Interdisciplinary Review of General, Forensic, Prison and Military Psychiatry and Psychology and the related subjects of Behavior and Law with the occasional notes and comments by Michael Novakhov, M.D. (Mike Nova).
Why all the fuss over DSM-5? Why did Robert Spitzer, the editor of DSM-III, begin to protest about the “secrecy” surrounding its production as early as 2007? Why did Allen Frances, editor of DSM-IV, begin in 2009 to challenge the American Psychiatric Association’s (APA) announced goal that when making DSM-5 “everything is on the table”? Why did he dispute the APA’s position that there had been enough progress in neuroscience to call for a “paradigm shift”? And why did Frances and others go on to protest repeatedly what they viewed as DSM-5’s “medicalization of normality?”
So, why all the fuss about DSM-5? After all, most psychiatrists, psychologists, social workers, and counselors don’t usually pull out their copy of the current DSM to run their fingers down the diagnostic criteria when they are required to make a diagnosis. And family doctors and internists, who prescribe over 80 percent of all psychotropic medications, almost never do.
There is a fuss for two main reasons. First, whether a health insurance company will pay mental health professionals for their recommended treatment for patients and clients hinges on the diagnosis the clinicians provide.
Second, and more vital, is that the diagnoses in the DSMs have come to affect the daily lives of millions of people in the United States, not to mention those abroad, since the DSM is translated into many languages. For these people much hangs upon whether a particular diagnosis is in the manual or is not. At stake is their treatment, insurance coverage, and decisions affecting such fundamental matters as where they will live, what jobs they can hold, and how their children will be educated. Significantly, the DSM is used by public housing authorities to decide eligibility, by employers who must comply with the Americans with Disabilities Act, and by public school systems to determine whether to provide free special services for students. In the criminal justice system, the DSM is employed by lawyers, judges, and prison officials. To these circumstances must be added the unfortunate reality that the stigma that may accompany one particular diagnosis but not another is of considerable concern to individuals who may be identified as having a mental disorder.
A short thirty years ago, this panoply of affairs (aside from problems with stigma) did not exist. The first two of the APA’s diagnostic manuals of 1952 and 1968 were mere blips, small spiral-bound booklets of some 130 pages, more overlooked than consulted by clinicians, and totally unknown to the general public. The third edition, the DSM-III of 1980, a massive hardbound volume of 494 pp., changed within a decade the benign neglect that the manual had been receiving. A revolution in American psychiatry had occurred. DSM-IV (1994) was a reiteration of III, and greatly expanded. By 2000 the revised IV was nearly 1,000 pages. In spite of some reorganization of chapters and several new diagnoses, DSM-5 bears a remarkable resemblance to its famous ancestors.
DSM-III discarded the psychoanalytic emphasis of DSM-II, with its theories of unconscious conflict as the root cause of most psychopathology. And then in a quest for diagnostic reliability—at that time mired in a state of abysmal inaccuracy—DSM-III inaugurated a new approach to mental disorders based solely on observable signs and symptoms. Checking off these “operational (eventually diagnostic) criteria” became the goal of an increasing number of psychiatrists. (Interestingly, the notion of operational criteria was derived from the principle of “operational analysis” as the road to knowledge, first propounded in 1927 by the Harvard physicist P. W. Bridgman.) In DSM-III mental disorders were now neatly divided into discrete descriptive categories, and the psychoanalytic idea of disorders ranging along a spectrum from normal to severe psychopathology was dropped. With a few exceptions—the most notable being Autism Spectrum Disorder—DSM-5 remains categorically based like III.
Yet there are notable differences between III and 5, and they speak to historical developments in psychiatry. Much attention has recently have been given to the new diagnoses to be found in 5, but some matters have received less publicity. One is that the multiaxial system, proudly introduced by Spitzer, has been shelved by the makers of 5.
For these individuals four points were at issue. To start with, it had been Spitzer’s idea that there be a separate axis (Axis II) to call attention to underlying personality disorders that might escape notice when clinicians focused on acute syndromes that had brought the patient into treatment. But that diagnostic neglect has mostly changed since 1980, a time when many researchers had challenged the authenticity and validity of what they considered to be the “soft” personality diagnoses. Today personality disorders are regarded as “legitimate,” drawing a great deal of clinical (and even research) attention, and therefore are not being placed on a separate axis. Second, Spitzer had been concerned that clinicians might not want to use Axis IV (“Severity of Psychosocial Stressors”) and V (“Highest Level of Adaptive Functioning Past Year”), and his surmises turned out to be largely correct. Over the years, a significant group of clinicians have complained that using the multiaxial system was burdensome and time consuming, and the makers of 5 decided to respond to this. The observer is tempted to ponder if this development in 2013 also speaks to psychiatrists’ greater attention to short “med-checks” as opposed to their psychotherapeutic focus 30 years ago.
The third point regarding the multiaxial system is that the architects of the new volume decided that they did not want to draw a sharp line between mental and medical conditions, as DSM-III’s Axis III (“Physical Disorders or Conditions”) had often dictated. Spitzer himself wanted DSM-III to be a tool to portray psychiatry as scientific in order to combat the anti-psychiatry movement of the 1960s and early ‘70s. However, the present builders of 5, with their goal of tying psychiatry to biology as openly as possible, have sought to reiterate that psychiatry, as a medical discipline, shares vital links with science. Finally, Spitzer’s multiaxial innovation was the victim of unintended consequences. It often occurred that health insurance companies reimbursed less for Axis II disorders, taking the listing of Axis I (“Clinical Syndromes”) before Axis II to mean Axis II disorders somehow ranked “below” Axis I disorders. (It did not help, of course, that personality disorders could be more expensive to treat than some acute Axis I disorders, since personality disorders often called for lengthy psychotherapeutic intervention.)
Another historical change from DSM-III to DSM-5 is that much greater attention was paid to possible monetary conflicts of interest of the DSM-5 Task Force and Work Group members than had ever been the case for the developers of DSM-III. For one thing, the creation of III was the first time that the making of a new manual had involved large numbers of contributors. DSM-I and II had been written by small committees whose financial ties had never been a consideration. Thus, the ties of the makers of III were barely scrutinized. Furthermore, substantial payments to researchers and clinical consultants from pharmaceutical companies—the source of most conflicts of interest—were just beginning in the early 1970s when III was being constructed. Psychiatrists then were more likely to get grant money from their institutions and the NIMH than from private companies. But it was the very form of III, with its new and specific categories, that had beckoned the pharmaceutical industry to develop medications for recently developed diagnoses. The professional landscape altered. To urge the prescribing of the new drugs, companies now paid psychiatrists who had done research (often with industry grants), or had other experience with their products, to disseminate information about them, often at delightful small dinners.
By the time the creators of DSM-5 were assembled c. 2007, it was widely recognized that financial support from “Big Pharma” posed serious potential conflicts of interest. Already certain prominent psychiatrists had been exposed as taking large sums from the pharmaceutical industry that they had not disclosed to their home institutions. There were accusations that the reports and papers of some researchers had been written for them by commercial organizations. Eventually, during the process of making of DSM-5, the American Psychiatric Association (APA) did considerable vetting of ties with drug companies and the Task Force and Work Groups members had to publish financial disclosures. They had to agree that their aggregate annual income derived from industry sources (excluding unrestricted research grants) would not exceed $10,000 in any calendar year.
A final historical development was barely a fleck on the screen until several weeks ago. DSM-III had had the enthusiastic support of the NIMH. The bulk of the field trials of DSM-III were supported by a grant from the NIMH. Since its formal establishment in 1949, the NIMH and the APA have had a close relationship. As the APA began to contemplate a revision of DSM-IV in 1999, a partnership was formed between it and the NIMH, “with the goal of providing direction and potential incentives for research that could improve the scientific basis of future classifications” (A Research Agenda for DSM-V, 2002.)
Thus, it came as a great shock to almost all when Thomas R. Insel, Director of the NIMH, announced on April 29 of this year, just three weeks before the release of DSM-5, that the NIMH would no longer be guided by the DSM. Insel acknowledged that ever since DSM-III appeared in 1980, the manual had helped produce reliability in psychiatric diagnosis because it enabled more consistent communication among clinicians. However, its great “weakness,” he went on, was its lack of validity. By this he meant that a descriptive diagnostic category, as found in III or IV, might in reality encompass several different disorders having different etiologies and needing diverse treatments, thus making the current diagnostic category invalid. This was hardly news, it being widely recognized that Spitzer had sacrificed validity for reliability.
