American Psychiatry At The Crossroads

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American Psychiatry At The Crossroads - Mike Nova's starred items


(title unknown):
PsychiatryOnline | Psychiatric News | News Article
psychnews.psychiatryonline.org
James H. Scully Jr., M.D., will retire as APA medical director and chief executive officer at the end of this year after a decade of remarkable change and progress.

Scully will leave behind an APA stronger than he found it when he became medical director 11 years ago, and one that is poised to face the future. “We are the voice of psychiatry,” he said. “No other group does what we do. If APA is not successful, psychiatry will not be successful.”
Comment:
I would phrase it a little differently, Dr. Scully:
If psychiatry is not successful, APA will not be successful.
Sometimes it is important to position chickens and eggs properly. And, maybe it is exactly this "mispositioning": prioritising psychiatry as a profession and as a professional organisation over psychiatry as a unique medical and social science and discipline, that is a part of the problem.
Michael Novakhov.

Mike Nova: American Psychiatry At The Crossroads


Last Update: 11:45 AM 5/10/2012


"It should broaden its theoretical and conceptual outlook... it should assume its rightful leadership role in World Psychiatry... by discarding the outdated stereotypes, not reinforcing them" |

Thank you, Dr. Frances; for your previous work and for your courageous and independent stand now. |

James Phillips: "Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations." |

Did American Psychiatry sell its soul to profit-hungry (Psycho) Pharmaceutical Industry? Is it not the time to stop all these "DSM-s In Perpetuity" madness? And not to spend another $25 or more ml. for the next round of controversies and wide-spread public scepticism?" |

"Empirical explanation and treatment repeatedly fail for psychiatric diagnoses. Diagnosis is mired in conceptual confusion that is illuminated by Ludwig Wittgenstein's later critique of philosophy (Philosophical Investigations).

A diagnosis is a sort of concept that cannot be located in or explained by a mental process. Conclusion: A diagnosis is an exercise in language and its usage changes according to the context and the needs it addresses."



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Drug companies like Pfizer are accused of pressuring doctors into over-prescribing medications to patients in order to increase profits - GALLO/GETTY
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American Psychiatry should broaden its theoretical and conceptual outlook beyond the narrow professional concerns about diagnostic systems and classifications (at this time, with all the enormous importance of these issues, we are not ready for the true scientific approach towards resolving them; and the practical problems with "reimbursements" and "parities" should be left for actuaries and medical records departments to resolve). Recent controversies about DSM-5 indicate that the whole conceptual direction of improving and perfecting diagnostic pseudonosological labeling system (and the professional and social power of labeling that comes with it) hit a roadblock and is in "no exit" blind alley. How can we introduce a true, medically scientific and evidence based classification system for mental disorders if we still know so little about their nature and origins? The attempts to codify the current clinical labels are methodologically and epistemologically dangerous because they reinforce the current clinical belief system with its multitude of misconceptions. The history of science and medicine in particular is replete with these kind of errors. Preoccupation with improving the reliability by forced agreement (which by itself proved to be impractical and next to impossible) does not affect the much more important issues of validity of psychiatric diagnosis, and, if anything, leads to their neglect and displacement (not only in psychodynamic, but real sense) from our area of interests and scientific horizons, almost relegating these issues to the province of "conspiracy of silence". How can we agree on something, if we don't really know what this "something" is or if it even really and "truly scientifically" exists? And why should we agree on this "unknown something?"
Medicine and psychiatry are empirical and "practical sciences"; we are not just "talkers" and "labellers"; we are "doers": our task is to ease mental pain and suffering (of which this world is aplenty) for individuals, groups and societies. We do it in the dark, our knowledge is still limited and trues are hidden. We should not reinforce these limitations, presenting "blind spots" as medical facts, but should accept them, be aware of them and work further, relentlessly, and completely with an open mind to resolve them. Narrow professional concerns with "parities and reimbursements" should not be a consideration and should not stand in the way of scientific research and progress in modern psychiatry. This probably was the "primal and original sin" which lead the whole DSM improvement effort astray.
American Psychiatry should assume its rightful leadership role in World Psychiatry with its bold and broad, open and independent minded, scientifically eclectic stance, discarding the outdated stereotypes, not reinforcing them; the stance worthy of this great nation and its spirit.

References and Links:

theoretical and conceptual outlook - Google Search

theoretical outlook - Google

conceptual outlook - Google Search

theory - Google Search

Theory - From Wikipedia, the free encyclopedia

concept - Google Search

Concept - From Wikipedia, the free encyclopedia

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methodology - Google Search

Methodology - From Wikipedia, the free encyclopedia

Psychiatric Mislabeling Is Bad For Your Mental Health | Psychology Today

Psychiatric Mislabeling Is Bad For Your Mental Health | Psychology Today

DSM5 in Distress
The DSM's impact on mental health practice and research.
by Allen Frances, M.D.
Allen Frances, M.D.
Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.
more...
Wednesday, May 9, 2012




James Phillips: "Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations. The progression from one DSM to the next is itself a strong reminder that these are historical documents that do not transcend their historical conditions."

Nowhere in contemporary psychiatry does this hermeneutics of historicity, of multiple perspectives, [End Page 66] and of the exposure of hidden assumptions, emerge more forcefully than in the area of diagnosis. It is appropriate then that the first AAPP sponsored monograph should be entitled Philosophical Perspectives on Psychiatric Diagnostic Classification (Sadler, Wiggins, and Schwartz 1994). Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations. The progression from one DSM to the next is itself a strong reminder that these are historical documents that do not transcend their historical conditions. Hermeneutic considerations are engaged at the opening bell with the famous (or infamous) statement that the DSM's diagnostic statements are atheoretical. The notion of an atheoretical diagnosis is, of course, an oxymoron hermeneutically.


James Phillips - Key Concepts: Hermeneutics - Philosophy, Psychiatry, & Psychology 3:1


http://forpn.blogspot.com/2012/05/james-phillips-key-concepts.html

James Phillips - Key Concepts: Hermeneutics - Philosophy, Psychiatry, & Psychology 3:1






Key Concepts: Hermeneutics


James Phillips




Keywords: psychoanalysis, philosophy of science, nosology, classification
Hermeneutics is a concept whose breadth and significance have continued to grow in contemporary thought--and in psychiatry. Since its scope can be best appreciated through an historical overview of its development, I will begin there and then proceed to a discussion of its place in psychiatry. Derived from the Greek verb hermeneuein, which means "to interpret," and the noun hermemeia, "interpretation" (and both associated with the god Hermes), the word was first used in the seventeenth century to mean biblical exegesis (Palmer 1969). The Protestant Reformation created a need to interpret the scriptures without the aid of church authority, and with the plurality of possible interpretations for any biblical text, a need arose to establish the principles of correct interpretation. Hermeneutics was the study of such principles.
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"I argue that clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts." - Theoretical Medicine and Bioethics, Volume 11, Number 1 - SpringerLink



Theoretical Medicine and Bioethics, Volume 11, Number 1 - SpringerLink

Humanities, Social Sciences and Law

Abstract


I argue that clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts. The literary critic reading a novel, the judge asked to apply a law, must arrive at a coherent reading of their respective texts. Similarly, the physician interprets the lsquotextrsquo of the ill person: clinical signs and symptoms are read to ferret out their meaning, the underlying disease. However, I suggest that the hermeneutics of medicine is rendered uniquely complex by its wide variety of textual forms. I discuss four in turn: the ldquoexperiential textrdquo of illness as lived out by the patient; the ldquonarrative textrdquo constituted during history-taking; the ldquophysical textrdquo of the patient's body as objectively examined; the ldquoinstrumental textrdquo constructed by diagnostic technologies. I further suggest that certain flaws in modern medicine arise from its refusal of a hermeneutic self-understanding. In seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject — the living, experiencing patient.
Key words clinical interpretation - embodiment - hermeneutics - history of medicine

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Philosophy and psychiatry - Google Search

Scholarly articles for philosophy and psychiatry

Philosophy and Psychiatry - Rowe - Cited by 3

Search Results

  1. Philosophy of Psychiatry (Stanford Encyclopedia of Philosophy)


    plato.stanford.edu/entries/psychiatry/Similar
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    28 Jul 2010 – Philosophical discussions of mental illness fall into three families. First, there are topics that arise when we treat psychiatry as a special science ...

Philosophy of Psychiatry

First published Wed Jul 28, 2010
Philosophical discussions of mental illness fall into three families. First, there are topics that arise when we treat psychiatry as a special science and deal with it using the methods and concepts of philosophy of science. This includes discussion of such issues as explanation, reduction and classification. Second, there are conceptual issues that arise when we try to understand the very idea of mental illness and its ethical and experiential dimensions. Third, there are interactions between psychopathology and the philosophy of mind; philosophers have used clinical phenomena to illuminate issues in the philosophy of mind, and philosophical findings to try to understand mental illness. This entry will discuss issues in the philosophy of science and philosophy of mind that pertain to psychiatry.

1. Introduction

Scholars and textbooks alike agree (though they might not like it) that psychiatry now adheres to the “medical model”, which advocates “the consistent application, in psychiatry, of modern medical thinking and methods” (Black 2005, 3) because psychopathology “represents the manifestations of disturbed function within a part of the body” (Guze 1992, 44) to wit, the brain. But what does it mean to adopt this view of psychiatry, and what difference does it make?
One might think that the medical model merely commits us to a brain-based view of mental illness with few implications for science, and it is true that clinical or scientific differences across practitioners seldom seem to have much to do with divergent interpretations of the medical model. However, many theorists have argued that our current diagnostic categories, as compiled into DSM-IV-T-R (American Psychiatric Association 2000), are faulty because they are derived from observable variables rather than underlying physical pathologies. These theorists are sceptical about many existing psychiatric diagnoses, and not just on empirical grounds; they see DSM diagnoses as collections of symptoms rather seeing them as medicine understands diseases—in terms of destructive processes realized in bodily tissues. Genuine mental illnesses, on this view, are not just sets of co-occurring symptoms but destructive processes taking place in biological systems. Following Murphy (2009), this may be termed the strong interpretation of the medical model. In contrast, a minimal interpretation of the medical model thinks of mental disorders as collections of symptoms that occur together and unfold in characteristic ways, but it makes no commitments about the underlying causes of mental illness.
These two interpretations correspond to different ways of cashing out the medical model. They are set out in section 2. Explanation is discussed in section 3. The strong interpretation naturally suggests that psychiatry should embrace the practices of medical explanation. If disease is a pathological process in bodily systems, then there must be a way of understanding how such processes occur in the brain, and how they explain the clinically observable facts about mental illness. But it seems that the logic of the medical model does not force us to privilege any one level of explanation—notably, it does not commit us to explanations restricted to the resources of molecular biology. Psychiatry, then, is a multi-level science. But we often know very little about the mental illnesses that psychiatrists study, and much explanation in psychiatry involves case studies or narrative accounts that cite the characteristics of a disorder, rather than underlying systems. Theorists disagree over whether these should be seen as different kinds of explanation, or as rudimentary forms of a full causal explanation. Section 4 discusses some recent treatments of specific mental illnesses that have been held to teach philosophical lessons.

2. The Medical Model and its Implications

The idea that psychiatry is a branch of medicine is not universal, but even if we stick to professed believers in the medical model with the same broad view of the subject, we find disagreements about how its core commitments should be understood. It may be helpful to distinguishminimal and strong interpretations. A minimal interpretation makes no commitments about the underlying physical structure that causes mental illness. The stronginterpretation of the medical model, in contrast, dissents on just this issue. It says that the proper medical understanding of disease is in terms of morbid anatomy. It is committed to specific causal hypotheses in terms of abnormalities in underlying neurobiological systems. Minimalists treat diagnostic labels as useful heuristics rather than natural kind terms, whereas a strong interpretation commits psychiatry to a view of mental illness as a medical disease in the strongest sense, that of a pathogenic process unfolding in bodily systems.
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  1. Association for the Advancement of Philosophy and Psychiatry


    www3.utsouthwestern.edu/aapp/Cached - Similar
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    Information on its conferences, journal and other activities.

Psychiatric diagnoses are not mental p... [Aust N Z J Psychiatry. 2012] - PubMed - NCBI

Aust N Z J Psychiatry. 2012 Apr 23. [Epub ahead of print]

Psychiatric diagnoses are not mental process: Wittgenstein on conceptual confusion.

Source

Centre for Mental Health Research, Australian National University, Canberra, Australia.

Abstract

Background: Empirical explanation and treatment repeatedly fail for psychiatric diagnoses. Diagnosis is mired in conceptual confusion that is illuminated by Ludwig Wittgenstein's later critique of philosophy (Philosophical Investigations). This paper examines conceptual confusions in the foundation of psychiatric diagnosis from some of Wittgenstein's important critical viewpoints.Argument: Diagnostic terms are words whose meanings are given by usages not definitions. Diagnoses, by Wittgenstein's analogy with 'games', have various and evolving usages that are connected by family relationships, and no essence or core phenomenon connects them. Their usages will change according to the demands and contexts in which they are employed. Diagnoses, like many psychological terms, such as 'reading' or 'understanding', are concepts that refer not to fixed behavioural or mental states but to complex apprehensions of the relationship of a variety of behavioural phenomena with the world. A diagnosis is a sort of concept that cannot be located in or explained by a mental process.Conclusion: A diagnosis is an exercise in language and its usage changes according to the context and the needs it addresses. Diagnoses have important uses but they are irreducibly heterogeneous and cannot be identified with or connected to particular mental processes or even with a unity of phenomena that can be addressed empirically. This makes understandable not only the repeated failure of empirical science to replicate or illuminate genetic, neurophysiologic, psychic or social processes underlying diagnoses but also the emptiness of a succession of explanatory theories and treatment effects that cannot be repeated or stubbornly regress to the mean.Attempts to fix the meanings of diagnoses to allow empirical explanation will and should fail as there is no foundation on which a fixed meaning can be built and it can only be done at the cost of the relevance and usefulness of diagnosis.

Updated: 5:43 PM 5/11/2012

Mike Nova: The Hermeneutic (Interpretational) Model Of Clinical Mental Health-Illness Assessment


Mental health and psychopathology on individual, group and social levels, along their biopsychosocial continuum, can be viewed and assessed with hermeneutic method of continuous analysis and interpretation by going from the whole picture to its particulars and back to the whole picture in the attempt to understand their connections, relationships and meanings.

This approach, viewing mental health-illness as a unitary homeostatic conceptual system is better suited for clinical mental health-illness assessment than traditional, medical, categorical diagnostic approach (vs. dimensional, widely used in psychology). The human being as an object of this assessment, in medical, interpersonal and social contexts, is always more than the sum of these parts and certainly more than his/her presumed "psychiatric diagnosis".
The goal of this assessment is three-prong: to identify target symptoms, syndromes, disorders and problems for psychopharmacological, psychotherapeutic and psychosocial interventions.
Thus, psychiatric diagnosis per se becomes the process and conceptual outcome of identification of syndromologically based psychopharmacological targets, which can be transcribed into any of existing categorical diagnostic systems (ICD-10, DSM-4, 5; etc.).
The task then becomes to conceptualise, organise, classify and systematise the historically formed and recognised general psychopathological syndromes (e.g. psychosis, affective states, etc.) as psychopharmacological dimensional targets, regardless of their presumed, hypothetical or known nosology, which corresponds with existing customs of psychopharmacological practice.

Psychiatric patient as "a clinical hermeneutic text"

Psychiatric patient as an object of clinical hermeneutic inquiry shares unique characteristics with the objects of general and traditional hermeneutics (which is the study of understanding and interpretations of "sacred texts"), such as oddity and special, public or private meaning, in content and presentations, the qualities of intuitive drives, puzzle and prophesy, etc. ("madness" and "sacred texts", in their various, including "real life" forms were often connected, throughout history), which might indicate the elements of common nature in these phenomena and confirm the suitability of hermeneutics as a theory, (heuristic) philosophy, method and approach in their studies.
Clinical psychiatric hermeneutics have a potential of developing into the new fields of both philosophical and psychiatric inquiries. Philosophy and psychiatry had always been close, and it looks like this romance might reignite lively and productively.

Psychiatric Diagnosis as a Clinical Interpretational "Hermeneutic Circle" of Understanding and Continuous Analysis and Integration of its particular symptomatological, syndromological; intrapsychic and psychosocial parts on their biopsychosocial continuum and the whole, continuously changing, redefining and refining Dynamic Psychiatric Diagnostic Formulation (although not necessarily and always in a psychodynamic sense). - (1)

Psychiatric diagnosis per se, or medical part of this diagnostic system is a systematic combination of Core (prevailing) Psychopathological Syndromes (with their subjective symptoms and objectively observed signs), psychometrically measured; and well established medical nosologies (if and when they can be recognised).

This system also corresponds with existing clinical practice of "provisional diagnoses". Any psychiatric diagnosis is, to a significant degree, "provisional"; just like any good medical diagnostic impression.

Psychodynamic interpretation and formulation as clinical hermeneutic devices

Psychodynamic interpretation and formulation as clinical hermeneutic devices - Google Search

Psychodynamic interpretation and formulation as clinical hermeneutic devices - Google Blog Search


Psychodynamic interpretation hermeneutics - Pubmed Search

Psychodynamic interpretation hermeneutics - Pubmed - RSS

References and Links


(1) Michael Novakhov - The Hermeneutic Round Of Understanding In Clinical Psychopathology - unpublished manuscript - 1983 - will be scanned and posted

 

via Behavior and Law by Mike Nova on 5/7/12

Mike Nova: The Health Of Nations


The idea of social justice is as old as are the ubiquitous and blatant practices of social injustice, first of all enslavement in its various forms and exploitation, on which "The Wealth Of Nations" was built. The 20th century Marxism seems to have combined both seamlessly.
Today we see more and more that "wealth of nations" depends to a large degree on "health of nations", namely, not only the conditions of their respective health services but their just (and therefore economically efficient) social and political order. The broad and universal concept of health with its notions of normal and abnormal social functioning can and should be applied to large social groups and systems, extending from the traditional notions of individual and small groups (family, industrial groups) to social health or socio-political pathology of countries and cultures (e.g. "failed states").


References and Links

Social class in the United States - From Wikipedia, the free encyclopedia:
Social class in the United States is a controversial issue, having many competing definitions, models, and even disagreements over its very existence.[1] Many Americans believe in a simple three-class model that includes the "rich", the "middle class", and the "poor". More complex models that have been proposed describe as many as a dozen class levels;[2][3] while still others deny the very existence, in the European sense, of "social class" in American society.[4] Most definitions of class structure group people according to wealth, income, education, type of occupation, and membership in a specific subculture or social network.
Sociologists Dennis Gilbert, William Thompson, Joseph Hickey, and James Henslin have proposed class systems with six distinct social classes. These class models feature an upper or capitalist class consisting of the rich and powerful, an upper middle class consisting of highly educated and affluent professionals, a middle class consisting of college-educated individuals employed in white-collar industries, a lower middle class, a working class constituted by clerical and blue collar workers whose work is highly routinized, and a lower class divided between the working poor and the unemployed underclass.[2][5][6]
A monument to the working and supporting classes along Market Street in the heart of San Francisco's Financial District


Mike Nova: Individual, group and social psychopathology can be viewed and conceptualised on the same biopsychosocial continuum. "Erich Fromm proposed that, not just individuals, but entire societies "may be lacking in sanity" - Sanity - Wikipedia, the free encyclopedia

Mike Nova: Individual, group and social psychopathology (and "normality") can be viewed and conceptualised on the same biopsychosocial continuum.

References and links:

biopsychosocial continuum - Google Search


Biopsychosocial model - From Wikipedia, the free encyclopedia

Sanity - Wikipedia, the free encyclopedia

In The Sane Society, published in 1955, psychologist Erich Fromm proposed that, not just individuals, but entire societies "may be lacking in sanity". Fromm argued that one of the most deceptive features of social life involves "consensual validation."[3]:
It is naively assumed that the fact that the majority of people share certain ideas or feelings proves the validity of these ideas and feelings. Nothing is further from the truth... Just as there is a folie à deux there is a folie à millions. The fact that millions of people share the same vices does not make these vices virtues, the fact that they share so many errors does not make the errors to be truths, and the fact that millions of people share the same form of mental pathology does not make these people sane.[4]

Fromm, Erich. The Sane Society, Routledge, 1955, pp.14–15.



References and Links:

Mike Nova: Breivik Trial and The Crisis Of Psychia...


Thursday, April 19, 2012

Mike Nova: Breivik Trial and The Crisis Of Psychiatry As A Science

Mike Nova

Breivik Trial and The Crisis Of Psychiatry As A Science

Breivik is not the only one who is on this trial. Psychiatry as a science is on this trial also, just like on many other trials where forensic psychiatric involvement is sought. This is highlighted by the two contradictory psychiatric assessments of the accused, with their directly opposing diagnostic impressions and directly conflicting main general conclusions. The first forensic psychiatric evaluation, completed on November 29, 2011 by the psychiatrists Torgeir Husby and Synne Sørheim found Breivik to be "paranoid schizophrenic" and "psychotic" at the time of the alleged crime and presently and therefore legally "insane". A leaked copy of the initial psychiatric examination described his crusader fantasy as a product of the "bizarre, grandiose delusions" of a sick mind.
The second evaluation, about 300 pages long, made by the psychiatrists Terje Toerrissen and Agnar Aspaas on a request from the court after widespread criticism of the first one, was completed on April 10, 2012, just six days before the trial, but was not released, and according to the leaked information, found him afflicted with "narcissistic personality disorder" with "grandiose self" and not psychotic at the time of the alleged crime and presently and therefore legally "sane".
The latest psychiatric report was confidential, but national broadcaster NRK and other Norwegian media who claimed to have seen its conclusions said it described Breivik as narcissistic but not psychotic.
Torgensen gets the impression that Breivik found an ideal place to nourish his delusions of grandeur in the anti-Islamic scene full of crusader fantasies. “This was coupled with an extremely sadistic disorder,” Torgensen says. “This disastrous combination could explain the scale of his violence.”
The new report from forensic psychiatrists Terje Tørrissen and Agnar Aspaas concludes that he did not have “significantly weakened capacity for realistic evaluation of his relations with the outside world, and did not act under severely impaired consciousness”.
"Our conclusion is that he (was) not psychotic at the time of the actions of terrorism and he is not psychotic now," Terje Toerrissen, one of the psychiatrists who examined Breivik in prison, told The Associated Press.
Thus, as it almost always happens in complex forensic psychiatric cases, it was left for the infinite wisdom and common sense of the court, unburdened by the "sophisticated" and empty psychiatric jargon, to decide by itself, and rightly so, the "main questions" of the accused's mental illness or mental health and his "sanity" or "insanity" and to make its own, judicial decision regarding the issue of legal responsibility. Both mutually conflicting (but not mutually exclusive) forensic psychiatric evaluations, which, no doubt, were performed in good faith and with utmost professional diligence, will be taken into account by the court, but were rendered almost irrelevant by their contradictions. Once again, psychiatry, pretending to be a medical discipline and a science, was humiliated and reduced to the position of a laughing stock for the public and the media.
Mr. Breivik's skillful and astute lead defense lawyer, Mr. Geri Lippestad, treating his client with respect and at the same time with appropriate professional distance and apparently convinced of his client's mental illness and "insanity", chose a strategy of presenting Mr. Breivik to the court and to the public "as is", letting him to reveal himself and his presumed mental illness fully as the engine of alleged criminal behavior, apparently counting that it will be convincing enough for both the judges and for the court of public opinion.
“This whole case indicated that he is insane,” Geir Lippestad told reporters. “He looks upon himself as a warrior. He starts this war and takes some kind of pride in that,” Lippestad said. Lippestad said Breivik had used “some kind of drugs” before the crime to keep strong and awake, and was surprised he had not been killed during the attacks or en route to Monday’s court hearing.
Lippestad, a member of the Labour party whose youth wing had been the target of Friday’s shooting rampage, said he would quit if Breivik did not agree to psychological tests.
Geir Lippestad said the new report means Breivik's testimony will be crucial "when the judges decide whether he is insane or not." The trial started on April 16 and is scheduled to last 10 weeks.
Mr. Breivik declared himself undoubtedly and completely "sane" and consistently, if somewhat eerily out of place and time, painted a self-portrait as a model and self-sacrificing ideological warrior, taking as an insult any, albeit "professional" opinions otherwise and dismissed them with anger and indignation.
“On this day,” he said, “I was waging a one-man war against all the regimes of Western Europe. I felt traumatized every second that blood and brains were spurting out. War is hell.”
"Breivik told the court that "ridiculous" lies had been told about him, rattling off a list which accused him of being a narcissist who was obsessed with the red jumper he wore to his first court hearing, of having a "bacterial phobia", "an incestuous relationship with my mother", "of being a child killer despite no one who died on Utoya being under 14".
He was not insane, he repeated many times. He claimed it was Norway's politicians who should be locked up in the sort of mental institution he can expect to spend the rest of his days if the court declares him criminally insane at the end of the ten-week trial. He said: "They expect us to applaud our ethnic and cultural doom... They should be characterised as insane, not me. Why is this the real insanity? This is the real insanity because it is not rational to work to deconstruct ones own ethnic group, culture and religion."
All this is fine and dandy, and, no doubt, the aforementioned infinite wisdom of Scandinavian level headed justice (embodied in a stern but motherly demeanor of the presiding Judge Wenche Elisabeth Arntzen) will eventually emanate from its somewhat obscure, slowly but surely turning and unstoppable wheels, hopefully to almost every one's satisfaction. And eventually, this horrendous crime, the purp and the trial will be almost forgotten and placed into archives for further studies.
But the nagging questions remain and will remain for some, and probably a long time: is psychiatry really a science? Or is it just a collection of "professional" opinions, mixed with convenient labels and outdated jargon? What is "sane" and what is "insane"? And how far should the justice go in its modern "humane" stance?

"Grete Faremo, Norway’s justice minister, has said that it plans to establish a committee to examine the role of forensic psychiatrists. She told Norwegian daily Aftenposten on April 13 the committee would have a “broad mandate” that would examine three key questions: What is sanity? What is the role of the forensic psychiatrist? And how do we take care of security when an insane man is sentenced?
“Much suggests that the medical principle is inadequate,” said Faremo. “It is a historic step we are now taking. It is an important step in light of the terrible incident and the trial we face and in consideration of people's sense of justice.”
“This is a big thing,” says Abrahamsen. “If it hadn’t been for Breivik, we wouldn’t have discussed this.”


