Thursday, May 10, 2012

Mike Nova: American Psychiatry At The Crossroads - full version with References and Links - Topic Review

Mike Nova: American Psychiatry At The Crossroads

Last Update: 8:55 AM 5/11/2012

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 by discarding the outdated stereotypes, not reinforcing them" |

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

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

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

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

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

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


"Much less clear, even in the US, is whether
the approach is commonly used by clinicians in ordinary
practice, thus really resulting in an increase of the reliability
of psychiatric diagnosis in clinical settings. It has been, for
instance, reported that several US clinicians have difficulties
to recall the DSM-IV criteria for major depressive disorder
and rarely use them in their practice (e.g., 2). Furthermore,
some of the DSM-IV cut-offs and time frames have been
found not to have a solid empirical basis (e.g., 3) and to
generate a high proportion of sub-threshold and “not otherwise
specified” cases (e.g., 4).

The spontaneous clinical process does not
involve checking in a given patient whether each of a series
of symptoms is present or not, and basing the diagnosis on
the number of symptoms which are present. It rather involves
checking whether the characteristics of the patient
match one of the templates of mental disorders that the clinician
has built up in his/her mind through his/her training
and clinical experience."

Mario Maj
President, World Psychiatric Association
Psychiatric diagnosis: pros and cons of prototypes...


Drug companies like Pfizer are accused of pressuring doctors into over-prescribing medications to patients in order to increase profits - GALLO/GETTY


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

References and Links:

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

Thursday, April 19, 2012

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

Mike Nova

Breivik Trial and The Crisis Of Psychiatry As A Science

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

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

References and LinksPsychiatry May Also Face Scrutiny at Norway Killer's Trial -

Breivik trial: Norwegians rethink role of psychiatry in courts -

Breivik Trial and The Crisis Of Psychiatry As Science - Links 


Friday, April 27, 2012

Response to Dr. Wessely

Response to Dr. Wessely

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

Michael Novakhov, M.D.

References and Links

Anders Breivik, the public, and psychiatry : The Lancet

Anders Breivik, the public, and psychiatry : The Lancet

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

References and Links

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

Breivik trial: Norwegians rethink role of psychiatry in courts -

Breivik Trial and The Crisis Of Psychiatry As Science - Links


  May 11 (1)
Psychiatrists say diagnosis manual needs overhaul ...
Psychiatrists say diagnosis manual needs overhaul - (Reuters) -

And the rest is history – a three year long debate ensued, often contentious, about the whole process - 1 Boring Old Man » quite a week…


theoretical and conceptual outlook - Google Search

theoretical outlook - Google

conceptual outlook - Google Search

theory - Google Search

Theory - From Wikipedia, the free encyclopedia

concept - Google Search

Concept - From Wikipedia, the free encyclopedia


methodology - Google Search

Methodology - From Wikipedia, the free encyclopedia

Methodology is generally a guideline system for solving a problem, with specific components such as phases, tasks, methods, techniques and tools.[1] It can be defined also as follows:
  1. "the analysis of the principles of methods, rules, and postulates employed by a discipline";[2]
  2. "the systematic study of methods that are, can be, or have been applied within a discipline";[2]
  3. "the study or description of methods".[3]
A methodology can be considered to include multiple methods, each as applied to various facets of the whole scope of the methodology.

Why Most Published Research Findings Are False by John P. A. Ioannidis

Why Most Published Research Findings Are False

PLoS Med. 2005 August; 2(8): e124.
Published online 2005 August 30. doi: 10.1371/journal.pmed.0020124
PMCID: PMC1182327
Why Most Published Research Findings Are False
John P. A. Ioannidis
John P. A. Ioannidis is in the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece, and Institute for Clinical Research and Health Policy Studies, Department of Medicine, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, United States of America. E-mail:
Competing Interests: The author has declared that no competing interests exist.

There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research.

epistemology - Google Search

Epistemology - From Wikipedia, the free encyclopedia

Stanford Encyclopedia of Philosophy articles:


belief system - Google Search

Belief system - From Wikipedia, the free encyclopedia


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Karl Popper - From Wikipedia, the free encyclopedia

errors in history of medicine - Google Search


Jump to Influential errors of Galen‎: His error, which will become the established medical orthodoxy for centuries, is to assume that the blood goes back ...

The influential errors of Galen: 2nd century AD

The newly appointed chief physician to the gladiators in Pergamum, in AD 158, is a native of the city. He is a Greek doctor by the name of Galen. The appointment gives him the opportunity to study wounds of all kinds. His knowledge of muscles enables him to warn his patients of the likely outcome of certain operations - a wise precaution recommended in Galen's Advice to doctors.

But it is Galen's dissection of apes and pigs which give him the detailed information for his medical tracts on the organs of the body. Nearly 100 of these tracts survive. They become the basis of Galen's great reputation in medieval medicine, unchallenged until the anatomical work of Vesalius.

Through his experiments Galen is able to overturn many long-held beliefs, such as the theory (first proposed by the Hippocratic school in about 400 BC, and maintained even by the physicians of Alexandria) that the arteries contain air - carrying it to all parts of the body from the heart and the lungs. This belief is based originally on the arteries of dead animals, which appear to be empty.

Galen is able to demonstrate that living arteries contain blood. His error, which will become the established medical orthodoxy for centuries, is to assume that the blood goes back and forth from the heart in an ebb-and-flow motion. This theory holds sway in medical circles until the time of Harvey.

Read more:


Science-Based Medicine » Lessons from History of Medical Delusions

16 Feb 2012 by Brennen McKenzie
A brief reference on the web site The Quackometer recently drew my attention to a very short book (really more of a pamphlet, in the historical sense) by Dr. Worthington Hooker, Lessons from the History of Medical Delusions, which I thought might be of interest to readers of this blog. ... However, the focus of this booklet is to illustrate more generally the sorts of errors in thinking that lead even otherwise intelligent and reasonable people to believe such nonsense.


errors in history of medicine - Pubmed Search

  • Performing your original search, errors in history of medicine, in PubMed will retrieve 930 records.
J Invest Surg. 2008 Mar-Apr;21(2):53-6.

Lessons from the history of medicine.


Lyman Briggs College at Michigan State University, East Lansing, Michigan 48824, USA.


