Friday, March 8, 2013

Report details flaws in Army's handling of PTSD

Report details flaws in Army's handling of PTSD: SEATTLE (AP) -- The Army has more than doubled its number of military and civilian behavioral health workers in the past five years, but a litany of shortcomings still plagues the force when it comes to diagnosing and treating soldiers for post-traumatic stress disorder, according to an Army report being released Friday....

Friday, March 1, 2013

Autism spectrum disorder, attention-deficit/hyperactivity disorder, bipolar disorder, major depressive disorder and schizophrenia all share common genetic risk factors, according to the results of the largest genetic study of psychiatric disorders to date

Mike Nova's starred items

via Psychiatric News Alert by (Psychiatric News Alert) on 3/1/13
In a study published in the Lancet, the Cross-Disorder Group of the Psychiatric Genomics Consortium, supported by the National Institute of Mental Health, has performed a genomewide single-nucleotide-polymorphism (SNP) data analysis seeking to identify specific variants underlying genetic effects shared between the following five disorders: autism spectrum disorder, attention-deficit/hyperactivity disorder, bipolar disorder, major depressive disorder, and schizophrenia.

Their study is the largest to date and the first to provide evidence that specific SNPs are significantly associated with a range of psychiatric disorders. In particular, they pointed to the effects of voltage-gated calcium channels on such disorders: "Our results implicate a specific biological pathway—voltage-gated calcium-channel signaling—as a contributor to the pathogenesis of several psychiatric disorders and support the potential of this pathway as a therapeutic target for psychiatric disease."

"These important findings indicate that fundamental alterations in brain development and biology can confer vulnerability to various types of mental disorders....," Jeffrey Lieberman, M.D., president-elect of APA told Psychiatric News." Overall, the study provides an important new clue about the etiology and pathogenesis of mental disorders."

APA President Dilip Jeste, M.D., also commented: "Research of this type would help in the development of future diagnostic systems in psychiatry that are based on validated biomarkers...this important study is one step in that direction."
(Image: Chepko Danich Vitalevich/
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International research group finds genetic link among five major psychiatric ...
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5 Disorders Share Genetic Risk Factors, Study FindsNew York Times
Share via e-mailBoston Globe
Five major psychiatric disorders, including autism and bipolar disorder ...GlobalPost
TIME -The Conversation -TopNews New Zealand
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Largest study reveals five major psychiatric disorders share common genetic ...
Medical Xpress
These findings are particularly relevant in view of the imminent revision of classifications in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD)." Writing in a linked Comment ...

Autism, Depression Genetically Linked
ABC News
The results are "new evidence that may inform a move beyond descriptive syndromes in psychiatry and towards classification based on underlying causes," Smoller said in a statement. Read this story on The findings are especially ...

Times of India

International research group finds genetic link among five major psychiatric ...
Public Radio International PRI
International research group finds genetic link among five major psychiatric diseases. Home | Stories | Health and Medicine | International research group finds genetic link among five major psychiatric diseases. Font size: Decrease font Enlarge font ...
5 Psychiatric disorders share genetic linkTimes of India
Study points to "shared biology" between 5 psychiatric disordersCBS News
Share via e-mailBoston Globe
The Takeaway (blog)
all 58 news articles »

Children with autism had higher levels of toxic metals
Researchers reported that children with autism had higher levels of toxic metals in their blood and urine vs. healthy children. The levels of those toxic metals were associated with the severity of the disorder. “These significant associations may ...

and more »

5 Psych Disorders Have Common Genetics
MedPage Today
The results are "new evidence that may inform a move beyond descriptive syndromes in psychiatry and towards classification based on underlying causes," Smoller said in a statement. The findings are especially important because of revisions to the ...

Five Major Psychiatric Disorders Genetically Linked
"These findings are particularly relevant in view of the imminent revision of classifications in the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases," said Dr. Smoller. The investigators add that ...

