation would have a great deal of interest for physiologists, the latter (behavioral) explanation has more usefulness and relevance for people working in the human service field, and indeed for people generally who are trying to understand human behavior, feelings, conflict, etc…

A complication in this area is the fact that biological malfunctions can and do occur, and occasionally these malfunctions can cause psychological/behavioral problems.  A number of such conditions are known, and the underlying biological damage/malfunction has been identified with various degrees of precision.

But, and this is the critical point, the vast majority of behavior that meets the APA’s criteria for a mental disorder is not associated with known biological pathology.

But then there’s yet another complication, which stems from the fact that people can learn.  We can acquire new skills and behaviors.  This process has been studied extensively by psychologists and others, but the underlying physiology/neurology is not well understood.

However, it is obvious that there is some neurological basis to every item of new learning.  If I take a walk in some place where I’ve never been before, and afterwards I can recall details of the area or even draw a map of the place, clearly there is something inside my brain that has changed.  Similarly newly acquired skills and habits, whether they are functional or dysfunctional, are underlain with some kind of neural “program”.  And this fact, though seldom articulated, is the basis for the psychiatric medicalization of all human problems.

Suppose I have, for instance, an extreme fear of public speaking.  This is an acquired fear (i.e. I wasn’t born with it), and it is likely that I have acquired this fear in the same general way that people acquire other fears (i.e. through social conditioning).  But there is something in my brain that corresponds to, and indeed causes, physiologically, this particular fear response.

Getting rid of this fear is generally not difficult.  I could design a program of systematically increasing exposure; I could ask a psychologist to help me; or I could join Toastmasters.  Assuming that the retraining is successful, then the neural underlay will also be removed, or disabled, or modified in some way.

Psychiatry’s approach, however, is to get rid of the fear by directly targeting the neurological basis, and they apply this approach to all human problems – not just fears.  The methods they use are drugs, electric shock, and scalpels.  It is a central theme of this website that their efforts in this regard are not only unsuccessful, but also do a great deal of harm.  But for now, let’s continue to explore the conceptual issues.

I have a picture “in my head” of a school I attended as a child.  Let’s say I have truly horrendous memories of this school, and let’s say that the neurological trace of this building is confined to one minute spot in my brain.  A neurosurgeon might conceivably be able to go in with a tiny electrode and burn out the offending tissue, and I would never again be troubled by this memory.

I’m not suggesting that anything of this sort is, or ever will be, possible (if for no other reason than that the bad memories are probably not confined to one tiny neural location).  But this is the essential reasoning behind the illness theory: that painful memories, bouts of depression, counterproductive habits, etc., are all best understood in terms of their neural underpinnings, which have to be removed, damped down, rebalanced, adjusted, burned out, or whatever, even though they are not in themselves pathological, either with regards to genesis or functioning.  My horrendous memories of the school are actually adaptive, and might conceivably help me avoid aversive situations of this sort in the future.

At the present time, and I suggest in the foreseeable future, the tools used by psychiatrists in their efforts to effect these adjustments are more analogous to soup spoons, or even jackhammers, than tiny electrodes.

Some of these issues can be clarified with a computer analogy.  I can take a photograph of my house and put it into my computer.  (Well, to be honest, I would have to ask my wife to do this.)  But the picture is in the computer in the form of a string of on or off magnetic fields.  If I decide to delete this picture, I (or Nancy) can press the various keys and the picture is gone.  In other words, I remove the picture using essentially the same technology that was used to store it in the first place.  This is analogous to helping people free themselves from fears, negative feelings, counterproductive habits, etc., by means of human contact, dialogue, support, etc…

Alternatively, I might in theory be able – if I knew a great deal about hardware – to go inside the physical apparatus with tiny drills, etc., find where the picture was stored, and physically obliterate the 1’s and 0’s, so that the picture would be destroyed.  Inevitably I will damage a good deal of the surrounding hardware and, of course, other information stored on this hardware.  Again, I’m not suggesting that any of this is even possible.  It would probably just destroy the computer!  But the point is that this tactic is analogous to the psychiatric/biological approach: tampering with the brain in a misguided attempt to get rid of unhappy thoughts or counterproductive habits, even though there is nothing wrong with the brain.  A person with a perfectly ok brain can acquire an extreme fear.  Remember Little Albert (here).