But Insel proceeded. The DSM was, “at best, a dictionary, creating a set of labels and defining each.” It was a collection of symptomatically-based diagnostic categories without any regard for etiology, at odds with the rest of medicine. “Patients with mental disorders deserve better, “ he declared, and proceeded to drop a bombshell: The NIMH would henceforth “be re-orienting its research away from DSM categories.” In their place the NIMH would create a new classification that would be based on “genetic, imaging, physiologic, and cognitive data” and would no longer support research projects based on the DSM nosology.
Have we come to the end of the DSM-III model, just 33 years after it was created? Is this the start of a new era that will bring to psychiatry the much-desired validity sought by Eli Robins and Samuel Guze in their famous 1970 paper, “Establishment of Diagnostic Validity in Psychiatric Illness”? Probably not right away. The NIMH has launched a new project, the Research Domain Criteria (RDoC), to transform diagnosis and create “precision medicine” such as has radically changed cancer diagnosis and treatment. But for the present, clinicians and the wider society that use the DSM, will have to rely on it or the International Classification of Diseases (ICD). After all, what else is there? The NIMH project is still in its infancy.
Insel predicts his project will be “a decade-long.” Even that seems overly optimistic considering the obstacles to such an etiological revolution. There is also the troubling feature that in his far-reaching blog he declaims that “mental disorders are biological disorders” with no mention of the role of human psychology.
History provides some perspective here. In 1845, a leading German psychiatrist, Wilhelm Griesinger, pronounced that “mental diseases are diseases of the brain,” which became the mantra of most medical students. Almost 30 years later, Theodor Meynert, Sigmund Freud’s teacher at the Vienna medical school, wrote in his textbook: “The reader will find no other definition of ‘Psychiatry’ in this book but the one given on the title page: Clinical Treatise on the Diseases of the Fore-Brain.” It was in reaction to such declarations, and their failure to advance knowledge, that the famous psychiatrist, Emil Kraepelin, coined the phrase “brain mythology.” Kraepelin, the father of the historic division of the psychoses into dementia praecox and manic-depressive illness, eschewed chasing after slippery etiologies and turned to describing what he observed. Freud, born the same year as Kraepelin (1856), was affected, as Kraepelin, by the identical disappointment with the sluggish progress in dealing with mental disorders. He went in another direction and created psychoanalysis. The two, Kraepelinian descriptive psychiatry and Freudian psychodynamic theories, have both contributed to our knowledge and have as well their recognized limitations. Importantly, they also stand as reminders of the arduous tasks involved in understanding human beings.
Hannah S. Deckeris Professor of History at the University of Houston, Adjunct Professor of Medical History in the Menninger Department of Psychiatry, Baylor College of Medicine, and Adjunct Faculty member, Center for Psychoanalytic Studies, Houston. She has recently publishedThe Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (Oxford University Press, 2013.)
A couple of weeks ago I attended the annual conference of the Association for Psychological Science (APS). APS was founded twenty years ago by psychologists and neuroscientists who were dismayed by trends in the American Psychological Association (APA). The APA had lost its old single-minded focus on the search for empirically based answers to psychological questions. This may have followed from the fact that
APA’s membership encompassed an ever-larger percentage of practicing psychologists with many immediate, practical concerns. Yet it is these very clinicians who are in such dire need of empirically validated procedures. For example, a common clinical procedure, assumed to be therapeutic, is catharsis. Yet the recent APS conference offered still more evidence
if not most instances, catharsis can be
rather than helpful. This is a point of view that I had personally expressed in a number of my own publications. Rather than walking away pleased at confirmation of what I had already concluded, I was dismayed by the realization that this newer literature with its important findings was not well known in the clinical community. I thought it might be time to summarize this newer, empirical literature on the effects of the expression of emotion, and on the frequently negative consequences of catharsis, while offering a concise description of the validated alternative procedures.
There are four closely related axioms that can be abstracted from the empirical studies on emotion and its expression. They each offer implications for treatment, or even how individuals should deal with their own experiences of emotional trauma.
1) Expression of strong negative emotions usually enhances the strength of these emotions and keeps them in focus, as opposed to dissipating them. Overt emotional expression, like other behaviors, carries self-defining information. That is, if you see yourself trembling, you’ll be convinced that you are afraid. Screaming will have the same effect. Expressing how frightening it is adds confirmation. Most of us have observed somebody “working himself into a frenzy.” But because of the impact of psychoanalytic thinking in our culture, we assume that catharsis has the effect of dissipating emotion, rather than recognizing the common experience (now supported by research), that fully expressing strong negative feelings will, more often than not, increase the feelings.
2) Given one encounters a distressing experience, focusing on the discomfort will make it worse. Noel-Hoeksema is famous, at least in some circles, for developing the concept of rumination. After a negative experience, asking “what am I feeling”“ ”why am I feeling this?” “What does this mean?’ “How long will this last?’ will prolong the experience. This type of rumination will lead to even more rumination. Changing the focus, being involved in anything that can otherwise engage you, whether sports, other challenges, or other issues in one’s life, can break the cycle. Sometimes the discomfited individual lacks the ability to change focus to something else. In such cases, even keeping the negative event in focus, the ruminating individual can be helped and encouraged to describe the negative event from a third party perspective. Choose a proper alternative perspective, with less negative implications. Describing, contemplating, and appreciating the event from this other perspective, the hurting individual can find a step by step retreat from the purely negative tone of the ruminative cycle.
3) Depression is partly defined by, and largely maintained by, self-focus. Changing to an external focus will help. Helen Mayberg has achieved recognition for deep brain stimulation of Brodman’s area 25 to relieve symptoms of depression. While nobody knows what function Brodman’s area 25 actually subserves, Mayberg’s patients report that when Mayberg turns off this area in the brain, they want to do something. One patient said that if he were home he would clean out the garage. A crucial difference between cleaning out the garage and being depressed is the presence of external focus ─ operating on the world rather than observing one’s feelings.
4) Positive affect is just as important for well-being as an absence of negative emotion. Barbara Fredrickson has explored the benefits of positive affect on health and cognition. Recent research finds that externally focused positive emotion, such as occurs with loving/kindness meditation, has a more powerful effect on health than self-focused positive emotion (hedonism or pride). The work on positive affect is very consistent with Fava’s recommendation to find traits in others that please you and focus on things for which you are grateful as a mechanism for treating depression (Journal of Personality, 2009).
In summary, following trauma, do not focus on the discomfort, do not focus on one’s self other than for positive assessments, and the experience should be reframed so that it is seen in a less negative light. Assuming the presence of therapists, the therapists should be assisting the clients in identifying positives in their daily lives. Identifying personally embraced goals and developing active behavioral strategies for achieving these goals is a useful practical road to shifting the focus away from internal focusing. A seeming contradiction to this advice is seen in the empirically supported technique involving extinction of fear (usually called re-exposure therapy, or flooding). Extinction of fear entails exposing the client to the terror-eliciting stimuli and then waiting the requisite 15 minutes for the terror to dissipate while no actual disaster occurs. But outside of war, extreme fear is not a frequent source of trauma and precipitant to seeking help. There is little evidence that extinction works well with other emotions. And extinction of fear through forced exposure is not really an example of the cathartic method, in that instead of the client emoting, the client remains passive while exposed to the stimuli associated with the trauma.
So why is it that the assumption that the mere expression of emotion is helpful, is still so widely embraced? Freud’s perspective was based on views on energy that were just beginning to be fully appreciated and fully utilized at the turn of the century (1900 not 2000): energy can be converted from one form to another but energy can neither be created nor destroyed. This physical principle was applied to human emotions and formed the basis for the catharsis hypothesis: emotion is trapped in the body where it causes symptoms, and is expunged or dissipated if externally expressed. But as previously discussed, that is seldom what occurs, and Freud’s view of emotion fails to comport with contemporary views of emotion: emotional reactions are determined by how one appraises the situation and/or by which situation one chooses to focus on or appraise. If there is a simple bottom line to this literature, it is that in order to ameliorate
quickly find something else to think about. For the longer term, change how you view the situation.
A final note on this issue. Since catharsis frequently prolongs emotional upset, and is frequently utilized, harm is being done. Yet we all believe in the first principle of doing no harm. Hopefully, disabusing the mental health community of the idea that catharsis is generally a good thing, may help us to follow the widely approved maxim: do no harm. Confusion on this topic should no longer be tolerated.