Times of India

International research group finds genetic link among five major psychiatric ...
Public Radio International PRI
International research group finds genetic link among five major psychiatric diseases. Home | Stories | Health and Medicine | International research group finds genetic link among five major psychiatric diseases. Font size: Decrease font Enlarge font ...
5 Psychiatric disorders share genetic linkTimes of India
Study points to "shared biology" between 5 psychiatric disordersCBS News
Autism, schizophrenia, and other psychiatric disorders share genetic (blog)
Wall Street Journal (blog) -The Takeaway
all 57 news articles »

via DSM5 in Distress by Allen J. Frances, M.D. on 3/1/13
A new way that DSM-5 mislabels the medically ill. Stress, risks factors, noncompliance, and unhealthy lifestyles will now be called a mental more

Anti-Soviet 'Psychiatric' prisoners want diagnoses reversed
Deutsche Welle (press release)
The film, “The Dissident," portrayed a 53-year-old Latvian lawyer who was locked up for many years in psychiatric hospitals. This kind of thing, it seems, was not an isolated incident. From the late 1960s to the mid 1980s, a group of Latvians were ...

Five Major Psychiatric Disorders Share Genetic Link
Medical News Today
These findings are particularly relevant in view of the imminent revision of classifications in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD)." In a linked editorial comment ...

UConn Advance (blog)

UConn Researchers Impacting Mental Health Treatment in Prison Population
UConn Advance (blog)
Researchers at the University of Connecticut Health Center are making significant contributions to the treatment of mental illness in prisoners, with their efforts earning international recognition and continued federal grant funding. With current ...

Five Major Psychiatric Disorders Share Genetic Link
Medical News Today
These findings are particularly relevant in view of the imminent revision of classifications in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD)." In a linked editorial comment ...

Anti-Soviet 'Psychiatric' prisoners want diagnoses reversed
Deutsche Welle (press release)
The film, “The Dissident," portrayed a 53-year-old Latvian lawyer who was locked up for many years in psychiatric hospitals. This kind of thing, it seems, was not an isolated incident. From the late 1960s to the mid-80s, a group of Latvians were ...

and more »

via NIMH | Recent Updates by Jules Asher on 3/1/13
Five major mental disorders share some of the same genetic risk factors, the largest genome-wide study of its kind has found.

via Uploads by NIMHgov by NIMHgov on 3/1/13
National Institutes of Health-funded researchers discovered that people with disorders traditionally thought to be distinct -- autism, ADHD, bipolar disorder, major depression and schizophrenia -- were more likely to have suspect genetic variation at the same four chromosomal sites. These included risk versions of two genes that regulate the flow of calcium into cells. Bruce Cuthbert, Ph.D., director of NIMH's Division of Adult Translational Research, explains the significance of the study findings for diagnosis and treatment of mental illnesses.
Time:01:56More inEducation

Autism spectrum disorder, attention-deficit/hyperactivity disorder, bipolar disorder, major depressive disorder and schizophrenia all share common genetic risk factors, according to the results of the largest genetic study of psychiatric disorders to date.“This study indicates that some specific genetic variants confer risk to a range of psychiatric disorders that are treated as clinically distinct,” study researcher Jordan Smoller, MD, of Massachusetts General Hospital in Boston, told Psychiatric Annals. “The findings also highlight the role of calcium channel genes, which may provide a treatment target that is relevant to a range of psychiatric disorders.”

Five major psychiatric disorders may share common genetic risk factors - Healio


Five major psychiatric disorders may share common genetic risk factors
Autism spectrum disorder, attention-deficit/hyperactivity disorder, bipolar disorder, major depressive disorder and schizophrenia all share common genetic risk factors, according to the results of the largest genetic study of psychiatric disorders to date.

and more »

Friday, February 8, 2013

Eddie Ray Routh, Accused of Killing Chris Kyle, ‘American Sniper,’ Had Troubled Past - NYT

(title unknown):
Eddie Ray Routh, Accused of Killing Chris Kyle, ‘American Sniper,’ Had Troubled Past
Eddie Ray Routh, accused of killing Chris Kyle, the author of “American Sniper,” had been released from a hospital over his parents’ objections just days before the shooting, his lawyers said.

Thursday, February 7, 2013

The recent revisions to the DSM's definition of depression are based on a questionable conception of what is "normal." Why is that dangerous?