___________________________

Friday, April 27, 2012

Response to Dr. Wessely

Response to Dr. Wessely

Normality or psychopathology of belief or belief system is determined first of all by the intrinsic qualities of belief in question. It is not determined by the fact that belief is shared or not shared: "Delusions are beliefs that are not only wrong, in the sense of not corresponding to the world as we know it, but they must also not be shared with others of the same cultural background."
There are many delusional beliefs that are or were shared, and some of them on a rather large scale. For example, the ancient Maya believed, that for the sun to rise they had to offer human sacrifices (of their best and brightest) every day, otherwise all kind of life on earth would come to a halt. This belief was shared very widely in precolumbian Maya culture, which does not make it less delusional.
Breivik's ultra nationalist anti-immigrant ideology is shared by great many people of various cultural backgrounds. The goal of his forensic psychiatric evaluation is to assess his own particular belief system, with all its peculiarities and idiosyncrasies, in order to determine its nature, qualities and psychopathological aspects, regardless of other similar beliefs. In the end, it was him, not others, who took these ideas to their logical (or rather illogical and "sick") extreme, although the (possibly facilitating) role of "significant others" in his case still has to be determined.
Neither the "monstrosity" and "grievous consequences" of his actions nor "popular misconceptions" should cloud the picture. The most important factor in his forensic psychiatric assessment is the presence or absence of identifiable and diagnosable mental illness and the degree of its causal relationship with the crime. In my opinion, whatever it is worth, psychopathological qualities of Breivic's beliefs: their highly systematised, structured, all embracing "world view" quality, along with their unshakable, messianic conviction and "call for action", indicate with high degree of probability the presence of Delusional Disorder, mixed, persecutory-paranoid type, and the direct and overwhelming causal connection of his psychopathology with the criminal act.
The cognitive aspect in psychopathology of Delusional Disorders (abnormalities and/or dysfunctions in concept selection, elimination and confirmation), indicating possible subtle but decisive organic involvement is much under-researched area, probably due to our neglect or inattention to biological aspects of these disorders and overestimation of its psychodynamic aspects. Delusional jealousy, secondary to chronic alcoholism (a very discrete and specific syndrome) is the case in point.
"The... misconception... that the purpose of psychiatry is to “get people off”" might be as wide spread as any other misconception, which does not make it any less of a misconception. The historically formed legal concept of "NGRI: not guilty by reason of insanity" is a witness to humanity and rationality on a part of a society; not to mention other, less important but present factors, such as political and social convenience, expediency and cultural traditions. (E.g.: Disraeli to Queen Victoria: "Only a madman can think about assassinating your Majesty..."). Modern psychiatry, very likely, was born out of the M'Naghten rules, as some psychiatric historians suppose.
And last, but certainly not least, is the difficult and complex subject of "Schizophrenia", its clinical concept (and/or misconcept) and diagnosis (and/or misdiagnosis). The diagnostic label of "Schizophrenia" became so wide spread and all encompassing (because it is so easy to apply, and is applied almost indiscriminately), as to loose its meaning and clinical value. In our rush to nosological (and reimbursement) parity with the rest of medicine we jumped over our heads too soon, introducing the (man made) diagnostic criteria based "nosological" system, which leads to premature ossification and codification of clinical concepts and experience, impeding the independent minded research greatly and precluding the normal development (albeit slow and lagging) of psychiatry as a medical science. Is it not more correct and probably clinically more productive, especially in the field of psychopharmacology, to return to syndromologically based classification system and to try to define, refine and research these historically formed clinical syndromes further, before rushing to judgements about their pseudonosological "pigeon holes"?
This is what Breivic trial, along with other issues, brings to the front. And these issues deserve a deep and long thought.

Michael Novakhov, M.D.

References and Links

Anders Breivik, the public, and psychiatry : The Lancet


Anders Breivik, the public, and psychiatry : The Lancet

The Lancet, Volume 379, Issue 9826, Pages 1563 - 1564, 28 April 2012
doi:10.1016/S0140-6736(12)60655-2Cite or Link Using DOI


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Sanity - Wikipedia, the free encyclopedia

In The Sane Society, published in 1955, psychologist Erich Fromm proposed that, not just individuals, but entire societies "may be lacking in sanity". Fromm argued that one of the most deceptive features of social life involves "consensual validation."[3]:

It is naively assumed that the fact that the majority of people share certain ideas or feelings proves the validity of these ideas and feelings. Nothing is further from the truth... Just as there is a folie à deux there is a folie à millions. The fact that millions of people share the same vices does not make these vices virtues, the fact that they share so many errors does not make the errors to be truths, and the fact that millions of people share the same form of mental pathology does not make these people sane.[4]

Fromm, Erich. The Sane Society, Routledge, 1955, pp.14–15.

sane society - Google Search


Erich Fromm - From Wikipedia, the free encyclopedia
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Posted by Mike Nova at Friday, April 27, 2012 

Read the complete post with news and journal articles:


Mike Nova: American Psychiatry At The Crossroads


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Sunday, May 13, 2012

Mike Nova: I support Dr. Frances' idea about founding some new... interdisciplinary body for establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis

Last Update: 9:20 AM 5/13/2012

Mike Nova: I support Dr. Frances' idea about founding some new, superpsychiatric (possibly under combined umbrella of all the appropriate agencies that he mentioned) interdisciplinary body for

Establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis,

which should include efficient participation of philosophers, neuroscientists, geneticists, biologists, psychologists, sociologists, specialists in forensic behavioral sciences and lawyers.

Maybe, with a little help from our friends the "heavenly gate" to a new, broader scientific paradigm in psychiatry will crack open; a little.

And this might lead to true and real (not imaginary, as a product of the wishful thinking), scientifically revolutionary "paradigm shift". Any new paradigm in psychiatry (just like in any other scientifically oriented ideational activity, according to Kuhn) has to be significantly broader than the previous one, incorporating the new body of knowledge, disciplines and theories in a new conceptual framework, resolving the "anomalous contradictions" of the old paradigm which becomes conceptually inadequate to contain them.

This new paradigm must also fit into the larger current paradigmatic systems of scientific and cultural beliefs, and the present lively debate about the meanings and the essence of psychiatric diagnosis is one, and maybe the best indication that the old paradigm "does not fit", that it is scientifically (which is not synonymous with medical practice) - inadequate.

It is also interesting to observe that the battle for this new paradigm is waged in a mainstream media, which might also indicate "the revolutionary situation" expressed as a heightened public awareness and concerns which are absolutely justified, legitimate and significant.

Posted by Mike Nova at Sunday, May 13, 2012


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Mike Nova's starred items

What is Critical Psychiatry? | Mad In America: Over the last twenty years there has emerged a body of work that questions the assumptions that lie beneath psychiatric knowledge and practice. This work, appearing as academic papers, magazine articles, books, and ...

via Mad In America » Blogs by Philip Thomas, M.D. on 1/21/13
Over the last twenty years there has emerged a body of work that questions the assumptions that lie beneath psychiatric knowledge and practice. This work, appearing as academic papers, magazine articles, books, and chapters in books, hasn’t been written by academics, sociologists or cultural theorists. It has emerged from the pens and practice of a group of British psychiatrists.
This is not antipsychiatry. There are important differences between the antipsychiatry of the 1960s and present-day critical psychiatry; there are also important points of convergence, but the two nonetheless are quite different. Some of these similarities and differences will become clear as this series of blogs, written to complement the narrative blogs I’ll occasionally be posting, evolve over time.
In this series of postings, to appear under the ‘Critical Psychiatry’ tag, I want to present an overview of some of this work. This is because interest in critical psychiatry is growing, especially in the USA. There will be presentations by British critical psychiatrists at the APA annual meeting in San Francisco, and the Institute on Psychiatric Services in Philadelphia, both this year. This series of blogs about critical psychiatry is also by way of a sneak preview of a book I’m writing about British critical psychiatry, to be published by PCCS Books – http://www.pccs-books.co.uk – in the near future; watch this space!
So what exactly is critical psychiatry? The bulk of this work has been written by a small group of psychiatrists, all of whom are, or were, practicing psychiatrists in the NHS in England. All are associated with the Critical Psychiatry Network – http://www.criticalpsychiatry.co.uk – which first met in Bradford, England in 1999. The most active members of this group have between them written ten single or dual author books, ten edited books with forty-two chapters, and one hundred and thirty seven papers mostly in peer-reviewed journals. A survey of this work reveals that it covers five themes:
  1. The problems of diagnosis in psychiatry
  2. The problems of evidence based medicine in psychiatry, and related to this, the relationship between the pharmaceutical industry and psychiatry.
  3. The central role of contexts and meanings in the theory and practice of psychiatry, and the role of the contexts in which psychiatrists work.
  4. The problems of coercion in psychiatry.
  5. The historical and philosophical basis of psychiatric knowledge and the practice of psychiatry.
These themes are not mutually exclusive, for example, there is a close relationship between some aspects of the problems of diagnosis, particularly the problem of validity, and the problems of evidence-based medicine. In addition, the problems of diagnosis in psychiatry may also be seen in terms of another set of issues, that of the application of the methods of scientific inquiry to human subjects. This in turn relates to a third, that of the neglect of contexts and meanings in contemporary psychiatric practice. And, at a conceptual level, these problems can be understood in terms of three key philosophical issues, the nature of knowledge and different ways of knowing about the world (epistemology), the nature of the body-mind relationship, and the relationship between mind and the world, especially the social world.
These three issues are of fundamental importance in understanding the limitations of scientific psychiatry. Most important of all, however, is a focus on the moral and ethical implications of the use of scientific knowledge (whether biological, psychological, sociological) in relation to madness and distress. Ultimately, critical philosophical thought has a great deal to offer when it comes to understanding how these different problems of psychiatric knowledge and practice are related. In this blog I will focus on the first of these themes. Subsequent blogs in the coming months will deal with the others.
The problems of diagnosis in psychiatry
The writings of critical psychiatrists see the problems of diagnosis in psychiatry in two areas: problems with the scientific basis of psychiatric diagnoses, and the moral problems that can arise from the use of psychiatric diagnosis.
The scientific basis of diagnosis in psychiatry
Joanna Moncrieff (1997) points out that despite extensive scientific research, there is no convincing evidence that specific biological causes account for either depression or schizophrenia. Research councils and other funding bodies have invested huge sums of money over the years in the quest for the biological basis of the condition called schizophrenia, but without success. Researchers in molecular genetics, neuroimaging and other neuroscientific fields persistently overstate the significance of their findings. Duncan Double (2000) also questions the evidence to support a biological basis for psychiatric diagnoses. He points out that a low level of agreement over the diagnosis of schizophrenia between psychiatrists in different countries has hampered psychiatric research.
Until the 1970s, American psychiatrists had a much broader conception of schizophrenia than their British colleagues, who used the diagnosis much less frequently. He also points out that the monoamine theory of depression and the dopamine theory of schizophrenia developed after the introduction of drugs that were claimed to ‘cure’ these conditions. Prior to this there was little interest in neurotransmitters like dopamine and the monoamines. This emerged when laboratory research drew attention to the effects of these drugs on neurotransmitters. Only then did these theories emerge. In contrast, the discovery of drugs to treat neurological conditions like Parkinson’s disease resulted from extensive laboratory research into the role of dopamine as a neurotransmitter.
The biological basis of schizophrenia remains elusive and unsubstantiated (Thomas, 2011). One reason for this as Duncan Double (2002) points out that is the poor level of agreement between psychiatrists over the diagnosis. This was one of the factors responsible for the move towards a more scientific psychiatry heralded by DSM-III. The first edition of the DSM published in 1952 gave definitions and criteria for 106 categories of psychiatric disorders, but the publication of the fourth edition in 1994 saw this number swell to 354. The third edition ‘…encouraged the reification of psychological conditions. Social phobia, post-traumatic stress disorder, for example, were first included in international classifications in DSM-III.’ (Double, 2002:902). The third edition, he suggests, coincided with the growing influence of scientific psychiatry, and a return to the values expounded by the German psychiatrist Emil Kraepelin a hundred years earlier.
Sami Timimi (2004) argues that the diagnosis of attention deficit hyperactivity disorder (ADHD) is a cultural construct. He points out that there are no specific biological or psychological markers for the condition, and as a result of disagreements and uncertainties over the definition there are wide variations in the prevalence of the condition. One thing that is clear from epidemiological studies is the condition has become much more common over time. In order to understand this we have to adopt a cultural perspective, and in particular recent changes in Western culture.
The expansion of diagnosis has also been a feature of child psychiatry. Until relatively recently the emphasis here was on child development, the family, and psychodynamic and social understandings of childhood. Sami Timimi (2004a) points out that before the introduction of DSM-III, depression was an uncommon diagnosis in childhood. It was also considered to be different from depression in adults, and not to respond to antidepressant drugs. This changed when an influential group of academic child psychiatrists claimed that childhood depression was more common than most people thought, and that it responded to physical treatments. Sami Timimi argues that current psychiatric diagnostic criteria in depression are so broad as to be useless. Most children can be identified as suffering from some form of psychiatric disorder. In addition there are low levels of agreement between the diagnosis of depression and the psychosocial problems that are usually associated with it. This raises serious doubts about the value of constructs like childhood depression.

The moral problems of diagnosis
In Britain this is seen most tragically in the problematic encounter between psychiatry and people from Black and Minority Ethnic (BME) communities. Suman Fernando (1991) argues that belief in the neutrality of psychiatric knowledge and practice has helped to conceal the racist assumptions in which the two are based. This problem operates nationally and globally. In Britain there a huge body of evidence has accumulated over the last fifty years that the incidence of schizophrenia is much higher in people from African-Caribbean communities, especially young men. This fact, allied with what is a widely held but racist perception that young Black men are dangerous, is linked to the higher rates of compulsion and coercion they experience in mental health services. Young black men are also more likely to receive physical treatments and higher doses of drugs in hospital than other groups.
But the problem doesn’t end there. Psychiatric theories resort to racist explanations for the raised incidence of schizophrenia in black people, based either in supposed biological or genetic differences between black people and the white majority, or in the family structures and life styles (especially cannabis use) that are said to characterise the African-Caribbean cultures. Psychiatry consistently locates the origins of the problem of schizophrenia in the biology or culture of these young men, and not in the experiences of racism and discrimination that feature prominently in their lives. This is a serious moral failure.
Racism is a difficult issue for health professionals to have to face up to. Kwame McKenzie (2003) argues that the experiences of racism have adverse effects upon the health of those affected. This can be seen in the raised incidence of high blood pressure, respiratory illnesses, anxiety, depression and psychosis in black people. Writing in the context of the Macpherson Report into the failure of the Metropolitan Police to bring about a prosecution in the racist murder of black teenager Stephen Lawrence, he (McKenzie, 1999) points out that like the police, doctors take offence to accusations of racism. This is where the idea of institutional racism is helpful, because it considers how the values and structures of mental health services inadvertently discriminate against minority groups.
More generally, as Duncan Double (2002) argues, the use of diagnosis based in biological explanations of experience eliminates the possible significance of the meaning of distress, and obscures its social and psychological origins. This encourages people to see themselves as powerless to do anything about their problems. This has important implications for recovery.
The use of diagnosis has become an important tool in the pharmaceutical industry’s attempts to extend its global commercial interests, and Suman Fernando (1991) points out that this has harmful consequences on local understandings of distress and madness and the systems of support that are based in this, especially in non-Western countries. Western scientific understandings of distress originate in historical and philosophical assumptions about the self that are a feature of Western civilization. International agencies like the World Health Organisation (WHO) place additional pressures on non-Western countries to adopt Western ‘solutions’ to the problem of madness, indirectly endorsing the pharmaceutical industry’s agenda and further weakening local support systems. Support for this view comes from a paper that Pat Bracken & I wrote (Bracken & Thomas, 2001), which argues that scientific accounts of distress exemplified by the DSM are rooted in the view that human suffering would ultimately yield to scientific progress.
The notion of progress through rational scientific thought originated in the European Enlightenment. One of the important outcomes of this period of thought and history was the replacement of religious belief and superstition by science and rationality in our attempts to understand our lives and our relationship to the world. The scientific approach, which reached its apogee in the Decade of the Brain, replaced a wide variety of non-scientific ways of understanding madness and distress, first in Europe, but increasingly through the second half of the twentieth century, across the globe.
If it is the case that psychiatric diagnoses have no firm scientific basis, and that they are little more than consensus statements produced by committees of experts, then it should come as no surprise to discover that political factors play an important part in their creation and abolition. Forty years ago the British and American psychiatric establishments rightly attacked the former Soviet Union for its use of the diagnosis sluggish schizophrenia as a means of silencing dissidents. At the same time gay activists in the USA campaigned politically to have homosexuality removed as a diagnosis from the DSM, and in 1973 it was replaced by the category sexual orientation disturbance. Derek Summerfield draws attention to the political nature of psychiatric diagnosis, and the moral problems that arise from this. He argues that the origin of the diagnosis of post-traumatic stress disorder (PTSD) was a political, not scientific, achievement.
Following the Vietnam War the U.S. anti-war movement persuaded military psychiatry to provide help and support for veterans. As a result the diagnosis of PTSD replaced earlier conceptions of battle fatigue and war neurosis, and drew attention to the traumatogenic nature of war. In doing so the diagnosis also transformed Vietnam veterans from perpetrators of war atrocities to victims of trauma; the category ‘…legitimized the “victimhood”, gave moral exculpation…’ (Summerfield, 2001:95). The diagnosis of PTSD has less to do with science and natural categories than it has to do with internal political struggles to salve a nation’s conscience after a terrible conflict.
Western concepts of trauma and the psychiatric diagnosis of PTSD attempt to redefine the moral consequences of conflict. In another paper Derek Summerfield points out that surveys of the residents of war zones tend to interpret feelings of revenge as an indicator of poor mental health (Summerfield, 2002) For example in Croatia, a foreign-led project told Croatian children affected by the war that not hating Serbs would help them to recover from trauma. In South Africa, studies of the victims of apartheid found that PTSD was significantly more common in those who were unforgiving (as measured by their score on a ‘forgiveness’ scale).
These, and similar, studies give weight to the view that forgiveness is necessary for recovery. Thus the emotional responses of those affected by war, ‘traumatisation’ or ‘brutalisation’, are held to be harmful and in need of modification. This belief, he argues, provides the basis for large scale counselling interventions by Western aid agencies. He challenges this view, by asking is anger and the need for revenge necessarily a bad thing. They draw attention to the moral aspects of injustice that lead to suffering in the first place, and the importance of social cohesiveness and solidarity as a social and cultural response to the injustices of war.

References
Bracken, P. & Thomas. P. (2001) Postpsychiatry: a new direction for mental health. British Medical Journal, 322, 724 – 727.
Double, D. (2000) Critical Psychiatry. CPD Bulletin Psychiatry, 2, 33 – 36.
Double, D. (2002) The Limits of Psychiatry. British Medical Journal, 324, 900-904.
Fernando, S. (1991) Mental Health, Race and Culture. Macmillan / Mind Publications, London. (1st edition).
McKenzie, K. (1999) Something borrowed from the blues? British Medical Journal, 318, 616 – 617.
McKenzie, K. (2003) Racism and Health. British Medical Journal, 326, 66.
Moncrieff, J. (1997) The medicalisation of modern living. Soundings, 6, 63 – 72.
Summerfield, D. (2001) The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal 322, 95 – 98.
Summerfield, D. (2002) Effects of war: Moral knowledge, revenge, reconciliation, and medicalised concepts of recovery. British Medical Journal, 325, 1105-1107.
Thomas, P. (2011) Biological explanations for and responses to madness. Chapter Fourteen in (eds. D. Pilgrim, A. Rogers and B. Pescosolido) The SAGE Handbook of Mental Helath and Illness. London, Sage. (pp 291 – 312).
Timimi, S. (2004) In Debate: ADHD is best understood as a cultural construct – For. British Journal of Psychiatry (In Debate) 184, 8-9.
Timimi, S. (2004a) Rethinking childhood depression. British Medical Journal, 329, 1394-1397.

Mike Nova's starred items

via Critical psychiatry by Duncan Double on 12/1/12
Recent article in The Lancet makes reference to an article that I commented on in a previous post. It suggests that in some ways psychiatry is a "speciality only beginning to define itself".

Wonder why it's taken so long to do that! Perhaps the article is trying to dissociate itself from psychiatry's history (see my chapter in Mental health ethics). If it's following the previous article, this means believing that psychiatry needs to "realign itself as a key biomedical specialty at the heart of mental health". That's always been the hope of psychiatry that it will find the biological basis of mental illness. And, what's that got to do with being a "branch of medicine that seeks to support some of the most marginalised members of society", which is what the article says psychiatry is?

The latter characterisation of psychiatry may even raise questions. The article favourably references The Lancet's Global Mental Health Series, which I have commented on in a previous post. However, social factors, such as poverty and injustice, are not necessarily at the centre of the understanding of mental health problems in modern psychiatric practice.

The article also mentions the Schizophrenia Commission's recent report, but doesn't mention the Inquiry into the schizophrenia label (ISL) (see previous post). Suman Fernando, one of the ISL co-ordinating group, has commented on the report. Psychiatry should be about treating people with mental health problems as persons, but this isn't always the case. A helpful feature of the Schizophrenia Commission's report is its recognition that too many people with a diagnosis of schizophrenia are in secure psychiatric provision.

via Critical psychiatry by Duncan Double on 12/5/12
Special article, with my name (see my book chapter on need for paradigm shift in psychiatry) as one of the 29 authors (first author Pat Bracken - see previous post), has been published in the British Journal of Psychiatry. An accompanying editorial by Arthur Kleinman, who I have mentioned in previous posts (eg. see entry), argues that academic psychiatry has been too biomedical. Perhaps it's easier for Kleinman to say this in a British journal, rather than in the USA where NIMH has dominated research (eg. see previous blog entry).
Congratulations to the BJPsych editor for encouraging this debate. I have said previously that I have been surprised by some of his comments from the editor's desk (eg. see post). He has made his position clearer in his current commentary. He seems worried that psychiatry may be no more than quackery. I'm not saying this to encourage a civil war in psychiatry, but his position could encourage neuromania (eg. see previous post). We need to move on from this.

via Critical psychiatry by Duncan Double on 1/19/13
Following the special article in the British Journal of Psychiatry (see previous post), the Critical Psychiatry Network has organised a day at the University of Nottingham on 15th April 2013 (see provisional programme).

via critical psychiatry - Google Blog Search by Duncan Double on 12/4/12
Special article, with my name (see my book chapter on need for paradigm shift in psychiatry) as one of the 29 authors (first author Pat Bracken - see previous post), has been published in the British Journal of Psychiatry.

via critical psychiatry - Google Blog Search by dave traxson on 1/14/13
The Critical Psychiatry Network is a group of British psychiatrists who first met in Bradford, England in January 1999 in response to proposals by the British government to amend the 1983 Mental Health Act (MHA). There was ...

via critical psychiatry - Google Blog Search by Philip Thomas, M.D. on 12/15/12
Over the coming months I will use these stories to examine the different ways of working that follow on from being a 'critical' psychiatrist. The great advantage with thinking about psychiatric practice in terms of narrative, as ...








Expanding mental health services is a far better alternative than armed guards
Kansas City Star
A yearlong study commissioned by the American Psychological Association found no evidence that zero tolerance contributes to school safety or improved behavior, and concluded that it worsens racial disparities in school discipline, causes hardship for ...

and more »

via critical psychology - Google Blog Search by desmondpainter on 9/17/12
I am attending the Third Critical Psychology Symposium in Diyarbakir, Turkey — another great opportunity for psychologists from the peripheries of North-Atlantic psychology to forge links, create alternative networks, and learn ...

via critical psychology - Google Blog Search by admin (Mark Burton) on 9/21/12
Statement agreed following discussion at the Third Critical Psychology Symposium (Diyarbakir, Turkey). It has been forwarded to those in Mexico campaigning for a proper investigation into the disappearance of Ana Belén, ...

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via critical psychology - Google Blog Search by Lisa Firestone, Ph.D. on 1/23/13
Overcoming that internal critic we all possess By Lisa Firestone, Ph.D....

via critical psychology - Google Blog Search by critpsych IKP on 1/15/13
The conference attempts to substantiate a critical situated approach to the experiences and actions of practicing human life in today's social and technological world, and to debate how the study of subjects in the context of ...

via critical psychology - Google Blog Search by Antonio C. S. Rosa on 10/12/12
`Critical psychology` has emerged in academic arenas very fast in recent years, and it stretches to the limit the self-critical reflexive activity that should characterise any good mainstream psychological research. It should be ...

via critical psychology - Google Blog Search by By Andy Greder, Sarah Horner and Will Ashenmacher Pioneer Press on 1/14/13
Peter Linnerooth was an affable, punctual and conscientious graduate student at Minnesota State Mankato. He later earned a doctorate degree, became an Army psychologist and was deployed to Iraq during the height of the ...

via critical psychology - Google Blog Search by Centre for Medical Humanities on 1/22/13
The 8th Biennial Conference of the International Society of Critical Health Psychology (ISCHP) will be held at the University of Bradford in Bradford, Yorkshire, England, 22nd-24th July 2013. This conference is being ...

via critical psychology - Google Blog Search by marianohadi on 1/8/13
How to Think Like a Psychologist: Critical Thinking in Psychology (2nd Edition) book download Donald McBurney Download How to Think Like a Psychologist: Critical Thinking in Psychology (2nd Edition) Teaching Critical ...

via critical psychology - Google Blog Search by admin (Mark Burton) on 9/21/12
Statement agreed following discussion at the Third Critical Psychology Symposium (Diyarbakir, Turkey). It has been forwarded to those in Mexico campaigning for a proper investigation into the disappearance of Ana Belén, ...

via critical psychology - Google Blog Search by desmondpainter on 9/17/12
I am attending the Third Critical Psychology Symposium in Diyarbakir, Turkey — another great opportunity for psychologists from the peripheries of North-Atlantic psychology to forge links, create alternative networks, and learn ...

Critical psychology has emerged as a vibrant site of research and reflection on the assumptions and practices of its host discipline. As serious scholarship flourishes in the area as never before, this new collection from the ...

via critical psychology - Google Blog Search by CritPsych IKP on 1/23/13
CfP Critical Health Psychology (http://criticalpsychology.wordpress.com #cfp #criticalpsychology #health) Call for Papers: 8th Biennial Conference of the International Society of Critical Health Psychology; Bradford, UK; 22-24 ...