What is the point of teaching the history of medicine? Many historians and clinicians find it regrettable that some medical students today will graduate knowing almost nothing of such "greats" of the past as Hippocrates, Galen, Vesalius, Harvey, Lister, and Pasteur. But does this really matter? After all, traditional history of medicine curricula tended to distort medicine's past, omitting the countless errors, wrong turns, fads, blunders, and abuses, in order to tell the sanitized stories of a few scientific superheroes. Modern scholarship has seriously challenged most of these heroic dramas; few of our heroes were as farsighted, noble, or obviously correct as once thought. Joseph Lister, for example, turns out to have had filthy wards, whereas William Harvey was devoted to the Aristotelianism he was long said to have overthrown [1]. But as the history of medicine has become less romanticized, it has also become much more relevant, for it promises to impart useful lessons in the vital importance of scientific scepticism.
[PubMed - indexed for MEDLINE]

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Errors In History Of Medicine - Topic Review Update from Behavior and Law 



  • Performing your original search, validity of psychiatric diagnosis, in PubMed Central will retrieve 13290 records.
Psychiatry (Edgmont). 2005 September; 2(9): 48–55.
PMCID: PMC2993536
The Validity of Psychiatric Diagnosis Revisited
The Clinician's Guide to Improve the Validity of Psychiatric Diagnosis
Ahmed Aboraya, MD, DrPH,corresponding author Cheryl France, MD, John Young, MD, Kristina Curci, MD, and James LePage, PhD
All from Department of Behavioral Medicine and Psychiatry, Robert C. Byrd Health Sciences Center of West Virginia University, Morgantown, West Virginia
corresponding authorCorresponding author.
ADDRESS CORRESPONDENCE TO: Ahmed Aboraya, MD, DrPH, Department of Behavioral Medicine and Psychiatry, Robert C. Byrd Health Sciences Center of West Virginia University, PO Box 9137, Morgantown, WV 26506-9137 Phone: (304) 269-1210; Fax: (304) 269-5849; E-mail:
Background: The authors reviewed the types and phases of validity of psychiatric diagnosis. In 1970, Robins and Guze proposed five phases to achieve valid classification of mental disorders: clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study. Objectives: The objectives of this paper are to review what has been learned since Robins and Guze's influential article as well as examine the impact of the new discoveries in neurosciences and neuroimaging on the practicing clinician. Method: The authors reviewed the literature on the concept of validity in psychiatry with emphasis on the role of clinical training, the use of structured interviews and rating scales, and the importance of the new discoveries in neurosciences. Results: Robins and Guze's phases have been the cornerstone of construct validity in psychiatry at the level of researchers. In the absence of the gold standard of psychiatric diagnosis, Spitzer proposed the “LEAD,” which is an acronym for longitudinal evaluation, and is done by expert clinicians utilizing all the data available. The LEAD standard is construct validity at the level of experts; however, guidelines are lacking to improve the validity skills of the practicing clinicians. Conclusions: The authors propose the acronym DR.SEE, which stands for data, reference definitions, rating scales, clinical experience, and external validators. The authors recommend that clinicians use the DR.SEE paradigm to improve the validity of psychiatric diagnoses.
Validity and reliability are two important topics vital to the development of modern psychiatry. Reliability refers to the extent to which an experiment, test or any measuring procedure yields the same results on repeated trials,1 and is the topic of another paper. Validity is a more difficult term to define because its meaning differs based on the context. Validity, in a very general sense, refers to examining the approximate truth or falsity of scientific propositions.2 When applied to measuring instruments, validity refers to how well the instrument measures what it purports to measure.1 When applied to a disease entity, such as bacterial pneumonia, validity refers to the evidence that bacteria is the cause (verified by sputum culture), lung pathology exists (confirmed by x-ray findings), the symptoms (shortness of breath, fever, and cough), and signs (tachpnea, rales) are compatible with etiology and the disease responds to appropriate antimicrobial treatment. In a psychiatric illness, the patient comes with a subjective complaint (e.g., anxiety, depression, paranoia), and the trained clinician elicits signs of the illness through observation of the patient's demeanor, behavior, and thought process. However, there are fewer definitive objective measures (akin to x-ray and sputum culture) that confirm the diagnosis

Thursday, May 10, 2012

Psychiatric Mislabeling Is Bad For Your Mental Health | Psychology Today

Psychiatric Mislabeling Is Bad For Your Mental Health | Psychology Today

DSM5 in Distress
The DSM's impact on mental health practice and research.

Psychiatric Mislabeling Is Bad For Your Mental Health

And DSM 5 will make it much worse
An accurate diagnosis is wonderful thing—a giant step toward explaining what previously seemed unexplainable and starting what is very likely to be an effective treatment. An inaccurate diagnosis can be a disaster—leading not only to inappropriate medication but also to stigma, ruined self confidence, reduced ambition, needless worries, despair about the future, and a deeply injured sense of self.
Every week, I receive one or two emails describing the pain inflicted by careless diagnosis. And when I give talks, almost invariably someone in the audience (often a mental health professional) will come up afterwards to describe their own personal ordeal—being misdiagnosed, mistreated, and given up as too ill to be productive.
The diagnoses that are most often harmfully misapplied are schizophrenia, bipolar disorder, schizoaffective disorder, ADHD, and autism. The most frequent cause of over-diagnosis is a clinician jumping to a rash conclusion based on insufficient evidence. Risk factors for mislabeling on the patient side are youth, a short track record of symptom evolution, an atypical presentation, drug use, and family or environmental stress. Risk factors on the system side are evaluator inexperience, diagnostic exuberance, and external pressures (eg whether insurance, disability, or needed school services depend on having the diagnosis).
Read more on this blog:
Psychiatric Mislabeling Is Bad For Your Mental Hea... 
Mike Nova:
Thank you, Dr. Frances; for your previous work and for your courageous and  independent stand now.

Wednesday, May 9, 2012 

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

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

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

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

Philosophy, Psychiatry, & Psychology 3.1 (1996) 61-69

Mike Nova:

Did American Psychiatry sell its soul to profit-hungry (Psycho) Pharmaceutical Industry?

 Is it not the time to stop all this "DSM-s In Perpetuity" madness? And not to spend another $25 or more ml. for the next round of controversies and wide-spread public scepticism?