Opinionator | The Stone: Depression and the Limits of Psychiatry


Opinionator - A Gathering of Opinion From Around the Web

February 6, 2013, 3:45 pm

Depression and the Limits of Psychiatry

I've recently been following the controversies about revisions to the psychiatric definition of depression. I've also been teaching a graduate seminar on Michel Foucault, beginning with a reading of his "History of Madness." This massive volume tries to discover the origins of modern psychiatric practice and raises questions about its meaning and validity. The debate over depression is an excellent test case for Foucault's critique.
At the center of that critique is Foucault's claim that modern psychiatry, while purporting to be grounded in scientific truths, is primarily a system of moral judgments. "What we call psychiatric practice," he says, "is a certain moral tactic . . . covered over by the myths of positivism." Indeed, what psychiatry presents as the "liberation of the mad" (from mental illness) is in fact a "gigantic moral imprisonment."
Foucault may well be letting his rhetoric outstrip the truth, but his essential point requires serious consideration. Psychiatric practice does seem to be based on implicit moral assumptions in addition to explicit empirical considerations, and efforts to treat mental illness can be society's way of controlling what it views as immoral (or otherwise undesirable) behavior. Not long ago, homosexuals and women who rejected their stereotypical roles were judged "mentally ill," and there's no guarantee that even today psychiatry is free of similarly dubious judgments. Much later, in a more subdued tone, Foucault said that the point of his social critiques was "not that everything is bad but that everything is dangerous." We can best take his critique of psychiatry in this moderated sense.
Current psychiatric practice is guided by the "Diagnostic and Statistical Manual of Mental Disorders" (DSM). Its new 5th edition makes controversial revisions in the definition of depression, eliminating a long-standing "bereavement exception" in the guidelines for diagnosing a "major depressive disorder." People grieving after the deaths of loved ones may exhibit the same sorts of symptoms (sadness, sleeplessness and loss of interest in daily activities among them) that characterize major depression. For many years, the DSM specified that, since grieving is a normal response to bereavement, such symptoms are not an adequate basis for diagnosing major depression. The new edition removes this exemption.
Disputes over the bereavement exemption center on the significance of "normal." Although the term sometimes signifies merely what is usual or average, in discussions of mental illness it most often has normative force. Proponents of the exemption need not claim that depressive symptoms are usual in the bereaved, merely that they are appropriate (fitting).
Opponents of the exemption have appealed to empirical studies that compare cases of normal bereavement to cases of major depression. They offer evidence that normal bereavement and major depression can present substantially the same symptoms, and conclude that there is no basis for treating them differently. But this logic is faulty. Even if the symptoms are exactly the same, proponents of the exemption can still argue that they are appropriate for someone mourning a loved one but not otherwise. The suffering may be the same, but suffering from the death of a loved one may still have a value that suffering from other causes does not. No amount of empirical information about the nature and degree of suffering can, by itself, tell us whether someone ought to endure it.
Foucault is, then, right: psychiatric practice makes essential use of moral (and other evaluative) judgments. Why is this dangerous? Because, first of all, psychiatrists as such have no special knowledge about how people should live. They can, from their clinical experience, give us crucial information about the likely psychological consequences of living in various ways (for sexual pleasure, for one's children, for a political cause). But they have no special insight into what sorts of consequences make for a good human life. It is, therefore, dangerous to make them privileged judges of what syndromes should be labeled "mental illnesses."
This is especially so because, like most professionals, psychiatrists are more than ready to think that just about everyone needs their services. (As the psychologist Abraham Maslow said, "If all you have is a hammer, everything looks like a nail"). Another factor is the pressure the pharmaceutical industry puts on psychiatrists to expand the use of psychotropic drugs. The result has been the often criticized "medicalization" of what had previously been accepted as normal behavior-for example, shyness, little boys unable to sit still in school, and milder forms of anxiety.
Of course, for a good number of mental conditions there is almost universal agreement that they are humanly devastating and should receive psychiatric treatment. For these, psychiatrists are good guides to the best methods of diagnosis and treatment. But when there is significant ethical disagreement about treating a given condition, psychiatrists, who are trained as physicians, may often have a purely medical viewpoint that is not especially suited to judging moral issues.
For cases like the bereavement exclusion, the DSM should give equal weight to the judgments of those who understand the medical view but who also have a broader perspective. For example, humanistic psychology (in the tradition of Maslow, Carl Rogers, and Rollo May) would view bereavement not so much a set of symptoms as a way of living in the world, with its meaning varying for different personalities and social contexts. Specialists in medical ethics would complement the heavily empirical focus of psychiatry with the explicitly normative concerns of rigorously developed ethical systems such as utilitarianism, Kantianism and virtue ethics.
Another important part of the mix should come from a new but rapidly developing field, philosophy of psychiatry, which analyzes the concepts and methodologies of psychiatric practice. Philosophers of psychiatry have raised fundamental objections to the DSM's assumption that a diagnosis can be made solely from clinical descriptions of symptoms, with little or no attention to the underlying causes of the symptoms. Given these objections, dropping the bereavement exception-a rare appeal to the cause of symptoms-is especially problematic.
Finally, we should include those who have experienced severe bereavement, as well as relatives and friends who have lived with their pain. In particular, those who suffer (or have suffered) from bereavement offer an essential first-person perspective. As Foucault might have said, the psyche is too important to be left to the psychiatrists.
Gary Gutting is a professor of philosophy at the University of Notre Dame, and an editor of Notre Dame Philosophical Reviews. He is the author, most recently, of "Thinking the Impossible: French Philosophy since 1960," and writes regularly for The Stone. He was recently interviewed in 3am magazine.