Examiner.com







Former Army psychologist critical of military dies by suicide
Pioneer Press
After his career as an Army psychologist, Linnerooth was critical of the Army and its response to the mental health needs of soldiers. In a 2010 interview, he lambasted military leadership for not being more connected with on-the-ground troops and for ...
Army psychologist critical of military rights abuses commits suicideExaminer.com

all 7 news articles »









Should babies be allowed to 'cry it out'?
CNN International
A few weeks ago, the journal Developmental Psychology published a study supporting the notion that a majority of infants over the age of 6 months may best be left to self-soothe and fall back to sleep on their own. Noting that sleep deprivation can ...

and more »









NZ Experts Join International Counterparts on Glenn Inquiry
Scoop.co.nz (press release)
Associate Professor in Critical Psychology and Head of School at the School of Psychology at Massey University. Involved in a research programme on domestic violence services and interventions. Recently collaborated with other researchers and ...

and more »


Global Times







Time starting to heal old wounds of Mubarak regime
Global Times
Predictions can seldom be accurate, but it is certain that the evolution of domestic politics and the social psychology will be critical to the final judgment. Despite strong opposition from his arch-opponents, the general political atmosphere will be ...

and more »


Straight.com







Wagner's Dream is a fitfully engaging film
Straight.com
Still, such messy psychology may be lost in the abstract vision of Robert Lepage as captured in this fitfully engaging film. For more than three years, ... Certainly, it glosses over the critical reaction this cycle generated from the start. The New ...










The Formula for Obesity
Huffington Post UK (blog)
Children's minds are very impressionable and this would allow me to gain lifetime customers because the children's minds would be made up about their favourite products before they became adults that could think intelligently and use their critical ...










Holding information hostage
RU Daily Targum
Overall, he touched on several critical issues that demand immediate attention — like how we need to deal with other nations more peacefully, which I can only assume means more drone strikes. I cannot help but think, however, that if we had better ...



Flickering Myth (blog)







The Gospel of American Mary – A Horror in the Shell of a Psychological Thriller
Flickering Myth (blog)
Whilst American Mary's singular identity as a horror does not span every critical and non-critical reaction to the film, it nevertheless felt fitting to write a piece on the perception of American Mary as a horror, and tackle its relationship with ...



National Post







Don't believe medicine's wizards of Oz
National Post
It does not hurt that TV doctors tend to have movie-star good looks, which studies of human psychology have long shown can inspire our confidence. Just think about the chiseled features and dreamy blue eyes of Dr. Travis Stork, star of The ... Jenny ...










Expanding mental health services is a far better alternative than armed guards
Kansas City Star
A yearlong study commissioned by the American Psychological Association found no evidence that zero tolerance contributes to school safety or improved behavior, and concluded that it worsens racial disparities in school discipline, causes hardship for ...

and more »

What is Critical Psychiatry? | Mad In America: Over the last twenty years there has emerged a body of work that questions the assumptions that lie beneath psychiatric knowledge and practice. This work, appearing as academic papers, magazine articles, books, and ...

In Memoriam: Dr. Thomas Szasz, Iconic Champion for Liberty & Co-Founder of CCHR


Sep 202012

Dr. Thomas Szasz
1920—2012
Professor Thomas Szasz, iconic champion for liberty, pioneer in the fight against coercive psychiatry and co-founder of Citizens Commission on Human Rights, has passed away at the age of 92. Considered by many scholars and academics to be psychiatry’s most authoritative critic, Dr. Szasz authored hundreds of articles and more than 35 books on the subject, the first being The Myth of Mental Illness, a book which rocked the very foundations of psychiatry when published more than 50 years ago. Szasz was Professor of Psychiatry Emeritus at the State University of New York, Adjunct Scholar at the Cato Institute, Lifetime Fellow of the American Psychiatric Association, Fellow of the International Academy of Forensic Psychology, whose life long list of educational accomplishments, credentials, honors, biographical listings and awards speak for themselves.
To the world, he was the foremost critic on psychiatry and its abusive practices, a brilliant debater and orator. To those who had the privilege of working alongside him, he was witty, charming, charismatic and fearless. But above all else, he was a defender of personal liberty. As Professor Richard E. Vatz of Towson University stated, “Thomas S. Szasz has steadfastly defended the values of humanism and personal autonomy against all who would constrain human freedom with shackles formed out of conceptual confusion, error, and willful deception.”

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via prison psychiatry - Google Blog Search by Andrew Sullivan on 9/19/12
Jacob Sullum celebrates the life of Thomas Szasz, "the great libertarian critic of coercive psychiatry, the 'therapeutic state,' and the war on drugs," who passed away recently: Szasz, a Reason ... [T]he anti-treatment movement Szasz intellectually inspired facilitated the release of tens of thousands of seriously ill mental patients who, when they relapsed, had nowhere to go and no one to help them, and often ended up in prison or living life on the streets. Many mental ...
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Dr. Thomas Szasz, Psychiatrist Who Led Movement Against His Field, Dies at 92

By
Published: September 11, 2012


Thomas Szasz, a psychiatrist whose 1961 book “The Myth of Mental Illness” questioned the legitimacy of his field and provided the intellectual grounding for generations of critics, patient advocates and antipsychiatry activists, making enemies of many fellow doctors, died Saturday at his home in Manlius, N.Y. He was 92.

Susan Kahn

Dr. Thomas Szasz in 2001.

He died after a fall, his daughter Dr. Margot Szasz Peters said.
Dr. Szasz (pronounced sahz) published his critique at a particularly vulnerable moment for psychiatry. With Freudian theorizing just beginning to fall out of favor, the field was trying to become more medically oriented and empirically based. Fresh from Freudian training himself, Dr. Szasz saw psychiatry’s medical foundation as shaky at best, and his book hammered away, placing the discipline “in the company of alchemy and astrology.”
The book became a sensation in mental health circles, as well as a bible for those who felt misused by the mental health system.
Dr. Szasz argued against coercive treatments, like involuntary confinement, and the use of psychiatric diagnoses in the courts, calling both practices unscientific and unethical. He was soon placed in the company of other prominent critics of psychiatry, including the Canadian sociologist Erving Goffman and the French philosopher Michel Foucault.
Edward Shorter, the author of “A History of Psychiatry: From the Era of the Asylum to the Age of Prozac” (1997), called Dr. Szasz “the biggest of the antipsychiatry intellectuals.”
“Together,” he added, “they tried their hardest to keep people away from psychiatric treatment on the grounds that if patients did not have actual brain disease, their only real difficulties were ‘problems in living.’ ”
This attack had some merit in the 1950s, Dr. Shorter said, but not later on, when the field began developing more scientific approaches.
To those skeptical of modern psychiatry, however, Dr. Szasz was a foundational figure.
“We did not agree on everything, like his view that there is no such thing as mental illness,” said Vera Hassner Sharav, president and founder of the Alliance for Human Research Protection, a patient advocacy group, and a longtime critic of the field. “But his message that people get designated as ill, labeled and then shafted out of society and preyed on by an industry dominated by drugs — that’s where he was very valuable.”
After making his name, Dr. Szasz only turned up the heat. From his base in the psychiatry department of SUNY Upstate Medical University in Syracuse, he wrote hundreds of articles and more than 30 books, including “Ideology and Insanity: Essays on the Psychiatric Dehumanization of Man” (1970) and “Psychiatric Slavery: When Confinement and Coercion Masquerade as Cure” (1977).
In 1969, in a move that damaged his credibility even among allies, he joined with the Church of Scientology to found the Citizens Commission on Human Rights, which portrays the field as abusive and regularly pickets psychiatric meetings.
Dr. Szasz was not a Scientologist himself, and he later distanced himself from the church, but he shared the religion’s critical view of psychiatry. His provocations were not without cost. In the 1960s, New York mental health officials, outraged at his attacks on the state system, blocked Dr. Szasz from teaching at a state hospital where residents trained, according to two former colleagues. Dr. Szasz bristled but had little recourse, and his teaching was curtailed.
Dr. Szasz opposed the American Psychiatric Association’s broadening of its diagnoses in its new manual.
“For the record, I will say that I admired him, even though I think he was dead wrong about the nature of schizophrenia,” said Dr. E. Fuller Torrey, founder of the Treatment Advocacy Center in Arlington, Va., which supports stronger laws to ensure treatment of people with severe mental disorders. “But he made a major contribution to the issue of the misuse of psychiatry. His message is important today.”
Thomas Stephen Szasz was born in Budapest on April 15, 1920, the second child of Julius Szasz, a lawyer, and the former Lily Wellisch. The family moved to Cincinnati in 1938, where the boy became a star student. He earned a degree in physics from the University of Cincinnati and graduated from the university’s medical school in 1944.
After an internship and residency, he enrolled at the Chicago Institute for Psychoanalysis, earning his diploma in 1950. He worked at the Chicago institute and served in the United States Naval Reserve before joining the faculty of SUNY Upstate.
He wife, Rosine, died in 1971. Beside his daughter Dr. Peters, he is survived by another daughter, Suzy Szasz Palmer; a brother, George; and a grandson.
Dr. Szasz was widely sought after as a speaker and presented with dozens of national and international awards. Until the end of his life he continued to discuss psychotherapy, the practice he was trained to perform and of which he became so skeptical.
“The goal is to assume more responsibility and therefore gain more liberty and more control over one’s own life,” he said of talk therapy in an interview in 2000 with the Web site Psychotherapy.net. “The issues or questions for the patient become to what extent is he willing to recognize his evasions of responsibility, often expressed as ‘symptoms.’ ”

A version of this article appeared in print on September 12, 2012, on page A29 of the New York edition with the headline: Dr. Thomas Szasz, Psychiatrist Who Led Movement Against His Field, Dies at 92.

Psychiatry’s Legitimacy Crisis

Wednesday, August 15, 2012

Psychiatry’s Legitimacy Crisis

All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders
by Allan V. Horwitz and Jerome C. Wakefield

Book Review by Andrew Scull
The Los Angeles Book Review
Originally published on August 8, 2012

ABOUT 40 YEARS AGO, American psychiatry faced an escalating crisis of legitimacy. All sorts of evidence suggested that, when confronted with a particular patient, psychiatrists could not reliably agree as to what, if anything, was wrong. To be sure, the diagnostic process in all areas of medicine is far more murky and prone to error than we like to think, but in psychiatry the situation was — and indeed still is — a great deal more fraught, and the murkiness more visible. It didn’t help that psychiatry’s most prominent members purported to treat illness with talk therapy and stressed the central importance of early childhood sexuality for adult psychopathology. In this already less-than-tidy context, the basic uncertainty regarding how to diagnose what was wrong with a patient was potentially explosively destabilizing.

The modern psychopharmacological revolution began in 1954 with the introduction of Thorazine, hailed as the first “anti-psychotic.” It was followed in short order by so-called “minor tranquilizers:” Miltown, and then drugs like Valium and Librium. The Rolling Stones famously sang of “mother’s little helper,” which enabled the bored housewife to get through to her “busy dying day.” Mother’s helper had a huge potential market. Drug companies, however, were faced with a problem. As each company sought its own magic potion, it encountered a roadblock of sorts: its psychiatric consultants were unable to deliver homogeneous populations of test subjects suffering from the same diagnosed illness in the same way. Without breaking the amorphous catchall of “mental disturbance” into defensible sub-sets, the drug companies could not develop the data they needed to acquire licenses to market the new drugs.

The entire story is here.
Posted by John D. Gavazzi, PsyD ABPP at 8:00 AM

via psychiatry - Google Blog Search by John D. Gavazzi, PsyD ABPP on 8/15/12

 

ABOUT 40 YEARS AGO, American psychiatry faced an escalating crisis of legitimacy. All sorts of evidence suggested that, when confronted with a particular patient, psychiatrists could not reliably agree as to what, if anything, ...


 

See more of Mike Nova's starred items ...

 

Break Up the Psychiatric Monopoly - NYTimes.com

May 11, 2012

Diagnosing the D.S.M.


By ALLEN FRANCES

AT its annual meeting this week, the American Psychiatric Association did two wonderful things: it rejected one reckless proposal that would have exposed nonpsychotic children to unnecessary and dangerous antipsychotic medication and another that would have turned the existential worries and sadness of everyday life into an alleged mental disorder.
But the association is still proceeding with other suggestions that could potentially expand the boundaries of psychiatry to define as mentally ill tens of millions of people now considered normal. The proposals are part of a major undertaking: revisions to what is often called the “bible of psychiatry” — the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M. The fifth edition of the manual is scheduled for publication next May.
I was heavily involved in the third and fourth editions of the manual but have reluctantly concluded that the association should lose its nearly century-old monopoly on defining mental illness. Times have changed, the role of psychiatric diagnosis has changed, and the association has changed. It is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy.
Psychiatric diagnosis was a professional embarrassment and cultural backwater until D.S.M.-3 was published in 1980. Before that, it was heavily influenced by psychoanalysis, psychiatrists could rarely agree on diagnoses and nobody much cared anyway.
D.S.M.-3 stirred great professional and public excitement by providing specific criteria for each disorder. Having everyone work from the same playbook facilitated treatment planning and revolutionized research in psychiatry and neuroscience.
Surprisingly, D.S.M.-3 also caught on with the general public and became a runaway best seller, with more than a million copies sold, many more than were needed for professional use. Psychiatric diagnosis crossed over from the consulting room to the cocktail party. People who previously chatted about the meaning of their latest dreams began to ponder where they best fit among D.S.M.’s intriguing categories.
The fourth edition of the manual, released in 1994, tried to contain the diagnostic inflation that followed earlier editions. It succeeded on the adult side, but failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children that has since occurred.
Indeed, the D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts.
Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.
Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role.
New diagnoses in psychiatry can be far more dangerous than new drugs. We need some equivalent of the Food and Drug Administration to mind the store and control diagnostic exuberance. No existing organization is ready to replace the American Psychiatric Association. The most obvious candidate, the National Institute of Mental Health, is too research-oriented and insensitive to the vicissitudes of clinical practice. A new structure will be needed, probably best placed under the auspices of the Department of Health and Human Services, the Institute of Medicine or the World Health Organization.
All mental-health disciplines need representation — not just psychiatrists but also psychologists, counselors, social workers and nurses. The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts. Primary care doctors prescribe the majority of psychotropic medication, often carelessly, and need to contribute to the diagnostic system if they are to use it correctly. Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.
Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots.
Allen Frances, a former chairman of the psychiatry department at Duke University School of Medicine, led the task force that produced D.S.M.-4.

via NYT > Opinion by By ALLEN FRANCES on 5/11/12
The time has come for us to admit that psychiatric diagnosis is too important to be left exclusively in the hands of psychiatrists.



The previous lack of a proper diagnostic system had set psychiatry adrift – lurching toward hermeneutics and away from healing. DSM-III ... Now it was the center of every clinical, research, teaching, forensic conversation.

Last Update: 9:20 AM 5/13/2012

Mike Nova: I support Dr. Frances' idea about founding some new, superpsychiatric (possibly under combined umbrella of all the appropriate agencies that he mentioned) interdisciplinary body for

Establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis,

which should include efficient participation of philosophers, neuroscientists, geneticists, biologists, psychologists, sociologists, specialists in forensic behavioral sciences and lawyers.

Maybe, with a little help from our friends the "heavenly gate" to a new, broader scientific paradigm in psychiatry will crack open; a little.

And this might lead to true and real (not imaginary, as a product of the wishful thinking), scientifically revolutionary "paradigm shift". Any new paradigm in psychiatry (just like in any other [scientifically oriented] ideational activity, according to Kuhn) has to be significantly broader than the previous one, incorporating the new body of knowledge, disciplines and theories in a new conceptual framework, resolving the "anomalous contradictions" of the old paradigm which becomes conceptually inadequate to contain them.

This new paradigm must also fit into the larger current paradigmatic systems of scientific and cultural beliefs, and the present lively debate about the meanings and the essence of psychiatric diagnosis is one, and maybe the best indication that the old paradigm "does not fit", that it is scientifically (which is not synonymous with medical practice) - inadequate.

It is also interesting to observe that the battle for this new paradigm is waged in a mainstream media, which might also indicate "the revolutionary situation" expressed as a heightened public awareness and concerns; absolutely justified, legitimate and significant.


American Psychiatry and Jewish Insecurities

I am fully aware that being a Jew does not provide automatic immunity against accusations of antisemitism, and, if anything, enhances them greatly. However, at the risk of invoking these accusations ( I am a Jew and NOT an antisemite at all), I dare to say that psychological significance and influence of ethnic factor in a profession intellectually dominated by Jews (historically, starting with Freud, and currently) has to be examined with scientific objectivity and distance.

It is a big, difficult and painful subject and it requires a great deal of tact and dispassionate, again, objectivity. But if we want to understand its significance, it has to be addressed.

American Psychiatry itself needs to be invited to Freud's couch for the final and in-depth analysis of not only this, relatively trivial, minor and insignificant "ethnic factor", but many, many much more significant and important factors in the pathogenesis of the depression that ails it.


jews history of psychiatry - Google Search



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Freud's Couch, 19 Bergasse Wien

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Mike Nova's starred items

Response to Dr. Wessely


Last Update: 12:25 PM 5/14/2012

Normality or psychopathology of belief or belief system is determined first of all by the intrinsic qualities of belief in question. It is not determined by the fact that belief is shared or not shared: "Delusions are beliefs that are not only wrong, in the sense of not corresponding to the world as we know it, but they must also not be shared with others of the same cultural background."
There are many delusional beliefs that are or were shared, and some of them on a rather large scale. For example, the precolumbian Maya believed, that for the sun to rise they had to offer human sacrifices (of their best and brightest) every day, otherwise all kind of life on earth would come to a halt. This belief was shared very widely in precolumbian Maya culture, which does not make it less delusional.
Breivik's ultra nationalist anti-immigrant ideology is shared by great many people of various cultural backgrounds. The goal of his forensic psychiatric evaluation is to assess his own particular belief system, with all its peculiarities and idiosyncrasies, in order to determine its nature, qualities and psychopathological aspects, regardless of other similar beliefs. In the end, it was him, not others, who took these ideas to their logical (or rather illogical and "sick") extreme, although the (possibly facilitating) role of "significant others" in his case still has to be determined.
Neither the "monstrosity" and "grievous consequences" of his actions nor "popular misconceptions" should cloud the picture. The most important factor in his forensic psychiatric assessment is the presence or absence of identifiable and diagnosable mental illness and the degree of its causal relationship with the crime. In my opinion, whatever it is worth, psychopathological qualities of Breivic's beliefs: their highly systematised, structured, all embracing "world view" quality, along with their unshakable, messianic conviction and "call for action", indicate with high degree of probability the presence of Delusional Disorder, mixed, persecutory-paranoid type, and the direct and overwhelming causal connection of his psychopathology with the criminal act.
The cognitive aspect in psychopathology of Delusional Disorders (abnormalities and/or dysfunctions in concept selection, elimination and confirmation), indicating possible subtle but decisive organic involvement is much under-researched area, probably due to our neglect or inattention to biological aspects of these disorders and overestimation of its psychodynamic aspects. Delusional jealousy, secondary to chronic alcoholism (a very discrete and specific syndrome) is the case in point.
"The... misconception... that the purpose of psychiatry is to “get people off”" might be as wide spread as any other misconception, which does not make it any less of a misconception.
The historically formed legal concept of "NGRI: not guilty by reason of insanity" is a witness to humanity and rationality of a Social System, not to mention other, less important but present factors, such as political and social convenience, expediency and cultural traditions. (E.g.: Disraeli to Queen Victoria: "Only a madman can think about assassinating your Majesty...").
Modern psychiatry, very likely, was born out of the M'Naghten rules, as some psychiatric historians suppose.
And last, but certainly not least, is the difficult and complex subject of "Schizophrenia", its clinical concept (and/or misconcept) and diagnosis (and/or misdiagnosis). The diagnostic label of "Schizophrenia" became so wide spread and all encompassing (because it is so easy to apply, and is applied almost indiscriminately), as to loose its meaning and clinical value. In our rush to nosological (and reimbursement) parity with the rest of medicine we jumped over our heads too soon, introducing the (man made) diagnostic criteria based "nosological" system, which leads to premature ossification and codification of clinical concepts and experience, impeding the independent minded research greatly and precluding the normal development (albeit slow and lagging) of psychiatry as a medical science. Is it not more correct and probably clinically more productive, especially in the field of psychopharmacology, to return to syndromologically based classification system and to try to define, refine and research these historically formed clinical syndromes further, before rushing to judgements about their pseudonosological "pigeon holes"?
This is what Breivic trial, along with other issues, brings to the front. And these issues deserve a deep and long thought.

Michael Novakhov, M.D.

References and Links

Anders Breivik, the public, and psychiatry : The Lancet



The Lancet, Volume 379, Issue 9826, Pages 1563 - 1564, 28 April 2012
doi:10.1016/S0140-6736(12)60655-2Cite or Link Using DOI

Anders Breivik, the public, and psychiatry : The Lancet

The Lancet, Volume 379, Issue 9826, Pages 1563 - 1564, 28 April 2012
doi:10.1016/S0140-6736(12)60655-2Cite or Link Using DOI

Anders Breivik, the public, and psychiatry

Original Text
Simon Wessely aEmail Address
On July 22, 2011, Anders Breivik detonated a car bomb outside the office of the Norwegian Prime Minister. The explosion killed eight people, and inflicted grievous damage on the infrastructure of the Norwegian Government. If he had done nothing else, that was already the worst act of terrorism in the history of Scandinavia. But as we know he did not stop there. Dressed in a police uniform he drove to Utøya, where he murdered a further 69 people, mainly teenagers attending a summer camp organised by Norway's Labour party's youth league.
In September, 2011, I was asked by the Norwegian Government to join an International Advisory Council tasked with reviewing the emergency response, both medical and psychosocial, to the dreadful events of July 22. Before coming to our conclusions, which were that the “Norwegian Health Service had responded very well to the greatest challenge it had ever faced”,1 we were briefed by many of those intimately involved in the events. We were left in no doubt that the crimes had shaken Norwegian society to the core. Nevertheless, much of the world came to admire the way in which the nation came together to reaffirm its commitment to a tolerant liberal society.2 But people remained perplexed about Breivik himself. What were his motives, and how should justice be done?
When people struggle to comprehend what lies behind the mass murder of adolescents gathered for a weekend of discussions and campfires, the simplest response is that the killer “must be mad”. The inexplicable can only be explained as an act of insanity, which by definition cannot be rationally explained. The act was so monstrous, the consequences so grievous, that the perpetrator had to be insane. Yet whilst I was in Oslo, the country was preparing to learn the results of Breivik's psychiatric examinations and all those who we spoke to were insistent that he should not be regarded as mad. And when, to everyone's surprise including my own, the psychiatrists did indeed state that Breivik was suffering from schizophrenia,3 there was an outcry.4 Such reactions are common. All the psychiatrists who interviewed Peter Sutcliffe, the so-called Yorkshire Ripper in the UK, agreed that he had schizophrenia. Normally this would lead to a finding of diminished responsibility and admission to a secure hospital facility. But despite defence and prosecution being in agreement the Judge insisted that the matter had to be put to a jury, because the general public would feel that otherwise Sutcliffe had escaped punishment.5 In practice it made little difference. Sutcliffe was convicted of murder and sent to prison, but soon transferred to Broadmoor Secure Hospital, where he will end his days. Whether he was being punished in prison, or treated in hospital, there was no doubt that he would never be released, since no Home Secretary would agree to that.
But Norway should be different. Norway is a country with one of the best developed mental health systems in the world.6 It prides itself on its tolerant attitude towards mental disorders. When former Prime Minister Kjell Magne Bondevik took leave of absence to be treated for depression in 1998 his career did not come to a halt.7 Offenders diagnosed with mental illness are dealt with within the health, not the criminal justice, system. And if the person then recovered, they would be released from hospital on the authority of the psychiatrists, without the possibility of political interference.8 But tolerance can only go so far, and the majority of the Norwegian public saw a label of schizophrenia as allowing Breivik to avoid having to answer to his crimes, and worse, that a psychiatric diagnosis raised the spectre that he could be free again.9
In fact that was always improbable. Many Norwegians themselves were confused about the checks and balances within their own judicial system. A prosecutor can, although they rarely do, challenge the psychiatrist's decision and the matter be returned to Court. And even if the offender has recovered, the power exists to transfer him to prison indefinitely if judged a continuing threat to society.8 Although at the time of writing the Court's verdict remains unknown, as Breivik gives his chilling testimony in Court the chances that he receives a psychiatric disposal rather than a criminal conviction seem to be receding.
The Breivik case highlights two popular misconceptions. First, that outrageous crimes must mean mental illness. Diagnoses in psychiatry are made on the basis of symptoms and motivations, rather than outcomes. For schizophrenia to explain Breivik's actions, they would have to be the result of delusions. Delusions are beliefs that are not only wrong, in the sense of not corresponding to the world as we know it, but they must also not be shared with others of the same cultural background. A psychiatric classic established that individuals with schizophrenia can identify others as mad, even when they share the same delusions.10
Breivik's views on the evils of multiculturalism, immigration, and the threat of Islam mixed in with nonsense about the Knights Templar and so on, are absurd, reprehensible, and abhorrent, but he is not alone. One fears that in the backwoods of Montana or among those who subscribe to what is loosely called “anti Jihadism” are other people like him, who may also have devoted a summer to playing World of Warcraft and believe that Dan Brown writes history. The meticulous way in which he planned his attacks does not speak to the disorganisation of schizophrenia. My colleagues in forensic psychiatry struggle to think of anyone who has had the foresight to bring along a sign stating “sewer cleaning in progress” to avoid drawing attention to the smell of sulphur from the homemade explosives in the back of his vehicle. If a psychiatric parallel is needed, the closest might be the classic case of German school teacher Ernst Wagner, who murdered 15 people in a small village, and was diagnosed with paranoia, or delusional disorder as it is now known.11
The second misconception is that the purpose of psychiatry is to “get people off”. In the UK, however, if you commit murder and want to spend as little time in detention as you can, putting forward a mental illness defence may mean that you will spend more—not fewer—years behind bars.12 And the forensic psychiatry system is not a soft or popular option either. Most offenders have the same prejudices towards mental illness as the general population, and would rather take their chances in prison than be what they call “nutted off”. Similarly, it is a commonplace observation among British forensic psychiatrists that those who have experienced both prison and hospital often prefer the former because “at least they don't try to do your head in”. The widespread anger when it seemed that Breivik was going to be sent to hospital rather than prison reminds us that liberal attitudes to mental illness are still often only skin deep.
I declare that I have no conflicts of interest.
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Full-size image (16K) Corbis
I declare that I have no conflicts of interest.