I have written, in previous posts, about the deleterious effects of antenatal inflammation – the effects on the mother’s mental and physical health, on birth outcomes, and on her child’s risks for chronic illness. Epigenetic effects of maternal inflammation are exacted through toxins excreted by aberrantly colonized guts, by high levels of reactive inflammatory cytokines, by poor antioxidant reserves and micronutrient resources. When you take a woman who has been eating processed food, taking The Pill, antibiotics, and maybe even a PPI, exposed to xenoestrogens, endocrine disruptors, and friendly-bacteria-slaughtering pesticides and you grow a baby in that womb, there is a good chance you have created a time-bomb. Throw in 70 doses of 16 neurotoxic and immunosuppressive vaccines by age 18, some formula, and genetically modified and processed baby food, 4 years of plastic diapers, and Johnson’s 1,4-dioxane babywash
we have a problem.
Our children are toxic. A 1/50 incidence of Autism is not better diagnosis. That’s like saying our planet has always been overpopulated, we just didn’t know how to count before. From some 1978 estimates of 1 in 10,000, this is not Mendelian genetics we are talking about. It is also not just autism. It’s learning disabilities, allergies, asthma, autoimmune disorders, cancer. We are in crisis and the denialism around contributing factors is gilded in dollars shared by our government and corporate interests. The toothless regulation of pharmaceutical companies, Monsanto, sugar, and chemical lobbies is responsible for this. Where is the too little too late corrective response? Where is the tipping point
of the collusion? Where is the feverish search for what is making our children sick? If not only because our country will buckle under the weight of the needs of these children coupled with the chronic diseases of the baby boomers and their children?
Here is the proposed solution: revisionist history.
Redefine and eliminate the epidemic. Change the diagnostic criteria
so that Autism is not the cause for alarm we all thought it was, just as the canaries in the coal mine were beginning to look like backyard finches. Use a pharmaceutically-driven set of hand-waving criteria to ignore the plight of millions of families in this country suffering at the hands of modern medicine and a government-sanctioned pathological lifestyle (make sure to get your 8 servings a day of genetically modified, glyphosate-sprayed processed grains!). Enter the DSM-V.
The culminating shame of a profession marked by hack-science, placebo-driven assertions of medication efficacy, manipulation of data and a total absence of objective diagnostic markers. Psychiatry had a precious opportunity to achieve a rebirth – to look beyond the epiphenomena of symptom clusters in search of common biomarkers and underlying pathophysiologic mechanisms. It would not serve; however, the APA’s relationship with Pharma to diminish or render more precise the demographic of patients for whom medications may be indicated. So, at once, we continue to pathologize normative human experience to better sanction mass prescribing to a populace convinced they need these magic pills, but we stop the hemorrhaging on the pediatric statistics that directly implicate the medical-industrial complex and the consequences of reckless obstetrical and pediatric interventions. Done and done.
There is precedent for this diagnostic revision and many write about the misattribution of polio eradication to the Salk Vaccine in 1954 when, in reality, the diagnostic criteria were changed shortly thereafter to require 60 days of paralysis (rather than 24 hours) and to distinguish coxsacki and aseptic meningitis from what had previously been lumped as poliomyelitis – an insta-resolution to an epidemic. While infectious disease and fear-mongering around contagion is at the helm of pharmaceutically-driven mandates in the name of public health, public health today looks a lot more like autoimmunity, neurodevelopmental dysfunction, and cancer. The impact of these chronic diseases on our society will be crippling if nothing is done to change the course of
it seems like the DSM has found a solution. Denialism.
The Affordable Care Act offers strong support for comparative effectiveness research, which entails comparisons among active treatments, to provide the foundation for evidence-based practice. Traditionally, a key form of research into the effectiveness of therapeutic treatments has been placebo-controlled trials, in which a specified treatment is compared to placebo. These trials feature high-contrast comparisons between treatments. Historical trends in placebo-controlled trials have been evaluated to help guide the comparative effectiveness research agenda. We investigated placebo-controlled trials reported in four leading medical journals between 1966 and 2010. We found that there was a significant decline in average effect size or average difference in efficacy [the ability to produce a desired effect] between the active treatment and placebo. On average, recently studied treatments offered only small benefits in efficacy over placebo. A decline in effect sizes in conventional placebo-controlled trials supports an increased emphasis on other avenues of research, including comparative studies on the safety, tolerability, and cost of treatments with established efficacy.
I’ve kind of developed a rule without thinking about it that people with hundreds of published articles must be dangerous characters. But I recognized Dr. Olfson’s name and found four of his articles on this blog previously quoted that I thought were well-done and right-thinking and PubMed lists him at 300 articles. So maybe my unconscious rule has exceptions:
In this study, they plotted effect size of drug/placebo differences in randomly chosen clinical trials from four major journals [JAMA,BMJ,NEJM,Lancet] going back to the time the trials became required. These are not just psychiatry articles, they cover all disease areas. Here’s the breakdown of their data set:
This is their prime finding – the fall in effect size of the clinical trials over their study period:
I graphed some of their tabular data to make it easier to see [all were significant]. On the left is the percent of Clinical Trials where PHARMA funding was acknowledged. This figure is confusing as that only became a requirement during the study period [NEJM 1985, JAMA 1989, BMJ 1994, Lancet1994]. On the right, the number of authors rose from a median of 2-3 to 8-20 over the study period! Who knew?
The left graph below shows the median number of sites used in the clinical trials. The trend to multiple sites is a striking phenomenon of the recent past, I presume reflecting the ascendency of of the Clinical Research Organizations. Similarly, in the center the median number of study subjects has soared over the last two decades [chasing significance]. And on the right, another way of showing the falling effect size – the mean odds ratio.
And finally some miscellaneous stats from their tables. In this study the % of non-US studies, studies with insignificant Primary Outcomes, and drop-out rates did not change significantly. Intent-to-treat analysis means all subjects that start the study are included including drop-outs etc [corrected for missing data]. Studies reporting number of subjects screened and ITT analysis increased significantly.
The article has an excellent but long discussion of the why of all of this, and concludes:
Substantial investments are made in clinical trials. In the United States, for example, more than $100 billion is spent each year on biomedical research, with most of the funding devoted to clinical trials. Concern over a slowdown in the discovery of innovative medical treatments has prompted calls for new public policies to stimulate drug development, including incentives for novelty drugs. During difficult economic times, however, private research sponsors may be tempted to take a cautious approach that favors incremental research focused on follow-on or “me too” drugs that offer little additional efficacy over more speculative high-risk/high-reward strategies.
The Affordable Care Act mandates a new national comparative effectiveness research agenda. Its great promise is to build the scientific foundation of clinical practice. Yet forty years of declining effect sizes in traditional placebo-controlled trials underscores the increasing challenge of discovering breakthrough interventions. Where established treatments achieve comparable efficacy, comparative effective research can help identify the safer, less expensive, and better-tolerated alternative. By placing clinical decision making on firmer footing, it is hoped that comparative effectiveness research will help patients receive the best possible care and save them from unnecessary risks, inconvenience, and costs.
I obviously liked this study – well-done, timely, well-analyzed. I’m not sure I’m through digesting it, but several things occurred to me. First, my focus has been on the deceit in the psychiatric clinical trial world and I tend to see the problems with clinical trials as localized to psychiatry. This study widens that lens to all of medicine. I was surprised by that. Besides deceit, I’ve also tended to blame the falling effect sizes on the Clinical Research Industry using recruited subjects often in far-away lands with culturally diverse subgroups. So I wouldn’t have expected the same decline in trials of biomarker-confirmed physical diseases. But there it is.
It’s the rare clinical trial article that doesn’t comment on the small effect sizes these days – blaming the placebo effect or other karmic forces. And this paper makes it very clear that they are escalating the number of subjects [requiring multiple sites] to chase significance with smaller effect sizes. But I find it impossible to look at this data and conclude anything except that, on the whole, they’re testing weaker and weaker drugs.
It makes perfect sense. They’ve increased their capacity to detect significance in drugs with a smaller effect size, but that does nothing to insure discovering better drugs. If anything – the opposite. It also makes sense to move towards comparative effectiveness studies to keep from iterating downward in effectiveness. Food for thought, this article…
hat tip to Pharmagossip…
… and the multiple author thing? Unsportsman-like conduct. Shame on them!