Wednesday, February 6, 2013

Personal Health: Effective Addiction Treatment

Personal Health: Effective Addiction Treatment: Many addiction treatment programs are rooted in outdated methods rather than new evidence-based approaches, dooming many addicts to failure.

Treatment, Not Jail, for the Mentally Ill

Treatment, Not Jail, for the Mentally Ill: In an ideal system, the mentally ill who commit minor offenses and pose no real danger to the public would never see the inside of a jail.

Boycott the DSM-5!

via Mad In America » Blogs by Jack Carney, DSW on 2/5/13

Boycott the DSM-5!

Believe it or not, there’s some confusion about what “boycott” means. Bluntly, it means “Don’t purchase or use the object being boycotted.” Remember the United Farm Workers and table grapes and iceberg lettuce? I remember walking a picket line daily for weeks in front of my neighborhood supermarket carrying a sign urging customers entering the store not to buy grapes and lettuce. It must have worked – this was back in the 1970’s – because the grape and lettuce growers in California’s Salinas Valley were obliged to sign contracts with the UFW and its members.
The Committee to Boycott the DSM-5 is comprised of regular, not-so-famous mental health professionals, users of psychiatric services and their family members and those who’ve managed to survive many years as patients in the mental health system. In short, folks like many others, who’ve grown to mistrust and/or been adversely affected by the psychiatric establishment and its series of “bibles” or DSMs, and who anticipate even worse experiences with the new DSM-5. Our objectives are to trigger the memories and sensibilities of those – professionals, patients, family members and survivors – who’ve had similar unhappy experiences; convince the professionals neither to buy nor use the new DSM; encourage current patients to urge their psychotherapists and psychiatrists to neither buy nor use the DSM-5; and ask the survivors to do what they do best, viz., reach out to those they know still caught up in the system and support their efforts to press those who treat them to neither buy nor use the DSM-5.
I think you get the message.
The Boycott statement below contains a series of brief rationales for our opposition to the DSM-5: that it’s unscientific, unsound and ultimately unsafe; that it continues the DSM tradition of pathologizing ordinary behaviors – the new DSM will contain over 300 diagnostic categories, up from DSM-IV TR’s 250; that it narrows “treatment of choice” to the prescription of psychoactive medications despite their known toxicity and suspect effectiveness; that the APA has undermined its own credibility by disregarding the many criticisms of the DSM’s nosology.
If you’re so inclined, additional and more detailed critiques can be obtained on this very website in the several articles about DSM-5 written by me and others over the last 12 and more months. My last post was on December 10, 2012 and entitled “Boycott The DSM-5: Anachronistic Before Its Time.”
If we succeed in getting a sizable number of the millions of prospective DSM buyers to sign on to our Boycott statement, a copy of which you’ll find at the end of this post, we’ll put a sizable dent in the sales needed by the American Psychiatric Association to recoup its investment in the development of the new DSM.
Allen Frances, the most well-known critic of the DSM-5, has estimated that the new DSM cost the APA $25 million to bring to press, which explains the hefty price for each volume — $199 per – the APA is charging. Which translates to a break-even figure of 12.5 million buyers world-wide. The APA is already soliciting pre-orders of on its website, nearly four months before the new DSM’s scheduled mid-May publication.
One final point. We realize that all professionals employed in the public mental health system, indeed any professional or agency seeking third party reimbursement for services rendered, must use diagnostic codes. Accordingly, we are recommending that, if you must use diagnostic codes, use those contained in the ICD-9. Please be advised that you do not need to rely on the DSM’s codes – they are entirely superfluous to billing procedures, which, by U.S. law and international treaty, must employ ICD codes. Our recommendation should not be construed as an endorsement of the ICD – we consider all diagnoses reductive and demeaning to the persons so diagnosed. Rather, our recommendation to use the ICD codes is meant as a bureaucratic expedient for those obliged to use them. In short, anything but the DSM-5.