References

1 International Advisory Council on the Health Sector Response to the Terrorist Attacks of June 22, 2011. Lessons for better preparedness. Health effort after the acts of terror July 22, 2011 [in Norwegian]. http://www.helsedirektoratet.no/publikasjoner/lering-for-bedre-beredskap-/Sider/default.aspx. (accessed April 23, 2012).
2 Orange R. “Answer hatred with love”: how Norway tried to cope with the horror of Anders Breivik. The Observer. http://www.guardian.co.uk/world/2012/apr/15/anders-breivik-norway-copes-horror. (accessed April 23, 2012).
3 Rettspsykiatrisk erklaering Breivik, Anders f. 130279 [in Norwegian]. http://pub.tv2.no/multimedia/TV2/archive/00927/Breivik_rapport_927719a.pdf. (accessed April 23, 2012).
4 Anda LG. Norwegian disbelief at Breivik's insanity. Nov 29, 2011. BBC News World. http://www.bbc.co.uk/news/world-15954370. (accessed April 23, 2012).
5 Jenkins P. Serial murder in England 1940—1985. J Crim Justice 1988; 16: 1-15. PubMed
6 Norwegian Ministry of Health and Care Services. Mental health services in Norway. Prevention—treatment—care. http://www.regjeringen.no/upload/kilde/hod/red/2005/0011/ddd/pdfv/233840-mentalhealthweb.pdf. (accessed April 23, 2012).
7 Bondevik K. Depression and recovery. Interview with Kjell Magne Bondevik by Sarah Mitchell. J Ment Health 2010; 19: 369-372. PubMed
8 Grøndahl P. Scandinavian forensic psychiatric practices : an overview and evaluation. Nord J Psychiatry 2005; 59: 92-102. CrossRef | PubMed

Nord J Psychiatry. 2005;59(2):92-102.

Scandinavian forensic psychiatric practices--an overview and evaluation.

Source

Centre for Research and Education in Forensic Psychiatry, Ullevaal University Hospital, Oslo, Norway. pagron@c2i.net

Abstract

The Scandinavian countries share a social-democratic and humanistic view in that mentally disturbed offenders should not be punished or sentenced to prison if they are considered unaccountable for their actions. The countries differ, however, for example regarding referrals for medico-legal examinations. This article gives: 1) an overview of the Scandinavian forensic psychiatric practices regarding organization, legislation, resources and use of methods, and 2) a study of forensic psychiatric assessment as they are done in the Scandinavian countries. From each country 20 forensic psychiatric court reports concerning male murderers were examined. Each report was scored in five sections: characteristics of the defendant, setting of the observation, acting professions, methods used and premises for the experts' conclusions. Data were summarized with descriptive measures. Danish and Swedish experts had a more frequent use of tests and instruments than Norwegian experts. Swedish experts used the Global Assessment of Functioning Scale (GAF), and they diagnosed the observant according to DSM-IV. The Scandinavian experts rarely referred to the tests they had applied nor did they refer to any kind of theory or literature as a basis for their conclusion. Only a few reports expressed doubt concerning the validity of the conclusion. Stating all the premises of the forensic psychiatric examination might improve the quality of the reports by doing them more explicit and verifiable. More use of standardized actuarial-based methods and more attention to knowledge about clinical judgmental processes is recommended.
PMID:
16195105
[PubMed - indexed for MEDLINE]
9 Korsvold K. The Norwegian system can produce many exonerations.Aftenposten April 13, 2012 [in Norwegian]. http://www.aftenposten.no/nyheter/iriks/22juli/—Det-norske-systemet-kan-gi-mange-feilaktige-frifinnelser-6803402.html. (accessed April 23, 2012).
10 Rokeach M. The three christs of Ypsilanti. New York: Knopf, 1964.
11 Gaupp R. Die wissenschaftliche Bedeutung des “Falles Wagner”. Munchener Medizinische Wochenschrift 1914; 61: 633-637. Translated by Marshall H.. In: Hirsch S, Shepherd M, eds. Themes and variations in European psychiatry: an anthology. Bristol: John Wright, 1974. PubMed
12 Grounds A. The transfer of sentenced prisoners to hospital 1960—83: a study in one special hospital. Br J Criminol 1991; 31: 54-71. PubMed
a Department of Psychological Medicine, Institute of Psychiatry, King's College London Weston Education Centre, London SE5 9RS, UK

NIMH · The Future of Psychiatry (= Clinical Neuroscience)

Director’s Blog
April 20, 2012

The Future of Psychiatry (= Clinical Neuroscience)

Last week a short piece in the British medical journal, The Lancet, described an “identity crisis” in psychiatry. In the U.K., the number of medical students choosing psychiatry has dropped more than 50 percent since 2009 and over the past decade the number of psychiatrists has dropped by 26 percent while the number of physicians overall has increased more than 31 percent. Ninety-five percent of posts for junior physicians across all specialties are generally filled; but psychiatry posts, as of last summer, were running more than one third unfilled.
Tom Brown, Assistant Registrar of Recruitment at the Royal College of Psychiatrists, U.K., told The Lancet: “Common perceptions within the medical profession include the view that psychiatry is just not scientific enough, is too remote from the rest of medicine, is often viewed negatively by other medical professionals, and is a specialty too often characterised by difficult doctor-patient relationships and limited success rates of therapeutic interventions.”
Meanwhile, psychiatry in the U.S. is undergoing a quiet resurgence which appears to run counter to the British experience. This might not have been apparent last month at match day, the day when medical students match with their post-graduate residencies. Match day is always a moment to track the popularity of different medical specialties. This year, slightly less than 4 percent of graduating students chose psychiatry, which is a bit lower than recent years. But this number hides an extraordinary trend: psychiatry has become the hot specialty for MD-PhD students who want to do research.
The number of MD-PhD students choosing psychiatry has more than doubled in the past decade. This year, 50 percent of the students who matched with the Yale psychiatry residency were MD-PhDs. At Columbia, 20 percent of psychiatric residents in recent years have been MD-PhDs. In other psychiatry residency programs, while the number of applicants has not increased, the number of MD-PhDs has. Why is this important? Getting into an MD-PhD training program is even more competitive than getting into medical school. The training includes intensive research experience, and many (but not all) graduates go on to do independent research either in the clinic or in a laboratory setting. In the past, most of these elite students have chosen a medical specialty such as oncology or a high paying surgical specialty such as ophthalmology.
Why are they now selecting psychiatry? I asked this question at Brain Camp a couple weeks ago. Each year, NIMH runs a 4-day intensive Brain Camp for some of the top physicians in their second year of psychiatric residency training. The faculty, including Nobel laureates and other distinguished scientists, describe recent insights from neuroscience relevant to the problems facing psychiatric residents. The residents, who are still at a very early stage of their training, are challenged with charting the future of psychiatry. The result is one of the most inspiring 4 days of the year for all of us who attend.
This year, 11 of the 17 psychiatric residents at Brain Camp were MD-PhDs. Many had been neuroscience majors in college, had published high impact papers in medical school, and were continuing to do research during their clinical training. Prior to residency, all 17 were medical students who had been at the top of their class and could have gone into any specialty. When I asked them why they had chosen psychiatry instead of another specialty, I heard various reasons but they all agreed that psychiatry is the specialty where they can have the greatest impact. To paraphrase, one student said, “The questions are profound, the patients are fascinating, and the tools are finally available to make unprecedented progress.” Another told me confidently, “This is the place to make a mark.”
These brilliant young scientists have mostly come from a neuroscience background. They are but a few of the gifted and committed trainees currently in the pipeline who have been attracted to psychiatry in the U.S. They see psychiatry as the natural application of their interest in how the brain works. They want to transform psychiatry into clinical neuroscience, not with less of a commitment to clinical excellence but with a great commitment to developing a new scientific basis for clinical care. This year Brain Camp was largely focused on neuromodulation—using cognitive training and repetitive transcranial magnetic stimulation (rTMS)—to alter symptoms of depression and anxiety by modulating specific brain circuits. For this new generation, psychiatry already is clinical neuroscience.
So maybe there is an identity crisis for psychiatry in the U.S. as well as the U.K. But the U.S. version seems filled with hope and excitement, with many of the best and brightest now deciding that they can bring new approaches to help people challenged by mental illness.

References

Lancet. 2012 Apr 7;379(9823):1274.

Mike Nova

Breivik Trial and The Crisis Of Psychiatry As A Science

Breivik is not the only one who is on this trial. Psychiatry as a science is on this trial also, just like on many other trials where forensic psychiatric involvement is sought. This is highlighted by the two contradictory psychiatric assessments of the accused, with their directly opposing diagnostic impressions and directly conflicting main general conclusions. The first forensic psychiatric evaluation, completed on November 29, 2011 by the psychiatrists Torgeir Husby and Synne Sørheim found Breivik to be "paranoid schizophrenic" and "psychotic" at the time of the alleged crime and presently and therefore legally "insane". A leaked copy of the initial psychiatric examination described his crusader fantasy as a product of the "bizarre, grandiose delusions" of a sick mind.
The second evaluation, about 300 pages long, made by the psychiatrists Terje Toerrissen and Agnar Aspaas on a request from the court after widespread criticism of the first one, was completed on April 10, 2012, just six days before the trial, but was not released, and according to the leaked information, found him afflicted with "narcissistic personality disorder" with "grandiose self" and not psychotic at the time of the alleged crime and presently and therefore legally "sane".
The latest psychiatric report was confidential, but national broadcaster NRK and other Norwegian media who claimed to have seen its conclusions said it described Breivik as narcissistic but not psychotic.
Torgensen gets the impression that Breivik found an ideal place to nourish his delusions of grandeur in the anti-Islamic scene full of crusader fantasies. “This was coupled with an extremely sadistic disorder,” Torgensen says. “This disastrous combination could explain the scale of his violence.”
The new report from forensic psychiatrists Terje Tørrissen and Agnar Aspaas concludes that he did not have “significantly weakened capacity for realistic evaluation of his relations with the outside world, and did not act under severely impaired consciousness”.
"Our conclusion is that he (was) not psychotic at the time of the actions of terrorism and he is not psychotic now," Terje Toerrissen, one of the psychiatrists who examined Breivik in prison, told The Associated Press.
Thus, as it almost always happens in complex forensic psychiatric cases, it was left for the infinite wisdom and common sense of the court, unburdened by the "sophisticated" and empty psychiatric jargon, to decide by itself, and rightly so, the "main questions" of the accused's mental illness or mental health and his "sanity" or "insanity" and to make its own, judicial decision regarding the issue of legal responsibility. Both mutually conflicting (but not mutually exclusive) forensic psychiatric evaluations, which, no doubt, were performed in good faith and with utmost professional diligence, will be taken into account by the court, but were rendered almost irrelevant by their contradictions. Once again, psychiatry, pretending to be a medical discipline and a science, was humiliated and reduced to the position of a laughing stock for the public and the media.
Mr. Breivik's skillful and astute lead defense lawyer, Mr. Geri Lippestad, treating his client with respect and at the same time with appropriate professional distance and apparently convinced of his client's mental illness and "insanity", chose a strategy of presenting Mr. Breivik to the court and to the public "as is", letting him to reveal himself and his presumed mental illness fully as the engine of alleged criminal behavior, apparently counting that it will be convincing enough for both the judges and for the court of public opinion.
“This whole case indicated that he is insane,” Geir Lippestad told reporters. “He looks upon himself as a warrior. He starts this war and takes some kind of pride in that,” Lippestad said. Lippestad said Breivik had used “some kind of drugs” before the crime to keep strong and awake, and was surprised he had not been killed during the attacks or en route to Monday’s court hearing.
Lippestad, a member of the Labour party whose youth wing had been the target of Friday’s shooting rampage, said he would quit if Breivik did not agree to psychological tests.
Geir Lippestad said the new report means Breivik's testimony will be crucial "when the judges decide whether he is insane or not." The trial started on April 16 and is scheduled to last 10 weeks.
Mr. Breivik declared himself undoubtedly and completely "sane" and consistently, if somewhat eerily out of place and time, painted a self-portrait as a model and self-sacrificing ideological warrior, taking as an insult any, albeit "professional" opinions otherwise and dismissed them with anger and indignation.
“On this day,” he said, “I was waging a one-man war against all the regimes of Western Europe. I felt traumatized every second that blood and brains were spurting out. War is hell.”
"Breivik told the court that "ridiculous" lies had been told about him, rattling off a list which accused him of being a narcissist who was obsessed with the red jumper he wore to his first court hearing, of having a "bacterial phobia", "an incestuous relationship with my mother", "of being a child killer despite no one who died on Utoya being under 14".
He was not insane, he repeated many times. He claimed it was Norway's politicians who should be locked up in the sort of mental institution he can expect to spend the rest of his days if the court declares him criminally insane at the end of the ten-week trial. He said: "They expect us to applaud our ethnic and cultural doom... They should be characterised as insane, not me. Why is this the real insanity? This is the real insanity because it is not rational to work to deconstruct ones own ethnic group, culture and religion."
All this is fine and dandy, and, no doubt, the aforementioned infinite wisdom of Scandinavian level headed justice (embodied in a stern but motherly demeanor of the presiding Judge Wenche Elisabeth Arntzen) will eventually emanate from its somewhat obscure, slowly but surely turning and unstoppable wheels, hopefully to almost every one's satisfaction. And eventually, this horrendous crime, the purp and the trial will be almost forgotten and placed into archives for further studies.
But the nagging questions remain and will remain for some, and probably a long time: is psychiatry really a science? Or is it just a collection of "professional" opinions, mixed with convenient labels and outdated jargon? What is "sane" and what is "insane"? And how far should the justice go in its modern "humane" stance?

"Grete Faremo, Norway’s justice minister, has said that it plans to establish a committee to examine the role of forensic psychiatrists. She told Norwegian daily Aftenposten on April 13 the committee would have a “broad mandate” that would examine three key questions: What is sanity? What is the role of the forensic psychiatrist? And how do we take care of security when an insane man is sentenced?
“Much suggests that the medical principle is inadequate,” said Faremo. “It is a historic step we are now taking. It is an important step in light of the terrible incident and the trial we face and in consideration of people's sense of justice.”
“This is a big thing,” says Abrahamsen. “If it hadn’t been for Breivik, we wouldn’t have discussed this.”


References and Links

Psychiatry May Also Face Scrutiny at Norway Killer's Trial - NYTimes.com

Breivik trial: Norwegians rethink role of psychiatry in courts - CSMonitor.com

Breivik Trial and The Crisis Of Psychiatry As Science - Links

Psychiatry May Also Face Scrutiny at Norway Killer's Trial - NYTimes.com

Psychiatry May Also Face Scrutiny at Norway Killer's Trial - NYTimes.com


April 10, 2012, 1:33 pm

Psychiatry May Also Face Scrutiny at Norway Killer’s Trial

By J. DAVID GOODMAN

Alexandra-Maeva Norya Peltre described her escape from Anders Behring Breivik, during which she was shot in the leg. She is set to testify against him at his trial, which begins next week.
After an earlier psychiatric report declared him to be a paranoid schizophrenic living in a “delusional universe,” a second evaluation by Norwegian psychiatrists released on Tuesday found Anders Behring Breivik, the anti-Muslim extremist who methodically killed 77 people in Oslo last year, to be legally sane, according to Norwegian officials.
As recently as last month, prosecutors in Norway said that Mr. Breivik would likely be placed in involuntary psychiatric care because he was considered psychotic.
But that approach appeared to be based on the first report, conducted by two psychiatrists in a court-ordered assessment. The new evaluation, also ordered by the court, followed widespread criticism of the earlier finding. The discrepancy between the two findings was not immediately explained.
The clinical disagreement prompted some Norwegian news media to speculate that the methods of psychiatric evaluation would also be put on trial along with Mr. Breivik when hearings begin next week.
The Norwegian daily, Aftenposten, said that the divergent evaluations presented the court with a unique challenge. Sven Torgersen of the University of Oslo told the paper that he anticipated that the trial would likely become, at least in part, a discussion of psychiatry.
Mr. Torgersen also told the news site, Global Post, that Mr. Breivik’s insistence on his own sanity could be an effort to influence the court. “It’s very dangerous to say, ‘I’m very satisfied to be declared insane.’ Because then I’m sane. That’s the paradox,” he said.
Indeed, Mr. Breivik’s lawyer said his client was “pleased” with the new result and that he would testify at trial that he has “regret that he didn’t go further,” the BBC reported.
Mr. Breivik has also been vigorously declaring his sanity, claiming in a letter last week that to be confined to a mental hospital would be “the ultimate humiliation,” according to excerpts published by Reuters and other news outlets. “To send a political activist to a mental hospital is more sadistic and evil than to kill him! It is a fate worse than death,” he wrote.
If found to be mentally fit for trial, he could face up to 21 years in prison. A finding that he was insane would likely result in three-year terms of psychiatric care, which could be extended, The Associated Press reported.
One of his victims, Alexandra-Maeva Norya Peltre, escaped after being shot in the leg. Now 18 years old, she returned to Utoya Island with a video crew from Reuters and described the scene of mayhem during which she said her eyes met with those of Mr. Breivik as he methodically tracked and killed young people at a political camp, even as some attempted to flee into the water.
“He was looking right at me and I just remember — poof! I had a hole in my leg,” she said, “and I started running.”

Psychiatry's identity crisis : The Lancet

The Lancet, Volume 379, Issue 9823, Page 1274, 7 April 2012
doi:10.1016/S0140-6736(12)60540-6Cite or Link Using DOI

Psychiatry's identity crisis

Original Text
The Lancet
Last week, the American Psychiatric Association issued a press release highlighting an ongoing decline in the recruitment of medical students into the specialty—at a time when the numbers of practising psychiatric professionals in the USA is falling. Various reasons are proposed, including the short-term nature of placements (usually just 4 weeks); the sheer breadth of an evolving specialty, which is drawing students towards newer areas such as clinical neuroscience; and concerns that psychiatry is not as lucrative as other specialties.
Tom Brown, Assistant Registrar of Recruitment at the Royal College of Psychiatrists (RCPsych), UK, views psychiatry's identity crisis as an international problem, and for profound reasons. He told The Lancet: “Common perceptions within the medical profession include the view that psychiatry is just not scientific enough, is too remote from the rest of medicine, is often viewed negatively by other medical professionals, and is a specialty too often characterised by difficult doctor—patient relationships and limited success rates of therapeutic interventions”.
So, what kind of therapy is psychiatry in need of? The RCPsych views the current problem crucial enough for a concerted campaign to promote the specialty, not just to medical students and doctors at foundation stage, but even to senior-school pupils studying psychology. While such initiatives may help raise the profile of psychiatry, perhaps there are more fundamental issues that need to change.
Psychiatrists, first and foremost, are clinicians. Evidence-based approaches should be at the core of the psychiatrist and non-clinical members of any mental health team. The evidence that psychiatric patients have poorer overall health than the general population should ensure that psychiatry is strongly connected to other medical specialties. But more fundamental still, it is time for the specialty to stop devaluing itself because of its chequered history of mental asylums and pseudo-science, and to realign itself as a key biomedical specialty at the heart of mental health.

The Guardian home Mental health

_____________________________________________________________________

  • 2 Aug 2012: Editorial: Mental health is one of those subjects on which there are more strongly-held than well-informed opinions 52 comments

Mental health is one of those subjects on which there are more strongly-held than well-informed opinions
Like the costs and benefits of staging the Olympics, or behavioural differences between boys and girls, mental health is one of those subjects on which there are more strongly-held than well-informed opinions. One problem is that such hard facts as there are can be twisted to fit every prejudice. New figures on antidepressant prescriptions confirm a runaway rise that has now pushed use up by 500% in 20 years. But what exactly does this prove?
For the stiff upper-lip brigade it is another sign of post-Diana national decline – of people mistaking life's slings and arrows for a pathology, and of soft-hearted physicians pandering to them. Kinder souls will regard the news as a welcome sign of an old taboo fading – evidence of patients, who would once have suffered from a crippling condition in silence, finally having the confidence to come forward and get help. Those with faith in scientific progress will discern GPs getting better at diagnosing and pharmaceutical companies producing smarter drugs. Materialists preoccupied with the economy will notice that last year's 9.1% rise exceeds the 6.8% average over the past decade – and blame the double dip.
So we can't settle arguments about the meaning of medicated misery by simply counting prescriptions. If we map them, however, we start to get a few insights. The BBC's Mark Easton shrewdly spotted that Blackpool, which topped the antidepressant chart, was also the lowest-scoring English town on happiness, as measured by the official life satisfaction survey released the week before. Scotland's Highlands and Islands boasted the broadest smiles in that data, and – sure enough – separate Scottish statistics confirm antidepressants are rarer in these corners of the kingdom too. The fit between self-rated misery and prescriptions for depression suggests, first of all, that both are measuring something real.
A deep north-south divide in prescriptions is, in part, a reminder that unemployment hurts. Redcar, Gateshead and Newcastle are all near the top of this table, and all have far more than their share of jobseeker's allowance claims. But economics is not the end of the story. Conurbations further south – from Birmingham to inner-London – are often also short on jobs, and yet anti-depressants are much rarer in these places, even where they have poor life satisfaction scores.
The most obvious difference between these places and the north-east is the ethnic mix. One fashionable view says too much diversity can impose strains, but here is an indicator of distress which points the other way. In truth, it is less likely to be a case of diversity vanquishing depression than a sign of continuing stigma about mental health in some immigrant communities. Mapping misery reveals a good deal about where it needs to be tackled.

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James Holmes-Colorado-shooting-Batman-Aurora The University of Colorado
27 Jul 2012:
Dr Lynne Fenton revealed as university employee who was mailed a notebook from Holmes detailing plans for an attack

Psychiatric Group Faces Scrutiny Over Drug Industry Ties

Published: July 12, 2008
It seemed an ideal marriage, a scientific partnership that would attack mental illness from all sides. Psychiatrists would bring to the union their expertise and clinical experience, drug makers would provide their products and the money to run rigorous studies, and patients would get better medications, faster.


Doug Mills/The New York Times
Senator Charles E. Grassley, right, Republican of Iowa, is demanding that the American Psychiatric Association give an accounting of its financing from the pharmaceutical industry.

Dr. Alan F. Schatzberg, president-elect of the American Psychiatric Association.
But now the profession itself is under attack in Congress, accused of allowing this relationship to become too cozy. After a series of stinging investigations of individual doctors’ arrangements with drug makers, Senator Charles E. Grassley, Republican of Iowa, is demanding that the American Psychiatric Association, the field’s premier professional organization, give an accounting of its financing.
The association is the voice of establishment psychiatry, publishing the field’s major journals and its standard diagnostic manual.
“I have come to understand that money from the pharmaceutical industry can shape the practices of nonprofit organizations that purport to be independent in their viewpoints and actions,” Mr. Grassley said Thursday in a letter to the association.
In 2006, the latest year for which numbers are available, the drug industry accounted for about 30 percent of the association’s $62.5 million in financing. About half of that money went to drug advertisements in psychiatric journals and exhibits at the annual meeting, and the other half to sponsor fellowships, conferences and industry symposiums at the annual meeting.
This weekend in Chicago, the psychiatry association’s board will meet behind closed doors, in part to discuss how to respond to the increasingly intense scrutiny and questions about conflicts of interest.
“With every new revelation, our credibility with patients has been damaged, and we have to protect that first and foremost,” said Dr. Steven S. Sharfstein, a former president of the association and now president of the Sheppard Pratt Health System in Baltimore. “I think we need to review all arrangements between doctors and industry and be very clear about what constitutes a conflict of interest and what does not.”
One of the doctors named by Mr. Grassley is the association’s president-elect, Dr. Alan F. Schatzberg of Stanford, whose $4.8 million stock holdings in a drug development company raised the senator’s concern. In a telephone interview, Dr. Schatzberg said he had fully complied with Stanford’s rigorous disclosure policies and federal guidelines that pertained to his research.
Blocking or constraining researchers from trying to bring medications to market “will mean less opportunities to help patients with severe illnesses,” Dr. Schatzberg said, adding, “Drugs that are helpful may not be developed by big pharmaceutical companies, for a variety of reasons, and we need some degree of communication between academia and industry” to expand options for patients.
Commercial arrangements are rampant throughout medicine. In the past two decades, drug and device makers have paid tens of thousands of doctors and researchers of all specialties. Worried that this money could taint doctors’ research plans or clinical judgment, government agencies, medical journals and universities have been forced to look more closely at deal details.
In psychiatry, Mr. Grassley has found an orchard of low-hanging fruit. As a group, psychiatrists earn less in base salary than any other specialists, according to a nationwide survey by the Medical Group Management Association. In 2007, median compensation for psychiatrists was $198,653, less than half of the $464,420 earned by diagnostic radiologists and barely more than the $190,547 earned by doctors practicing internal medicine.
But many psychiatrists supplement this income with consulting arrangements with drug makers, traveling the country to give dinner talks about drugs to other doctors for fees generally ranging from $750 to $3,500 per event, for instance.
While data on industry consulting arrangements are sparse, state officials in Vermont reported that in the 2007 fiscal year, drug makers gave more money to psychiatrists than to doctors in any other specialty. Eleven psychiatrists in the state received an average of $56,944 each. Data from Minnesota, among the few other states to collect such information, show a similar trend.
In both states, individual psychiatrists are not top earners, but consulting arrangements are so common that their total tops all others. The worry is that this money may subtly alter psychiatrists’ choices of which drugs to prescribe.
An analysis of Minnesota data by The New York Times last year found that on average, psychiatrists who received at least $5,000 from makers of newer-generation antipsychotic drugs appear to have written three times as many prescriptions to children for the drugs as psychiatrists who received less money or none. The drugs are not approved for most uses in children, who appear to be especially susceptible to the side effects, including rapid weight gain.
Senator Grassley’s investigations have not only detailed how lucrative those arrangements can be but have also shown that some top psychiatrists failed to report all their earnings as required.
After The Times reported on such an arrangement involving Dr. Melissa P. DelBello of the University of Cincinnati, Mr. Grassley asked the university to provide her income disclosure forms and asked AstraZeneca, the maker of the antipsychotic Seroquel, to reveal how much it paid her.
In scientific publications, Dr. DelBello has reported working for eight drug makers and told university officials that from 2005 to 2007 she earned about $100,000 in outside income, according to Mr. Grassley.
But AstraZeneca told Mr. Grassley it paid her more than $238,000 in that period. AstraZeneca sent some of its payments through MSZ Associates, an Ohio corporation Dr. DelBello established for “personal financial purposes.”
The University of Cincinnati agreed to monitor those payments more closely.
In early June, the senator reported to Congress that Dr. Joseph Biederman, a renowned child psychiatrist at Harvard Medical School, and a colleague, Dr. Timothy E. Wilens, had reported to university officials earning several hundred thousand dollars apiece in consulting fees from drug makers from 2000 to 2007 when in fact they had earned at least $1.6 million each.
Another member of the Harvard group, Dr. Thomas Spencer, reported earning at least $1 million after being pressed by Mr. Grassley’s investigators. The Harvard psychiatrists said they took conflict-of-interest policies seriously and had abided by disclosure rules.
In late June, after Mr. Grassley singled out Dr. Schatzberg, Stanford disputed some of the numbers in the report and has denied that Dr. Schatzberg violated any research rules devised to police such conflicts.
In an interview on Wednesday, Dr. Nada L. Stotland, president of the psychiatric association, said the group had studied Mr. Grassley’s letter and Stanford’s response and agreed with Stanford. Dr. Schatzberg will take over as president of the association as planned, she said.
“The larger issue here is that there’s a revolution going on” in how medicine handles industry money, said Dr. Stotland, a psychiatrist at Rush Medical College in Chicago. “That’s good, that’s what we need, and I believe we’ve been on the cutting edge of that revolution in many ways.”
Dr. Stotland said that the association began reviewing the income it received from pharmaceutical companies last March, to identify potential conflicts. Doctors and academic researchers generally worked at arm’s length from industry until the early 1980s, when Congress passed the Bayh-Dole Act. This legislation encouraged closer collaboration between researchers and industry to bring products to market more quickly. The act helped foster the growth of the biotech industry, and soon professors and universities were busy obtaining patents and building relationships with industry.
Some psychiatrists have long argued that consulting with a company — to help design a rigorous drug trial, for instance — benefits patients, as long as the researcher has no financial stake in the product and is not paid to speak about the drug to other doctors, like a traveling pitchman.
Others say industry and academic researchers are now so deeply intertwined that exposing doctors’ private arrangements only stokes suspicion without correcting the real problem: bias.
“Having everyone stand up like a Boy Scout and make a pledge isn’t going to quell suspicion,” said Dr. Donald Klein, an emeritus professor at Columbia, who has consulted with drug makers himself. “The only hope to rule out bias is to have open access to all data that’s produced in studies and know that there are people checking it” who are not on that company’s payroll.
Studies have shown that researchers who are paid by a company are more likely to report positive findings when evaluating that company’s drugs. The private deals can directly affect patient care, said Dr. William Niederhut, a psychiatrist in private practice in Denver who receives no industry money.
Dr. Niederhut said company-sponsored doctors had spread the word that new and expensive drugs were better in treating bipolar disorder than lithium, the cheaper old standby treatment.
“It’s a sales pitch, and now it’s looking like a whole lot of people would have done better if they’d started on lithium in the first place,” Dr. Niederhut said in a telephone interview. “The profession absolutely has to come clean on these industry deals, and soon.”
Tighter rules, stronger statements and more debate may not make much difference, if Mr. Grassley’s findings are any guide. Universities have rules requiring that faculty members disclose their outside income so that conflicts of interest in research or patient care can be managed. But some of the psychiatrists named in the investigations apparently ignored the rules.
“I think we may be coming to a point where hospitals and medical schools have to get serious about sanctioning,” said Dr. Paul S. Appelbaum, director of the division of psychiatry, medicine and the law at Columbia. “You can suspend doctors’ privileges, or suspend their right to treat patients; both have a huge impact on income and career. But if you’re serious about these disclosure policies, you have to be willing to back them up.”