Read the whole story
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DSM-5.0by George Dawson, MD, DFAPA (firstname.lastname@example.org)
I finally saw a copy of the DSM-5 today. It was sitting on a table at a course on the DSM put on by theMinnesota Psychiatric Society. The DSM-5 portion of the course was about 3 1/4 hours of lectures (98 information dense PowerPoint slides) by Jon Grant, MD. Dr. Grant explained that he was in a unique position to provide the information because he and Donald Black, MD had been asked by the American Psychiatric Association (APA) to write the DSM-5 Guidebook. In this unique position they were privy to all of the notes, minutes, e-mails and documents of the DSM Work Groups. In the intro it was noted that Dr. Grant had written over 150 papers and 5 books. He was probably one of the best lecturers I have ever seen with a knack to keep the audience engaged in some very dry material. There were times that he seemed to be riffing like a stand up comedian. The content was equally good. I thought I would summarize a few of the high points that I think are relevant to this blog.
The first section was an overview of the history. The original DSM was published in 1952, but before that there were several efforts to classify mental disorders dating back to ancient times. Some of the systems persisted for hundreds of years. He credited Jean-Etienne Esquirol (1772-1840) as one of the innovators of modern classification. The philosophical approaches to the subsequent DSMs were reviewed and they generally correlate with the theories of the day.
The development of DSM-5 began in 1999. The original goals included the definition of mental illness, dimensional criteria, addressing mental illness across the lifespan, and to possibly address how mental disorders were affected by various contexts such as sex and culture. Darrel Regier, MD was recruited from the NIMH to coordinate the development of DSM-5 in the year 2000. Between 2003 and 2008 there were 13 international conferences where the researchers wrote about specific diagnostic issues and developed a research agenda. This produced over 100 scientific papers that were compiled for use as reference volumes. As far as I can tell the people on the ground on this issue was the DSM Task Force and the Work Groups. The Task Force addressed conceptual issues like spectrum disorders, the interface with general medicine, functional impairment, measurement and assessment, gender and culture and developmental issues. The Work Groups met weekly or in some cases twice a week by conference call and twice a year in person. The work groups had several goals including revising the diagnostic criteria according to a review of the research, expert consensus and "targeted research analyses". No cost estimate of this multi-year infrastructure was given.
Like any volume of this nature the originators had some guiding principles including a focus on utility to clinicians, maintaining historical continuity with previous editions, and the changes needed to be guided by the research evidence. The most interesting political aspect of this process was the elimination of people closely involved in the development of DSM-IV in order to encourage "out of the box" thinking. This was a conscious decision and I have not seen it disclosed by some of the professional critics out there.
Final approval of the DSM occurred after feedback was received through the DSM-5 web site. There were thousands of comments from individuals, clinicians and advocacy organizations. Field trial data was analyzed and discussed. A scientific committee reviewed the actual data behind the diagnostic revisions and confirmed it. Hundreds of expert reviewers considered the risks in revising the diagnoses. The APA Assembly voted to approve in November 2012.
Some of the criticisms of the DSM-5 were discussed in about 4 slides. Dr. Grant was aware of all of the major criticisms and I have reviewed most of them here on this blog such as the issue ofdiagnostic proliferation. Dr. Grant's lecture contained this graphic for comparison:
Rather than repeat what I have already said, it should be apparent to anyone who knows about this process that it was open, transparent and involved a massive effort of the part of the psychiatrists and psychologists involved. It should also be apparent that the DSM process was clinically focused and that safeguards were in place to consider the risk of diagnostic changes. I have not seen any of that discussed in the press and don't expect it to be.
What about the final product? The DSM-5 ends up including 19 major diagnostic classes. Some of the highlights include moving some disorders around. Obsessive-compulsive disorder and Post Traumatic Stress Disorder were moved out of the Anxiety Disorders section to their own separate categories. Bipolar and Depressive Disorders each have their own diagnostic class instead of both being placed in a Mood Disorders class. Adjustment Disorders have been moved into the Trauma and Stress Related Disorders class and there are two new subtypes. As previously noted here, all of the Schizophrenia subtypes have been eliminated. The Multiaxial System of diagnosis has been scrapped. One of the changes impacting the practice of addiction psychiatry is the elimination of the categories of Substance Abuse and Substance Dependence and collapsing them into a Substance Use Disorder.
The controversial Personality Disorders section is unchanged but there is a hybrid diagnostic system that includes dimensional symptoms, the details of which (I think) are in the Appendix. Mapped onto all of the diagnostic classification and criteria changes are a number of subtypes and specifiers as well as a number of ways to specify diagnostic certainty. As with previous editions since DSM-III there is a mental disorder definition that indicates that behavior or criteria are not enough. There must be functional impairment or distress. The definition specifies that socially deviant behavior or conflicts between the individual and society do not constitute a mental illness unless that was the actual source of the conflict.
The overall impression at the end of these lectures was that this was a massive 18 year effort by the APA and hundreds and possibly thousands of volunteer psychiatrists and psychologists. None of those volunteers has a financial stake in the final product. Many of the criticisms were addressed in the process and many of the critics have a financial stake in the DSM-5 criticism industry. The criticisms of the DSM-5 seem trivial compared with the process and built in safeguards. The DSM-5was also designed to be updated online instead of waiting for another massive effort to start to make modifications, hence this is not DSM-5 but DSM-5.0.
If Dr. Grant is lecturing in your area and you are a psychiatrist or a psychiatrist in training, these lectures are well worth attending. If you have a chance to look at his Guidebook, I think that it will be a very interesting read.
I debated putting "reform" in quotes. The term has essentially become meaningless. I have been hearing about health care reform for over 20 years and things continue to get worse and worse. They get worse at a much faster rate whenever mental health care reform is considered. I won't belabor the facts that I have already listed here before, but I witnessed an event yesterday to highlight why any reform of the mental health system is completely hopeless at this point.
The event was a panel discussion entitled "Many Perspectives on Patient-Centered Care and Building a Stronger Mental Health System". There were 5 panelists including two psychiatrists, a local celebrity, a reporter, and a mental health advocate. It was scheduled as a one hour event and I left at about the 1:05 point. The hour began with the panelists disclosing their personal experiences with the system and what that seemed to imply for reform. There were stories about a system that is fairly refractory to input. Psychiatrists can't get people hospitalized when it is a true emergency, the family can't get input into the clinicians treating their loved ones, and there is minimal if any cross talk among physicians. There were two stories of misdiagnosis, in one case over a period of 20-30 years. The problem of documentation came up and the fact that there seems to be "no narrative" any more about the patient's diagnosis and problems - only check lists and electronic health record forms.
After the initial presentations the audience got involved. The audience was essentially all psychiatrists and the solutions are predictably more infuriating anecdotes, workarounds, and tales of the one unique person who might be able to save the day. From the panel, the advocacy standpoint seemed to be that progress was being made and that no more hospital beds were necessary or at least they should be discussed as an absolute last resort since they are the most expensive treatment option. That discussion focused on a point by an audience member who I would consider to be one of the top experts in child and adolescent mental health in the state when he mentioned there were only "2.5 acute care beds in the State" available for children in crisis. I may have missed the actual solutions because I had to leave the meeting. I have seen meetings and panels like this before and they go nowhere.
So what is the problem and what can be done about it?
The problem is quite simply managed care and all of its permutations. I waited for 65 minutes and nobody uttered the word. Managed care and all of its special interests is directly responsible for the ridiculous time constraints on clinicians. There is no time for a complex diagnostic evaluation much less time to talk with the family. It is responsible for the rationed inpatient beds and the lack of bed capacity. It is responsible the fact that systems of care are set up to optimize cash flow to large health care organizations rather than the quality of care. There is perhaps no better example than what currently passes for inpatient psychiatric care. We currently have case managers running the care of hospitalized patients and telling their psychiatrists when to discharge them. I talked directly with an inpatient psychiatrist the other day who told me that case managers and social workers at her hospital frequently have the discharge plan set up before she sees and assesses the patient. They simply tell her the patient can be discharged. All in the service of making sure that nobody extends beyond the DRG payment and the hospital continues to make money. Inpatient units seem to have become holding tanks for people to sit around until they are "cleared" for discharge.
All of this flows
the ridiculous managed care concept that "dangerousness" is the only reason people need to be on a psychiatric unit. All of that occurring at a time when mental health advocates are concerned about stigmatizing the mentally ill as violent.