The Boycott statement itself can be found and signed by those who agree with its contents and intent at Boycott the DSM-5 ( on I realize that our Boycott statement is far from perfect – frankly, it’s impossible to address or anticipate all the concerns of prospective supporters in a brief document. But, as I like to say, any rock that’s handy, I’ll toss it at the behemoth.
And that’s also why we have a companion information website — Boycott DSM-5— ( where additional information will be posted by the Committee and where those who wish to can post comments. Should any reader wish to join the Committee and do some work on its behalf or should you belong to an organization that might be interested in co-sponsoring the Boycott, please contact me via MIA e-mail, via our support website or directly to me at
I trust that most readers will find themselves able to support the Boycott and sign the Boycott statement. Feel free to cut and paste it, send it on to friends and colleagues, post it on your Facebook pages or websites. Thanks.
Remember, “Don’t mourn, organize! We are all prisoners of hope.”
For the Committee, Jack Carney
Carney, J., “Boycott The DSM-5: Anachronistic Before Its Time,” December 10, 2012,
Frances, A., Price Gouging: Why Will DSM-5 Cost $199 a Copy?
* * * * * *
Boycott the DSM-5!
We, the undersigned, will not purchase nor will we use the new DSM-5 when it is published by the American Psychiatric Association. Further, those of us associated with professionals who use the DSM – as persons receiving services from them or as family members, friends or advocates – will urge service providers not to use the DSM-5:
• DSM-5 is unsafe and scientifically unsound.
Its categories or diagnoses, including newly introduced diagnoses, are not supported by scientific evidence. These diagnoses will pathologize rather than bring relief to persons in distress.
• DSM-5 will drastically expand psychiatric diagnosis, mislabel millions of people as mentally ill, and cause unnecessary treatment with medication.
All references to psychosocial, environmental and spiritual factors have been removed from DSM-5. This sends a clear message to clinicians that treatment for persons judged to have psychiatric disorders can be reduced to the prescription of psychoactive medications, despite growing concerns of their dangers and skepticism about their effectiveness.
• The APA has been unresponsive to widespread opposition.
The APA has been unresponsive to criticism received from professional, advocacy and lay public stakeholders during the three public reviews of its proposals. The concerns expressed by over 14,000 signatories to the “Open Letter to the DSM-5” and the request for independent, scientific review of proposed changes to the DSM have been ignored.
• The APA has undermined it own credibility, choosing to protect its intellectual property and publishing profits, not the public trust.
Accordingly, we agree to boycott the DSM-5 and to urge service providers and others not to use it. If we find ourselves obliged to employ diagnostic codes, we agree to disregard the new DSM and utilize the codes listed in the ICD-9 and the next edition of ICD, when the latter is implemented in October, 2014.

DSM5 in Distress


Monday, February 4, 2013

DUOS: jung & freud

DUOS: jung & freud
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eddie ray routh - GS

eddie ray routh - GS

Eddie Ray Routh - News Review

Last Update: 2.10.13

"A puzzle inside of an enigma wrapped in a mystery"

Eddie Ray Routh, Accused of Killing Chris Kyle, ‘American Sniper,’ Had Troubled Past
Eddie Ray Routh, accused of killing Chris Kyle, the author of “American Sniper,” had been released from a hospital over his parents’ objections just days before the shooting, his lawyers said.

Chris Kyle’s Alleged Killer – Who Is Eddie Ray Routh?

He’s been charged with murdering Chris Kyle, the deadliest sniper in U.S military history but who is Eddie Ray Routh and what made him allegedly turn his gun on one of the countries’ most decorated Iraq war heroes?
Routh is accused of killing both Kyle, a retired Navy Seal and author of the best-selling American Sniper, and his neighbor, Chad Littlefield, at the posh Rouge Creek Lodge gun range near Glen Rose, Texas.
Now is looking at new details about the man behind bars.
PHOTOS: James Holmes’ Yearbook Photos


Saturday, February 2, 2013

NYT: Veterans Make Up Shrinking Percentage of Suicides

Veterans Make Up Shrinking Percentage of Suicides »
The convergence reflects the fact that suicide numbers are rising slightly among both veterans and everyone else, but has increased more in the general population.