Allen Frances, M.D.: My Debate With The DSM 5 Chair


DSM5 in Distress



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Allen Frances, M.D.
Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.
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Published on Psychology Today (http://www.psychologytoday.com)


My Debate With The DSM 5 Chair

By Allen J. Frances, M.D.
Created Jun 25 2012 - 3:40pm
Recently, I voiced my concerns about DSM 5 in a Medscape interview (http://www.medscape.com/viewarticle/763886) with Dr Stephen Strakowski. DSM-5 Task Force Chair David Kupfer then entered the debate and provided his defense (http://www.medscape.com/viewarticle/764735).

Here is my reply to Dr Kupfer:

I think 'Newspeak' is the best way to characterize the APA defense of DSM 5. For those who haven't read George Orwell's '1984' lately, 'Newspeak' was his term for the kind of bureaucratic upside-down language that attempts to turn night into day. The idea is that if you say something enough times, the repetition will magically make it so.

Let's do a quick back-translation from APA 'newspeak' to DSM 5 reality.

APA Newspeak: DSM 5 has been open and "transparent to an unprecedented degree."
DSM 5 Reality: APA forced work group members to sign confidentiality agreements; has kept its 'scientific' review committee report secret; tries to censor the internet using bullying threats of trademark litigation; keeps secret the content of public input; and has not, as promised, provided more complete data sets from its failed field testing.

APA Newspeak: DSM 5 has been an "inclusive" process.
DSM 5 Reality: APA has rejected the input of 51 mental health associations requesting an open and independent scientific review of the controversial DSM 5 proposals; has not responded to highly critical editorials in the Lancet, New England Journal, New York Times, and many other publications; has ignored the unanimous opposition by the leading researchers in the field to its unusable personality disorder section; has ignored the opposition of sexual disorder researchers and forensic experts to its forensically dangerous paraphilia section; has brushed off outrage by consumer groups representing the bereaved and the autistic; has not made any changes in DSM 5 that can be associated with outside input- professional or public; and is unresponsive even to its own APA members, dozens of whom have told me they can't get a straight (or any) answers from a staff whose salaries come from their dues.

APA Newspeak: "The stakes are far reaching: the first full revision since 1994 of the DSM, a document that influences the lives of millions of people around the world."
DSM 5 Reality: APA quietly cancelled its own planned Stage 2 of field testing. Stage 2 was to provide quality control with much needed editing and retesting to demonstrate improved reliability. Canceling quality control was a crucial mistake and was done for one reason only-money. Because Stage 1 of the field trial was completed 18 months late, DSM 5 was running out of time in meeting its arbitrarily imposed publishing deadline. Given the choice of striving for quality or cashing in on publishing profits, APA went for the cash. Definitely dispiriting, but not surprising. APA is in deficit, has a budget that is totally dependent on the huge publishing profits from its DSM monopoly; and has wasted an absolutely remarkable $25 million in producing DSM 5 (DSM IV cost only one fifth as much). The simple reality is that APA is rushing a poor quality and unreliable DSM 5 to press purely for financial reasons and totally heedless of the detrimental effect this will have on "the lives of millions of people around the world.

APA Newspeak: "Charges that DSM-5 will lower diagnostic thresholds and lead to a higher prevalence of mental disorders are patently wrong. Results from our field trials, secondary data analyses, and other studies indicate that there will be essentially no change in the overall rates of disorders once DSM-5 is in use."
DSM 5 Reality: DSM 5 made a fatal and unaccountable error in its field testing- it failed to measure the impact of any of its changes on rates and APA therefore has no meaningful data on this most important question. With the exception of autism, all of the suggested DSM 5 changes will definitely raise rates, some dramatically. Adding Binge Eating Disorder by itself would add more than ten million new 'patients'; adding Disruptive Mood Dysregulation Disorder and Minor Neurocognitive Disorder would add millions; as would removing the bereavement exclusion to MDD and lowering thresholds for ADHD and GAD.

Read the full Medscape exchange for more Newspeak from Dr Kupfer, but you get the idea. It is not at all clear to me if APA talks Newspeak cynically, because of naivete, or because Newspeak is the language its expensive public relations consultants put in its mouth.

It doesn't really matter why. Newspeak is devastating- not because anyone outside DSM 5 believes it (DSM 5 defenses are too transparently out of touch with reality to fool outsiders), but because APA may believe its own Newspeak or at least acts as if it does. Reflexive Newspeak, substituting for insight, has prevented DSM 5 from the serious self correction that would have saved it from itself. Bob Spitzer presciently predicted five years ago that a secretive, closed, defensive DSM 5 process would lead inevitably to this failed DSM 5 product.

Medscape has opened a physician-only discussion on the proposed DSM revision. If you are an MD and want to add your thoughts, you can do this at:
http://boards.medscape.com/forums/.2a3285ea/39

If you are a non-MD health care worker with an interest in psychiatric diagnosis, please add your thoughts at: http://boards.medscape.com/forums/.2a32ceea

The public has a big stake in the outcome and can participate by commenting below. DSM 5 is very close to being set in stone. It may or may not do any good to speak up now, but this is a last chance for people to have their say.


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[16] http://www.psychologytoday.com/tags/mental-health-associations
[17] http://www.psychologytoday.com/tags/new-england-journal
[18] http://www.psychologytoday.com/tags/new-york-times
[19] http://www.psychologytoday.com/tags/newspeak-0
[20] http://www.psychologytoday.com/tags/over-diagnosis
[21] http://www.psychologytoday.com/tags/over-treatment
[22] http://www.psychologytoday.com/tags/paraphilia
[23] http://www.psychologytoday.com/tags/personality-disorder
[24] http://www.psychologytoday.com/tags/reliability
[25] http://www.psychologytoday.com/tags/scientific-review-committee-1
[26] http://www.psychologytoday.com/tags/sexual-disorder
[27] http://www.psychologytoday.com/tags/task-force-chair
[28] http://www.psychologytoday.com/tags/trademark-litigation
[29] http://www.psychologytoday.com/tags/unanimous-opposition
[30] http://www.psychologytoday.com/tags/unprecedented-degree-0
[31] http://www.psychologytoday.com/tags/work-group-members-3

Journal of Nervous & Mental Disease:
June 2012 - Volume 200 - Issue 6 - p 517–519
doi: 10.1097/NMD.0b013e318257c699
Original Article

A Critique of the DSM-5 Field Trials

Jones, K. Dayle PhD, LMHC

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Abstract

Abstract: This article provides an overview and critique of the field trials for the current revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The purpose of the DSM-5 field trials was to evaluate the use, feasibility, safety, reliability, and validity of the DSM-5 proposals. In this article, the procedures for evaluating these properties of the DSM-5 are reviewed, and several concerns—such as delays, disorganization, missed deadlines, field trial cancelations, lack of adequate validity testing, and high clinician attrition rates—and their likely impact on the field trial results are presented.

DSM5 in Distress
The DSM's impact on mental health practice and research.
by Allen Frances, M.D.

Top 10 Indicators Of DSM-5 Openness

Challenging APA newspeak.
Published on June 15, 2012 by Allen J. Frances, M.D. in DSM5 in Distress
In '1984', George Orwell introduced the term 'Newspeak'- the abuse of language by totalitarian bureaucracies to create an upside down, looking glass world of misinformation. He was probably inspired by 'Pravda,' the Soviet Union's propaganda paper that literally means 'truth' in Russian but was famous for publishing everything but.
This brings us to the American Psychiatric Association. Its medical director recently justified the astounding $25 million APA has already spent on DSM 5 (5 times the cost of DSM IV) with a curious claim- DSM 5 was so exorbitantly expensive because it was so unprecedentedly open. This classic Newspeak kills two truth birds with one stone — DSM 5 didn't waste a huge amount of money and DSM 5 didn't fail because it was a closed shop. The futile hope is that black will become white if only you say it enough times.
In fact, it is very cheap to run an open process — and very expensive to run a PR disinformation campaign. It cost me nothing but an hour's time to write this blog. How much, I wonder, will it cost APA to pay off GYMR (its high powered public relations producer of newspeak pravda) to defend its indefensible claims that DSM 5 is an open process and that it can meet its unrealistic timetable with a reliable manual?
Here is a top 10 list of great moments in the history of APA 'openness'.
1) APA forces work group members to sign confidentiality agreements to protect DSM 5 'intellectual property'.
2) DSM 5 does a confidential and super-secret 'scientific' review of itself- real science is never secret.
3) APA rebuffs calls from 51 mental health associations for an open and independent scientific review.
4) APA's legal office tries to stifle criticism and censor the internet using inappropriate and bullying threats of trademark litigation.
5) APA plans to steeply jack up licensing costs for use of DSM criteria sets in order to recoup its unaccountably huge investment on its 'intellectual property'.
6) DSM 5 only reluctantly engages on the issues and instead stonewalls criticism with offensive and defensive tactics.
7) The original DSM 5 plan for field trials included no prior public viewing of criteria sets and no period for public comment. These are added only under heavy outside pressure.
8) DSM 5 publishes no aggregations of key areas of concern identified during public reviews; doesn't respond publicly to them. and there is no indication that public input has had any impact whatever on DSM 5.
9) The APA 'charitable' foundation (meant to provide open public education) is named by a watchdog group as the 7th worst charity in all of the US.
10) APA promises to post a complete set of DSM 5 reliability data in time to allow comments during the final period of public review- but fails to do so.
And this is just a taster. At least a dozen reporters have spontaneously mentioned to me that never in their careers have they encountered anything so byzantine as the APA press office. And dozens of APA members have emailed their frustration at not being able to get a straight (or any) answer from a staff whose salaries are paid by their membership dues.
It requires lots of time, money, and brain power to create 'pravda.' Perhaps this explains why everything connected with DSM 5 is always so late and so expensive and why a high flying hired gun like GYMR is needed to run its interference. The real truth is fast, cheap, and very simple to explain.
Additional research is available at Suzy Chapman's website. She monitors DSM-5 development at http://dxrevisionwatch.wordpress.com.

Follow The Money | Psychology Today

DSM5 in Distress
The DSM's impact on mental health practice and research.
by Allen Frances, M.D.

Follow The Money

APA puts publishing profits above public trust
Published on June 11, 2012 by Allen J. Frances, M.D. in DSM5 in Distress
According to its own original schedule, DSM-5 was to have conducted its quality control in a Stage 2 of field testing. Stage 2 would be for rewriting criteria sets that did poorly in Stage 1 and retesting them to ensure they could now achieve reliability.
Stage 1 was a disaster — poorly designed and badly implemented. Constantly missing deadlines, it came in 18-30 months late (depending on how you count its start date). And many diagnoses had crazily low reliability, far below acceptable historical standards-suggesting either that the criteria sets were poorly written or the testing poorly done, or more likely both. The results were pretty much uninterpretable — except for confirming all the other indications that DSM-5 was badly off track and needed lots more work.
APA was faced with 2 choices: 1) go ahead with Stage 2 to clean up the mess; or 2) cancel Stage 2 and publish a poorly edited, unreliable, and untested DSM-5. APA cancelled Stage 2 and is rushing toward a forced, premature birth of DSM-5.
Since there is no pressing need to publish the DSM-5 quickly, let's follow the money. The APA budget depends heavily on the huge publishing profits generated by its DSM monopoly. APA needs the money badly. It is rapidly losing paying members; other sources of funding are also on a downward trend; and its budget projections require a big May 2013 injection of DSM-5 cash.
And APA also has to adjust to the bloated cost of doing DSM-5 — an incredible $25 million dollars. For comparison, DSM IV cost about $5 million, more than half of which came from outside funding. APA feels compelled to recoup on this huge, mostly wasted, investment by getting DSM-5 to the bookstores ASAP. The assumption is that the market is captive and that DSM-5 will be a best seller despite its quality problems.
APA treats DSM-5 like a valuable publishing property, not as a public trust that importantly impacts on people's lives and public policy. It is excellent at protecting its 'intellectual property' with confidentiality agreements and at protecting its trademark and copyright with bullying threats of lawsuits. But APA has been sadly incompetent and wildly profligate in the day to day work of actually producing a safe and scientifically sound DSM-5. The rush now is all about money.
APA Medical Director Jay Scully strongly disagrees with me. He states his case in a piece titled 'DSM-5 Inaccuracies: Setting the Record Straight' Here are Dr Scully's comments (provided in full):
"In his Huffington Post blog dated May 30, 2012 titled 'DSM-5 Costs $25 Million, Putting APA in a Financial Hole,' Allen Frances, M.D., demonstrates either an embarrassing lack of knowledge and understanding of financial reporting or an intentional misrepresentation of facts in his continuing effort to attack the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is published by the American Psychiatric Association. Contrary to Dr. Frances's contention, APA is not in a "financial hole" at all. In fact, the very treasurer's report he purports to cite from in page two expressly states that there was a "preliminary year end surplus of $2.4M for the APA (the (c) (6) nonprofit entity) on a stand-alone basis and a deficit of $2.7M for the APF." The APF, or American Psychiatric Foundation, is an independent charitable subsidiary of APA whose mission is to advance the understanding, prevention, and treatment of mental disorders through public education, research, and training.
APF has no relationship with DSM-5. The APF deficit was a planned deficit encountered to support its philanthropic work, which benefits psychiatry, patients, and the public. The APA (the (c) (6) entity with the $2.4 million surplus) is responsible for the development of DSM-5. APA reports to its board of trustees on a consolidated basis, offsetting APF's deficit with APA's gains."
"Dr. Frances's statement that the consolidated deficit "was caused by reduced publishing profits, poor attendance at its annual meeting, rapidly declining membership, and wasteful spending on DSM-5" is either ignorant or intentionally false. And Dr. Frances apparently missed slide six of the report about reserves, which demonstrate an extremely healthy cash reserve that increases year after year. The strength of APA's reserves and the fiscally conservative approach of consolidating balances of the APA and the APF for a balanced consolidated budget demonstrate the competence of APA leadership."
"Dr. Frances also complains that the revision of DSM-5 has been more expensive than that of DSM-IV. That should not come as a surprise to anyone, particularly Dr. Frances. DSM-5, unlike DSM-IV, invited comments from the world, and the work groups and task force considered every one of the more than 25,000 comments received and conducted further research where indicated. DSM-5 has employed an open process where all comments are considered, revisions are made where appropriate and the ideas are sent out again for comment with the process repeating itself. The transparency associated with the process is expensive, but it is beneficial, and will help to ensure that DSM-5 is a meaningful tool for diagnosis of mental illness when it is published, on time, in 2013."
By saying "when it is published, on time, in 2013," Dr. Scully offers a fait accompli. He has set the DSM-5 publication date without any attention to the lousy Field Trial results, the petition from fifty-one mental health professional associations, the opposition from the Lancet and New England Journal of Medicine, the terrible beating DSM-5 is taking in the press, and the outraged consumer groups. Nothing in his response offers any reason for DSM-5 adhering to his arbitrary timeline. There is nothing to indicate that he understands that DSM-5 is the public trust and not an APA cash cow. Dr Scully is asking us to believe ten very unbelievable things:
1) Its three legal entities aren't just different parts of one APA pocket;
2) the American Psychiatric Foundation just cares about charity- somewhat hard to believe since APF was recently picked as America's 7th worst charity by a watchdog group. This is a pretty spectacular accomplishment given the number of charities in our country. See http://allreaders.net/top10worstcharities.html
3) APA isn't concerned about the budget deficit caused by reduced publishing profits and poor attendance at its annual meeting;
4) APA isn't worried about its rapid loss of membership and isn't trying to find more publishing dollars to fill the budget gap;
5) APA reserves haven't fallen below the one year's operating budget generally expected for a non-profit;
6) DSM-5 has cost $25 million (five times more than DSM IV) because it has had such a wonderfully open process;
7) DSM-5 can produce a usable product by next May;
8) APA isn't completely dependent on the publishing profits from its DSM monopoly to avoid suffering deficits that would be between $5-10 million a year.
9) DSM-5's Stage 2 Quality Control was not cancelled purely for financial reasons. What would be another excuse?
10) DSM-5 is not being rushed to press next May to fill what would otherwise be a gaping hole in the APA budget.
You decide how much, if any, of Dr Scully's arguments make sense. My view — if you want to understand why an unreliable and unsafe DSM-5 is being rushed prematurely to market — "Follow The Money."

A few other problems with diagnosis in Psychiatry and the DSM - Maggie's Farm

Thursday, June 7. 2012

A few other problems with diagnosis in Psychiatry and the DSM


Except for some clearly defined, obvious ailments (eg dementia, the schizophrenias, PDD, autism, addiction, melancholia), most diagnoses in the handbook (the DSM, which many of us refer to as "the insurance manual") attempt to define common clumps of symptoms or behaviors without assuming any validity (ie, without any assumption that the clumping refers to any one cause or underlying abnormality) to those clumps.

Many of our "diagnoses" are akin to saying that a patient has a fever. There's a problem of some sort, but you don't know what it is yet, or whether it's serious or not. Lots of them are "life problems." The DSM is, sorry to say, largely pseudo-scientific. That's because we have very little validity to demonstrate.

Since the validity of most of our diagnoses cannot be tested in any way, all people do is to test their reliability (ie how often will two docs make the same diagnosis in a given patient). In a sense, measuring reliability is nothing but a measure of group-think and, in Psychiatry, the reliability of our diagnoses is quite low - in the "poor" range. (This is measured by a "kappa" score of inter-rater reliability.)

A pain researcher discusses use of kappa:


Landis and Koch45 have proposed the following as standards for strength of agreement for the kappa coefficient: ≤0=poor, .01–.20=slight, .21–.40=fair, .41–.60=moderate, .61–.80=substantial, and .81–1=almost perfect. Similar formulations exist,4648 but with slightly different descriptors. The choice of such benchmarks, however, is inevitably arbitrary,29,49 and the effects of prevalence and bias on kappa must be considered when judging its magnitude.

OK, Psychiatry has only a few rare spots of validity, but even its reliability is mostly in the "poor" to "fair" range. The good Psychiatrist here discusses the abysmal reliability of Psychiatric diagnoses.

As Robin Hanson discusses, Psychiatry uses "depressingly low standards" for reliability. Indeed, most of the time Psychiatrists disagree on how to label a given patient because few patients fit the molds, and most sort-of "fit" multiple categories. Furthermore, many diagnoses fade imperceptibly into normal variants: ADD, anxiety, mild depression, pbobias, PTSD, Bipolar 2, and OCD, and personality disorders, for some common examples. (I recently read that 40% of people have some obsessional symptoms at some point in their lives.)

In Psychiatry, you have to be able to tolerate ambiguity. It's not a mechanical profession except for the amateurs. Most if not all people on the sidewalk are at least what we might term "normal-neurotic" in some ways.

As a result, the American Psychiatric Association recommends that the DSM not be applied clinically in the cook book manner in which it is written, but as a guideline to which clinical experience - and understanding the patient in as much depth as possible - inform one's clinical impression. As Dr. Frances says, "It's not a Bible," and should not be applied as if it were.

Indeed it is not. Scientifically, it's mostly a failure but it's a kind of casual dictionary. I do not take it too seriously, and often use diagnostic descriptions which do not appear in the DSM (such as "neurosis"). I can usually find a way to help people anyway, regardless of how I might label them (and often I do not bother to label them at all). Generally, the more clinical experience a doc has under his belt, and the more psychodynamically-oriented he is, the less seriously he takes the diagnostic obsessional nit-picking.

We muddle through, struggle to understand, and still are able to help lots of people in the end. A true diagnosis of a patient goes far beyond anything in the superficial DSM. For example, a real diagnosis must consider the nature and quality of somebody's "object relations," their character strengths and weaknesses, their sublimatory capacities, their defensive structure, their superego functioning, etc. etc. In other words, really knowing what a person is all about.

Wikipedia has a surprisingly good review of the DSM, with the major critiques. They seem to omit a discussion of its massive profitability.

That's enough for now. More later.

DSM critique in the New England Journal of Medicine is not what it seems « ALTmentalities

DSM critique in the New England Journal of Medicine is not what it seems 05/21/2012Posted by ALT in DSM-5, Mental Health Research.
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I heard the rumors of a fight, and I came a-running.

Fisticuffs, you say? I’m in!
This morning, I read [here] that the following inflammatory remarks were published in this week’s New England Journal of Medicine:
… [Only when psychiatrists address] psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations … by the causal processes and generative mechanisms known to provoke them … will psychiatry come of age as a medical discipline and a field guide [the DSM – Diagnostic and Statistical Manual] cease to be its master work.
- Paul McHugh, MD and Phillp Slavney, MD in the NEJM [emphasis added]
Damn, that’s cold. And did I mention it was published in the New England Journal of Medicine (!), which is “one of the world’s most prestigious medical journals… cited in scientific literature more frequently than any other biomedical journal”? All kinds of doctors, clinicians, and practitioners read this thing!
A big deal.
Sounds like the authors are saying mental illness is fundamentally NOT like diabetes, that psychiatry as a discipline will continue to suffer from its immaturity and crippling inferiority complex (“we wanna be scientists, too!”) as long as diagnosis doesn’t rest on a firmly established foundation of physical pathology, and that the DSM is a poor substitute for that kind of a foundation.
Them’s fighting words. Words that might make the NEJM readership think twice before handing out diagnoses and their accompanying pharmacological interventions like the proverbial candy.

Don’t believe every rumor you hear

Having matured a bit from my high school days of running directly to join the ring of kids chanting “fight, fight, fight!”, I decided to get a little context. Who are these guys -– researchers? psychiatrists? some other kind of doctors? — and what does the rest of their NEJM editorial say?
“These guys” are two psychiatrists, professors at the Johns Hopkins School of Medicine. Paul McHugh, the lead author, is a rather famous one. He’s attended Harvard, designed a famous cognitive test often used as a dementia/Alzheimer’s diagnostic tool (a mere 11 questions!), served on the Presidential Council of Bioethics under GW and on a lay panel put together by the Catholic Church to look into the abuse of young boys by priests – none of these things being very high recommendations in my book. The two, together, have written a popular paperback for the general public entitled The Perspectives of Psychiatry which takes the biopsychiatric/disease-based approach to mental health.
And their editorial? It starts off very nicely with a critique of the DSM-delineated “field guide” method of diagnosis – the main problem being that clinicians no longer think too long or hard about causation. This promotes a “rote-driven” method of treating folks, and as the authors so rightly state “identifying a disorder by its symptoms does not translate into understanding it.” Or treating it effectively, if long-term studies of schizophrenia outcomes are any indication.
But things go sour real fast as we get to the “what’s to be done about it” part. We simply must establish causation for psychiatric disorders, and – guess what?—the authors have already done that!
The causes of psychiatric disorders derive from four interrelated but separable families: brain diseases, personality dimensions, motivated behaviors, and life encounters.
-McHugh et al.
Good, good.
They have also helpfully sorted out some common psychiatric disorders into the four families, or “causal perspectives”:

It’s written in a table so it MUST be true!
Right there, in the NEJM (remember – prestigious medical journal read by everybody), we’ve got schizophrenia neatly categorized as “brain disease.”
Oh, dear.

I diagnose thee… Flipfloppers!

Contrast the NEJM editorial with the polite phrasing the authors used in the aforementioned co-authored The Perspectives of Psychiatry, chapter 6:
The continuing failure to identify a particular cerebral pathology or pathophysiology in these disorders [manic depression and schizophrenia] undermines attempts to proclaim them as diseases with complete confidence. They remain mysteries in the sense that a confirmation of their essential nature is lacking…
- authors Paul McHugh, MD and Phillp Slavney, MD in The Perspectives of Psychiatry [emphasis added]
And yet they feel comfortable, only a few years after these words were published, with proclaiming schizophrenia as a “brain disease,” without providing any citations for new, groundbreaking research whatsoever. Clearly this “DSM critique” is not what it seems.