Tuesday, May 1, 2012

The subject of Industry Ties of DSM Workers - PsychiatryOnline | Psychiatric News | News Article

The subject of Industry Ties of DSM Workers

PsychiatryOnline | Psychiatric News | News Article

Psychiatric News |
Volume 47 Number 8 page 1a-14
American Psychiatric Association
Professional News
Article Misrepresents Industry Ties of DSM Workers
Mark Moran

More than 70 percent of DSM-5 Task Force and work group members now have no ties to industry.
Abstract Teaser
An article in the online journal Public Library of Science (PLoS) has misrepresented facts about conflicts of interest among members of the DSM-5 Task Force and work groups, according to APA.
And it ignored the extent to which industry influence has been eliminated or greatly reduced because of strict financial disclosure requirements mandated by APA.
In a statement, APA President John Oldham, M.D., said the article, written by Lisa Cosgrove, Ph.D., and Sheldon Krimsky, Ph.D., “does not take into account the level to which DSM-5 Task Force and work group members have minimized or divested themselves from relationships with the pharmaceutical industry.”
Cosgrove is a research lab fellow at the Edmond J. Safra Center for Ethics at Harvard University. Krimsky is an adjunct professor in the Department of Public Health and Family Medicine at the Tufts School of Medicine
The article, “A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations With Industry: A Pernicious Problem Persists,” states that APA’s financial disclosure policy for DSM-5 has not resulted in a reduction of conflicts of interest and concludes that “transparency alone cannot mitigate the potential for bias and is an insufficient solution for protecting the integrity of the revision process.”
The article appeared online March 13.
But Oldham said the authors of the article drew comparisons to DSM-IV—for which there were not the stringent requirements for financial disclosure that exist for DSM-5 contributors—to suggest erroneously that there has been an increase in conflicts of interest.
“[S]ince there were no disclosure requirements for journals, symposia, or the DSM-IV Task Force at the time of the 1994 release of DSM-IV, Cosgrove and Krimsky’s comparison of DSM-IV and DSM-5 Task Force and work group members is not valid,” Oldham said. “In assembling DSM-5 ’s Task Force and work groups, APA’s Board of Trustees developed an extensive process of written disclosure of potential conflicts of interest. These disclosures are required of all professionals who participate in the development of DSM-5. An independent APA committee reviews these disclosure documents, which are updated annually or whenever a member’s financial interests change.”
Oldham’s response noted that currently, 72 percent of the 153 members reported no relationships with the pharmaceutical industry during the previous year. Moreover, the scope of the relationships reported by the remaining 29 percent varies:
  • 12 percent reported grant support only, including funding or receipt of medications for clinical trial research.
  • 10 percent reported paid consultations including advice on the development of new compounds to improve treatments.
  • 7 percent reported receiving honoraria.
These figures contradicted those cited by Cosgrove and Krimsky, who wrote, “Currently, 69 percent of the DSM-5 task force members report having ties to the pharmaceutical industry.”
They went on to add, “This represents a relative increase of 21 percent over the proportion of DSM-IV Task Force members with such ties (57 percent of DSM-IV task force members had ties).”
When queried for a response to APA’s challenge to the PLoS article, Cosgrove said their data for DSM-IV were “based on objective information we obtained from published sources since DSM did not disclose at that time the financial interests of panel members.”
She added, “We used the same methodology in the current study although the sources of information were different because DSM-5 did a lot of work for us by disclosing the financial ties.”
With regard to the apparent discrepancy in reported industry ties, Cosgrove said in her response that the figures she derived for the DSM-5 group include the full three-year period prior to each person’s nomination to the task force or work group, as was required for participation in DSM-5.
She added, “It is important in reporting financial interests that one chooses a time period prior to the publication of the document. Thus, in order to compare the commercial ties of the DSM-IV and DSM-5 groups, we relied on the best available data for each group: published disclosures (for example, in peer-reviewed medical journals) of financial ties for DSM-IV and the disclosure forms for the DSM-5 groups.”
But Darrel Regier, M.D., M.P.H, APA’s director of research, said that using the entire three-year reporting data and presenting the data as current ignores the degree to which DSM-5 reporting requirements have resulted in minimization or divestment of industry ties over time.
“As documented in their previous publications, these authors take the position that if there was ever any kind of relationship with the pharmaceutical industry, the clinician should be excluded from DSM-5 participation—an extreme position with which we disagree,” Regier told Psychiatric News. “As a result, they counted all disclosures for all years that were posted for DSM-IV Task Force members after 1994 publication of DSM-IV and contrasted that with DSM-5 Task Force member disclosures for three years prior to their appointment—without recognizing the substantial decrease in member affiliations as the DSM process progressed over five years.”
Regier added, “It is clear that there has been a sea change in how academic investigators related to industry over the past seven years since 2005—three years before the work group members were reviewed for their 2008 appointments to the DSM-5 Task Force. A good number of investigators were providing lectures at industry-sponsored symposia at the APA [annual meeting] and other meetings from 2005 to 2007, when those who were invited to participate in DSM-5 agreed to limit and often end such relationships.
“The use of the words ‘a pernicious problem persists’ in the headline is unfortunate and highly inaccurate,” Regier said. “The implication is that the relationships continue to exist as previously, when in fact there has been a marked drop in industry relationships—which the authors fail to recognize or acknowledge.”inline-graphic-1.gif
“A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations With Industry: A Pernicious Problem Persists” is posted at


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Mass psychosis in the US—How Big Pharma got Americans hooked on anti-psychotic drugs

Tuesday, July 12th, 2011
ALJAZEERA – July 12, 2011
by James Ridgeway

Drug companies like Pfizer are accused of pressuring doctors into
over-prescribing medications to patients in order to increase profits