Outpatient care is not much better. Some of the panelists were talking about the virtues of outpatient care where there is a team that knows the patient and everything is idyllic. There is no reason to expect that an outpatient case manager is any more virtuous than an inpatient one. I have talked with many psychiatrists who notice that their care is basically completely marginalized by low to mid level bureaucrats who have no professional responsibility to the patient. I have be pointing this out for 20 years and recently other physicians are also talking about the problem.
As long as you pretend that making money off rationing your care and treating you is not a conflict of interest - the system will continue to deteriorate. As long as nobody
in the room can clearly say
of all there is no systemand second, managed care and the associated rationing and low quality are the
problems here" - reform will remain meaningless political rhetoric.
Subscribers to Mad in America might be interested in a Keynote Lecture given by Professor Nikolas Rose in Nottingham on May 15th 2013. Nikolas Rose is Professor of Sociology and Head of the Department of Social Science, Health and Medicine at King’s College, London. He was previously Martin White Professor of Sociology, and Director of the BIOS Centre for the Study of Bioscience, Biomedicine, Biotechnology and Society at the London School of Economics and Political Science. He is also co-PI for the EPSRC funded Centre for Synthetic Biology and Innovation (CSynBI). His most recent books are The Politics of Life Itself : Biomedicine, Power, and Subjectivity in the Twenty-First Century (Princeton, 2006); Governing The Present (with Peter Miller, Polity, 2008) and Neuro: the New Brain Sciences and the Management of the Mind (with Joelle Abi-Rached, Princeton, forthcoming, 2012). He is a longstanding member of the Editorial Board of Economy and Society, co-editor of BioSocieties: an interdisciplinary journal for social studies of the life sciences, Chair of the European Neuroscience and Society Network, and a member of numerous advisory groups including the Nuffield Council on Bioethics.
Britain’s premier institute for the study of mental illness has become embroiled in a damaging row over its decision to invite a disgraced US academic to give the inaugural lecture for a new research centre. The decision by the Institute of Psychiatry at Kings College, in central London, Europe’s largest psychiatric research organisation, to invite Professor Charles Nemeroff, an expert in the treatment of depression, has split the psychiatric profession and been attacked by members of the institute itself. Professor Nemeroff, a leading authority on the biological causes of mental illness, is one of the highest profile doctors to have been exposed for concealing large payments from pharmaceutical companies.
He was forced to resign his post at Emory University, Atlanta, in 2008 after an investigation revealed that he had failed to report more than $1.2m of payments from GlaxoSmithKline, despite having signed an undertaking to limit payments to $10,000 a year. He received the payments whilst undertaking a study on behalf of the National Institutes of Health into drugs made by GSK.
In 2009, Professor Nemeroff was appointed chair of psychiatry at the University of Miami and was subsequently awarded a research grant of $400,000 a year for the next five years by the National Institutes of Health. In 2012 it emerged that US Senator Charles Grassley, whose 2008 investigation triggered Professor Nemeroff’s downfall, had written to the National Institutes of Health to ask why they had given him a grant when he was still under federal investigation.
Now a group of UK psychiatrists have written to the Institute of Psychiatry protesting against its decision to invite Professor Nemeroff to give the “inaugural annual lecture for the new Centre for Affective Disorders”, which is due to take place at the institute next Monday. The group representing the radical Critical Psychiatry Network claims the Nemeroff case is frequently cited as “one of the starkest examples of the financial corruption of medicine” through its “overly cosy relationship with the pharmaceutical industry”. “Many medical institutions have recognised this relationship is unhealthy and is bringing the profession into disrepute. We find it surprising therefore that the Institute of Psychiatry has seen fit to invite Nemeroff to deliver this important lecture,” they wrote.
Separately, Derek Summerfield, honorary senior lecturer at the Institute, wrote in the BMJ, formerly called the British Medical Journal, last week that the Institute of Psychiatry’s lauding of Professor Nemeroff as “one of the world’s leading experts” showed how psychiatric academe “sails blithely on as if such revelations beg no broader questions about its associations and supposed scientific independence.”
In a response, the Institute said it was “aware of the concerns” and took the issue of declaring financial conflicts of interest “extremely seriously”. “We have been informed by Professor Nemeroff that he will not be presenting any research that was funded by commercial companies or affected by commercial implications. Obviously, he will be declaring any relevant conflicts of interest prior to his lecture.” Professor Nemeroff could not be contacted for comment. He has previously said that his payments from GSK were for talks about GSK drugs now on the market, while his research funded by NIH involved basic laboratory studies of GSK chemical compounds that were years away from market.
Dr. Nemeroff was exposed for recommending treatments where he had a financial interest without disclosure in a review article in 2004. In 2006, he was again exposed when he published a ghost-written article reviewing a treatment that he and other authors had a financial interest in without disclosure in a journal that he, himself, edited. He was asked to step down as editor and censured by Emory University where he was Chairman. In 2008 after the US Senate investigated him for unreported pharmaceutical income, he was removed as Chairman at Emory. On the left above are the number of outside PHARMA consulting jobs he held per year and on the right the number of promotional talks he gave for GSK per month. Below, the journal articles he published per year…
There is no rational explanation why the Institute of Psychiatry at Kings College would select Dr. Charlie Nemeroff to give an annual lecture to inaugurate a new Affective Disorders Centre. His quirky research hinges around proving that childhood trauma reverse engineers the brain and predisposes to later depression – or that people are genetically loaded to be harmed by psychological trauma. He uses trendy terms like epigenetic or neurogenesis and all the latest technologies to come at these hypotheses from a variety of directions – always on the cutting edge, always seeing amazing breakthroughs just around the corner. Self reference punctuates every presentation
in his assertion that he's somehow connected to Jan Evangelista Purkinje, the famous Czech neurophysiologist, in a recent grand rounds
He chases and then jumps in front of every fad that washes over the world of bio·psychiatry – a man for all seasons. But if he’s actually excelled at something, it’s making funny money for his corporate sponsors, his departments and universities, and for himself. So there’s simply no rational explanation why they would select Dr. Charlie Nemeroff to give an annual lecture to inaugurate their new Affective Disorders Centre – leaving us to ponder in disbelief that the Institute of Psychiatry at the prestigious Maudsley would voluntarily don the shroud that is Dr. Charlie Nemeroff?
I can’t find anything about this Centre. What it is. How it’s funded. Who is involved. I think we’re going to have to rely on our friends on the far side of the pond to figure it out and let us know. For now, we are simply…
It has been a good time to bury controversy. With all eyes on Washington and the fallout from the publication of DSM-5, over here in England the Institute of Psychiatry has been discretely sending out invitations to a lecture. This is not a public lecture; it is by invitation only. It is the Inaugural Lecture of a new Centre for Affective Disorders. What could possibly be controversial about that, you might well ask? It is perfectly normal for an august institution to invite an esteemed colleague to mark the launch of a new development by giving a guest lecture. This is slightly different. The lecture will be hosted by luminaries of the Institute of Psychiatry. Professor Carmine Pariante will chair the event; the guest speaker introduced by Professor Allan Young, and the vote of thanks proposed by Professor Sir Robin Murray. And who is this esteemed guest? None other than Professor Charles Nemeroff M.D., Ph.D.
… There are two things you won’t find on Professor Nemeroff’s personal page on the University of Miami website. The first is details of his extensive business interests in the pharmaceutical industry. You have to scour the pages of Bloomberg Business Week to unearth this. Here you will find out that he has had consultancies with various industry leaders, including Forrest Laboratories, GlaxoSmithKlein, Janssen, Merck, Otsuka Pharmacia/Upjohn, Somerset Pharmaceuticals and Wyeth-Ayerst Laboratories. He has also served on the scientific advisory boards of most of these companies.