Middle way protestors all the way

As it turns out, these guys are total middle way DSM protestors – the only thing they’d like to fight is the bad public image of the DSM, not the institution of psychiatric diagnoses masquerading as science, and all of the poor treatment that goes along with such posturing (symptom suppression via pharmaceuticals, coercive treatment, et al.).
According to McHugh and Slavney, “no replacement of the criterion-driven diagnoses of the DSM would be acceptable; clinicians are too accustomed to them.” Rather, the only solution is for everyone [clinicians, researchers, families, patients] to embrace their causation groupings – and for that to be coded and billable, too, one can only presume.
In no other field would you continue to reach for an admittedly blunt, ineffective tool simply because it’s “what people are used to.” Surely there are some other possiblities?
I believe that there is another way – instead of fitting people and their “symptoms” into predetermined boxes, we could communicate with each unique individual, offering our support and encouragement (help) when it’s wanted, and offering our respectful non-interventionism and acknowledgement of the humanity of the suffering individual when our “help” is neither helpful nor desired.
I believe there is life after the DSM – and I’d like, as a society and a community, to live it!
Mike Nova's starred items

Give your psychiatrist a diagnosis of his own: Six disorders to choose from



af3353b6e9Doctor.jpg Give your psychiatrist a diagnosis of his own: Six disorders to choose from

(NaturalNews) Given the controversy over the legitimacy of the Diagnostics and Statistics Manual (DSM) used for psychiatric diagnosis, I thought I'd clear things up by submitting the following revisions. These carefully considered and researched new labels should do the trick, as they are intended to make the DSM more balanced by offering the patient an opportunity to diagnose the doctor.

If you are a doctor and are offended by these proposed DSM additions, then they certainly apply to you. If you are a patient or concerned citizen and are ready to bust one of these onto an unsuspecting doc, you can follow it with the remedy at the end of this article. Here are my six proposed additions to the DSM (others are being researched).

CRD: Compassion repression disorder

Symptoms: When the doc is in the presence of human suffering, he pretends nothing is happening. He could be watching a chess match for all we know. When a patient reaches emotional extremes (as in extraordinarily depressed) he realizes it is time to initiate electro-convulsive therapy and send electric shocks through her brain, possibly wiping out much of her memory. The doc is fine with this and proceeds to go out for a sandwich.

GNTFY: Got no time for you syndrome

Symptoms: Due to concerns about making his yacht payment and country club dues, the doc obsessively packs in 4-5 patients every hour. When you ask a question that takes more than 7.5 seconds to answer, the doc quickly regurgitates several medical terms, hands you a brochure and dashes for the door.

PCSD: Pervasive communication skills disorder

Symptoms: When the doc holds sensitive information and needs to break the news to the patient, he hits the patient over the head with it in the most dismissive way possible. If the patient has cancer, for example, the doctor might say, "You have cancer. We can't operate. You are going to die. The exit is to your left just down the hall."

In less severe cases, such as delivering inconclusive test results (most likely from inadequate testing methods or not knowing what to look for) to a patient who had hopes of finding the cause of a symptom, the doctor takes a more compassionate route, such as, "The results are negative. I guess it really is all in your head."

IAGS: I am God syndrome (also known as "power trip simplex")

Symptoms: The doc behaves as if he were all-powerful and all-knowing. When confronted with the truth that he is just guessing most of the time and that there are a variety of effective, alternative ways to heal from mental and emotional issues, he recoils in righteous indignation.

CPWD: Compulsive prescription writing disorder

Symptoms: Due to repressed feelings of inadequacy and improper toilet training methods used by his parents, the poor doctor compensates by compulsively reaching for the prescription pad every time he hears a symptom. He can't tolerate messes and when patients lives are a bit messy, he has to clean it up as quickly as possible.

BPDD: Big pharma dependency disorder

Symptoms: The doc displays little or no ability to actually help people and has no interest human nature anyway, so he is 100% (one HUNDRED percent) dependent upon the pharmaceutical industry to tell him what to do with his patients. Aside from studying which medication matches which symptoms (as can be discerned in 12 minutes or less) the doctor has no other skills. Poor communication skills. No compassion. Little interest in the emotional causes of problems. No taste for nutrition therapy. Nothing!

There really isn't much there, folks. This guy is a pill-pusher and that's about it! I guess we should show some compassion of our own. After all, once the doc gets a little taste of how easy and lucrative it is to prescribe a pill, he gets sucked right in. Before you know it, he is hooked on the easy money.

He doesn't have a medical practice that seeks to solve deep problems at the heart of the human condition. He isn't connecting with people in their suffering and helping them work out their emotional problems. He is no teacher or mentor. He is a pill pusher caught up in the drug cartel's deadly game.

Worst of all, now it is too late. You see, he's got overhead. Bills! Actually helping people takes time he no longer has. You have to get to know people. You need to contemplate their circumstance in life. You can't do it in 15 minutes. You can see one patient per hour at most. There goes that $600,000 annual income. You'd have to cut back to a mere $150,000 annually, or something close to it. So, yeah, it's tough for these guys.

The remedy to all of the above. A sincere plea to the doctor: Please, please stop. We need good doctors. You have so much opportunity to assist people who put their trust in you. Slow down. Learn to really help people who are suffering with emotional problems. Learn to work with other practitioners of all kinds. The work is rewarding, unlike the pill factory you currently operate. Please consider this request to make a real difference.

About the author:
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Mike Bundrant is the host of Mental Health Exposed, a Natural News Radio program, and the co-founder of the iNLP Center.

Dr. Robert L. Spitzer, Noted Psychiatrist, Apologizes for Study on Gay ‘Cure’ - NYTimes.com

May 18, 2012

Psychiatry Giant Sorry for Backing Gay ‘Cure’


By

PRINCETON, N.J. — The simple fact was that he had done something wrong, and at the end of a long and revolutionary career it didn’t matter how often he’d been right, how powerful he once was, or what it would mean for his legacy.
Dr. Robert L. Spitzer, considered by some to be the father of modern psychiatry, lay awake at 4 o’clock on a recent morning knowing he had to do the one thing that comes least naturally to him.
He pushed himself up and staggered into the dark. His desk seemed impossibly far away; Dr. Spitzer, who turns 80 next week, suffers from Parkinson’s disease and has trouble walking, sitting, even holding his head upright.
The word he sometimes uses to describe these limitations — pathetic — is the same one that for decades he wielded like an ax to strike down dumb ideas, empty theorizing and junk studies.
Now here he was at his computer, ready to recant a study he had done himself, a poorly conceived 2003 investigation that supported the use of so-called reparative therapy to “cure” homosexuality for people strongly motivated to change.
What to say? The issue of gay marriage was rocking national politics yet again. The California State Legislature was debating a bill to ban the therapy outright as being dangerous. A magazine writer who had been through the therapy as a teenager recently visited his house, to explain how miserably disorienting the experience was.
And he would later learn that a World Health Organization report, released on Thursday, calls the therapy “a serious threat to the health and well-being — even the lives — of affected people.”
Dr. Spitzer’s fingers jerked over the keys, unreliably, as if choking on the words. And then it was done: a short letter to be published this month, in the same journal where the original study appeared.
“I believe,” it concludes, “I owe the gay community an apology.”
Disturber of the Peace
The idea to study reparative therapy at all was pure Spitzer, say those who know him, an effort to stick a finger in the eye of an orthodoxy that he himself had helped establish.
In the late 1990s as today, the psychiatric establishment considered the therapy to be a nonstarter. Few therapists thought of homosexuality as a disorder.
It was not always so. Up into the 1970s, the field’s diagnostic manual classified homosexuality as an illness, calling it a “sociopathic personality disturbance.” Many therapists offered treatment, including Freudian analysts who dominated the field at the time.
Advocates for gay people objected furiously, and in 1970, one year after the landmark Stonewall protests to stop police raids at a New York bar, a team of gay rights protesters heckled a meeting of behavioral therapists in New York to discuss the topic. The meeting broke up, but not before a young Columbia University professor sat down with the protesters to hear their case.
“I’ve always been drawn to controversy, and what I was hearing made sense,” said Dr. Spitzer, in an interview at his Princeton home last week. “And I began to think, well, if it is a mental disorder, then what makes it one?”
He compared homosexuality with other conditions defined as disorders, like depression and alcohol dependence, and saw immediately that the latter caused marked distress or impairment, while homosexuality often did not.
He also saw an opportunity to do something about it. Dr. Spitzer was then a junior member of on an American Psychiatric Association committee helping to rewrite the field’s diagnostic manual, and he promptly organized a symposium to discuss the place of homosexuality.
That kicked off a series of bitter debates, pitting Dr. Spitzer against a pair of influential senior psychiatrists who would not budge. In the end, the psychiatric association in 1973 sided with Dr. Spitzer, deciding to drop homosexuality from its manual and replace it with his alternative, “sexual orientation disturbance,” to identify people whose sexual orientation, gay or straight, caused them distress.
The arcane language notwithstanding, homosexuality was no longer a “disorder.” Dr. Spitzer achieved a civil rights breakthrough in record time.
“I wouldn’t say that Robert Spitzer became a household name among the broader gay movement, but the declassification of homosexuality was widely celebrated as a victory,” said Ronald Bayer of the Center for the History and Ethics of Public Health at Columbia. “ ‘Sick No More’ was a headline in some gay newspapers.”
Partly as a result, Dr. Spitzer took charge of the task of updating the diagnostic manual. Together with a colleague, Dr. Janet Williams, now his wife, he set to work. To an extent that is still not widely appreciated, his thinking about this one issue — homosexuality — drove a broader reconsideration of what mental illness is, of where to draw the line between normal and not.
The new manual, a 567-page doorstop released in 1980, became an unlikely best seller, here and abroad. It instantly set the standard for future psychiatry manuals, and elevated its principal architect, then nearing 50, to the pinnacle of his field.
He was the keeper of the book, part headmaster, part ambassador, and part ornery cleric, growling over the phone at scientists, journalists, or policy makers he thought were out of order. He took to the role as if born to it, colleagues say, helping to bring order to a historically chaotic corner of science.
But power was its own kind of confinement. Dr. Spitzer could still disturb the peace, all right, but no longer from the flanks, as a rebel. Now he was the establishment. And in the late 1990s, friends say, he remained restless as ever, eager to challenge common assumptions.
That’s when he ran into another group of protesters, at the psychiatric association’s annual meeting in 1999: self-described ex-gays. Like the homosexual protesters in 1973, they too were outraged that psychiatry was denying their experience — and any therapy that might help.
Reparative Therapy
Reparative therapy, sometimes called “sexual reorientation” or “conversion” therapy, is rooted in Freud’s idea that people are born bisexual and can move along a continuum from one end to the other. Some therapists never let go of the theory, and one of Dr. Spitzer’s main rivals in the 1973 debate, Dr. Charles W. Socarides, founded an organization called the National Association for Research and Therapy of Homosexuality, or Narth, in Southern California, to promote it.
By 1998, Narth had formed alliances with socially conservative advocacy groups and together they began an aggressive campaign, taking out full-page ads in major newspaper trumpeting success stories.
“People with a shared worldview basically came together and created their own set of experts to offer alternative policy views,” said Dr. Jack Drescher, a psychiatrist in New York and co-editor of “Ex-Gay Research: Analyzing the Spitzer Study and Its Relation to Science, Religion, Politics, and Culture.”
To Dr. Spitzer, the scientific question was at least worth asking: What was the effect of the therapy, if any? Previous studies had been biased and inconclusive. “People at the time did say to me, ‘Bob, you’re messing with your career, don’t do it,’ ” Dr. Spitzer said. “But I just didn’t feel vulnerable.”
He recruited 200 men and women, from the centers that were performing the therapy, including Exodus International, based in Florida, and Narth. He interviewed each in depth over the phone, asking about their sexual urges, feelings and behaviors before and after having the therapy, rating the answers on a scale.
He then compared the scores on this questionnaire, before and after therapy. “The majority of participants gave reports of change from a predominantly or exclusively homosexual orientation before therapy to a predominantly or exclusively heterosexual orientation in the past year,” his paper concluded.
The study — presented at a psychiatry meeting in 2001, before publication — immediately created a sensation, and ex-gay groups seized on it as solid evidence for their case. This was Dr. Spitzer, after all, the man who single-handedly removed homosexuality from the manual of mental disorders. No one could accuse him of bias.
But gay leaders accused him of betrayal, and they had their reasons.
The study had serious problems. It was based on what people remembered feeling years before — an often fuzzy record. It included some ex-gay advocates, who were politically active. And it did not test any particular therapy; only half of the participants engaged with a therapist at all, while the others worked with pastoral counselors, or in independent Bible study.
Several colleagues tried to stop the study in its tracks, and urged him not to publish it, Dr. Spitzer said.
Yet, heavily invested after all the work, he turned to a friend and former collaborator, Dr. Kenneth J. Zucker, psychologist in chief at the Center for Addiction and Mental Health in Toronto and editor of the Archives of Sexual Behavior, another influential journal.
“I knew Bob and the quality of his work, and I agreed to publish it,” Dr. Zucker said in an interview last week. The paper did not go through the usual peer-review process, in which unnamed experts critique a manuscript before publication. “But I told him I would do it only if I also published commentaries” of response from other scientists to accompany the study, Dr. Zucker said.
Those commentaries, with a few exceptions, were merciless. One cited the Nuremberg Code of ethics to denounce the study as not only flawed but morally wrong. “We fear the repercussions of this study, including an increase in suffering, prejudice, and discrimination,” concluded a group of 15 researchers at the New York State Psychiatric Institute, where Dr. Spitzer was affiliated.
Dr. Spitzer in no way implied in the study that being gay was a choice, or that it was possible for anyone who wanted to change to do so in therapy. But that didn’t stop socially conservative groups from citing the paper in support of just those points, according to Wayne Besen, executive director of Truth Wins Out, a nonprofit group that fights antigay bias.
On one occasion, a politician in Finland held up the study in Parliament to argue against civil unions, according to Dr. Drescher.
“It needs to be said that when this study was misused for political purposes to say that gays should be cured — as it was, many times — Bob responded immediately, to correct misperceptions,” said Dr. Drescher, who is gay.
But Dr. Spitzer could not control how his study was interpreted by everyone, and he could not erase the biggest scientific flaw of them all, roundly attacked in many of the commentaries: Simply asking people whether they have changed is no evidence at all of real change. People lie, to themselves and others. They continually change their stories, to suit their needs and moods.
By almost any measure, in short, the study failed the test of scientific rigor that Dr. Spitzer himself was so instrumental in enforcing for so many years.
“As I read these commentaries, I knew this was a problem, a big problem, and one I couldn’t answer,” Dr. Spitzer said. “How do you know someone has really changed?”
Letting Go
It took 11 years for him to admit it publicly.
At first he clung to the idea that the study was exploratory, an attempt to prompt scientists to think twice about dismissing the therapy outright. Then he took refuge in the position that the study was focused less on the effectiveness of the therapy and more on how people engaging in it described changes in sexual orientation.
“Not a very interesting question,” he said. “But for a long time I thought maybe I wouldn’t have to face the bigger problem, about measuring change.”
After retiring in 2003, he remained active on many fronts, but the reparative study remained a staple of the culture wars and a personal regret that wouldn’t leave him be. The Parkinson’s symptoms have worsened in the past year, exhausting him mentally as well as physically, making it still harder to fight back pangs of remorse.
And one day in March, Dr. Spitzer entertained a visitor. Gabriel Arana, a journalist at the magazine The American Prospect, interviewed Dr. Spitzer about the reparative therapy study. This was not just any interview; Mr. Arana went through reparative therapy himself as a teenager, and his therapist had recruited the young man for Dr. Spitzer’s study (Mr. Arana did not participate).
“I asked him about all his critics, and he just came out and said, ‘I think they’re largely correct,’ ” said Mr. Arana, who wrote about his own experience last month. Mr. Arana said that reparative therapy ultimately delayed his self-acceptance as a gay man and induced thoughts of suicide. “But at the time I was recruited for the Spitzer study, I was referred as a success story. I would have said I was making progress.”
That did it. The study that seemed at the time a mere footnote to a large life was growing into a chapter. And it needed a proper ending — a strong correction, directly from its author, not a journalist or colleague.
A draft of the letter has already leaked online and has been reported.
“You know, it’s the only regret I have; the only professional one,” Dr. Spitzer said of the study, near the end of a long interview. “And I think, in the history of psychiatry, I don’t know that I’ve ever seen a scientist write a letter saying that the data were all there but were totally misinterpreted. Who admitted that and who apologized to his readers.”
He looked away and back again, his big eyes blurring with emotion. “That’s something, don’t you think?”

Psychiatry’s Billing Bible Prompts ‘Bickering, Contention, Organized Revolt and finally, A Backdown’ « CCHR International




Psychiatry’s Billing Bible Prompts ‘Bickering, Contention, Organized Revolt and finally, A Backdown’


Photo: Garry Mcleod; Origami: Robert Lang

Medical ‘bible’ squabble

The Australian – May 18, 2012
by Sue Dunlevy
EFFORTS to update the psychiatrists’ bible – the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – have led to bickering, contention, organised revolt and, finally, a backdown.
The association announced it has abandoned plans to class so-called attenuated psychosis syndrome and internet addiction as psychiatric disorders.
And four disputed additional criteria for diagnosing attention deficit hyperactivity disorder (ADHD) have been dumped: “impatience”, “acting without thinking”, “uncomfortable doing things slowly and systematically” and “finds it difficult to resist temptations or opportunities”.
The battle over the book used worldwide to define mental illness matters as it’s the arbiter of who is normal and who is mentally ill and, therefore, qualifies for special help with their education, subsidies for their medicines and access to treatment programs.
After more than 13,000 international psychiatrists signed a petition objecting to the way the manual was being revised, the US psychiatrist heading the review committee, in an opinion piece in The New York Times this week, called for a new independent process of defining mental illness.
“We need some equivalent of the Food and Drug Administration to mind the store and control diagnostic exuberance,” Allen Frances writes. “Experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabelled as mental disorders.”
The biggest concern among psychiatrists is that many of the proposed changes to diagnostic criteria and new mental health conditions run the danger of medicalising normal behaviour. They fear it could result in patients taking unnecessary, even harmful, prescription drugs.
Despite the squabbling, Australian anxiety expert Gavin Andrews – who heads one of the committees writing the fifth edition of the manual, or DSM-5 – argues the APA’s backdown this month shows the revision process is working. “Science says, here’s a good idea, let’s test it. Then science says, no, its unreliable, and you drop it,” he explains.
The committees updating the diagnostic criteria collected new research, carried out field trials of proposed new diagnostic criteria to see how they would be used by doctors on patients, and took criticism on board, Andrews says.
He adds that sometimes – as in the case of “early psychosis”, promoted but now abandoned by Australian psychiatrist Patrick McGorry – a proposed disorder is dropped because it would have led to large numbers of young people being medicated unnecessarily. For instance, Australian author, ADHD campaigner and Labor state MP Martin Whitely remains alarmed about the inclusion in the manual of a condition called “attention deficit hyperactivity disorder not elsewhere classified”. He says it would allow doctors to diagnose people who didn’t meet the ADHD criteria with the disorder.
Other new diagnoses that have survived the DSM-5 process include premenstrual dysphoric disorder, disruptive mood dysregulation disorder in children and autism spectrum disorder – a single condition combining the previous diagnoses of autism, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.
Andrews says he’s fascinated by the interest in the debate in Australia. After all, technically DSM-5 is written by Americans for the US and has no legal standing here.
The World Health Organization’s International Classification of Diseases version 10 is the legal classification used in Australia.
However, Andrews admits that doctors here use DSM because it’s “more informative”.
It contains about 2000 words on each disorder and is more helpful to doctors.
According to Andrews, the WHO would be the ideal body to take on the job of developing a definitive diagnostic manual, but it needs the resources to do so.
The APA has so far spent more than $US35 million on developing DSM-5, but it will get its investment back as it can sell the manual all over the world.
In contrast, the WHO has limited funding and cannot charge for its more limited manual.
Flinders University child psychiatrist Jon Jureidini tells Weekend Health the to-ing and fro-ing over the DSM-5 diagnostic criteria for ADHD “highlighted the invalidity of the whole construct”.
The degree of debate indicates “we are not dealing with a valid disorder”, he claims.
And Frances says the body setting diagnostic criteria should include not just psychiatrists. Doctors, psychologists, counsellors, social workers and nurses should also be permitted to have some input.
“The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts,” he says.
Andrews counters that psychologists, counsellors, social workers and nurses are already involved in the field trials of DSM-5 diagnoses.
Meanwhile, Whitely asks the fundamental question: why does Australia continue to follow the American lead?
“Are mental health outcomes in the US good enough to justify our continued devotion to the DSM model?” he says. “Or is it time to go it alone?”
Those interested have until June 15 to comment on the latest draft of DSM-5.
http://www.theaustralian.com.au/news/health-science/medical-bible-squabble/story-e6frg8y6-1226359242372
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Johns Hopkins Experts Say Psychiatry’s Diagnostic Manual Needs Overhaul — Tri-City Psychology Services

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Tri-City Psychology Services» Mental Health» Johns Hopkins Experts Say Psychiatry’s Diagnostic Manual Needs Overhaul

Johns Hopkins Experts Say Psychiatry’s Diagnostic Manual Needs Overhaul

May 16, 2012
DSM IV TR Johns Hopkins Experts Say Psychiatry’s Diagnostic Manual Needs OverhaulThe Diagnostic and Statistical Manual of Mental Disorders (DSM), long the master reference work in psychiatry, is seriously flawed and needs radical change from its current “field guide” form, according to an essay by two Johns Hopkins psychiatrists published in the May 17 issue of the New England Journal of Medicine.
“A generation ago it served useful purposes, but now it needs clear alterations,” says Paul R. McHugh, M.D., a professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine and co-author of the paper with Phillip R. Slavney, M.D., a professor emeritus in the same department. “They say they can’t do any better. We disagree and can show how.”
The original DSM, published in the 1950s, was intended as a public health service documenting the incidence and prevalence of mental illnesses. By its third edition in 1980 (DSM-III), however, it had evolved into a reference book prescribing how clinicians should identify and classify psychiatric disorders.
Today, the Johns Hopkins psychiatrists say, DSM provides checklists of symptoms, offering few clues to the underlying causes of mental disease and making it difficult to direct treatment or investigate the disorders it details. A new edition, DSM-5, is due out in 2013.
The manual, put together by the American Psychiatric Association, currently identifies hundreds of conditions via lists of diagnostic criteria and symptoms, functioning exactly as does a naturalist’s field guide but for mental illness. It offers no way to make sense of mental disorders and no way to distinguish illnesses that appear to be similar but actually are quite different and require different treatments, the psychiatrists argue.
“If you just name things and don’t explain what the causes are, you do not know how to rationally treat or study the diseases,” says McHugh, former director of Hopkins’ psychiatry department. “The DSM gives everything a name but not a nature.”
Before DSM-III, McHugh and Slavney say, psychiatrists typically used a “bottom-up” method of diagnosis, based on a detailed life history, painstaking examination of mental status and corroboration from third parties. The new emphasis on symptoms, they say, has unfortunately encouraged a cursory “top-down” method that relies on checklists and ignores much of the narrative of the patients’ lives.
The causes of psychiatric disorders derive from four interrelated but separable categories: brain diseases, personality dimensions, motivated behaviors and life encounters, write McHugh and Slavney. The two physicians suggest that organizing mental illnesses based on these four causalities would “promote fruitful thought and, consequently, progress.”
“Psychiatrists would start moving toward the day when they address psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations as products of nature to be comprehended not simply by their outward show but by the causal processes and generative mechanisms that provoke them,” they write. “Only then will psychiatry come of age as a medical discipline and a field guide cease to be its master work.”
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After more than 13000 international psychiatrists signed a petition objecting to the way the manual was being revised, the US psychiatrist heading the review committee, in an opinion piece in The New York Times this week, ...






Mental Illness (Stanford Encyclopedia of Philosophy)

Mental Illness

First published Fri Nov 30, 2001; substantive revision Mon Feb 22, 2010
Psychiatry involves theories of the mind, theories of the causes of mental disorders, classification schemes for those disorders, research about the disorders, proven treatments and research into new treatments, and a number of professions whose job it is to work with or on behalf of people with mental disorders. The philosophical study of psychiatry discusses conceptual, ethical, metaphysical, social, and epistemological issues that arise in all these aspects of psychiatry. Central to this study is the nature of mental illness.
The central philosophical debate over mental illness is not about its existence, but rather over how to define it, and whether it can be given a scientific or objective definition, or whether normative and subjective elements are essential to our concept of mental illness. One desideratum for a successful definition of mental illness is that it will settle debates over particular purported mental illnesses.
The connection between philosophical issues in the study and treatment of mental illness and these other areas of philosophy is in many cases obvious, as in the question of when and how people with mental disorders are responsible for their actions is connected with the insanity defense in law, and the more general debate over the justification of punishment. The philosophical investigation of the nature of mental illness is therefore relevant to many other areas of philosophy. While there is no sharp divide between the philosophical discussion of the nature of mental illness and the wider philosophical discussion of psychiatry, we can focus on four major issues that have preoccupied the philosophical literature.

What can philosophy do for psychiatry?