Has America become a nation of psychotics? You would certainly think so, based on the explosion in the use of antipsychotic medications. In 2008, with over $14 billion in sales, antipsychotics became the single top-selling therapeutic class of prescription drugs in the United States, surpassing drugs used to treat high cholesterol and acid reflux.
Once upon a time, antipsychotics were reserved for a relatively small number of patients with hard-core psychiatric diagnoses – primarily schizophrenia and bipolar disorder – to treat such symptoms as delusions, hallucinations, or formal thought disorder. Today, it seems, everyone is taking antipsychotics. Parents are told that their unruly kids are in fact bipolar, and in need of anti-psychotics, while old people with dementia are dosed, in large numbers, with drugs once reserved largely for schizophrenics. Americans with symptoms ranging from chronic depression to anxiety to insomnia are now being prescribed anti-psychotics at rates that seem to indicate a national mass psychosis.
It is anything but a coincidence that the explosion in antipsychotic use coincides with the pharmaceutical industry’s development of a new class of medications known as “atypical antipsychotics.” Beginning with Zyprexa, Risperdal, and Seroquel in the 1990s, followed by Abilify in the early 2000s, these drugs were touted as being more effective than older antipsychotics like Haldol and Thorazine. More importantly, they lacked the most noxious side effects of the older drugs – in particular, the tremors and other motor control problems.
The atypical anti-psychotics were the bright new stars in the pharmaceutical industry’s roster of psychotropic drugs – costly, patented medications that made people feel and behave better without any shaking or drooling. Sales grew steadily, until by 2009 Seroquel and Abilify numbered fifth and sixth in annual drug sales, and prescriptions written for the top three atypical antipsychotics totaled more than 20 million. Suddenly, antipsychotics weren’t just for psychotics any more.
Not just for psychotics anymore
By now, just about everyone knows how the drug industry works to influence the minds of American doctors, plying them with gifts, junkets, ego-tripping awards, and research funding in exchange for endorsing or prescribing the latest and most lucrative drugs. “Psychiatrists are particularly targeted by Big Pharma because psychiatric diagnoses are very subjective,” says Dr. Adriane Fugh-Berman, whose PharmedOut project tracks the industry’s influence on American medicine, and who last month hosted a conference on the subject at Georgetown. A shrink can’t give you a blood test or an MRI to figure out precisely what’s wrong with you. So it’s often a case of diagnosis by prescription. (If you feel better after you take an anti-depressant, it’s assumed that you were depressed.) As the researchers in one study of the drug industry’s influence put it, “the lack of biological tests for mental disorders renders psychiatry especially vulnerable to industry influence.” For this reason, they argue, it’s particularly important that the guidelines for diagnosing and treating mental illness be compiled “on the basis of an objective review of the scientific evidence” – and not on whether the doctors writing them got a big grant from Merck or own stock in AstraZeneca.
Marcia Angell, former editor of the New England Journal of Medicine and a leading critic of the Big Pharma, puts it more bluntly: “Psychiatrists are in the pocket of industry.” Angell has pointed out that most of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of mental health clinicians, have ties to the drug industry. Likewise, a 2009 study showed that 18 out of 20 of the shrinks who wrote the American Psychiatric Association’s most recent clinical guidelines for treating depression, bipolar disorders, and schizophrenia had financial ties to drug companies.
In a recent article in The New York Review of Books, Angell deconstructs what she calls an apparent “raging epidemic of mental illness” among Americans. The use of psychoactive drugs—including both antidepressants and antipsychotics—has exploded, and if the new drugs are so effective, Angell points out, we should “expect the prevalence of mental illness to be declining, not rising.” Instead, “the tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007 – from one in 184 Americans to one in seventy-six. For children, the rise is even more startling – a thirty-five-fold increase in the same two decades. Mental illness is now the leading cause of disability in children.” Under the tutelage of Big Pharma, we are “simply expanding the criteria for mental illness so that nearly everyone has one.” Fugh-Berman agrees: In the age of aggressive drug marketing, she says, “Psychiatric diagnoses have expanded to include many perfectly normal people.”
Cost benefit analysis
What’s especially troubling about the over-prescription of the new antipsychotics is its prevalence among the very young and the very old – vulnerable groups who often do not make their own choices when it comes to what medications they take. Investigations into antipsychotic use suggests that their purpose, in these cases, may be to subdue and tranquilize rather than to treat any genuine psychosis.
Carl Elliott reports in Mother Jones magazine: “Once bipolar disorder could be treated with atypicals, rates of diagnoses rose dramatically, especially in children. According to a recent Columbia University study, the number of children and adolescents treated for bipolar disorder rose 40-fold between 1994 and 2003.” And according to another study, “one in five children who visited a psychiatrist came away with a prescription for an antipsychotic drug.”
A remarkable series published in the Palm Beach Post in May true revealed that the state of Florida’s juvenile justice department has literally been pouring these drugs into juvenile facilities, “routinely” doling them out “for reasons that never were approved by federal regulators.” The numbers are staggering: “In 2007, for example, the Department of Juvenile Justice bought more than twice as much Seroquel as ibuprofen. Overall, in 24 months, the department bought 326,081 tablets of Seroquel, Abilify, Risperdal and other antipsychotic drugs for use in state-operated jails and homes for children…That’s enough to hand out 446 pills a day, seven days a week, for two years in a row, to kids in jails and programs that can hold no more than 2,300 boys and girls on a given day.” Further, the paper discovered that “One in three of the psychiatrists who have contracted with the state Department of Juvenile Justice in the past five years has taken speaker fees or gifts from companies that make antipsychotic medications.”
In addition to expanding the diagnoses of serious mental illness, drug companies have encouraged doctors to prescribe atypical anti-psychotics for a host of off-label uses. In one particularly notorious episode, the drugmaker Eli Lilly pushed Zyprexa on the caregivers of old people with Alzheimer’s and other forms of dementia, as well as agitation, anxiety, and insomnia. In selling to nursing home doctors, sales reps reportedly used the slogan “five at five”—meaning that five milligrams of Zyprexa at 5 pm would sedate their more difficult charges. The practice persisted even after FDA had warned Lilly that the drug was not approved for such uses, and that it could lead to obesity and even diabetes in elderly patients.
In a video interview conducted in 2006, Sharham Ahari, who sold Zyprexa for two years at the beginning of the decade, described to me how the sales people would wangle the doctors into prescribing it. At the time, he recalled, his doctor clients were giving him a lot of grief over patients who were “flipping out” over the weight gain associated with the drug, along with the diabetes. “We were instructed to downplay side effects and focus on the efficacy of drug…to recommend the patient drink a glass a water before taking a pill before the meal and then after the meal in hopes the stomach would expand” and provide an easy way out of this obstacle to increased sales. When docs complained, he recalled, “I told them, ‘Our drug is state of the art. What’s more important? You want them to get better or do you want them to stay the same–a thin psychotic patient or a fat stable patient.’”
For the drug companies, Shahrman says, the decision to continue pushing the drug despite side effects is matter of cost benefit analysis: Whether you will make more money by continuing to market the drug for off-label use, and perhaps defending against lawsuits, than you would otherwise. In the case of Zyprexa, in January 2009, Lilly settled a lawsuit brought by with the US Justice Department, agreeing to pay $1.4 billion, including “a criminal fine of $515 million, the largest ever in a health care case, and the largest criminal fine for an individual corporation ever imposed in a United States criminal prosecution of any kind,”the Department of Justice said in announcing the settlement.” But Lilly’s sale of Zyprexa in that year alone were over $1.8 billion.
Turning people into zombies
As it turns out, the atypical antipsychotics may not even be the best choice for people with genuine, undisputed psychosis.
Read the rest of the article here: 


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How American Psychiatry Can Save Itself: Part 1 - ...
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How do controversial revisions in psychiatry's gui...

