Sunday, May 13, 2012

DSM-5 and the Prisons - YouTube#at=11#!

DSM-5 and the Prisons - YouTube#at=11#!

Published on May 6, 2012 by
Marcia Goin, M.D. and Ken Rosenberg, M.D. talk to APA TV about the huge challenges faced by the criminalization of people with mental health and the problems faced with so many people with mental illness facing custodial sentences.



Real Psychiatry: Why Allen Frances has it wrong

Real Psychiatry: Why Allen Frances has it wrong

Sunday, May 13, 2012

Why Allen Frances has it wrong

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

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

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

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

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

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

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

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

George Dawson, MD, DFAPA

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

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

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

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


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

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

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

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

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

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

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

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

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

Diagnosing the DSM - New York Times - Forensic Psychiatry News

Google Reader - Forensic Psychiatry News

Diagnosing the DSM
New York Times
AT its annual meeting this week, the American Psychiatric Association did two wonderful things: it rejected one reckless proposal that would have exposed nonpsychotic children to unnecessary and dangerous antipsychotic medication and another that would ...

and more »

For women prisoners, a bittersweet Mother's Day behind bars - Chicago Tribune - Forensic Psychiatry News

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via prisons - Google News on 5/12/12

Independent Online

For women prisoners, a bittersweet Mother's Day behind bars
Chicago Tribune
CHINO, California (Reuters) - On a recent Saturday morning, hundreds of sleepy children tumbled out of buses and into a dusty jail parking lot in southern California to pay a rare visit to their mothers in prison. A hundred feet (Thirty meters) away, ...
Mother's Day event provides children opportunity to see moms behind (blog)
A bittersweet Mother's Day for those behind barsTVNZ

all 27 news articles »

Selected Blogs - 10:35 AM 5/13/2012

Google Reader - Selected Blogs

Selected Blogs - 10:35 AM 5/13/2012

"Selected Blogs" bundle created by Mike Nova

Description: The most notable blogs on general and forensic psychiatry and psychology
A bundle is a collection of blogs and websites hand-selected by your friend on a particular topic or interest. You can keep up to date with them all in one place by subscribing in Google Reader.
There are
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  • 1 Boring Old Man
  • Battleland » Military Mental Health
  • candidaabrahamson
  • Psychology, Philosophy and Real Life
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  • In the news by Karen Franklin PhD
  • go it alone (together)
  • Prison Watch Network
  • Mental Health Writers' Guild
  • Health News
  • rajpersaud
  • Observations
  • Streams of Consciousness
  • The Amazing World of Psychiatry: A Psychiatry Blog
  • CCHR International
  • Death Penalty Information Center
  • Health Therapy
  • NIMH | Director’s Blog
  • DSM5 in Distress
  • Sue Bailey - The President's Blog - TRCP

via Faktensucher by curi56 on 5/13/12
The Dalai Lama is voicing concerns the Chinese are plotting his assassination. In an exclusive interview with Britain’s Sunday Telegraph, the Dalai Lama shared details he says come directly from sources inside Tibet on how the Chinese would kill him. Based on this information, he…
viaDalai Lama Reveals Fears of Assassination Attempt.

via 1 Boring Old Man by Mickey on 5/13/12
After the DSM-III and later DSM-IIIR were launched and in play, people began to look back at the origins and ask if the actual Manuals had lived up to their grand design. One obvious area of criticism was the derivation of the criteria. About the process that lead to the Feighner Criteria, they said that they came from the evaluation of actual cases using:
  1. Clinical Description
  2. Laboratory Studies
  3. Delimitation from Other Disorders
  4. Follow-up Study
  5. Family Study
… a claim I would have no reason to doubt, except for:
While no psychiatric syndrome has yet been fully validated by a complete series of steps, a great deal of work has been published indicating that substantial validation is possible. This communication is a summary of that work in the form of specific diagnostic criteria.