World Psychiatry. 2004 October; 3(3): 130–135.
PMCID: PMC1414692
Copyright World Psychiatric Association
What can philosophy do for psychiatry?
Kenneth WM Fulford,1,2,3 Giovanni Stanghellini,3,4 and Matthew Broome3,5
1Department of Philosophy, University of Warwick, Coventry, UK
2Department of Psychiatry, University of Oxford, UK
3WPA Section on Philosophy and Humanities in Psychiatry
4Department of Mental Health, University of Florence, Italy
5Institute of Psychiatry, University of London, UK
Small right arrow pointing to: This article has been cited by other articles in PMC.
Abstract
This article illustrates the practical impact of recent developments in the philosophy of psychiatry in five key areas: patient-centred practice, new models of service delivery, neuroscience research, psychiatric education, and the organisation of psychiatry as an international science-led discipline focused on patient care. We conclude with a note on the role of philosophy in countering the stigmatisation of mental disorder.
Keywords: Concepts of disorder, classification, neuroimaging, early diagnosis, values-based practice, patient-centred practice
According to the great 20th century psychologist and philosopher William James, philosophy is "an unusually stubborn effort to think clearly" (1). The need for clear thinking in psychiatry arises from the fact that our subject raises problems of meaning alongside empirical difficulties in a particularly acute way. A recent Forum in World Psychiatry, dealing with "the challenge of psychiatric comorbidity" (2), makes the point. That Forum covered empirical issues such as the likely impact on psychiatric classifications of future advances in behavioural genetics (2, 3), but much of the debate was about conceptual difficulties; about the meanings, for example, of such key terms as "disease" and "disorder" (4), and "syndrome" (5); about the tension between "reliability" and various aspects of "validity" (6); and about the competing claims of categorical and dimensional classifications to reflect "the state of nature, not merely how clinicians think about the state of nature" (7).
As Allen Frances pointed out in his role as Chairperson of the DSM-IV Task Force (8), it is one thing to recognise the importance of conceptual difficulties in psychiatry, it is quite another to do something about them. In this article, therefore, we will be focusing not on problems but on solutions. The last few years have witnessed a remarkable explosion of cross-disciplinary work between philosophy and psychiatry (9). Rather than attempting a full review of the field, however, we will be illustrating what philosophy can do for psychiatry, with examples of what it is already doing in five key areas: a) patient-centred practice, b) models of service delivery, c) research, d) education and e) international organisations.
Philosophy, through a new model linking values with evidence, called values-based practice (VBP), gives us specific tools to help make science work for us in a more patient centred way (10). VBP is the theory and skills-base for effective healthcare decision-making where different (and hence potentially conflicting) values are involved. VBP, somewhat like a political democracy, starts from respect for different values and relies on good process for its practical effectiveness.
Good process in VBP, as shown in Table ​Table1, depends1, depends on 10 key "pointers". The starting point of good process in VBP is careful attention to individual patients' values (pointer 1). Where values conflict, however, VBP seeks to achieve a balanced approach to clinical decision-making by drawing on a range of different value perspectives, represented here by the multi-disciplinary team (pointer 2). Achieving a balance of value perspectives in turn depends on four key clinical skills: raising awareness, reasoning skills, knowledge and communication skills (pointers 3 to 6). Values-based and evidence-based approaches, as the next three pointers (pointers 7 to 9) indicate, are complementary. In particular, as David Sackett, one of the leaders of evidence-based practice, has emphasised, they are both essential to building genuine partnership between professionals, their patients and their patients' families (11). This aspect of good process in VBP is reflected in the partnership model of decision-making summarised in Table ​Table11 in pointer 10.
Table 1
Table 1
Ten pointers to good process in values-based practice
The philosophical sources of VBP include abstract formal disciplines such as linguistic analysis, phenomenology and hermeneutics (10). But its practical applications already include a number of both treatment (12) and policy and service development initiatives within the Modernisation Agency of the UK's National Health Service (www.connects.org.uk/conferences). Central to all these initiatives, is a training workbook covering the skills of VBP (13). This workbook, which is the result of a unique collaboration between a Philosophy Department (at Warwick University) and an in-service training provider (the Sainsbury Centre for Mental Health), has been recently launched in London by the Minister of State responsible for mental health, Rosie Winterton, and will be the basis for training of front-line clinical staff from April of next year in each of the main national health service (NHS) regions of England and Wales.
Future developments in VBP will be supported by a lively international programme of ongoing research. A particular focus of this research is the role of values in classification and diagnosis. The American psychiatrist and co-editor (with Fulford) of the international journal Philosophy, Psychiatry, & Psychology, John Sadler, has been particularly active in this field (14, 15). A research methods meeting last year in London, funded by the UK government, brought together work on values in diagnosis from phenomenological (16, 17) and empirical (18) as well as philosophical sources. This work will contribute to the development of more inclusive models of psychiatric classification through the work of the WPA Sections on Philosophy and Humanities in Psychiatry and on Classification, Diagnostic Assessment and Nomenclature (19).
There is also ongoing educational research. Werdie van Staden, a psychiatrist and philosopher at Pretoria University, and founder, with Tuviah Zabow at Capetown University, of the Philosophy Special Interest Group in the South African Society of Psychiatrists, has established a joint educational research programme with Warwick University Medical School, dealing with the effectiveness of training in VBP for medical students.
Mental health services in many parts of the world are nowadays delivered by multi-disciplinary teams. This ensures that a variety of different skills– medical, psychological, social, etc. – are available to meet the needs of individual patients. However, team working is too often associated with conflicts and failures of communication, with the result that patients are at risk of "falling through the net" through lack of collaborative decision-making (20). In addition, there are some cultures with very different models of disorder altogether, for example where families and social networks are valued more highly than individual autonomy (21).
In a study combining philosophical work on concepts of disorder with empirical social science methods, Anthony Colombo and colleagues at Warwick University have shown that such difficulties in multi-disciplinary team working are often driven by unrecognised differences in models of disorder (22). Despite the contested status of the concept of mental disorder, most mental health professionals nowadays claim to work within a shared biopsychosocial model (23). But what Colombo et al's study showed is that in practice, and often without being aware of it, different professional disciplines actually work with very different implicit models – hence the conflicts and difficulties in multi-disciplinary teamworking. Studies paralleling Colombo et al's project are currently underway at Linköping University in Sweden and at the Maudsley Hospital in London.
Colombo et al's study illustrates one of the general roles of philosophy in psychiatry. As the Oxford philosopher J. L. Austin put it, the characteristic output of philosophical "clear thinking" is to give us a more complete picture of the full meanings of the complex concepts by which we make sense of the world around us (24).
Phenomenology, and its close relatives existentialism and hermeneutics, are particularly helpful in giving us a "more complete" picture. Phenomenology, as Karl Jaspers (25, 26) recognised, provides a range of practical tools for working with personal meanings, alongside scientific findings, in psychopathology. This is important in research (see below). But phenomenology and related disciplines are already generating new models of service delivery more directly geared to individual and cultural meanings. Such models include the Irish psychiatrist and philosopher Patrick Bracken's use of Heideggerian phenomenology to support new approaches to the management of post-traumatic stress disorder in traditional societies (27), the American psychologist and philosopher Steven Sabat's use of discursive analysis to improve communication with Alzheimer's disease sufferers (28), and the Dutch philosopher Guy Widdershoven's work on collaborative decision-making, also in Alzheimer's disease, employing the "hermeneutic circle" (29).
It is no coincidence that the emergence of a new and vigorous philosophy of psychiatry in the closing years of the 20th century coincided with dramatic advances in the neurosciences (9). As no less a neuroscientist than Nancy Andreasen has pointed out, the neurosciences themselves are among the factors pushing traditional philosophical problems, such as the nature of personal identity and of our knowledge of "other minds", to the top of our agenda in psychiatry (30).
The new philosophy of psychiatry is certainly not shy of problems of this magnitude (31-33). The British psychiatrist Sean Spence's brain imaging studies of hysteria, for example, raise a number of the traditional problems of psychiatry in exactly the challenging way that Andreasen anticipated (34), and a joint research programme between Warwick and Oxford Universities and the Institute of Psychiatry in London, funded by the McDonnell-Pew Centre for Cognitive Neuroscience in Oxford, has brought together philosophers, neuroscientists and patients, in a collaborative study of schizophrenia published as a special double issue of Philosophy, Psychiatry, & Psychology, edited by the Warwick philosopher Christoph Hoerl (35).
It is however particularly through the phenomenological tradition, with its focus on subjective experience, that the new philosophy of psychiatry is connecting most directly with neuroscience research (36-39). Imaging studies, in particular, demand more sophisticated ways of characterising and defining the contents of experience and how these are linked to brain functioning (40, 41). The work of the Cologne group on early detection and prediction of psychotic illnesses, for example, draws directly on phenomenological methods (42). Research in this area is a two way process, however, in which phenomenology and philosophy of mind also draw on the rich varieties of psychopathology (43, 44).
Early in the field with the potential applications of phenomenology to psychopathology was of course Karl Jaspers (45), perhaps the first philosopher-psychiatrist. Building on a strong 20th century tradition of conceptually informed work on classification and diagnosis (46, 47), the new philosophy of psychiatry has picked up Jaspers' concern to link meanings with causes in psychopathology (48-51). But a strong tradition of phenomenological work was maintained through much of the 20th century in a number of European countries (notably France, Germany and Italy), in Japan and in South America (9).
It is impossible within the scope of this article even to list the many distinguished recent contributors to this tradition. The main areas of work include both specific symptoms (52-55) and wider issues of psychiatric nosology (56). Examples of work in this area, drawing on the phenomenologies of such seminal 20th century philosophers as Martin Heiddegger, Maurice Merleau-Ponty and Jean Paul Sartre, are included in a number of recent collections (9, 57); new work is reviewed regularly in the History and Philosophy section of Current Opinion in Psychiatry (e.g., 58); and a more comprehensive treatment will be given in one of the volumes in the new book series from Oxford University Press on International Perspectives in Philosophy and Psychiatry (59).
Research in the philosophy of psychiatry requires the same high-level skills as in any other technical discipline. When it comes to education and training, however, philosophy has a wider contribution to make to psychiatry, through the development of the generic thinking skills, the "clear thinking" of William James' aphorism (above), that are essential in all areas of practice.
The training manual for VBP noted above is a well-developed example of the effectiveness of philosophy in this respect (13). The exercises used for the development of VBP-skills are based directly on ideas from philosophers such as J.L. Austin (24) and R.M. Hare (60), working in the most abstract areas of philosophical value theory. Yet, these training exercises have been particularly well received, in pilot studies, not by academic psychiatrists, but by patient advocates, mental health nurses, social workers and others, working in such challenging areas of front-line mental health practice as crisis intervention and assertive outreach (61).
A full curriculum for philosophy of psychiatry has been introduced in the latest revision of the Royal College of Psychiatrists' curriculum for higher psychiatric training, the "MRCPsych" (62). Besides other sources cited in this article, training in this area will build on rich resources from classical philosophy (63, 64) and history of ideas (65, 66).
Psychiatry is peculiar among medical disciplines in being particularly vulnerable to abusive uses for purposes of political or social control. The notorious "delusions of reformism", the basis on which political dissidents were diagnosed with "schizophrenia" in the former Soviet Union, is but one example of our vulnerability in this respect (67).
The prevention of such abuses involves a wide range of resources –political, scientific, legal and educational. Philosophy contributes generally in each of these areas, drawing on cross-cultural (68) and historical (69, 70) scholarship and political philosophy (71). Among other results, such work shows that the underlying vulnerability of psychiatry in this respect arises from a failure to maintain a balance of different perspectives. In the Soviet Union, it was the unbalanced dominance of the Soviet ethic that distorted diagnostic judgements (72). This led to a kind of conceptual blindness arising from what the 17th century political philosopher, and founder of British empiricism, John Locke, called "enthusiasms" (73). We have seen similar "enthusiasms" in psychiatry throughout the 20th century– for psychoanalysis at one stage in America, for example, and more recently, in some quarters, for a narrow model of "biological psychiatry" (74).
We can counter such "enthusiasms" only by maintaining what Jim Birley, a Past President of the Royal College of Psychiatrists, and founder chair of the reforming organisation Geneva Initiative for Psychiatry, has called an "open society" in international psychiatry (75). The new philosophy of psychiatry will contribute to maintaining such an open society, partly through the more complete picture of the conceptual structure of the subject which, as noted above, is its characteristic output, but also, and importantly, through its own organisation as an open and collegial discipline, inclusive of methodological pluralism, and embracing intellectual and cultural diversity (9).
Future international developments in the philosophy of psychiatry will be supported by an International Network for Philosophy and Psychiatry (INPP), launched from South Africa as part of the 2002 biennial meeting of the South African Society of Psychiatrists, hosted by Professors Tuviah Zabow and Werdie van Staden. The INPP has been set up to support local, national and subject based organisations. Collaborating closely with new Sections in both the WPA and the European Psychiatric Association, the INPP will aim to contribute to the development of international psychiatry as a strongly dynamic "open society" of the kind Jim Birley envisaged.
Perhaps the deepest difficulty with which psychiatry ended the 20th century was the continuing stigmatisation to which both patients and practitioners were subject. Despite developments in the neurosciences, psychiatry was still perceived by many as being somehow "unscientific" (76), and mental disorders continued to carry unwarranted negative associations such as violence and untreatability (12).
Philosophy, in giving us a more complete picture of the conceptual structure of psychiatry, shows that our subject, far from being scientifically deficient, is simply a good deal more difficult than other areas of healthcare. Philosophy is important in psychiatry for much the same reason that it is important in theoretical physics. Both disciplines demand clear thinking about concepts as well as sophisticated scientific instruments for gathering data.
As we enter the 21st century, however, other areas of medicine, besides psychiatry, will increasingly face conceptual difficulties driven by scientific advances (77). In engaging with philosophy, therefore, across the five key areas outlined in this article, psychiatry, far from running second to the rest of medicine as it did in the 20th century, is leading the way for 21st century medical science.
Acknowledgement
The Table is based on a figure published in Woodbridge K, Fulford KWM. Whose values? A workbook for values-based practice in mental health care. London: Sainsbury Centre for Mental Health (in press), and we are grateful to the Sainsbury Centre for Mental Health in London for permission to reproduce it here.
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2. Pincus HA, Tew JD, First MB. Psychiatric comorbidity: is more less? World Psychiatry. 2004;3:18–23.
3. Regier DA. State-of-the-art psychiatric diagnosis. World Psychiatry. 2004;3:25–26.
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10. Fulford KWM. Ten principles of values-based medicine. In: Radden J, editor. The philosophy of psychiatry: a companion. New York: Oxford University Press; 2004. pp. 205–234.
11. Sackett DL, Straus SE, Scott Richardson W, et al. Evidence-based medicine: how to practice and teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; 2000.
12. Allott P, Loganathan L, Fulford KWM. Discovering hope for recovery. Can J Commun Ment Health. 2002;21:13–33.
13. Woodbridge K, Fulford KWM. Whose values? A workbook for values-based practice in mental health care. London: Sainsbury Centre for Mental Health; (in press)
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15. Sadler JZ, editor. Descriptions and prescriptions: values, mental disorders, and the DSMs. Baltimore: Johns Hopkins University Press; 2002.
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21. Okasha A. Ethics of psychiatric practice: consent, compulsion and confidentiality. Curr Opin Psychiatry. 2000;13:693–698.
22. Colombo A, Bendelow G, Fulford KWM, et al. Evaluating the influence of implicit models of mental disorder on processes of shared decision making within community-based multi-disciplinary teams. Soc Sci Med. 2003;56:1557–1570.[PubMed]
23. Fulford KWM. Mental illness: definition, use and meaning. In: Post SG, editor. Encyclopedia of bioethics. 3rd ed. New York: Macmillan; 2003.
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34. Spence SA. Free will in the light of neuropsychiatry. Philosophy, Psychiatry, & Psychology. 1996;32:75–90.
35. Hoerl C. Introduction: understanding, explaining, and intersubjectivity in schizophrenia. Philosophy, Psychiatry, & Psychology. 2001;8:83–88.
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41. Thornton T. Reasons and causes in philosophy and psychopathology. Philosophy, Psychiatry, & Psychology. 1997;4:307–318.
42. Klosterkotter J. Diagnosing schizophrenia in the initial prodromal phase. Arch Gen Psychiatry. 2001;58:158–164.[PubMed]
43. Gipps R, Fulford KWM. Understanding the clinical concept of delusion: from an estranged to an engaged epistemology. Int Rev Psychiatry. (in press)
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51. Van Staden CW, Fulford KWM. Changes in semantic uses of first person pronouns as possible linguistic markers of recovery in psychotherapy. Aust N Zeal J Psychiatry. 2004;38:226–232.
52. Sass LA. The paradoxes of delusion: Wittgenstein, Schreber, and the schizophrenic mind. Cornell: Cornell University Press; 1995.
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54. Morris KJ. The phenomenology of body dysmorphic disorder: a Sartrean analysis. In: Fulford KWM, Morris KJ, Sadler JZ, et al., editors. Nature and narrative: an introduction to the new philosophy of psychiatry. Oxford: Oxford University Press; 2003. pp. 270–274.
55. Heinimaa M. Incomprehensibility. In: Fulford KWM, Morris KJ, Sadler JZ, et al., editors. Nature and narrative: an introduction to the new philosophy of psychiatry. Oxford: Oxford University Press; 2003. pp. 217–230.
56. Kraus A. (2003) How can the phenomenological-anthropological approach contribute to diagnosis and classification in psychiatry? In: Fulford KWM, Morris KJ, Sadler JZ, et al., editors. Nature and narrative: an introduction to the new philosophy of psychiatry. Oxford: Oxford University Press; 2003. pp. 199–216.
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Articles from World Psychiatry are provided here courtesy of
The World Psychiatric Association

Philosophy and Mental Health - Tim Thornton

Philosophy and Mental Health






Because of its very nature, mental health care raises as many conceptual questions as empirical ones. The philosophy of mental health - also called the 'new philosophy of psychiatry' although it is not narrowly psychiatric - is a rapidly developing field developed by philosophers, clinicians (e.g. psychiatrists and mental health nurses) and mental health service users.
As well as its youth, the new philosophy of psychiatry has two further features that make it stand out. Firstly, it is not a 'natural kind'. There is not an established set of inter-related problems with familiar, if rival, solutions. It is an area where philosophical methods, accounts and theories can be applied to psychiatric phenomena and thus it also serves to test those accounts. To take one type of example, psychopathology is a test track for theories in the philosophy of mind. Symptoms such as thought insertion, where subjects experience their thoughts as somehow not their own, challenge accounts of the everyday 'ownership' of thoughts. But there is also traffic the other way. Three centuries of discussing the relationship of mind and body have furnished philosophers with a variety of subtle models (from forms of dualism, through gradations of physicalism, to eliminativism with modern alternatives such as enactivism) which can help in the interpretation of psychiatric data.
Secondly, unlike some areas of philosophy, philosophy of psychiatry can have a genuine impact on practice. It is a philosophy of, and for, mental health care. It provides tools for critical understanding of contemporary practices, and of the assumptions on which mental health care more broadly, and psychiatry more narrowly, are based. Thus it is not merely an abstract area of thought and research, of interest only to academics. In providing a deeper, clearer understanding of the concepts, principles and values inherent in everyday thinking about mental health, psychiatric diagnoses and the theoretical drivers of mental health policy, it can impact directly on the lives of people involved in all aspects of mental health care.
Values, meanings, facts
A brief examination of the history of the subject reveals why the discipline of psychiatry is particularly suited to contributions from philosophy. Whilst the father of psychopathology, the German philosopher and psychiatrist Karl Jaspers, combined psychiatric and philosophical expertise, within the English speaking tradition philosophy and psychiatry went their separate ways throughout most of the twentieth century. (By contrast, in mainland Europe the connection between psychiatry and phenomenological philosophy has continued since Jaspers' day.)
But towards the end of the twentieth century, the rise of the anti-psychiatry movement prompted a resurgence of philosophical interest in psychiatry. This was because a key element of the anti-psychiatric criticism of mental health care turned on a contentious claim about the nature of mental illness: mental illness does not exist; it is a myth. Such a sceptical claim is paradigmatically philosophical and one of the main proponents of anti-psychiatry, the psychiatrist Thomas Szasz, put forward a number of philosophical arguments in support of it. These turned on the fact that psychiatric diagnosis is essentially evaluative. From this he concluded that, unlike physical illness, it could not be medically treated because as illness it was not real. (The apparent reality of mental illness is best explained, according to Szasz, as the reality of non-medically treatable life problems.)
Szasz's sceptical arguments spurred responses by both psychiatrists and philosophers questioning whether diagnosis is, after all, essentially evaluative and, if it is, whether Szasz's conclusions followed. Thus the analysis of mental illness, and the role of values in that analysis, lies at the heart of recent philosophy of psychiatry.
In addition to the importance of values, two further key areas of mental health care prompt immediate philosophical questioning. Firstly, psychiatry since Jaspers has sought to balance two key elements: investigation of the bio-medical facts and empathic investigation of subjects' experiences. Both bio-medical facts and meanings (broadly construed to include experiences, beliefs and utterances) need somehow to be integrated into mental health care. This marks a sharp delineation from other areas of medicine where subjects' experiences are subordinate to the physically described symptoms and organic pathology with which they present. By contrast, psychiatric disorders seem to involve problems of the 'self' (however this is construed) in which experiences, behaviour and beliefs play a fundamentally important role in the onset, course and recovery of symptoms.
This raises questions of both the nature of the distinction between explanation according to the canons of the natural sciences (the 'realm of law') and understanding meaningful connections (in the 'space of reasons') and the relationship between natural scientific facts and meanings. If there is a clear distinction and meanings are conceptually irreducible to biomedical facts, efforts to understand the nature of this relationship become all the more philosophically interesting.
Secondly, there has been much work by psychiatrists since the Second World War to develop psychiatric classification or taxonomy. This has, historically, been in response to a concern about a lack of agreement or reliability about psychiatric diagnosis. More recently, there has been growing concern that reliability has been improved but only at the cost of validity, or underlying truth, of classificatory schemas. The worry is that psychiatric diagnostic systems may not 'carve nature at the joints'. This concern has also been reflected in philosophy of psychiatry as an instance of a broader question of the role of science in mental health care. Thus the nature of the facts in question is still very much up for grabs.

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience): Dr. John Z. Sadler MD, Dr. Osborne P. Wiggins Jr. PhD, Dr. Michael A. Schwartz MD: 9780801847707: Amazon.com: Books

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience) [Paperback]

Dr. John Z. Sadler MD (Editor), Dr. Osborne P. Wiggins Jr. PhD (Editor), Dr. Michael A. Schwartz MD (Editor)

Book Description

Publication Date: April 1, 1994 | Series: The Johns Hopkins Series in Psychiatry and Neuroscience
As the biological and psychosocial technologies in psychiatry continue to expand, the need for careful critical reflection on the scientific, ethical and practical aspects of psychiatry becomes ever greater. In "Philosophical Perspectives on Psychiatric Diagnostic Classification", John Osborne Wiggins, Michael Scwartz and others present a philosophical exploration of conceptual difficulties in psychiatric taxonomies or nosologies, using the current official American Psychiatric Association diagnostic handbook, the "Diagnosis and Statistical Manual of Mental Disorders (DSM)" as an example.

Editorial Reviews

Review

"The book begins with a 'must read' introductory and historical chapter by Edwin R. Wallace IV that provides a good foundations for readers embarking on a philosophical journey through psychiatric taxonomy." -- Journal of the American Medical Association

Values and Psychiatric Diagnosis - John Z. Sadler - Google Books

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Values and Psychiatric Diagnosis

By John Z. Sadler

UN Seeking Global “Mental Health” Plan

Monday, 30 January 2012 17:35

UN Seeking Global “Mental Health” Plan

Written by

On January 20, the WHO Executive Board released a resolution entitled “Global Burden of Mental Disorders and the need for a comprehensive, coordinated response at the country level.” The document calls for, among other measures, collaboration between national governments and the global health body in developing a “comprehensive mental health action plan” for the world.
The resolution asks the WHO Director-General to draft a “comprehensive” plan which includes model legislation and policy measures for member states. The program would encompass everything from education and human rights to health-care delivery and employment, with the WHO boss instructed to integrate all relevant sectors of society and government into the “comprehensive” scheme.
Just a few days before the WHO released its controversial resolution, a team of academics published a peer-reviewed paper in the journal PLoS Medicine calling for exactly what the global health body envisions: An international regime to deal with mental health. Led by Vikram Patel of the London School of Hygiene and Tropical Medicine and Judith Bass from Johns Hopkins School of Public Health, the authors even called for a world “People's Charter for Mental Health."
“The time has come for recognition at the highest levels of global development, namely the U.N. General Assembly, of the urgent need for a global strategy to address the global burden of MNS [mental, neurological, and substance-abuse] disorders,” the authors wrote, citing data on global mental-health trends. “The fact that MNS disorders affect people in all countries should offer considerable incentive for investments by both public and private sectors in this initiative."
Meanwhile, the government of India was among the busiest promoters of the global scheme. It was joined by the Obama administration and other governments around the world in helping to advance the WHO’s resolution, according to Indian media reports.
Critics, however, slammed the developing push to grant the UN and its organs more authority over mental health. Across the political spectrum, commentators actually worried about giving global bodies and the massively powerful psychiatry industry any expanded powers — let alone the ability to craft global policy. And as the debate heats up, scrutiny is expected to continue growing.
“Even within individual national boundaries, the Psychiatric/Psychological complex has vastly more authority that it needs or deserves,” noted Brandon Turbeville in a widely publicized report, blasting the track records of both the UN and the psychiatric industry. “When one multiplies that oppressive authority with the global jurisdiction of the United Nations, as well as the U.N’s tendency to introduce tyrannical guidelines in its own right, we can see a clear recipe for disaster.”
Turbeville, the author of “Codex Alimentarius The End of Health Freedom” — a book exposing a well-developed UN plot to limit the availability of vitamins and promote controversial genetically modified food — also highlighted an array of global bodies working to implement oppressive policies. And a UN mental-health program would almost certainly follow in their footsteps, he warned.
Another organization which regularly criticizes the UN offered a dire warning about the emerging mental-health scheme, too. According to analysts at the Daily Bell, the sudden onslaught of “propaganda” promoting a global psychiatric plan managed by world bodies is no surprise — but it definitely has the potential to become a threat to individual liberty and national sovereignty.
“It's merely the latest example of a fear-based, power-elite dominant social theme,” noted a Daily Bell staff report, pointing out that powerful forces are continually seeking to consolidate control at the global level. “First the elites create the ‘problem’ via various kinds of social chaos and war; then the problem is documented in an elite ‘scientific journal;’ and finally, an elite globalist facility is trotted out as a resource — one that will create yet another layer of bureaucracy that will further expand elite, globalist control.”
The analysis also noted that, in a worst-case scenario, the UN and its emerging “mental-health” apparatus could conceivably even seek the power to lock certain people away in mental institutions or send them to “re-education camps.” However, with the Internet exposing the machinations of the world elite, it is becoming increasingly difficult to transform authoritarian propaganda into action, the commentators wrote.
Still, the UN has been expanding its power and domain since it was created. It already has agencies and bureaus dealing with every imaginable area of human life, from war and food to the environment and economic development. The UN’s global health regime, the WHO — despite suffering a major setback in public opinion following its discredited swine-flu hysteria — still wields immense authority.
Critics also point to the mindset and beliefs of key players within the global bodies. The first director of the WHO, Brock Chisholm, for example, is widely reported to have said something along the lines of: “To achieve world government, it is necessary to remove from the minds of men their individualism, their loyalty to family traditions and national identification.”
Other senior UN personalities have for decades made statements which are equally alarming to critics. Meanwhile, almost all elements of the increasingly powerful UN’s operations have come under fire — from UN troops raping and massacring civilians around the world to massive corruption scandals among top officials to controversial “population control” efforts and everything in between.
The UN, of course, is a collection of the world’s governments — most of which are led by tyrants of various persuasions and more than a few of which still use bogus psychiatric labels to imprison dissidents. Giving such an entity the power to govern global mental-health policy, critics say, would be absolutely insane.