Friday, May 4, 2012

How do controversial revisions in psychiatry's guidebook make you feel?

How do controversial revisions in psychiatry's guidebook make you feel?

How do controversial revisions in psychiatry's guidebook make you feel?

When upward of 10,000 members of the American Psychiatric Association meet here this weekend, they'll be met by protesters - there are always protesters - and tough questions about where their profession is headed and how it will define normalcy for the rest of us. The official theme of the annual meeting, which opens Saturday at the Pennsylvania Convention Center, is integrated care, a nod to the increasingly interdisciplinary nature of medicine in the health-reform era. But many sessions will also focus on the association's highly controversial overhaul of the Diagnostic and Statistical Manual of Mental Disorders, the dominant guidebook to mental maladies and a key factor in determining insurance payments.
The current tome, the DSM-IV, was published in 1994 and updated in 2000. The book now in the works, the DSM-5 (yes, they dropped the Roman numerals), is due out by next year's APA meeting.
Supporters say the revisions incorporate more current science into the highly influential book. It also strives for diagnoses that show how seriously ill patients are.
Critics say the changes jump ahead of the science and expand what is considered mental illness. While the association tries to detect illnesses earlier and possibly prevent their most tragic symptoms, it risks calling essentially normal people mentally ill, needlessly exposing thousands to stigma and strong medicines, and handing drugmakers a bonanza.
One hot-button proposal allows grieving people to be considered depressed after two weeks of symptoms. Another addresses children who were being labeled bipolar by creating a different diagnosis: disruptive mood dysregulation disorder. Some worry that diagnoses meant to identify thinking problems in the elderly will turn normal aging into a disorder.
The University of Pennsylvania was one of 11 academic medical centers that field-tested the book's new approach. It looked at five diagnoses, including three new ones: hoarding disorder, binge-eating disorder, and mixed depression and anxiety.
In what is surely biting criticism in the mental-health world, David N. Elkins, a psychology professor emeritus at Pepperdine University, said the APA "should listen. They don't listen very well. They need to listen to the outcry and take it seriously."
The APA must have listened a little. It announced this week that it had moved the new attenuated psychosis syndrome, which attempted to identify young people likely to develop psychosis, and mixed anxiety and depression to a book section for conditions that need more research. They also tried to better differentiate normal grief from depression.
Last fall, Elkins, president of the Society for Humanistic Psychology, helped draft an open letter critiquing proposed changes. It got 13,000 signatures online, he said.
His and other groups are so miffed that they plan to write their own book. "We are calling for a summit in New York City in the summer of 2013 of all the mental-health professions," Elkins said. "We need a manual that is produced in an egalitarian way."
One of the most vocal critics is psychiatrist Allen Frances, who edited the DSM-IV. He said that overdiagnosing and overprescribing of antipsychotic drugs, particularly in children and the elderly, were already big problems. Psychiatry, he said, should be asking, "How can we put a governor on this? What DSM-5 will do, instead, is open up the flood gates."
The new approach, he said, gives "drug companies a free pass to convince everyone in the world that they have one disorder or two or three."
There's also the matter of autism. Its proposed definition is more restrictive. That has caused an outcry from autism advocates, who fear children will lose school services.
Frances thinks his group has made the current definition too broad. If fewer children with mild symptoms are diagnosed, "that's a good thing."
He also thinks the APA has too much money at stake to be objective. He says it makes $5 million to $10 million a year on sales of the manual.
The APA says it has invested $25 million in developing the new DSM over the last 12 years. It deflected a question about how much income the book generates.
David Kupfer, a University of Pittsburgh psychiatrist who heads the DSM-5 task force, said nothing was set in stone. A third six-week comment period opened Wednesday. The APA already has received close to 10,800 comments.
"We do want more public commentary," Kupfer said. "We are carefully examining this with some of our review groups. We certainly do not want to make changes for the sake of making changes."
For the record, he said, the number of diagnoses is dropping from 280 to 220.
John Oldham, the psychiatric association's president, said one of the DSM's roles has been to provide definitions that lead to better research. Mental health and illness are on a continuum with no clear lines of demarcation, but scientists need to find the earliest signs of dysfunction. "It's important for us," he said, "to be trying to understand when the right time is to intervene."
Thomas R. Insel, a psychiatrist who directs the National Institute of Mental Health, sees psychiatry heading toward what he calls "clinical neuroscience." Psychiatrists should study the brain the way cardiologists study the heart, he said.
While people assume that thinking of mental illnesses as brain disorders will lead to more medication, Insel said his agency has funded research into cognitive training, therapy that uses the brain's ability to change. It also is studying diet and family support.
"There is no biochemical imbalance that we have ever been able to demonstrate," he said. "What we think about are changes in circuitry and how the brain is processing information."
It makes sense to him to try to identify at-risk youths before they develop symptoms that can devastate their ability to work or have fulfilling relationships. The most debilitating of the mental illnesses, schizophrenia and bipolar disorder, often are diagnosed in early adulthood, but researchers are studying signs that emerge years earlier.
Critics say that lots of teens have eccentric behaviors but won't become mentally ill. This is true, Insel said, but "science entirely supports" figuring out who's going to become psychotic and preventing it. "That doesn't mean medicate earlier," he said.
The institute has embarked on its own attempt to classify mental illnesses based on what's happening in the brain rather than on symptoms.
Asked whether the association should delay rewriting the DSM until the science advances, he said, "That's a fair question. I'm not going to answer it." Then he said, "I think the DSM-IV is extremely helpful."
Mahendra Bhati, a psychiatrist who headed the Penn field trial, is confident that the new disorders his clinic tested are genuine mental illnesses. They don't necessarily need drug treatment.
But he found the new approach to personality disorders "clinically impractical."
Overall, he said, "I honestly don't think it's going to make a huge difference in how I practice psychiatry." His prescriptions, he said, are based on symptoms, not diagnoses.
On Saturday, as psychiatrists inside the convention center discuss proposed DSM changes, protesters outside plan to "Occupy the American Psychiatric Association." They'll have a "label rip," where they tear up the very diagnosis names that the psychiatrists are intent on defining.
"We'd have to be Don Quixote to think we're going to stop it at this point," David Oaks said of the DSM-5. A veteran of many such protests, Oaks, a Harvard grad who has been called schizophrenic and bipolar, is executive director of MindFreedom International and one of the event organizers. He says psychiatrists have not listened enough to their "customers," who often find peer and social support more helpful than drugs.

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

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

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

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


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


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

    [PubMed - as supplied by publisher]

    Free full text


  • World Psychiatry Journal - World Psychiatric Assoc...