The second thing concerns conflicts of interest. In 2009, an investigation initiated by Iowa’s Republican Senator Charles Grassley found that when Nemeroff was Departmental Chair at Emory University, he failed to report in excess of $1 million income from GlaxoSmithKlein for giving over 250 talks to psychiatrists between 2000 – 2006. During this period he held a grant for $9 million from GSK for a trial of its drug, Paxil. In December 2009 he was dismissed from his post at Emory, and also banned by the National Institutes of Health from applying for research funding for two years. Shortly after this Nemeroff was appointed to his current post in the University of Miami, after Dr. Thomas Insel, the Director of the National Institute of Mental Health, reassured the University that Nemeroff would be eligible to apply for research funding once in post…
There is something of the night about Professor Nemeroff, and the darkness in his past can be grasped through reports some years ago of the part he played in the decision by the Centre for Addiction and Mental Health in Toronto to withdraw the offer of a Chair to Professor David Healy. Professor Nemeroff’s lecture at the Institute of Psychiatry goes under the title of “The Neurobiology of Child Abuse: Treatment Implications”. The question this raises is why is the Institute of Psychiatry so keen to ingratiate itself with this soiled Phoenix. The Director of the new Centre for Affective Disorders, and the person chairing the lecture is Professor Carmine Pariante. Professor Pariante worked at Emory in 2001, when Nemeroff was Departmental Chair. Is the Institute of Psychiatry courting Nemeroff for financial favors through his links with the pharmaceutical industry? Who knows? We do know, however, that as recently as March 2013 the Institute, in conjunction with the London School of Hygiene and Tropical Medicine, announced nine new scholarships in global mental health funded by Janssen to the tune of almost £300,000.
British psychiatry is in no sense perfect, but to be fair, the Royal College of Psychiatrists has worked hard to tighten up the egregious relationship between the profession and the industry… Yet on the surface it seems that one of our most esteemed institutions, a centre of academic excellence, is beyond the moral compass that guides the rest of the profession. In the interests of transparency we should be told why Professor Nemeroff has been invited to speak at the Institute of Psychiatry. Where has the funding for the new Centre for Affective Disorders come from? Is it linked to Nemeroff’s appearance and rehabilitation? We should be told.
Dr. Carmine Pariante studies stress responses as does Dr. Nemeroff. He was at Emory for a visiting professorship over ten years ago, and has published reviews with Dr. Nemeroff in 1995 and in 2012. He is directing the new Centre for Affective Disordersat the Institute of Psychiatry and I would guess he did the inviting. With a title like “The Neurobiology of Child Abuse: Treatment Implications”, Nemeroff’s lecture will likely be very much the same as the Grand Rounds I mentioned before with a dash of his recent American Journal of Psychiatry article [Decreased Cortical Representation of Genital Somatosensory Field After Childhood Sexual Abuse][see coffee-house science… ]. The connection with Affective Disorders seems a bit loose, and one wonders what treatment implications he’ll come up with.
Although the personal relationship between Dr. Nemeroff and Dr. Pariante and their shared interests might explain the invitation, it still doesn’t explain why wiser heads at the Institute of Psychiatry didn’t intervene at the suggestion. And Dr. Thomas’ questions at the end "…we should be told why Professor Nemeroff has been invited to speak at the Institute of Psychiatry. Where has the funding for the new Centre for Affective Disorders come from? Is it linked to Nemeroff’s appearance and rehabilitation?" remain unanswered.
Parenthetically, while I don’t care much for Dr. Nemeroff’s attempts to biologify traumatic illness, there’s one part of his thesis that has always seemed a paradox to me. On the one hand, he’s chasing a genetic predisposition to being afflicted in response to childhood trauma. On the other hand, he talks about trauma somehow causing changes in the brain – in the recent iteration adaptive or protective structural changes. And these two things end up in the same lecture? Both sound far-fetched to me, but they’re also arguing with each other. Is the genetically susceptible subject then prone to have the brain undergo trauma induced changes? Something of a tongue twister. But that aside, choosing Dr. Nemeroff as a keynote speaker for the opening of a Centre at the Institute of Psychiatry, Kings College, London remains bizarre – old pals or colleagues notwithstanding. So we’re frankly…
For the second time in little more than a year, Charles Nemeroff is the subject of protest by other psychiatrists. The latest instance involves an invitation by the Institute of Psychiatry, the leading center in the UK for psychiatric research, to the University of Miami psychiatry professor to lecture next week at its new Centre for Affective Disorders. A group of UK psychiatrists, however, object to the invitation and point to his tenure as a sort of poster boy for undisclosed conflicts of interest. In the view of the Critical Psychiatry Network, which his planned appearance will reflect badly on all psychiatrists and they want the IoP to withdraw its invitation [here is the letter]. In fact, one IoP senior lecturer also wrote BMJ to protest the move [read here]…
In the IoP response, Drs. Carmine Piriante and Allan Young say:
The lecture is on ‘The Neurobiology of Childhood Abuse: Treatment Implications’ and is a purely academic event, advertised to local academics and mental health professionals, and not open to the public. Professor Nemeroff has been invited due to his world – leading expertise in this research field, specifically in the neuroscience underpinning the relationship between experiences of early abuse and the subsequent development of affective disorders. This is an area where his academic impact, in terms of publications in prestigious journals, invited lectures at conferences and academic events worldwide, and recognition by professional societies, is irrefutable .
In the comments to the Pharmalot piece, Dr. Bernard Carroll makes quick work of their argument on beyond obvious ethical grounds:
Nemeroff has been impeached by his peers. That is the reason for the protests: He brought dishonor on our field, and heavy sanctions were applied, to a degree that is almost unprecedented – banned from involvement in NIH grants for 2 years; eased out of a prestigious journal editorship [Neuropsychopharmacology]; dismissed from his departmental chairmanship at Emory University. It says a lot about the ethical sensibility and moral compass at Institute of Psychiatry, King’s College, London that they persist in their invitation of Nemeroff.
Who cares about his perceived expertise? Is he an ethical role model for peers and trainees? What were they thinking? Were they thinking? The IoP will be tainted by this episode for years to come, and the responsible administrators deserve all the frowns and brickbats that will come their way. Here is a general discussion of the need for academic institutions to show some spine in such matters.
I would echo every bit of Dr. Carroll’s response except for one sentence, "Who cares about his perceived expertise?" I do. I actually I care a lot about his assertions about "The Neurobiology of Childhood Abuse: Treatment Implications." A blog is no place to go into all the reasons why, though my comments on his recent publication [coffee-house science…] have some of them. I wouldn’t disagree that childhood abuse predisposes people to all kinds of later life mental illness and problems, but I question both of his hypotheses: that resilience against or susceptibility to the psychological consequences of traumatic experience is genetically determined and that childhood abuse exerts it’s effects in later life because of actual physical changes in the brain.
I don’t agree with those things intuitively or clinically, but more importantly, having heard and read Dr. Nemeroff’s body of work for over twenty years, it has always felt like teflon science with the same opacity as his expense reports or excuses when he’s been busted for one thing or another. And it says something that few outside his own orbit ever bother to repeat his findings. In my mind, these are conclusion in search of supportive evidence without ever coming in for a three point landing. As I’ve mentioned before, you can preview a version of his IoP presentation here [sans "treatment implications"].
More to the point, Drs. Carmine Piriante and Allan Young imply that one can separate the integrity of a person’s scientific work from their integrity in other matters. I’ve never found that to be true. Let me rephrase that. It’s not true. Character is pervasive…
Many young people diagnosed with mental disorders are essentially anarchists with the bad luck of being misidentified by mental health professionals who: (1) are ignorant of the social philosophy ofanarchism, (2) embrace, often without political consciousness, it’s opposite ideology of hierarchism, and (3) confuse the signs of anarchism with symptoms of mental illness.
The mass media equates anarchism with chaos and violence. However, the social philosophy of anarchism rejects authoritarian government, opposes coercion, strives for greatest freedom, works toward “mutual aid” and voluntary cooperation, and maintains that people organizing themselves without hierarchies creates the most satisfying social arrangement. Many anarchists adhere to the principle of nonviolence (though the question of violence has historically divided anarchists in their battle to eliminate authoritarianism). Nonviolent anarchists have energized the Occupy Movement and other struggles for economic justice and freedom.
In practice, anarchism is not a dogmatic system. So for example, “practical anarchist” parents will use their authority to grab their child who has begun to run out into traffic. However, practical anarchists strongly believe that all authorities have the burden of proof to justify control, and that most authorities in modern society cannot bear that burden and are thus illegitimate—and should be eliminated and replaced by noncoercive, freely participating relationships.
My experience as a clinical psychologist for almost three decades is that many young people labeled with psychiatric diagnoses are essentially anarchists in spirit who are pained, anxious, depressed, and angered by coercion, unnecessary rules, and illegitimate authority. An often used psychiatric diagnosis for children and adolescents is oppositional defiant disorder (ODD); its symptoms include “often actively defies or refuses to comply with adult requests or rules” and “often argues with adults.”