In addition, we in this department have carried out a study of interrater reliability and validation of reliability with an 18-month follow-up study of 314 psychiatric emergency room patients (to be published) as well as a seven-year follow-up study of 87 psychiatric inpatients (to be published), each of whom was interviewed personally and systematically. There were four different raters in the emergency room study. Agreement ranged from 86% to 95% about diagnosis with diagnostic criteria similar to those outlined in this report. There were two different raters in the inpatient study ; reliability between those raters was 92%. In the emergency room study and in the inpatient study, validity, as determined by correctly predicting diagnosis at follow-up by criteria such as those of this report, was 93% and 92%, respectively.
And exclusivity was also mostly a wish:
It will be apparent below that certain diagnoses are mutually exclusive (primary affective disorders and schizophrenia), while others may be made in the same patient (antisocial personality disorder with alcoholism or drug dependency ; hysteria or anxiety neurosis with secondary depression). More work will be necessary before the full significance of various diagnostic combinations becomes evident.
So the criteria came from their actual patients, some of whom they followed and checked for inter-rater reliability and diagnostic stability. But later critics noted that the DSM-IIIs didn’t follow even that lead, relying primarily on expert opinion, the very thing they’d complained about in the DSM-I and DSM-II. During the lead-up to the DSM-IV a decade later, Dr. Spitzer responded to some of those criticisms.
An outsider-insider’s views about revising the DSMs
by Spitzer RL.
Journal of Abnormal Psychology. 1991 100[3]:294-296.

…In discussing the development of DSM-III, Widiger et al. noted the increasing role of empirical validation in psychiatry and the five phases for validating a psychiatric diagnosis proposed by Robins and Guze. Their approach led Robins and Guze to recognize only 16 diagnoses that they believed had been validated by follow-up and family studies [Feighner et al., 1972]. Clearly, if the DSM-III Task Force had adopted this strategy, as Widiger et al. implied, it would not have recommended that DSM-III include over 200 categories — most of which were included on the basis of expert clinical judgment [face validity] alone. The Task Force recognized, correctly I believe, that limiting DSM-III to only those categories that had been fully validated by empirical studies would be at the least a serious obstacle to the widespread use of the manual by mental health professionals. The approach that was adopted by the DSM-III Task Force, from Robins and Guze’s recommendations, was the use of specified diagnostic criteria for virtually all of the disorders—the major innovation of DSM-III.

Expert Consensus Versus Empirical Basis: It is understandable that Widiger et al. (1991) emphasized the many ways in which DSM-IV can improve on the process involved in the development of DSM-III and DSM-III-R, such as by systematically reviewing the relevant literature, documenting the rationale for all changes, and conducting many focused field trials. The DSM-IV leadership is to be congratulated for the tremendous effort that is involved in these projects. However, I am troubled by the tendency [intended or not] to play down the major role that expert consensus will have in the final decision-making process for DSM-IV. My own prediction is that when final decisions are made about DSM-IV, they will still be based primarily on expert consensus, rather than on data, as was the case with the DSM-III and DSM-III-R…
Dr. Spitzer gave a straightforward answer. The critics were right. They had primarily relied on expert opinion. And in spite of the DSM-IV Task Force’s attempts to get on a more empirical footing with literature reviews and Field Trials, Dr. Spitzer predicted that the DSM-IV would end up doing the same thing – relying on expert consensus. The part they’d taken from Robins and Guze, or the Feighner Criteria was the use of specified diagnostic criteria. The list, it seems, was dwindling out of the gate:
  1. no a priori principles
  2. descriptive criteria
  3. follow-up
  4. family studies
  5. exclusivity
  6. reliability
  7. undiagnosed psychiatric disorder
Now we come to no a priori principles. We all know that the predominance of psychoanalytic thinking in psychiatry was the problem being dealt with in those days. But critics raised the question about the DSM-III thinking that replaced it. Was it really etiologically neutral? Spitzer responded in this paper a decade later:

Are DSM-III and DSM-II1-R Atheoretical With Regard to Etiology? As is well known, the developers of DSM-III and DSM-IIIR claim that—with only a few exceptions, such as the organic mental disorders and adjustment disorder—the classification does not subscribe to any particular etiologic theories. For example, some investigators who have studied panic disorder believe that the disorder arises from learned avoidance responses to conditioned somatic symptoms of anxiety; other investigators believe the disorder results from a dysregulation of biological systems mediating separation anxiety. However, neither etiologic theory has any effect on the diagnostic criteria for the disorder, which are solely based on the descriptive features of the disorder. Therefore, I am puzzled by Millon’s (1991) statement that "despite assertions to the contrary, recent DSMs are a product of implicit causal or etiologic speculation"…
I accept that Dr. Spitzer believed what he said. However, he was not the only psychiatrist involved. There were others – lots of others. I was actually alive during most of this period. In the sixties, I was a medical student and later Internal Medicine resident in Memphis Tennessee. We all knew that the center of the biological psychiatry world was St. Louis. The reason we knew is that’s what we were told. In medical school, in the sparse behavioral science course, a lecturer drew a US map, and told us that the biological psychiatrists were in programs along the Mississippi River, putting a line around the center of the country that included St. Louis, Memphis, New Orleans. My friend Bill married a psychiatry resident who told us [every time she had too much wine]. Later, as a psychiatry resident in the 1970s, we heard the same thing. We had people in Atlanta trained in St. Louis, young psychiatrists on staff at the VAH mainly, who literally preached about the non-scientific-ness and non-medical-ness of psychoanalysis – talking only of biology and the neo-Kraepelinian creed, which is where I first heard it. They said all of these things, repetitively [with or without beverages]:
    1. Psychiatry is a branch of medicine.
    2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.
    3. Psychiatry treats people who are sick and who require treatment.
    4. There is a boundary between the normal and the sick.
    5. There are discrete mental illnesses. They are not myths, and there are many of them.
    6. The focus of psychiatric physicians should be on the biological aspects of illness.
    7. There should be an explicit and intentional concern with diagnosis and classification.
    8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.
    9. Statistical techniques should be used to improve reliability and validity.
During the time when the DSM-IV Revision was coming to a close, the question of a priori principles in the DSM Revolution was still being debated:
On Values in Recent American Psychiatric Classification
by John Z. Sadler, Yosaf F. Huglus and George J. Agich
The Journal of Medicine and Philosophy 1994 19:261-277.

The DSM-IV, like its predecessors, will be a major influence on American psychiatry. As a consequence, continuing analysis of its assumptions is essential. Review of the manuals as well as conceptually-oriented literature on DSM-III, DSM-III-R, and DSM-IV reveals that the authors of these classifications have paid little attention to the explicit and implicit value commitments made by the classifications. The response to DSM criticisms and controversy has often been to incorporate more scientific diversity into the classification, instead of careful inquiry and assessment of the principal values that drive the nosologic process. Implications for psychiatric science and future DSM classifications are discussed.
It’s a long and deep article about a lot of things, but it gets around to the a priori principles point along the way:
One reason why value conflict is not seen as such by DSM-IV – and its predecessors, to be sure – is the apparent adherence of the Task Force to a particular view of classification and science. A large literature establishes that medical practice [and scientific practice as well], including classification, necessarily involves value commitments… For a psychiatric classification example, consider the above mentioned dispute over DSM-III/III-R’s descriptive terms. Psychodynamically oriented psychiatrists believe the nosology ignored theoretically important terms essential to their practice [such as "neurosis" and "defense mechanism"]. The syndromatic approach used by DSMIII/ III-R, however, met the descriptive needs of biological psychiatry much better… The implicit value choice made by the authors of DSM-III/III-R was that the biological descriptive approach was more important than the psychodynamic descriptive approach, presumably for a variety of reasons. We doubt that this preference for biological approaches that is implicit in the descriptive, syndromatic approach was consciously intended by the authors of the DSM-III and III-R. Instead, we suspect that this preference and its associated commitments were more the byproduct of a naive view of science and psychiatric nosology as value-free or value-neutral… Although the notion of value-free or value-neutral science has been discredited by a large number of authors, philosophers and scientists… the view nonetheless persists. The reasons for the rejection of value-neutral language are many, but can be summarily stated:
    Values, not cognitions, determine what we select as "important," "crucial," "central," "decisive," or "related." In other words, values lend structure to the field of attention, pre-defining background and foreground, and clustering disparate items into groups. Consequently, "descriptive" statements about psychopathology issue from presupposed value stances that conceal their own deeper sources, compatibilities, and incompatibilities…
It’s a complicated way of saying it, but it’s on point. Dr. Spitzer and his colleagues may not have wanted to make a choice between psychology and biology, but they for sure didn’t want to choose psyhology or psychoanalysis. So they chose the language of the biologists, and by doing so implicitly chose biology. These authors must’ve struck a nerve with Dr. Spitzer, because seven years later, he was still thinking about their article – some two decades after the publication of the DSM-III:
Values and Assumptions in the Development of DSM-III and DSM-III-R:
An Insider’s Perspective and a Belated Response to Sadler, Hulgus, and Agich’s “On Values in Recent American Psychiatric Classification”
Journal of Nervous and Mental Disease. 2001 189:351–359.

…Let us broadly divide etiological perspectives into two major … groupings: according to the biological perspective, the causes of mental disorders will ultimately be shown to be disturbances in biological functioning that are relatively independent of life experience; according to the psychological perspective, the major causes of mental disorders will ultimately be shown to be disturbances in life experiences. The author challenges anyone to show how grouping disorders together on the basis of their shared descriptive features … inherently suggests favoring either perspective.