  • Psychiatric diagnosis: pros and cons of prototypes...

  • Sunday, April 29, 2012

    Psychiatric diagnosis: pros and cons of prototypes - World Psychiatric Association

    World Psychiatric Association / English

    Psychiatric diagnosis: pros and cons of prototypes
    vs. operational criteria


    Mario Maj
    President, World Psychiatric Association

    The development of operational diagnostic criteria for
    mental disorders in the 1970s was a response to serious concerns
    about the reliability of psychiatric diagnosis. Initially
    intended only for research purposes, the operational approach
    was subsequently proposed also for ordinary clinical
    practice by the DSM-III. That this approach increases the
    reliability of psychiatric diagnosis in research settings is now
    well documented. Much less clear, even in the US, is whether
    the approach is commonly used by clinicians in ordinary
    practice, thus really resulting in an increase of the reliability
    of psychiatric diagnosis in clinical settings. It has been, for
    instance, reported that several US clinicians have difficulties
    to recall the DSM-IV criteria for major depressive disorder
    and rarely use them in their practice (e.g., 2). Furthermore,
    some of the DSM-IV cut-offs and time frames have been
    found not to have a solid empirical basis (e.g., 3) and to
    generate a high proportion of sub-threshold and “not otherwise
    specified” cases (e.g., 4).
    More in general, it has been maintained that a “prototype
    matching” approach is more congruent with human (and
    clinical) cognitive processes than a “defining features” approach
    (e.g., 5). The spontaneous clinical process does not
    involve checking in a given patient whether each of a series
    of symptoms is present or not, and basing the diagnosis on
    the number of symptoms which are present. It rather involves
    checking whether the characteristics of the patient
    match one of the templates of mental disorders that the clinician
    has built up in his/her mind through his/her training
    and clinical experience.
    Moreover, some recent research focusing on various
    classes of mental disorders (i.e., personality disorders, eating
    disorders, anxiety disorders) suggests that a diagnostic system
    based on refined prototypes may be as reliable as one
    based on operational criteria, while being more user friendly
    and having greater clinical utility (e.g., 6).

    World Psychiatric Association / The WPA-WHO Global... 


    Money Motivates Mental Health Moves: DSM-5, Meet M...

    Sunday, April 29, 2012

    Money Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine | candidaabrahamson

    Money Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine | candidaabrahamson

    Money Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine

    In the interest of full disclosure, let me be perfectly clear.
    As a therapist, I use the DSM (Diagnostic and Statistical Manual of Mental Disorders), the ‘mental health bible’ that helps diagnose and define treatment, frequently. I find it pivotal in making diagnoses, and then in providing a shared language to discuss those diagnoses with consulting psychiatrists, with other treaters, with educators. I share it with clients to assist them in understanding their illnesses and potential treatments, and it’s a useful tool to help third-party payers understand the needs of the patients.
    Really, overall I’m a fan, and I rely upon it.
    Which is probably why I find myself so frustrated with the current process of updating the (ready for this one?) DSM-IV-TR (don’t ask) to the DSM-5.
    Perhaps I’m an innocent (highly unlikely), but I had counted on the American Psychiatric Association (APA), the group responsible for the updating of the DSM (soon this will be an alphabet soup), to keep the process relatively untainted.
    I had counted wrong.

    Again in the interest of full disclosure, I had already found myself frustrated with several of the committee on the DSM-5‘s decisions. In an act of tremendous restraint, I won’t go over again my opposition to doing away with the bereavement exclusion [but won't deprive you of a hyperlink to my mini-rant], nor will I carry on again about the potential inclusion of Hypersexuality and Internet Addiction [ok--link here if you can't keep yourself away]. But the APA’s process of updating ‘the mental health bible’ crawled under my skin once again–not for its lack of full disclosure, really, as much as its seeming indifference to what the disclosure indicated.
    Just for some background: There are 141 panel members on the 13 DSM-5 panels and 29 task force members. The members of these 13 panels are the ones in charge of revisions to diagnostic categories and inclusion of new disorders.
    So far, so good.
    Until you look a bit further, and realize the DSM-5 process has enough ties to big money (pharmaceutical money, of course), to make good old Bernie Madoff, who, it turns out, had very few ties to actual money, squirm with jealousy.
    In “A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists,” Lisa Cosgrove, PhD, from the Edmond J. Safra Center for Ethics at Harvard University, and Sheldon Krimsky, PhD, from the Department of Public Health and Community Medicine at Tufts University, write the following astonishing facts about the DSM’s financial connections to big pharm:
    Three-fourths of the work groups continue to have a majority of their members with financial ties to the pharmaceutical industry. It is also noteworthy that, as with the DSM-IV, the most conflicted panels are those for which pharmacological treatment is the first-line intervention. For example, 67% . . . of the panel for Mood Disorders, 83% . . . of the panel for Psychotic Disorders, and 100% . . .[Note to reader: this 100% is a personal favorite of mine. How can you beat it?] of the Sleep/Wake Disorders (which now includes “Restless Leg Syndrome”) have ties to the pharmaceutical companies that manufacture the medications used to treat these disorders or to companies that service the pharmaceutical industry.