Among young people diagnosed with attention deficit hyperactivity disorder (ADHD), psychologist Russell Barkley, one of mainstream mental health’s leading ADHD authorities, says that they have deficits in “rule-governed behavior,” as they are less responsive to rules of authorities and less sensitive to positive or negative consequences. A frequently used research tool that distinguishes alcohol/drug abuser personalities was developed by Craig MacAndrew (commonly called the MAC scale), and it reveals that the most significant “addictive personality type” have discipline problems at school, are less tolerant of boredom, are less compliant with authorities and some laws, and engage in more disapproved sexual practices.
I have encountered many people who had been diagnosed with bipolar disorder, schizophrenia, and other psychoses, and who are now politically conscious anarchists, including Sascha Altman DuBrul, author of Maps to the Other Side: The Adventures of a Bipolar Cartographer. DuBrul, several times diagnosed with bipolar disorder, has lived in rebel communities in Mexico, Central America, and Manhattan’s Lower East Side, worked on community farms, participated in Earth First! road blockades, demonstrated on the streets in the Battle for Seattle, and he reports that many of his anti-authoritarian friends also have been diagnosed with mental illness.
Teenagers, as evidenced by their musical tastes, often have an affinity for anti-authoritarianism, but most do not act on their beliefs in a manner that would make them vulnerable to violent reprisals by authorities. However, I have found that many young people diagnosed with mental disorders—perhaps owing to some combination of integrity, fearlessness, and naïvity—have acted on their beliefs in ways that threaten authorities. Historically in American society, there is often a steep price paid by those who have this combination of integrity, fearlessness, and naïvity.
While DuBrul and his friends have political consciousness, my experience is that most rebellious young people diagnosed with mental disorders do not, and so they become excited to hear that there is actual political ideology that encompasses their point of view. They immediately become more whole after they discover that answering “yes” to the following questions does not mean that they suffer from a mental disorder but instead have a certain social philosophy:
Do you hate coercion and domination?
Do you love freedom?
Are you willing to risk punishments to gain freedom?
Do you instinctively distrust large, impersonal, and distant authorities?
Do you think people should organize themselves rather than submit to authorities?
Do you dislike being either an employer or an employee?
Do you smile after reading the Walt Whitman quote “Obey little, resist much”?
Young people who oppose inequality and exploitation, reject a capitalist economy, and aim for a society based on cooperative, mutually-owned enterprise are essentially left-anarchists—perhaps calling themselves “anarcho-syndicalists” or “anarcho-communitarians.” When they discover what Noam Chomsky, Peter Kropotkin, Kirkpatrick Sale, or Emma Goldman have to say, they may identify with them. These young people have a strong moral streak of egalitarianism and a desire for social and economic justice. Not only are they not mentally ill but, from my perspective, they are the hope of society.
There is another group of freedom-loving young people who hate the coercion of parents, schools, and the state but lack an egalitarian moral streak, and are very much into money and capitalism. Some of them may have been dragged into the mental health system after having been caught drug dealing, and are labeled with conduct disorder and/or a personality disorder. While these young people rebel against they themselves being controlled and exploited, many of them are not averse to controlling and exploiting others, and so are not anarchists, but some have spiritual transformations and become so.
An Underground Resistance for Oppressed Young Anarchists
There are at least two ways that mental health professionals can join the resistance: (1) speak out about the political role of mental health institutions in maintaining the status quo in society, (2) depathologize and repoliticize rebellion in one’s clinical practice, which includes helping young anarchists navigate an authoritarian society without becoming self-destructive or destructive to others, and helping families build respectful, non-coercive relationships.
If a nonviolent anarcho-communitarian (politically conscious or otherwise) is dragged by parents into my office for failing to take school seriously but is otherwise pleasant and excited by learning, I tell parents that I do not believe that there is anything essentially “disordered” with their child. This sometimes gets me fired, but not all that often. It is my experience that most parents may think that believing a society can function without coercion is naive but they agree that it’s not a mental illness, and they’re open to suggestions that will create greater harmony and joy within their family.
I work hard with parents to have them understand that their attempt to coerce their child to take school seriously not only has failed—that’s why they’re in my office—but will likely continue to fail. And increasingly, the pain of their failed coercion will be compounded by the pain of their child’s resentment, which will destroy their relationship with their child and create even more family pain. Many parents acknowledge that this resentment already exists. I ask liberal parents, for example, if they would try to coerce a homosexual child into being heterosexual or vice versa, and most say, “Of course not!” And so they begin to see that temperamentally anarchist children cannot be similarly coerced without great resentment.
It has been my experience that many rebellious young people labeled with psychiatric disorders and substance abuse don’t reject all authorities, simply those they’ve assessed to be illegitimate ones, which just happens to be a great deal of society’s authorities. Often, these young people are craving a relationship with mutual respect in which they can receive help navigating the authoritarian society around them.
The U.S. Centers for Disease Control on May 17, 2013, in “Mental Health Surveillance Among Children—United States, 2005–2011,” reported: “A total of 13%–20% of children living in the United States experience a mental disorder in a given year, and surveillance during 1994–2011 has shown the prevalence of these conditions to be increasing.”
Is there an epidemic of childhood mental illness, or is there a curious revolt? My experience is that many young Americans—feeling helpless, hopeless, bored, scared, misunderstood, and uncared about—ultimately rebel; but given their wherewithal, their rebellion is often disorganized, futile, self-destructive, and appears to mental health professionals as a disorder or illness. Underlying many of psychiatry’s diagnoses is the experience of helplessness, hopelessness, boredom, fear, isolation, and dehumanization. Does society, especially for young people, promote:
Respectful personal relationships—or manipulative impersonal ones?
Diversity and stimulation—or homogeneity and boredom?
Emotional and behavioral problems are often natural human reactions to a society that cares little about: (1) autonomy—self-direction and the experience of potency, (2) community—strong bonds that provide for economic security and emotional satisfaction, and (3) humanity—the variety of ways of being human, the variety of satisfactions, and the variety of negative reactions to feeling controlled rather than understood. Young anarchists are especially sensitive to American society’s absence of autonomy, community, and humanity—and this can result in overwhelming anxiety and depression.
While giant pharmaceutical corporations promote psychiatry’s authority as a vehicle for increased drug sales, the whole of the corporate state supports psychiatry so as to maintain the status quo. In the old Soviet Union, political dissidents were diagnosed by psychiatrists as mentally ill, then hospitalized and drugged. Even more effective for those at the top of the hierarchy is what now occurs in the United States: diagnosing and treating anti-authoritarians before they have reached political consciousness and before they have created communities of resistance.
One reason that there is so little political activism in the United States is that a potentially huge army of anti-authoritarians are being depoliticized by mental illness diagnoses and by attributions that their inattention, anger, anxiety, and despair are caused by defective biochemistry, not by their alienation from a dehumanizing society. These diagnoses and attributions make them less likely to organize democratic movements to transform society.
In the early nineteenth century in the United States, a network of secret routes, conductors, and safe houses were utilized by African-Americans to escape from slavery. This network was commonly called “The Underground Railroad,” organized by runaway slaves, free African-American abolitionists, and white abolitionists. Today, communities of ex-psychiatric patients (see, for example, MindFreedom and the Icarus Project) are helping young anti-authoritarians resist their mental illness labeling and coercive treatments. There are also a handful of mental health professional dissident organizations that, while not promoting the social philosophy of anarchism, do oppose dehumanizing diagnoses and coercive treatments (for example, the International Society for Ethical Psychology and Psychiatry).
While there are career risks for modern day mental health professional dissidents, these are small risks compared with those taken by slavery abolitionists. So as a mental health professional, I find it quite embarrassing that there are so few professionals involved in the current resistance.
In American history, there have been several shameful periods where groups—including Native Americans, homosexuals, and assertive women—have been pathologized, dehumanized, and meted out oppressive treatments by mental health professionals in an attempt to alter their basic being. Today’s psychiatrists, psychologists, social workers, and counselors would do well to recognize that historians do not look kindly on those professionals who participated in institutional dehumanization and oppression.