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Google Reader - Selected Blogs

via ISEPP Blog by isepp on 5/14/12
Published on May 7, 2012 by jimgotts Robert Whitaker, author of the acclaimed books, Mad in America, and Anatomy of an Epidemic, speaks about how the data shows, we could have far better outcomes for people diagnosed with mental illness by going to a selective use of medications, rather than putting everyone on this very [...]

Althouse: "D.S.M.-5 promises to be a disaster... it will introduce many new and unproven diagnoses that will medicalize normality...."

May 13, 2012



"D.S.M.-5 promises to be a disaster... it will introduce many new and unproven diagnoses that will medicalize normality...."

Despite some last-minute changes, there are big problems, says Allen Frances, who led the task force that produced D.S.M.-4.
[T]he D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts....
Frances rejects the accusation that the D.S.M. is "shilling for drug companies":
The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role....

Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists....
Posted by Ann Althouseat 8:39 AM

Real Psychiatry: Why Allen Frances has it wrong

Sunday, May 13, 2012



Why Allen Frances has it wrong



Allen Frances has been a public critic of the DSM process and as an expert he frequently get his opinions out in the media. Today he has an op-ed piece on the New York Times that is a more general version of a more detailed post on the Health Care blog. His main contention is the stakeholder argument and that is that there are too many stakeholders both public and professional to allow the American Psychiatric Association to maintain its "monopoly" on psychiatric diagnosis. I will attempt to deconstruct his argument.

He discusses the earlier DSM versions as revolutionizing the field and the associated neuroscience but then suggests that diagnostic proliferation has become a central problem and the only solution is political arbitration. What about the issue of diagnostic proliferation? The number of diagnostic entities per DSM entity are listed below:

DSM-I, 268 entities
DSM-II, 339 entities
DSM-III, 322 entities
DSM IIIR, 312 entities
DSM-IV, 374 entities
DSM-V, 370 - 400 entities (depending on final form)

In terms of the total diagnostic entities, I have not seen any stories in the media pointing out that the total number of diagnoses may be less than DSM-IV. I have also not seen any discussion of major diagnoses where that is clearly true, such as the elimination of schizophrenia subtypes. I have also not seen any discussion of the role of psychiatrists in making a psychiatric diagnosis. Psychiatric diagnosis does not depend on looking up a diagnosis in a catalog of symptoms. It involves being trained in psychopathology and knowing the patterns of these illnesses. The patterns of psychotic disorders have basically been unchanged across DSMs.

The "medicalization of normality" is another argument. The media routinely runs stories about the percentage of the population that is "mentally ill" based on DSM diagnoses. One of the common stories is the estimate that as many as 50% of the population has a DSM diagnosis over the course of the year. There is never any critical look at that statistic. The first dimension is whether any percentage should be too high or too low. For example, would anyone be surprised to learn that 100% of the population has a medical diagnosis in the previous year? With a high prevalence of gastroenteritis and respiratory infections - probably not. The second dimension speaks directly to the issue of threshold for an illness. One of the key papers in this area shows that although the one year prevalence using DSM criteria may be high limiting the diagnoses to severe disorders reduces the prevalence to 8%.

The use of high prevalence numbers for mental illness based on DSM diagnoses also ignores the extensive Epidemiological Catchment Area (ECA) work that estimated lifetime prevalence. Readers are generally not told that the methods used include addictive disorders and neurological disorders that cause cognitive impairment. Would anyone doubt that 32% of adults would report a psychiatric disorder that included an addiction or cognitive impairment at any point in their lifetime?

Dr. Frances correctly points out that the other common media theory that DSM diagnoses are driven by the pharmaceutical industry is a myth. He continues on to suggest that the public and other mental health professionals somehow have a stake in the DSM and that organized psychiatry has frozen them out. He concludes: “Psychiatric diagnosis is too important to be left exclusively in the hands of psychiatrists.” I don’t understand how the specialty who invented the technology, who is trained and tested on it, and who is focused on a comprehensive view of psychopathology that extends beyond it should somehow give way to political considerations. As he points out – there are always political considerations – even in science. I would suggest that there is no such thing as “independent scientific review” of anything that psychiatry does. There are many ways to address issues of professional bias in terms of including a diagnosis or not.

The arguments against the DSM and psychiatric influence vary across the usual spectrum of there being no such thing as a psychiatric diagnosis to there are too many to they are nonspecific. There is no practical way to incorporate that spectrum into a diagnostic manual that is designed for psychiatrists to make clinical diagnoses and do research. The single most important fact that is left out of these debates is that psychiatrists are effective in treating serious mental illness and they are undoubtedly more effective now than they have been in the past. That is the only reason we need a DSM and that is why it stays squarely in psychiatry.

George Dawson, MD, DFAPA

Frances A. Diagnosing the DSM. New York Times May 11, 2012.

Frances A. DSM5 begins its belated and necessary retreat. Health Care Blog May 10, 2012.

Kessler RC, Avenevoli S, Costello J, Green JG, Gruber MJ, McLaughlin KA,
Petukhova M, Sampson NA, Zaslavsky AM, Merikangas KR. Severity of 12-month DSM-IV disorders in the national comorbidity survey replication adolescent supplement
Arch Gen Psychiatry. 2012 Apr;69(4):381-9.

Regier D, Kaelber CT. The Epidemiological Catchment Area Program: Studying the Prevalence and Incidence of Psychopathology. in Textbook in Psychiatric Epidemiology eds. Ming T Tsuang, Mauricio Tohen, and Gwnedolyn EP Zahner. John Wiley and Sons, 1995. p141.




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DSM-V is Discussed at the American Psychiatric Association’s 165th Conference – News Round-Up: May 2012 2nd Edition « The Amazing World of Psychiatry: A Psychiatry Blog

The Amazing World of Psychiatry: A Psychiatry Blog

DSM-V is Discussed at the American Psychiatric Association’s 165th Conference – News Round-Up: May 2012 2nd Edition

Posted in psychiatry by Dr Justin Marley on May 12, 2012

This week there has been a large media response to the discussion of DSM-V at the American Psychiatric Association’s (APA) 165th Annual Conference (see also Appendix I). Positive Psychiatry, DSM-V and Mental Health in the older adult population have all been important topics at the APA Conference. There are several videos from the APA Conference on the Webs Health Edge Channel.
Dr James Scully, CEO of the APA gives an overview of the 165th Annual Conference in this video

The President Elect Professor Jeremy Lazarus of the American Medical Association speaks in this video about a trend towards integrated care where Medical and Psychiatric services can work together

An important issue that was addressed at the conference was the criminalisation of people with mental illnesses and this is discussed by Dr Marcia Goin and Dr Ken Rosenberg in this video

In this video, Judge Steven Leifman talks about strategies for keeping people with mental illnesses out of prison

In this video there is a discussion of some of the research that is being presented at the conference

The APA is inviting people including non-APA members to submit comments in response to the draft version of DSM-V in the 6 week period from May 2nd 2012-June 15th. This means that interested individuals or groups can become stakeholders in the revision process. Professor Kupfer has indicated that there have already been more than 11,000 comments submitted from across the world. The APA is inviting people including non-APA members to submit comments in response to the draft version of DSM-V in the 6 week period from May 2nd 2012-June 15th. This means that interested individuals or groups can become stakeholders in the revision process. Professor Kupfer has indicated that there have already been more than 11,000 comments submitted from across the world.
The latest changes in draft version include a clarification on Bereavement Reactions, field trial data supporting the categorical diagnosis of Borderline Personality Disorder, a separation of Language and Speech Disorders, Somatic Symptom Disorder as a combination of two separate disorders and changes to the Neurocognitive and Anxiety Disorders. The more recent changes have also been covered elsewhere in the media.
The New York Times has several feature articles on DSM-V. In this article there is an examination of the Addiction category with the prediction that diagnosis rates will increase with the new criteria. This article looks at the decision to remove Mixed Anxiety and Depressive Disorder as well as the Psychosis Risk Syndrome. There is also a look at the proposed changes in the Autistic Spectrum Disorders and Asperger Syndrome along with recent research findings in this area. Time Magazine covers the proposed change of Post Traumatic Stress Disorder to Post Traumatic Stress Injury in response to the perceived stigma of the word disorder. There is also coverage of the removal of Psychosis Risk Syndrome at Nature. There is also a Reuters piece on some of the changes.
In the Blogosphere there is coverage of the APA Conference at ShrinkRap while in another post, Dinah responds to a critical post about DSM-V by Paula Caplan. There is a good round-up of DSM-V related news at Shrink Things. There is also a round-up which links to more critical views of DSM-V at the AltMentalities Blog which are broadly divided into camps which are either against the concept of a Diagnostic Manual or else are critical of some of the changes advocated in DSM-V.
Appendix I – Other DSM-V Articles on the TAWOP Site
Explaining DSM-V: Interview with Professor David Kupfer, Chair of the APA DSM-V Taskforce
Another Scientific American Article on DSM-V: Is This A Step Too Far?
The Debate on DSM-V with Scientific American Continues
The Day I Got Frustrated Reading An Article About Psychiatry In Scientific American
Asperger Syndrome Could Be Removed As A Diagnosis In DSM-V
Causality and DSM-V
Appendix II – Previous DSM-V Related News Items Discussed on the TAWOP Site
The news items below are unedited and must be interpreted in terms of the subsequent developments. They help to set the context for the current discussion.
2011
DSM-V and ICD-11
The draft DSM-V criterion for a mixed depressive episode are being expanded to fit more closely with clinician’s experience and there are further details here. The new version of the World Health Organisation Classification of Disease (ICD-11) is displayed in draft version here. This is a work in progress with daily updates and it will allow people to comment from July 2011 onwards. I checked out the Mental and Behavioural Disorders section and there was just a little information there (relating to indexes for mortality) at the moment. The World Psychiatric Association have a very interesting paper on the use of the ICD-10 diagnostic system by psychiatrists. The researchers surveyed 4887 psychiatrists across the world using an internet based survey tool. The use of ICD-10 varied from 0% in Kenya and 1% in the USA to 100% in Kyrgyzstan, FYRO Macedonia and Slovenia. 71% of the psychiatrists surveyed used ICD-10 as their main diagnostic system. DSM-IV was the main diagnostic system for 23% of the psychiatrists surveyed (unweighted). 14.1% (unweighted) of the sample set ‘sometimes’ used a diagnostic system and 1.3% used the older versions of ICD-10 – ICD-9 or ICD-8 for diagnostic purposes. There is also a critical look at DSM-V at ‘Boring Old Man’ which highlights the wider debate in society.
2010
The draft changes for DSM-V have been published by the American Psychiatric Association Draft Development Team for DSM-V here. I might have overlooked something but it looks as though it is an overview of the changes being suggested for specific conditions that are being presented.
Firstly I was interested in what amounts to a wholescale reclassification of the Dementias and related conditions into Major and Minor Neurocognitive Disorders. There are some nice ideas contained within this move including the consideration that it is not only memory which needs to be affected. However I was unclear on reading the descriptions of whether it would include the subtypes as I could find no mention of this. However it would be unusual if the various subtypes of dementia for which there is an abundance of evidence were not included as subtypes within this framework as this could be considered a step backward. Additionally I couldn’t find any mention of the term Mild Cognitive Impairment (although there are some broad similarities with minor neurocognitive disorder) and the various subtypes for which there is an emerging evidence base and which is the focus of research in the hope that a better understanding could lead to prevention or amelioration of subsequent dementia.
There were very few changes here. One suggestion was to use a catatonia specified elsewhere instead of catatonia secondary to a medical disorder.
There are some big changes in the Personality Disorders. These have been reduced from 10 to 5. One of the difficulties with the current Personality Disorder types is the diagnostic overlap. A person may fulfill the criteria for more than one type of personality disorder. There are a number of changes to the criteria which should improve reduce the number of comorbid personality disorder diagnoses. A simple Likert-scale is used for quantifying personality and personality traits and the five types are Borderline Personality Disorder, Antisocial/Psychopathic Type, Avoidant Type, Obsessive-Compulsive Type and Schizotypal Type.
There are a large number of new diagnostic labels being considered for inclusion and subsuming current labels. For instance alcohol dependence syndrome may be subsumed under Alcohol-use disorder. Cannabis withdrawal is another diagnosis being introduced. The discussions around the terms ‘addiction’ and ‘dependence’ are discussed below.
There are big changes to the diagnosis of Schizophrenia with a proposal for removing subtypes including Paranoid Schizophrenia, Disorganised and Catatonic schizophrenia. Changes are being suggested in order to bring DSM-V into closer alignment with ICD-10. Proposed changes to the criteria for Schizoaffective Disorder are meant to increase reliability. ‘Psychosis Risk Syndrome‘ is being introduced (see further discussion below) and a Catatonia Specifier is being suggested. This is apparently because catatonia is ‘often not recognised’.
Mixed anxiety and depression disorder is being introduced with criteria that avoid ambiguity. This is currently included in the appendix of DSM-IV. There is a proposal to rename Dysthymic Disorder as chronic depressive disorder. There is a proposal to replace Bipolar Disorder Most Recent Episode Mixed with a mixed specifier. There are a number of changes in the criteria of Manic Episode particularly around energy levels.
The proposal is to include Obsessive-Compulsive Disorder under a new category of ‘Anxiety and Obsessive-Compulsive Spectrum Disorders’. The changes here are further discussed in the ‘PsychBrownBag’ Blog and the ‘OCD Center of Los Angeles’ Blog below.
There is a proposed amalgamation of four conditions into ‘Complex Somatic Symptom Disorder‘ but for further discussion see the ‘OCD Center of Los Angeles’ Blog below.
The proposal is to reclassify Factitious Disorders under Somatic Symptom Disorders.
Theere is a proposal to subsume Dissociative Fugue under Disssociative Amnesia. Similarly there is a proposal to remove Dissociative Trance Disorder and integrate the criteria into the diagnosis of Dissociative Identity Disorder which has a number of other proposed changes.
There are a number of new diagnoses.
A new diagnosis of Binge-Eating Disorder is recommended (for further discussion see below). In Anorexia Nervosa there is the proposal to remove the criterion of amenorrhoea whilst in Bulimia Nervosa there are some proposed changes to the frequency of binge eating episodes and the purging criteria.
There are a number of new conditiosns (a number of which subsume other conditions) including Klein-Levin Syndrome, Primary Central Sleep Apnoea, Primary Alveolar Hypoventilation, Rapid Eye Movement Behaviour Disorder and Restless Leg Syndrome amongst others. There are a number of changes to the criteria for narcolepsy including hypocretin deficiency.
There are a large number of suggested changes including the removal of Rett’s Disorder, a number of proposed changes to the Attention Deficit and Hyperactivity Disorder criteria, the inclusion of Post-Traumatic Stress Disorder in school age children and Temper Dysregulation Disorder with Dysphoria which is further discussed below. Interestingly the wording for Separation-Anxiety Disorder may be changed so that it can be used with adults also. This is because there is evidence for an adult separation-anxiety disorder.
There is a proposal to include Pathological Gambling with substance-related disorders. There are proposed changes for Trichotillomania further discussed below.
There is a proposal to move Adjustment Disorder to a grouping of Trauma and Stress-Related Conditions.
Discussion of the Draft DSM-V Changes Elsewhere in the Media
Links to some of the discussions elsewhere in the media are given below.
General
The Time article looks at a number of proposed changes for DSM-V which includes the criteria for making a diagnosis of depression,use of a continuum and the case for autistic spectrum disorders, the possible grouping of non-dependence inducing substances together with dependence inducing substances in the addiction and related disorders, reducing the number of personality disorder types and making some amendments to some of the sexual disorders. Over at PsychCentral, Dr Grohol looks at a number of features of the DSM-V draft. He is encouraging of the inclusion of Binge Eating Disorder, but is critical of the criteria used in Minor Neurocognitive Disorder, Behavioural Addictions and also Temper Dysregulation Disorder which has a narrow time period fo 6 to 10 years for diagnosis. Over at the ‘Psyche Brown Bag‘ blog, Joyce Anestis comments on the restructuring of the multiaxial system as well as the arrival of a number of new disorders including ‘hoarding disorder’, ‘olfactory reference syndrome’, ‘skin picking disorder’ and ‘psychosis risk syndrome’ amongst others and is also confused by the proposed changes to the personality disorders. The Times has a look at a number of the proposed changes including ‘sluggish cognitive tempo disorder’. Web MD has an article on the changes and features an interview with Dr First who is critical of the utility of the diagnosis of ‘Psychotic Risk Syndrome’.
Dr Dan Carlat has a discussion of the proposed criteria on his blog and seems fairly positive on these (however I would just add that there are neurobiological criteria for a number of disorders in DSM-IV/DSM-V draft e.g Hypocretin Deficiency in Narcolepsy above). He notes that Temper Dysregulation Disorder is being favoured as it would avoid a diagnosis of Bipolar Disorder in children in a number of cases. He’s in favour the use of addiction in place of dependence or abuse and also the use of the concept of Binge-Eating Disorder. The New York Times has a piece featuring interviews with several psychiatrists and 230 comments at the time of writing. Integral Options cafe has links to a number of posts including those on the NPR site. An article at the NPR website examines the limits of the checklist approach and how severity might be measured when using a dimensional approach. The Economist has a piece on the history of the diagnostic criteria but also cover some of the disputes that have taken place. ‘DSM-V and ICD-11 watch’ have some interesting links as well as a brief look at suggestions for medically unexplained symptoms. Dr Finnerty has an overview of proposed changes as well as some useful links. Mind Hacks has coverage here and here. The APA have a facebook site that interested readers can join.
‘Addictions’
Stanton Peele covers the proposed use of the term addictions in this ‘The Huffington Post’ article. The ‘Join Together‘ website features an interview with Dr Charles O’Brien who is chair of the APA’s DSM substances related disorders workgroup. He explains the distinction between dependence and addiction and the consideration of including the term addiction in DSM-V. They also discuss the possibility of collecting behavioural addictions together with alcohol and other drug related disorders.
Anxiety Disorders and OCD
Tom Corboy director of the ‘OCD Center of Los Angeles’ writes about a number of proposed changes over at the ‘OCD Center of Los Angeles’ blog. Thus Corboy discusses the suggested use of an ‘Anxiety and Obsessive Compulsive Disorder Spectrum’. Corboy is also critical of the suggestion of agaraphobia without panic disorder, in favour of moving Body Dysmorphic Disorder into the ‘Anxiety and Obsessive Compulsive Disorder Spectrum’ and adding a muscle dysmorphia variant, critical of the aggregation of 4 somatoform disorders including hypochondriasis, in favour of the relabelling of trichotillomania as ‘hair pulling disorder’ and also for the inclusion of skin picking disorder.
Intellectual Disability
Over at the blog ‘Mental Incompetence and the Death Penalty‘ there is a guest post by Dr Watson. He criticises the proposed criteria for intellectual disability on the basis that there doesnt appear to be a consideration of the standard error for IQ testing meaning that there is what he describes as a ‘bright light’ cut-off point of 70 or below whereas in practice there is a group that are scored over 70 who would still be included amongst a number of criticisms.
Bipolar Disorder in Children
Over at the NPR website, there is a wider discussion of the diagnosis of Bipolar Disorder in children as well as the more recent ‘Temper Dysregulation Disorder’.
Autistic Spectrum Disorders
The Left-Brain Right-Brain blog compares the criteria in DSM-IV with those in DSM-V for autistic disorder and autistic spectrum disorders respectively and links to a number of other articles on the subject. There is another discussion of the autistic spectrum disorders proposition here. There is further coverage here and here.
Eating Disorders
Time has a piece on orthorexia which hasn’t made it into the draft version of DSM-V. There is also coverage of the proposed changes at the Ed-Bites blog (with 15 comments at the time of writing).
Dr Dan Carlat takes a further look at the DSM-V draft proposals here. Dr Charles Parker has further coverage here and also over at the Corpus Callosum blog. There is a look at grief in the draft DSM-V proposals at Psychotherapy Brown Bag.
2009
DSM-V and ICD-11
In the BJPsych there is an interesting article by Professor Michael First who writes about the potential for harmonisation of DSM-V and ICD-11 which is a widely discussed topic (First, 2009). There are a number of points of interest in the article and he notes that there are investigators involved with revisions of both systems which should help to contribute to attempts to harmonise both systems. The discussions around these systems will no doubt increase.
There was discussion recently of the diagnosis of Asperger syndrome being dropped from the next edition of the DSM and this will mean an expansion of the autism diagnostic category. This was originally discussed in a New York Times article (which requires (free) registration). The article features an interview with Dr Catherine Lord, who is one of 13 members of the working group on autism and Neurodevelopmental Disorders. The group are considering a number of amendments to the autism diagnosis including the addition of comorbidity that have been associated with the condition including disorders of attention and anxiety. However the suggestion regarding Asperger syndrome has not yet been ratified by the group. There have been a number of responses in the media. This article contains interviews with a doctor who runs a clinic, a parent of a child with Asperger’s syndrome and the president of a non-profit organisation for raising awareness of the condition. There is some information on the DSM-V process here.
DSM-V is due to appear in 2012. A twitter campaign has been started to petition for the inclusion of Depressive Personality Disorder in DSM-V. Professor Simon Baron-Cohen has argued against the removal of the Asperger Syndrome label in this New York Times article. Dr Anestis offers his views on this article and Baron-Cohen responds in this blog post.
References
Michael First. Harmonisation of ICD-11 and DSM-V: Opportunities and challenges. The British Journal of Psychiatry. 2009. 195. 382-390.
An index of the TAWOP site can be found here and here. The page contains links to all of the articles in the blog in chronological order. Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link. Podcast: You can listen to this post on Odiogo by clicking on this link (there may be a small delay between publishing of the blog article and the availability of the podcast). It is available for a limited period. TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link. Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk. Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

The New Psychiatric Manual (DSM-5) Will Make You Crazy | Independent Sentinel

The New Psychiatric Manual (DSM-5) Will Make You Crazy

May 12, 2012
By
That’s right, Mr. Martini. There is an Easter Bunny.
~ McMurphy in One Flew Over A Cuckoos Nest
Under the new psychiatric guidelines, the man in the lampshade will qualify for mental health care and medication. If he doesn’t do his job well, the boss will have to make the job work for him or face lawsuits and compensation payouts. When he gets older, accommodations will have to be made for him at work.
We are all crazy now. It’s going to cost us money but we get to blame mental illness for every wrong or silly thing we do. What a deal!
Cravings now count as addictions. So does Parental Alienation Syndrome which should include most of the country’s teenagers.
It gets worse.
They’ve made the definitions overly broad for addictions and require fewer symptoms to qualify. No one is irresponsible, no one is immoral because there is a diagnosis to cover you.
The changes to the new DSM-5 make a mockery of real mental illnesses and it is going to cost taxpayers, health insurance companies, schools who handle handicapped children, and Medicare at a time they can least afford it.
The DSM is the guidebook for insurers and government health plans and schools indirectly so they will be stuck with the costs. The manual is written by 162 professionals in secrecy. They receive comments but they’re secret too. It rakes in $5 million for the authors.
Apparently, psychiatrists want to drum up more business so they are changing the DSM (Diagnostic and Statistical Manual of Mental Disorders) to expand the list of recognized symptoms for addictions to include cravings and mild problems. It makes definitions for certain addictions and disorders very broad while reducing the number of symptoms needed for a diagnosis.
This could add 20 million new subscribers at a cost of hundreds of millions of dollars. Funds for more serious problems will likely be misdirected to cover the new costs. Medicare costs will go up considerably – we really can’t afford that. Special Education costs in schools will balloon.
Psychiatrist say the broader definitions allow for earlier treatment and saves preventive costs. As my grandfather used to say – hogwash.
There will be so many unwanted side effects. Employers could wave a right to trial and class actions suits and go pscyho instead. On the other hand, employers will be faced with a broader array of disorders by employees that will affect evaluations, suits and compensation.
Now gamblers are addicts and fall under “behavior addiction – not otherwise specified.” Rather broad, don’t you think? Where does personal responsibility come in? I see no place for it. We’re not responsible for anything anymore, we have a mental disorder.
Alcoholics will no longer be people who routinely miss work, drive while under the influence, or are arrested. Now it will include people who drink more than intended and crave alcohol. That includes a lot of people I know who like to party.
The DSM-5 includes new disorders like “mild neurocognitive disorder” (defined as a “minor cognitive decline” – often associated with aging – that requires “greater effort, compensatory strategies, or accommodation” to perform daily activities).
So the aged who can’t do their job also won’t be hirable because who is going to take a chance on having to accommodate them.
Then we have “attenuated psychosis syndrome” (a combination of low-level psychotic symptoms, distress and social dysfunction that the patient views as “sufficiently distressing and disabling” to seek professional help. That takes in a lot of people going through tough times. It takes in normal reactions to those times.
If you find these definitions extremely broad, you are not alone. Critics of the proposed DSM-5 continue to push for less expansive definitions, fearing that overly broad definitions will lead to over-diagnosis and hypochondria.
In an open letter from the Society for Humanistic Psychology, three major concerns with the proposed draft of the DSM-5 were outlined -
  • Lowering of diagnostic thresholds. It expands disorders like ADD which is already overly diagnosed with people being overly medicated.
  • Introduction of new disorders. Children and adults can be more easily victimized by the overzealous.
  • Lack of empirical grounding for some proposals.
The protesters also reject proposed changes in the definition of “mental disorder,” arguing that it de-emphasizes sociocultural factors and over-emphasizes biological theory.
The letter is in response to an unsatisfactory put-off by the DSM-5 Task Force Members. They justified their testing and they plan to do make these changes no matter what.
The British Psychological Association, an esteemed organization, roundly condemns the DSM-5 and its outrageous move to take normal behavior and classify it as a disorder – “Medicalizing normal experience stigmatizes and cheapens the human condition and promotes overtreatment with unnecessary and potentially harmful drugs. But the BPS critique goes too far and wide in denying the value of all psychiatric diagnosis.”
For instance, they want to take the serious illness of Schizophrenia and put it in the same category as a broad and unknown, unproven “psychosis risk disorder.” There is serious opposition to even including “psychosis risk disorder.” Seriously, what the heck is it? It could be anything.
The changes represent the single biggest expansion in 40 years coming at a time when we are borrowing 40 cents of every dollar spent and when Americans are now being encouraged to cast blame as the answer to all our problems. We are no longer behaving badly, we are mentally disordered.
The liberal definition will certainly increase addiction rates. Even people who didn’t think of themselves as addicts, now get to do so. I’m certain that is not a good mind set.
There is room for massive corruption here as psychiatrists increase business and with their close ties to Big Pharma, both enter into a possibly corrupt business expansion and mutual financial feeding frenzy. Psychiatrists love to drug people. In fact, that’s mostly what they do. They diagnose and then drug.

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