    So if I’ve got this right [and I have a good sense that I do; it isn't as difficult as the proverbial rocket science], and if I return for the moment to the DSM-5′s exclusion of the bereavement clause, which means, just to sum up, that after two weeks of grief symptoms (which, it is already known and accepted, overlap with depressive symptoms), a bereaved person can be diagnosed with depression, I could be looking at something like this, if I were take the most Machiavellian view. Depression, as opposed to grief, can be treated with and has found to be responsive to psychotropic medications. Thus turning grief into a depression yields more prescriptions, which could potentially benefit any of that high percentage of doctors sitting on the committee with connections to the companies that make these meds.
    I don’t really think that the 67% of the Mood Disorders committee members insisted on turning grief into a mood disorder with the thought that they would profit financially, hoping that the pharmaceutical companies they’re connected would step in to provide psychotropics to the bereaved. Not for a moment. But it might be difficult for those committee members to completely keep that idea out of their heads. That’s why conflicts of interests are problems.
    Krimsky himself clarified that his article was not meant to be a ‘witch hunt.’ He said, “I don’t believe that anyone on the panel is purposefully making decisions that favor industry. The issue is more subtle and just as impactful. We all have the potential for bias in a conflicted situation, and we’re all really defended against looking at those biases, and therein lies the danger.”
    I enjoyed some of the APA’s responses to the Krimsky-Cosgrove article. Take David Elkins, president of the American Psychological Association’s Society for Humanistic Psychology (a society I, myself, had never heard of until the other day, but one with a title that piques my interest. And–who knew?–it’s division #32 of the American Psychological Association. I think my time could be well spent finding what the first 31 divisions are.).
    When asked what he had to say in response to the fact that seven in 10 DSM-5 task force members have drug company ties, Elkins was eloquent.
    He was, not to put too fine a point on it, “dismayed.”
    I love a man of few words.
    But it gets better. The APA medical director and CEO is one Dr. James Scully. And he says–and I don’t want people to miss this:
    We wanted to include a wide variety of scientists and researchers with a range of expertise and viewpoints in the DSM-5 process. Excluding everyone with direct or indirect funding from the industry would unreasonably limit the participation of leading mental health experts in the DSM-5 development process.
    Ok, I admit it. Those are my own italics. I can’t help it; it’s priceless.
    So, according to Scully, it’s worse than we even thought. Looking for a mental health expert? Just know she’s connected to the pharmaceutical companies. So much so, that if you keep anyone connected to the drug makers out of a given process, you’ve lost your expertise base.
    Now I feel better about the whole thing.
    And the truth is that this isn’t as much of a shock to me as it might have been. One incident proves little, but it made an impression on me, and, woven into the tapestry of the Scully argument, bolsters my concern about the infiltration of the drug companies into clinical practice.
    The consulting psychiatrist and I met together with a patient to get all views on the table at once, and to present a cohesive treatment plan. We met in the psychiatrist’s office, where the doctor kindly proffered me a pen as I searched my purse for one I couldn’t find [of course, now that I didn't need them, I could locate my glasses, my bottle of baby aspirin, and the receipt for the panty hose I'd been meaning to return--but couldn't find the receipt].
    This was no plain pen–it was a Paxil pen–with the medicine’s name and logo written large upon it. The pad of paper he provided was dominated by Effexor’s name–and, I kid you not, he had a Seroquel mug. My patient and I sanitized our hands from a plastic bottle emblazoned with ‘Pristiq,’ and I actually watched time pass on a cheap plastic clock with Abilify’s name plastered across the face.
    I stayed put, for I was certain, had I gone to the restroom, I would have been met with toilet paper carrying Zyprexa’s name, and that, really, was the limit.

    And here’s the thing: This office isn’t unusual in its collection of tchotchkes advertising psychotropics or other meds. It’s all over.
    In the interest of full disclosure, let me clarify: I thought this was an excellent psychiatrist. Probably he’s sitting on the Mood Disorders committee of the DSM-5, offering his expert opinion, and writing down notes on his Zoloft clipboard.
    Because if you cut him out of the DSM-5 process just because he’s connected to the pharmaceutical companies–really, who do you have left?
    You know what? In the interest of full disclosure I tell you: I’ve never heard of the APA’s society for humanistic psychology, but I’m right there with its president. When it comes to how the DSM-5 is being compiled, I too am–in a word–”dismayed.”
    What You Really Shouldn’t Miss
    This entry was posted in Bereavement, Mood Disorders and tagged , , , , . Bookmark the permalink.

    13 Responses to Money Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine

    1. Pingback: Money Motivates Mental Health Moves: DSM-5, Meet Makers of …
    2. Dismayed, indeed. What an alarming post. The big question is, what can we do?

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    3. psachno says:
      Your posts are so educational! Thanks for all this info–AND for your references.
      Can I sign a petition if I am unlicensed? (Probably not, hey?)

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    4. Paul says:
      Very good, informative article. I don’t think the bereavement exemption issue is as one-sided as you present it, however. By removing that exemption, it doesn’t cause all mourners to gain the diagnosis of depression. What it does is *allow* the diagnosis of depression. While it would be silly to say that everyone who suffers from the symptoms of depression for several weeks after a loved one has died is clinically depressed, it would be equally silly to say that it is impossible for someone who had a loved one die to become depressed. Removing the exemption allows help-seeking individuals who are indeed suffering from a depressive episode triggered by the death of a loved one to get help. Right now, that group of people don’t qualify for the diagnosis, and therefore might not be able to get insurance reimbursement for help.
      I had the worse deppresive episode of my life for about 6 months after my cat died. Luckily for me, my diagnosis is type-II bipolar which doesn’t have a (pet) bereavement exclusion clause, b/c I was suffering terribly and I was able to recover with the combination of medicine and therapy. I’m not saying that there aren’t potential negative consequences of removing the bereavement exemption, but I really don’t think you should lump it in with the negative consequences of undue involvement by the industry in the revision process.
      If nothing else, removing the exemption, along with some other things like changing from a more categorical to dimensional approach, represents a change in the dsm-III/iv philosophy of mental disorders being discrete disease entities with an implied fully biological etiology. I’m not saying this will hamper the industry or slow down the monetezation of mental illness, but it is an interesting trend worth watching.


    Psychiatry’s bible, the DSM, is doing more harm th...

    Sunday, April 29, 2012

    Psychiatry’s bible, the DSM, is doing more harm than good - The Washington Post

    Psychiatry’s bible, the DSM, is doing more harm than good - The Washington Post

    Psychiatry’s bible, the DSM, is doing more harm than good

    By Paula J. Caplan, Published: April 27

    About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.

    After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.

    Since the 1980s, when I first made public my concerns about psychiatric diagnosis, I have heard from hundreds of people who have been arbitrarily slapped with a psychiatric label and are struggling because of it. About half of all Americans get a psychiatric diagnosis in their lifetimes. Receiving any of the 374 psychiatric labels — from nicotine dependence disorder to schizophrenia — can cost anyone their health insurance, job, custody of their children, or right to make their own medical and legal decisions. And if patients take psychiatric drugs, they risk developing physical disorders such as diabetes, heart problems, weight gain and other serious conditions. In light of the subjectivity of these diagnoses and the harm they can cause, we should be extremely skeptical of them.

    Psychiatric diagnosis is unregulated, so the doctor who met briefly with the aforementioned patient wasn’t required to spend much time understanding what caused her heart to race or to seek another doctor’s opinion. If he had, the patient would have realized that her bipolar diagnosis wasn’t necessary or appropriate. Neither on her ER trip nor in later visits to therapists did anyone explain how sleep deprivation impairs the body’s ability to handle pressure.

    In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.

    According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.

    When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.

    Over the next 10 months, the woman lost her friends, who attributed her normal mood changes to her alleged disorder. Her self-confidence plummeted; her marriage fell apart. She moved halfway across the country to find a place where, on her dwindling savings, she and her son could afford to live. But she was isolated and unhappy. Because of the drug she took for only six weeks, she now, more than three years later, has an eye condition that could destroy her vision.