So finally, let’s get back to Sam’s question:  What proof is there that mental distress is illness?  The question can be rephrased as follows:  If a person’s behavior or feelings are causing him distress, should the neural underpinnings of these behaviors/feelings be considered an illness?  And it is immediately clear that this is not something that admits of proof; rather it is a matter of semantics.  Not long ago the International Astronomical Union decided that Pluto is no longer to be considered a planet.  It is now a dwarf planet.  This was not something that had to be proven.  It was a decision about the use of the terms.  If someone were to ask the astronomers to prove that Pluto was not a planet, the only possible way to respond would be to elucidate the meanings of the various terms.

Psychiatrists choose to call all human problems illnesses (“just like diabetes”).  Normally, like Dr. Pies, they make no attempt to justify this position.  They simply state it to be so.

When psychiatrists do try to rationalize their practice of calling human problems illnesses, it is always along the lines of “correcting” brain structure, physiology, or programming, even though there is no evidence of a neural pathology.  If the neural entities are causing distress or pain or disability or the risk of incarceration, then by definition, they are illnesses.

And that’s all there is to it.  Human problems are illnesses because the APA say so.

The common usage of the term “illness,” however, implies physical pathology, i.e. something wrong with the structure or functioning of the organism.  Psychiatrists implicitly endorse this notion when they tell their clients that depression (or ADHD, or anxiety, etc.) is a real illness “just like diabetes.”  What does the phrase “just like diabetes” mean in this context?  I suggest it means real physical pathology.  And psychiatrists routinely push this notion even though it is false, and even though there is no requirement of physical pathology in their definition of a mental illness.  Within the APA’s conceptual framework, human problems are illnesses because the APA say so.  There really is nothing more to it than that.

 

 

 

 

 

Transforming Diagnosis: The Thomas Insel Article

BACKGROUND

On April 29, Thomas Insel, Director of NIMH, published a paper called Transforming Diagnosis.  You can see it here.

Dr. Insel is critical of DSM:

“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 weakness is its lack of validity.”

This has created quite a stir, in that it appears to support the position of those of us who have been criticizing the DSM on these kinds of grounds for decades.  It also suggests a fundamental rift between the NIMH and the APA, two groups who up till now had appeared to be joined at the hip.

The article has generated a great deal of comment.  So far, there’s been nothing from the APA.

APPRAISAL

Those of us who have been critical of psychiatry’s routine medicalization of all human problems and their widespread pushing of destructive “treatment,” have often focused on the DSM as the central target.  This was a valid approach because DSM was the vehicle that the APA used to promote their spurious and destructive agenda.

Up till recently our efforts had been largely futile – like gnats attacking a battleship.  But in the last five years or so there have been some important developments.  Firstly, some heavy hitters from outside the mental health arena joined the fray (e.g. Robert Whitaker, Chris Lane, etc.).  Secondly there have been some serious defections from the ranks of the believers.

But more important than either of these developments has been the growth of the survivor movement.

Psychiatry is under attack.  Its spurious concepts are being unmasked, and its destructive practices are being exposed.

Just as politicians distance themselves from allies who become tainted with scandal, so the NIMH is distancing itself from the DSM and, by implication, from the APA.

But, and this is the critical point, the NIMH is emphatically not distancing itself from the medicalization of human problems, nor from the promotion of destructive “treatments.”

Here are some more quotes:

“NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.”

“Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.”

“Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior.”

In other words, human problems are caused by brain illnesses.