If psychiatry is not successful, APA will not be successful

(title unknown):
PsychiatryOnline | Psychiatric News | News Article
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.”
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.

(title unknown)

(title unknown):
The Complicated World of Higher Education for Troops and Veterans
With more than $10 billion being spent this year educating troops and veterans, the order has been given: help them graduate. But how?

Thursday, January 24, 2013

News Review: What is Critical Psychiatry? | Critical Psychiatry and Psychology News


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 – – 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 – – 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.

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.

Reprinted from CPD Bulletin Psychiatry (2000) 2 33-36

Critical Psychiatry

    • Modern-day psychiatry relies too much on the "medical model" and emphasises diagnostic decisions. If psychiatrists adopted a more social or therapeutic community approach treatments would be more effective.

    • The categorisation of psychiatric illness is not as clear as most psychiatrists believe. Assessment of aetiology too often fails to take personal and social factors into account.

    • There is too much emphasis on the scientific possibilities of randomised controlled trials. The evidence of these trials is biased.


    Psychiatry is open to criticism because of its power of compulsory detention and treatment. This issue could be avoided by psychiatrists restricting themselves to voluntary treatment, and psychotherapists indeed routinely do practise on this basis. However, the social responsibility of caring for the mentally ill is an essential function of psychiatry and should not be neglected. The question is how well psychiatry fulfills its role.

    Critical psychiatry suggests that psychiatric practice is often inadequate for a number of reasons. This article will review this critique of psychiatry by examining its main constituents. Over recent years mainstream psychiatry has marginalised its critics by dismissing them as "antipsychiatrists". However, those identified as part of the antipsychiatry movement, such as David Cooper, Thomas Szasz and RD Laing do not represent a single view (Tantam 1991). Cooper was politically Marxist and the only one that accepted the designation "antipsychiatrist"; Szasz (1972) regards mental illness as a myth; Laing recognised the turmoil of mental suffering, whilst acknowledging that the term mental illness is used metaphorically. Arguably, the "antipsychiatrists" are only linked by their willingness to criticise psychiatric practice.

    Biological bias in psychiatry

    Detaining the mentally ill creates the potential for abuse. From the 1950s, attempts were made to make psychiatric hospitals more therapeutic by unlocking the doors (WHO 1953). The maltreatment of patients in hospital was exposed in several scandals that gave an impetus to the dehospitalisation of patients (Martin 1984). Conversely, inquiries over recent years, particularly following homicides by psychiatric patients, have expressed concern about neglect of patients in the community (Peay 1996). Psychiatric services have to find a precarious balance beside abuse and neglect.

    Accordingly it can be difficult to sustain interpersonal relationships. One temptation is to retreat into objectification of those identified as mentally ill, insisting on the somatic nature of their illness. An advantage of this strategy is that it protects those trying to provide care from the pain experienced by those needing support. Notwithstanding some intuitive understanding of mental illness as a disorder of the mind, it is simpler to concentrate on its bodily substrate. Such a biological bias is not new in psychiatry, although psychopharmacological developments following the discovery of antipsychotics and antidepressants have reinforced this emphasis. As expressed by John Haslam (1798) over two centuries ago: "[T]he various and discordant opinions, which have prevailed in this department of knowledge, have led me to disentangle myself as quickly as possible from the perplexity of metaphysical mazes."

    Both the dopamine theory of schizophrenia (dopamine overactivity in schizophrenic brains) and the amine hypothesis of depression (amines depleted in depressed brains) arose following the introduction of psychotropic drugs, at a time when only few neurotransmitters had been discovered. Despite the subsequent discovery of a vastly more complex neurotransmitter network, psychiatrists still use such simplistic notions in their everyday management of patients when they explain that mental illness is due to "chemical imbalance".

    The evidence for the organic basis of functional psychiatric conditions such as schizophrenia is not as considerable as certain claims suggest. Functional imaging of receptors has produced equivocal results. Structural and functional cerebral abnormalities in schizophrenia are at best subtle rather than gross (Chua & McKenna 1995). In contrast, the identification and cloning of genes and the elucidation of chromosomal abnormalities has led to major progress in the molecular biology of genetic neuropsychiatric disorders, such as Huntington's disease, in which the abnormality of triplet repeat on chromosome four has now been demonstrated.