The latest issue of Transcultural Psychiatry is devoted to “Cultures of the Internet” – also the title of the 2011 McGill Advanced Study Institute (ASI) in Cultural Psychiatry at which many of the papers were originally presented. In our introductory essay to the issue, Laurence Kirmayer, Sadeq Rahimi and I examine some of the issues which the Internet and other new media raise for cultural psychiatry. In addition to giving some context for the papers in the issue, we review the social science and clinical literatures in four thematic areas:
”(a) how the Internet is transforming human functioning, personhood, and identity through the engagement with electronic media; (b) how electronic networking gives rise to new groups and forms of community, with shifting notions of public and private, local and distant; (c) the emergence of new pathologies of the Internet, e.g., Internet addiction, group suicide, cyberbullying, and disruptions of neurodevelopment; and finally, (d) the use of the Internet in mental health care, for example, by consumer advocacy and support groups, as well as for the delivery of health information, web-based consultation, treatment intervention, and mental health promotion,” (Kirmayer, Raikhel and Rahimi 2013).
Laurence J. Kirmayer, Eugene Raikhel, and Sadeq Rahimi
The Internet and World Wide Web have woven together humanity in new ways, creating global communities, new forms of identity and pathology, and new modes of intervention. This issue of Transcultural Psychiatry presents selected papers from the annual McGill Advanced Study Institute (ASI) in Cultural Psychiatry on ‘‘Cultures of the Internet’’ which took place in Montreal, April 26–29, 2011.…In addition to some of the ASI papers, this issue includes other recent contributions to the journal on related themes. In this introductory essay, we set out some of the broad implications of the Internet and related new media and information communication technologies (ICT) for cultural psychiatry.
The use and misuse of digital technologies among adolescents has been the focus of fiery debates among parents, educators, policy-makers and in the media. Recently, these debates have become shaped by emerging data from cognitive neuroscience on the development of the adolescent brain and cognition. “Neuroplasticity” has functioned as a powerful metaphor in arguments both for and against the pervasiveness of digital media cultures that increasingly characterize teenage life. In this paper, we propose that the debates concerning adolescents are the meeting point of two major social anxieties both of which are characterized by the threat of “abnormal” (social) behaviour: existing moral panics about adolescent behaviour in general and the growing alarm about intense, addictive, and widespread media consumption in modern societies. Neuroscience supports these fears but the same kinds of evidence are used to challenge these fears and reframe them in positive terms. Here, we analyze discourses about digital media, the Internet, and the adolescent brain in the scientific and lay literature. We argue that while the evidential basis is thin and ambiguous, it has immense social influence. We conclude by suggesting how we might move beyond the poles of neuro-alarmism and neuro-enthusiasm. By analyzing the neurological adolescent in the digital age as a socially extended mind, firstly, in the sense that adolescent cognition is distributed across the brain, body, and digital media tools and secondly, by viewing adolescent cognition as enabled and transformed by the institution of neuroscience, we aim to displace the normative terms of current debates.
This paper reviews the persuasion techniques employed by jihadist websites with particular reference to the patterns of rhetoric, image, and symbolism manifested in text, videos, and interactive formats. Beyond symbolic communication, the online media needs to be also understood through its persuasive tendencies as a medium which elicits social response through its design architecture. This double articulation of new media technologies, as a medium for information and as a form of persuasive technology, has provided new means to market the radical. The marketing techniques of jihadist websites through multimedia formats have consequences for the formation of identities, both collective and individual. As a marketing tool it combines established forms of rhetoric and propaganda with new ways to reach audiences through both popular culture and religious ideologies. The paper analyses the implications for further research and counterterrorism strategies.
Jeffrey G. Snodgrass, H. J. Francois Dengah II, Michael G. Lacy, and Jesse Fagan
Yee (2006) found three motivational factors—achievement, social, and immersion—underlying play in massively multiplayer online role-playing games (“MMORPGs” or “MMOs” for short). Subsequent work has suggested that these factors foster problematic or addictive forms of play in online worlds. In the current study, we used an online survey of respondents (N= 252), constructed and also interpreted in reference to ethnography and interviews, to examine problematic play in the World of Warcraft (WoW; Blizzard Entertainment, 2004–2013). We relied on tools from psychological anthropology to reconceptualize each of Yee’s three motivational factors in order to test for the possible role of culture in problematic MMO play: (a) For achievement, we examined how “cultural consonance” with normative understandings of success might structure problematic forms of play; (b) for social, we analyzed the possibility that developing overvalued virtual relationships that are cutoff from offline social interactions might further exacerbate problematic play; and (c) in relation to immersion, we examined how “dissociative” blurring of actual- and virtual-world identities and experiences might contribute to problematic patterns. Our results confirmed that compared to Yee’s original motivational factors, these culturally sensitive measures better predict problematic forms of play, pointing to the important role of sociocultural factors in structuring online play.
Chun Yan Yang, Takeshi Sato, Niwako Yamawaki, and Masakazu Miyata
The aim of the present study was to compare risk factors for problematic Internet use (PIU) among Japanese and Chinese university students. A sample of 267 Japanese and 236 Chinese first year university students responded to questionnaires on the severity of PIU, depression, self-image/image of others, and perceived parental child-rearing styles. The results indicated that Japanese participants were more likely to demonstrate PIU than their Chinese counterparts. Compared to Chinese students, Japanese students reported more negative self-image, lower parental care, greater overcontrol, and higher depression scores. The PIU group had a higher depression score compared to the normal Internet use group. Compared with the non-PIU group, the PIU group consisted of more male and Japanese participants. Further, they tended to have more negative self-images, saw their mothers to be less caring, and perceived their mothers and fathers as more overcontrolling. PIU is strongly associated with depression, negative self-image, and parental relations. Finally, mediation analysis revealed that such national differences in PIU between Japanese and Chinese were clarified in depression and perceived mother’s care. This cross-national study indicated that depression and perceived mother’s care were both significant risk factors that were associated with the national difference in PIU between Japanese and Chinese participants.
Ai Ikunaga, Sanjay R. Nath, and Kenneth A. Skinner
Netto shinju, or Internet group suicide, is a contemporary form of Japanese suicide where strangers connect on the Internet and make plans to commit suicide together. In the past decade, numerous incidents have occurred whereby young Japanese make contact on the Internet, exchange tips on suicide methods, and make plans to meet offline for group/individual suicide. A systematic qualitative content/thematic analysis of online communications posted on a popular Japanese suicide bulletin board yielded a textured, thematic understanding of this phenomenon. Themes identified reflected Shneidman’s theory of suicide but with an emphasis on interpersonal concerns that are embedded in Japanese culture.
As a tool of instant information dissemination and social networking, the Internet has made possible the formation and affirmation of public identities based on personality traits that are usually characterized by clinicians as pathological. The wide variety of online communities of affirmation reveals new conditions for permissiveness and inclusiveness in expressions of these socially marginal and clinically pathologized identities. Much the same kind of discourse common to these online communities is evident in some suicide forums. Web sites with suicide as their central raison d’être, taken together, encompass a wide range of ideas and commitments, including many that provide collective affirmation outside of (and often with hostility toward) professional intervention. The paradox of a potentially life-affirming effect of such forums runs counter to a stark dualism between online therapy versus “prochoice” forums and, by extension, to simple models of the influence of ideas on the lethality of suicide. Different forums either intensify or mitigate self-destructive tendencies in ways that are significant for understanding the place of communication in the occurrence of suicide and for therapeutic practice.
Johana Monthuy-Blanc, Stéphane Bouchard, Christophe Maïano, and Monique Séguin
Telemental health is the use of information and communications technologies and broadband networks to deliver mental health services and support wellness. Although numerous studies have demonstrated the efficiency and utility of telemental health, certain barriers may impede its implementation, including the attitudes of mental health service providers. The current study draws on the technology acceptance model (TAM) to understand the role of mental health service providers’ attitudes and perceptions of telemental health (psychotherapy delivered via videoconferencing) on their intention to use this technology with their patients. A sample of 205 broadly defined mental health service providers working on 32 First Nations reserves in the province of Quebec completed the questionnaire adapted to assess TAM for telepsychotherapy. Confirmatory factor analysis and structural equation modeling provided evidence for the factor validity and reliability of the TAM in this sample. The key predictor of the intention to use telepsychotherapy was not mental health providers’ attitude toward telepsychotherapy, nor how much they expected this service to be complicated to use, but essentially how useful they expect it to be for their First Nations patients. If telemental health via videoconferencing is to be implemented in First Nations communities, it is essential to thoroughly demonstrate its utility to mental health providers. Perceived usefulness will have a positive impact on attitudes toward this technology, and perceived ease of use will positively influence perceived usefulness. Cultural issues specific to the populations receiving telemental health services may be more efficiently addressed from the angle of perceived usefulness.