So what Dr. Insel is committing his agency to is twenty more years of futile research, looking for the Holy Grail – the putative brain illnesses that supposedly cause all emotional suffering and counterproductive habits.  He is also committing his agency to ignoring the vast and growing body of legitimate research that demonstrates clearly that emotional and behavioral problems are best conceptualized (and alleviated) within an entirely different set of paradigms.

Another glaring feature of Dr. Insel’s article is that he presents the criticisms of DSM as if they were his ideas.  There is no recognition that many of us on this side of the fence have been saying these things for years – sometimes decades.

And let’s not forget that it was Dr. Insel who played a lead role in the concepts that ultimately led to the promotion of SSRI’s in the treatment of depression and “OCD.”

If the NIMH want to promote serious, vital, and genuinely helpful research, I suggest that they start funding studies to explore the links between SSRI’s and suicide and homicide.

LOOKING AHEAD

Meanwhile, nothing is going to change in the trenches.  Psychiatrists will continue to promote their nonsensical concepts (depression is an illness just like diabetes) and push their dangerous products (you must take these pills for life).  Victims will be lured in and damaged, sometimes irreparably, and the psychiatrists’ pharma buddies will continue to get rich and spread their corrupting rewards back to the pushers.

NIMH’s rejection of DSM is good news.  It opens a rift in the bio-pharma-psychiatric bloc, and it represents a victory of sorts for those of us in the opposition.  But we still have miles to go.  We need to keep writing; keep speaking out; keep spreading the word.

 

Social Effect of DSM

I keep two dictionaries on my desk.  The first is a 1964 Webster’s; the second is a 2009 Webster’s.  This morning I looked up the word “depression” in both books.

1964:

n. 1. a depressing or being depressed.  2. a depressed part or place; hollow or low place.  3. low spirits; dejection.  4. a decrease in force, activity, amount, etc.  5. a period marked by slackening of business activity, much unemployment, falling prices and wages, etc.

2009:

1 a: the angular distance of a celestial object below the horizon  b: the size of an angle of depression  2: an act of depressing or a state of being depressed: as  a: a pressing down: LOWERING  b(1): a state of feeling sad: DEJECTION  (2): a psychoneurotic or psychotic disorder marked esp. by sadness, inactivity, difficulty in thinking and concentration, a significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and sometimes suicidal tendencies  c(1): a reduction in activity, amount, quality, or force  (2): a lowering of vitality or functional activity  3: a depressed place or part: HOLLOW  4: LOW 1b  5: a period of low general economic activity marked esp. by rising levels of unemployment

I was a little surprised, because I thought that the notion of depression as an illness had been current by 1964, and perhaps other dictionaries at the time might have reflected that.  But the point is that conceptualizing depression as an illness is a relatively recent phenomenon which has been fully integrated into the language.

In the 50’s and 60’s, if a person said he was depressed, friends and family members used to ask questions like:  What’s the matter?  What’s got you down?  Is there something I can do?  etc…

The prevailing ethos was that the depression was rooted in the individual’s context, and was intrinsically understandable within that context.  The individual might respond that the children were sick; or that he had been laid off; or that he just felt overwhelmed by a lot of little things, etc..

This would usually be followed by commiserations, efforts to help, encouragement, etc., and for the most part bouts of depression were relatively short-lived and non-recurrent.

Today, however, if a person indicates that he’s depressed, there is a widespread tendency to encourage him to “get help.”  This almost always means psychiatric help.  The ethos has changed.  No longer is depression seen as one of the relatively ordinary facets of living, to be alleviated by old-fashioned support and encouragement from family and friends.  Today depression is an “illness.”  It’s “treated” by pills which often produce more problems than they solve.  And bouts of depression are much more likely to become recurrent.