    Taken to its extreme, the danger is that people with mental health problems will be reduced to purely physical terms wherein their brain chemistry needs correction. Moreover, the biological hypothesis is used to give justification to medical control in the treatment of mental illness. In relations of power, it suits psychiatrists to keep other mental health professionals thinking that they may be missing vital knowledge about bodily processes. The authority of the challenge to the biological hypothesis is thereby undermined.


    Single-word diagnoses fail to give an adequate understanding of a person's mental health problems. The modern explicit and intentional concern with diagnosis and classification disguises uncertainty about psychiatric disease entities.

    In particular, over recent years, psychiatric diagnosis has become increasingly codified following the original paper by Feighner et al (1972), and the introduction of the Research Diagnostic Criteria (Spitzer et al 1975), through editions of DSM-III, DSM-IIIR and DSM-IV (APA 1994) and ICD-10 (WHO 1992). Robert Spitzer, who chaired the DSM-III Task Force, was particularly concerned about a study by Rosenhan (1973), which raised the fear that unreliable diagnoses may invalidate the whole process of psychiatric practice (Spitzer & Fleiss 1974). Rosenhan demonstrated that normal people could gain admission to hospital and acquire a diagnosis of schizophrenia by merely feigning a mundane, simple hallucination, saying they were hearing a voice say "thud", "empty" or "hollow". He concluded that professionals were unable to distinguish the sane from the insane. Operationalisation of psychiatric criteria arose as a response to the perceived need for objectification in diagnosis.

    The US-UK Diagnostic Comparison Study demonstrated that American psychiatrists were using the term schizophrenia more inclusively than their British counterparts (Kendell et al 1971). This finding also contributed to a tightening of diagnostic criteria, particularly a restriction of the use of the term schizophrenia. Concern about stigmatisation has made psychiatrists much less ready over recent years to use a diagnosis of schizophrenia which tends to imply poor prognosis.

    The movement to create explicit diagnostic criteria has been called neo-Kraepelinian, as it promotes many of the ideas associated with the views of Emil Kraepelin, often seen as the founder of modern psychiatry (Klerman 1978). Adolf Meyer was regarded as extremely influential in American psychiatry in the first half of this century, and his influence came to Britain via Aubrey Lewis and David Henderson (Gelder 1991). Meyer (1951/2) is remembered for his opposition to the preoccupation of the Kraepelinians with diagnosis. Although he accepted that there may be a place for classification, he argued that if diagnosis was meaningful, it was secondary to the assessment of the patient as a person (Double 1990). He may be held responsible for helping to create a trend which depreciated the role of diagnosis, which the neo-Kraepelinian movement deliberately countered. Psychoanalysis was strong in academic psychiatry in the post-war period in America and also appears to have played a role in de-emphasising the importance of diagnosis and classification..

    It is illegitimate to postulate an underlying disease entity just because mental disorders may seem unintelligible. Assessment should concentrate on the "facts of the case", as Meyer was fond of saying, and diagnosis usually does justice to only part of "the facts". Even if "the facts" do not constitute a diagnosis, clinical management has to act on them. Meyer favoured a psychogenic explanation of mental illness and regarded it as not completely foreign to normal experience. In particular, he explained schizophrenia (dementia praecox) as a maladaptation that could be understood in terms of the patient's life experiences. Psychiatric assessment too often fails to appreciate personal and social precursors of schizophrenia by avoiding or not taking account of such considerations.

    Social therapy

    Several experimental attempts have been made to provide a more therapeutic milieu than the traditional hospital environment. For example, Harry Stack Sullivan established a small ward for schizophrenic men that was staffed with hand-picked attendants, set apart from the rest of the Sheppard Pratt Hospital in the 1920s (Barton Evans III 1996). He gave his staff autonomy to operate on their own with patients. As Sullivan (1962) stated:

    [W]e found intimacy between the patient and the employee blossomed unexpectedly, that things I cannot distinguish from genuine human friendship sprang up between patient and employee, that any signs of the alleged apathy of the schizophrenic faded, to put it mildly, and that the institutional recovery rate became high.

    Sullivan's experimental ward could be seen as a precursor of the therapeutic community movement, whose influence came to be integrated with mainstream psychiatry (Jones 1952, van Putten 1973). This emphasis on the social aspects of treatment, though, is much less obvious in the current climate of risk assessment and psychotropic drug management (Clark 1974).