    This patient is well-educated and white, and before her illness, she was wealthy. Research reflects that she was more likely to be diagnosed as mentally ill than a man in her circumstances. Racism, classism, ageism and homophobia can also affect who receives a psychiatric diagnosis.

    It would be less troubling if such diagnoses helped patients, but getting a label often hinders recovery. It can lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is causing the patient’s suffering.

    The marketing of the DSM has been so effective that few people — even therapists — realize that psychiatrists rarely agree about how to label the same patient. As a clinical and research psychologist who served on (and resigned from) two committees that wrote the current edition of the DSM, I used to believe that the manual was scientific and that it helped patients and therapists. But after seeing its editors using poor-quality studies to support categories they wanted to include and ignoring or distorting high-quality research, I now believe that the DSM should be thrown out.

    An undeserved aura of scientific precision surrounds the manual: It has “statistical” in its title and includes a precise-seeming three- to five-digit codefor every diagnostic category and subcategory, as well as lists of symptoms a patient must have to receive a diagnosis. But what it does is simply connect certain dots, or symptoms — such as sadness, fear or insomnia — to construct diagnostic categories that lack scientific grounding. Many therapists see patients through the DSM prism, trying to shoehorn a human being into a category.

    At a convention in Philadelphia starting May 5, the DSM’s publisher, the American Psychiatric Association, is due to vote on whether to send the manual’s next edition, the DSM-5, to press. The APA is a lobbying group for its members, not an organization with patients’ interests as its top priority. It has earned $100 million from sales of the current edition, the DSM-IV.

    Allen Frances, lead editor of the current DSM, defends his manual as grounded in science, but at times he has acknowledged its lack of scientific rigor and the overdiagnosing that has followed. “Our net was cast too wide,” Frances wrote in a 2010 Los Angeles Times op-ed, referring to the explosion of diagnoses that led to “false ‘epidemics’ ” of attention deficit disorder, autism and childhood bipolar disorder. The current manual, released in 1994, he wrote, “captured many ‘patients’ who might have been far better off never entering the mental health system.”

    Frances has even said that “there is no definition of a mental disorder. . . . These concepts are virtually impossible to define precisely.”

    Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.

    Patients should not be limited in their choices of treatment, but they should be better informed. If someone knows about the many ways that suffering can be addressed, including a drug or a treatment with potential benefits and harms, and they still want to try it, they should be able to.

    While patients who think they have been harmed by a diagnosis can file a lawsuit or a complaint with a state licensing body, that almost never happens. However, this weekend marks a big change, as some people are speaking up: About 10 people who received diagnoses from the current DSM edition are filing complaints against the manual’s editors. (I have worked with the patients to prepare their complaints, and I’m filing my own as a concerned clinician.)

    The complainants allege that the DSM’s editors failed to follow the APA’s ethical principles, which include taking account of scientific knowledge and respecting patients’ welfare and dignity. They are asking the APA to order the editors to redress the harm done to them — or in one case, to a deceased relative — and to anyone else hurt by receiving a label. They want the APA to hold a public hearing about the dangers of psychiatric diagnosis to gather information about the extent of the damage and look for ways to minimize it. Additionally, they are asking the APA to make clear to therapists and to the public that psychiatric diagnoses are not scientific and that they often put patients at risk.

    As the patient labeled as bipolar told me: “If I had never been diagnosed, I probably would still be married, would live close to family and friends and not be so lonely, and would not be living on the financial edge.”

    Paula J. Caplan, a clinical and research psychologist, is a fellow in the Women in Public Policy Program at Harvard’s Kennedy School of Government. She is the author of “They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal.”

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    Books on psychiatric diagnosis

    Book Review: Psychology's Ghosts -

    NIMH · The Future of Psychiatry (= Clinical Neuros...


    Apr 25 (13)

    Wednesday, April 25, 2012

    Psychiatric Diagnosis: Challenges and Prospects: Patterns and Prospects (World Psychiatric Association) by Ihsan M. Salloum, Juan E. Mezzich

    Psychiatric Diagnosis: Challenges and Prospects: Patterns and Prospects (World Psychiatric Association) by Ihsan M. Salloum, Juan E. Mezzich


    Psychiatric Diagnosis: Challenges and Prospects: Patterns and Prospects (World Psychiatric Association)

    Product Description

    Psychiatric diagnosis is one of the most important topics within the broad field of psychiatry. Clear, accurate definitions of the various disorders are essential for clinicians around the world to be confident that they are classifying patients in the same way, thereby enabling comparisons of treatment regimens and their outcomes. There are two major classification systems in use, one produced by the World Health Organization, the WHO International Classification of Diseases, Mental Disorders Chapter, and one by the American Psychiatric Association, the well known Diagnostic and Statistical Manual of Mental Disorders. Both of these are being revised so this book from the prestigious World Psychiatric Association is especially timely.In this book, leading experts in the field provide a broad and integrated coverage of the concepts, structure and context of psychiatric diagnosis. It begins by addressing mental health and illness around the world from historical, philosophical and cultural perspectives. Health is approached comprehensively, to include such aspects as resilience, resources and quality of life. The book then covers major specific psychopathology topics in Section II, including new categorizations and dimensional approaches. Section III concentrates on the complex problem of comorbidity, a primary challenge for modern diagnostic classifications in psychiatry. Finally, Section IV reviews emerging international diagnostic systems in psychiatry, considering innovative models and adaptations.This book will be essential reading for anyone involved in the diagnosis of psychiatric disorders.

    From the Back Cover

    Improved diagnostic systems are necessary to enhance clinical care, teaching and research. Written by leading experts in the field, this book provides broad, integrated coverage of psychiatric diagnosis from historical and conceptual roots to novel diagnostic approaches.Divided into four accessible sections, the book covers: Concepts of mental health and illness around the world from historical, philosophical and cultural perspectives. Health is approached comprehensively, to include such aspects as resilience, resources and quality of life Major specific psychopathology topics, including new categorizations and dimensional approaches The complex problem of comorbidity in mental and general health, a major challenge for modern diagnostic classifications in psychiatry Emerging international diagnostic systems in psychiatry, considering innovative models and adaptationsPsychiatric Diagnosis: Challenges and Prospects presents innovative and helpful models for improved evaluation and care and should be read by all mental health professionals, as well as practising clinicians, researchers and postgraduate students in psychiatry and psychology.


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