In the old days people conceptualized their depression as a problem that they could do something about.  “I just need to get outdoors a bit more.”  “I need to change jobs.”  “I need to lay off the booze.”  Etc…

Today this is gone.  Instead we hear:  “I need to renew my prescription.”  “I need to ask the doctor to up my dose.”  Etc…

Psychiatry/pharma laud this change.  They claim that we are finally recognizing the reality, and alleviating the suffering of this “illness.”  In fact, it’s a tragedy of monumental proportions, that’s not only destroying people physically, but is sapping the strength and vitality of whole generations worldwide.

The shift to the spurious disease concept is not based on any kind of scientific discovery.  It is a product of psychiatry/pharma marketing, which is one of the most destructive forces in modern society.

Internet Addiction: A Bad Habit, Not An Illness

The DSM-5 drafting committee considered including Internet addiction in the upcoming revision, but eventually backed off, at least for now.  Apparently they decided to put it in the category “requiring further study.”  So it’ll be in DSM-6.

Meanwhile, people are being given the “diagnosis” anyway – and of course, the “treatment.”

AN ILLUSTRATIVE CASE

I’m grateful to Tallaght Trialogue for sending me a link to a recent article in the UK’s MailOnline.  It was written by Rebecca Seales and Eleanor Harding.  You can see it here.

The article is about a four-year-old girl who “…is having psychiatric treatment after becoming Britain’s youngest known iPad addict.”

“Doctors say she is so addicted to games on her parents’ iPad that she experiences withdrawal symptoms when it is taken away.”

The treating psychiatrist is Dr. Richard Graham, who runs the Capio Nightingale Clinic in London.  The Capio, which describes itself as London’s leading private mental hospital, reportedly charges £16,000 ($24,320 US) a month for a digital detox program, which is designed to wean “patients” off their electronic devices.

In the Mail article, it is reported that Dr. Graham commended the 4-year-old girl’s parents for seeking help quickly, adding that “…by age 11, the problem might have become so severe that she would have required in-patient care.”

Apparently the problem is common, and a great many children throw temper tantrums if the devices are taken from them.

LET’S GET REAL

What’s involved here is parent-child conflict, which has probably been going on since we were hunting and gathering in the Rift Valley.  The only “treatment” needed is perhaps a boot camp for parents to help them regain some of the sense they were born with and have apparently lost.

There will always be a certain amount of conflict in parenting, and as a general rule, if the child wins in the short term, he loses in the long term.

One of the “side effects” of modern child psychiatry is the widespread disempowerment of parents.  The unspoken message is:  You can’t deal with this; it’s much too abstruse and technical; send your children to us; we understand; we have pills; you can trust us – we’re doctors.

Internet addiction is not an illness.  It’s a habit.  It can become severe and can be significantly counter-productive.  In the case of children, parents simply need to step up to the bat and curtail the activity, and take positive steps to involve the child in more wholesome and fulfilling activities.  If they can’t manage this, they need to get help – not from psychiatrists, but from their parents, grandparents, neighbors, friends, etc…, and perhaps helping professionals who are not aligned with bio-psychiatric pharma.  Help is there, but people won’t offer unless they’re asked.

Dr. Graham was correct about one thing, though.  The longer you leave it, the worse it gets.

If you’re not already doing so, please speak out against the madness.

The Bereavement Exclusion and DSM-5

In DSM-IV, a “diagnosis” of major depressive disorder is based on the presence of a major depressive episode.

A major depressive episode, in turn, is defined by the presence of five or more items from the following list during a two-week period:

(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) insomnia or hypersomnia nearly every day

(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) fatigue or loss of energy nearly every day

(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide      (DSM-IV p 327)

For the “diagnosis” to be made, the “symptoms” must cause clinically significant distress or impairment in social, occupational or other areas of functioning.

In addition, there are three exclusions.  A “diagnosis” of major depressive disorder is not to be made if:

– the “symptoms” meet the criteria for a mixed episode
– the “symptoms” are due to a substance or a general medical condition, or
– the symptoms are due to bereavement

This latter item is called the bereavement exclusion, and the APA has decided to drop this exclusion from the DSM-5.  This decision generated a good deal of debate, and I thought it might be helpful to examine the issue in some detail.