    The "antipsychiatrists" also experimented with institutional alternatives. For example, David Cooper set up Villa 21 in Shenley Hospital, although Cooper's positioning as an antipsychiatrist makes it difficult to appreciate the similarity with ventures like that of Sullivan. Cooper's (1967) "experiment in antipsychiatry" failed to change the ward staff's role-bound behaviour. Laing's Kingsley Hall was outside the hospital system and was perhaps more like a commune. Criticism of its laissez-faire ethos should take account of Laing's own concession - that he had failed to find "a tactical, workable, pragmatic . . . . sort of thing that could work for other people" (Mullan 1995).

    Scepticism about therapeutic efficacy

    Historically doctors have prescribed medications which are now regarded as useless and often dangerous. Non-specific placebo effects can be powerful (Shapiro & Shapiro 1997). Uncontrolled evaluation of the efficacy of treatment was eventually replaced by clinical trials and the acceptance and use of the double-blind method. However, randomised controlled trials are commonly flawed in practice and the most rigorous trials are associated with less treatment benefit than poor quality trials (Moher et al 1998). The recent emphasis on evidence-based medicine with initiatives such as the Cochrane Collaboration has also focused on methodological issues.

    The double-blind method is not infallible because frequently the double blind can be broken (Fisher & Greenberg 1997). Patients and doctors may be cued in to whether patients are taking active or placebo medication by a variety of means. For example, they may notice that placebo tablets they have been taking taste differently from medication to which they have previously become accustomed. Active medication may produce side effects which distinguishes it from inert medication. There is evidence even of deliberate deceit in clinical trials so that randomised allocation is not concealed (Schultz 1996).

    Studies where an attempt to measure unblinding has been made confirm that it does occur and significant correlations with efficacy ratings have been found (Shapiro & Shapiro 1997). These problems of unblinding may be minimised by trialists because there seems to be nothing that can be done to prevent it completely. Nonetheless, there should then be no pretence that unbiased evaluation of treatment is being carried out. Although the apparent specific effect of treatment may not be as great as the placebo effect itself, it may merely be the wishfulfilling amplification of nonspecific effects. Using active drugs without apparent specific treatment effects as controls generally reduces the effect size of the active treatment, maybe because patients are less likely to be unblinded in the trial because of the detection of active effects in the control drug (Thomson 1982).

    The placebo effect may be relevant to problems in discontinuation. People may form attachments to their medication more because of what it means to them than what it does. Any change threatens an equilibrium related to a complex set of meanings that their medication has acquired. These issues of reliance on medication should not be minimised, yet commonly compliance with treatment is reinforced by emphasising that antidepressants, for example, are not addictive (Double 1997). Psychotropic medication is often prescribed in life crises reinforcing defensive mechanisms against overwhelming anxiety, and the power of the placebo effect should be recognised. Counteracting such placebo effects may not be easy when discontinuing medication.

    Conclusion and future developments

    Psychiatric practice can be criticised for its failure to regard the patient as a person. Mainstream psychiatry acts on the somatic hypothesis of mental illness to the detriment of understanding people's problems. Laing's (1982) primary motivation was his appreciation that schizophrenia, in particular, was more understandable than mainstream psychiatry recognized. This stance is consistent with Adolf Meyer's (1951/2) philosophy. The neo-Kraepelinian has eclipsed the Meyerian approach over recent years and encouraged excessive enthusiasm about diagnosis and treatment which requires critical analysis (Double 1991).

    Antipsychiatry has been marginalised because it accuses psychiatry of social control (Farrell 1979). Renewed criticism of modern psychiatry is required and the Critical Psychiatry Network gives expression to a "post-psychiatry" (Critical Psychiatry Network website). Psychiatry need not feel negative about this process. Patients and society will continue to demand its services and appreciate realistic expectations.


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    Sex is major reason military commanders are fired

    via AP Top Headlines At 8 a.m. EST by By LOLITA C. BALDOR on 1/20/13
    WASHINGTON (AP) -- Brig. Gen. Jeffrey Sinclair, fired from his command in Afghanistan last May and now facing a court-martial on charges of sodomy, adultery and pornography and more, is just one in a long line of commanders whose careers were ended because of possible sexual misconduct....

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