The DSM-IV wording is interesting.  The “diagnosis” can and should be made unless the symptoms are “… better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.”

The language is somewhat convoluted, but you can clearly see that the exclusion is only partial.  The “diagnosis” can be made if:

1.  the bereavement lasts more than two months
2.  or, there is marked functional impairment
3.  or, morbid preoccupation with worthlessness
4.  or, suicidal ideation
5.  or psychotic symptoms
6.  or psychomotor retardation

In other words, the bereavement exclusion does not apply if any one of these six items is present.

What’s troubling about all this is that it’s difficult to imagine (or at least I find it difficult to imagine) a bereavement in which at least one of these factors wouldn’t be present.  In fact, I suggest that in most cases of bereavement, four, five, or even all six factors would be present.  Think about it!

– lasts more than two months     [yes]
– marked functional impairment      [yes]
– morbid preoccupation with worthlessness      [maybe]
– suicidal ideation (thoughts, not necessarily action)      [probably]
– psychotic symptoms (I’ve never known a bereaved person who didn’t at some point hallucinate the loved one’s voice)      [likely]
– psychomotor retardation      [definitely]

What I’m getting at here is that there never was a bereavement exclusion in DSM-IV!

Compare this to DSM-III-R:  “Uncomplicated Bereavement is distinguished from a Major Depressive Episode and is not considered a mental disorder even when associated with the full depressive syndrome.”  (p 222)  This is a bereavement-exclusion and is pretty clear, though they did muddy the waters a little, later in the text.  In the DSM-IV, the bereavement exclusion is effectively gone, though the appearance of a bereavement exclusion is retained.  Probably because of this appearance and the convoluted language, it was widely believed in mental health circles that a “diagnosis” of major depression could not be assigned in cases of bereavement, and in practice this “diagnosis” was usually only assigned in cases where the bereaved person attempted suicide.  In DSM-5, even the appearance is to be deleted.

In their Highlights of Changes… document, the APA lists four reasons for omitting the bereavement exclusion from DSM-5:

1.  “…to remove the implication that bereavement typically lasts only 2 months”
2.  “…bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual…”
3.  “…bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes.”
4.  “…the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression.”

The APA continues:

“In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive episode.  Thus, although most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.”

There are a number of noteworthy points.  Firstly, the four reasons given for the change do not – at least in my view – seem very compelling.  In the context of the six decades of “diagnostic” expansion, this just seems like more of the same:  bereavement is now a mental illness because the APA say so.

Although the APA state that most episodes of bereavement will not develop into a major depressive episode, it is clear that the great majority of people who have lost a loved one will in fact fall into this category and will receive a “diagnosis” of major depressive disorder.  I can’t imagine a bereaved person not meeting five or more of the depressive episode criteria listed earlier.  And remember, the criteria have to be met for only two weeks!

In my view the essential dynamics of the matter are as follows.  DSM-IV did not have a bereavement exclusion, but did have the appearance of a bereavement exclusion (presumably for window dressing).  Most psychiatrists took the apparent exclusion seriously and didn’t usually assign a “diagnosis” of major depression in cases of bereavement.  In DSM-5, this problem will be fixed.  So old-fashioned do-it-yourself-with-the-help-of-family-and-friends grieving will be a thing of the past.

About 2.5 million people die in the US each year, and it is reasonable to assume that almost every one of these will leave at least one bereaved person behind.  This is an enormous under-tapped market for the pharmaceutical industry.  But don’t worry; their friends in the APA are on the job.

And don’t forget, 69% of the APA’s DSM-5 work group members have financial ties to pharma.  But the APA have assured us that this didn’t influence their professional judgment in the slightest.

Once again, I find myself asking where do they get the gall?  How dare they presume to decide whose bereavement is “normal” and whose is pathological!?!

They aren’t going to stop until they have everybody diagnosed and everybody on drugs.  They are purely and simply out of control.