…I recall a psychoanalyst and chair of a DSM-III oversight committee who commenting on a draft of DSM-III said, “There is so much more that we know.” By this, he meant that DSM-III did not include all of the knowledge that his fellow clinicians had painstakingly learned about human behavior and motivation from the intensive study of patients in long-term psychotherapy. In a sense, the real controversy about DSM-III was a controversy about who were the leaders in the profession and whether progress in our field was most likely to come from empirical research studies or from clinical wisdom collected by intensive long-term psychotherapy. It is hard to see how the controversy would have been conducted at a higher level if the DSM-III committee had made any clearer their value commitments.
Sadler et al. are correct when they assert that basic values, assumptions, and commitments determine how developers of a classification system of mental disorders approach their difficult task. In this paper, we have presented those values, assumptions, and commitments, which were, for the most part, widely known and were contained in the ongoing DSM-III and DSM-IIII-R literature. It is not true that DSM-III and DSM-III-R gave greater emphasis to reliability than to validity, and it is not true that the DSM atheoretical approach with regard to etiology is implicitly biased toward a particular etiological perspective [organic or behavioral].
He stood by his claim of neutrality with the counter that the alternative couldn’t be proven, but added, "In a sense, the real controversy about DSM-III was a controversy about who were the leaders in the profession and whether progress in our field was most likely to come from empirical research studies or from clinical wisdom collected by intensive long-term psychotherapy," which was, of course, the real central question in his mind. So I’ll accept what Dr. Spitzer thinks about his own compromise. But as for Psychiatry as a whole, I buy the implicit choice argument. I was alive then too, and my immediate thought when I got around to reading the DSM-III was, "This is that St. Louis thing." I trust that thought. So from my perspective, revisiting the dream, we now have:
  1. no a priori principles
  2. descriptive criteria
  3. follow-up
  4. family studies
  5. exclusivity
  6. reliability
  7. undiagnosed psychiatric disorder
There were other criticisms, one of which is almost too big to even talk about – Validity. Were the disorders of the DSM-III and its followers valid? I’ll punt that one down the road for the moment…

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I’m a huge fan of infographics. I have a big collection of them on a pinterest board (you’d think I’d have better things to do with my time–which I do. But my daughter has introduced me to the time-drain of social media–and, fortunately, managed some of its more peripheral details [aka pinterest boards]). Infographics do in an [...]

via 1 Boring Old Man by Mickey on 5/12/12
The Robins and Guze article that lead to the DSM-III Revolution was accepted for publication in January 1970, not long after the DSM-II came out – highlighting the fact that the conflict between nature and nurture was living and well before its ink dried. While it’s seen as a Manifesto, it’s only a few lines long:
Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia
American Journal of Psychiatry. 1970 126[7]:107-111.

Since Bleuler, psychiatrists have recognized that the diagnosis of schizophrenia includes a number of different disorders. We are interested in distinguishing these various disorders as part of our long-standing concern with developing a valid classification for psychiatric illnesses. We believe that a valid classification is an essential step in science. In medicine, and hence in psychiatry, classification is diagnosis.

One of the reasons that diagnostic classification has fallen into disrepute among some psychiatrists is that diagnostic schemes have been largely based upon a priori principles rather than upon systematic studies. Such systematic studies are necessary, although they may be based upon different approaches. We have found that the approach described here facilitates the development of a valid classification in psychiatry. This paper illustrates its usefulness in schizophrenia…
The essence of their approach [the St.Louis Group] was to move psychiatry to a diagnostic system based on systematic studies rather than expert opinion. In 1972, they followed with a seminal article laying out sixteen psychiatric diagnoses with descriptive criteria that they considered to be research level diagnoses, now known as the Feighner Criteria which stressed descriptive criteria, follow-up, and family studies as the alternative to "best clinical judgement and experience" AKA expert opinions used in the DSM-I and DSM-II:
Diagnostic criteria for use in psychiatric research
Archives of General Psychiatry. 1972 26:57-63.

This communication presents specific diagnostic criteria for those adult psychiatric illnesses that have been sufficiently validated by precise clinical description, follow-up, and family studies to warrant their use in research as well as in clinical practice. These criteria are not intended as final for any illness. The criteria represent a distillation of our clinical research experience, and of the experiences of others cited in the references. This communication is meant to provide common ground for different research groups so that diagnostic definitions can be emended constructively as further studies are completed. The use of formal diagnostic criteria by a number of groups, regardless of whether their interests are clinical, psychodynamic, pharmacologic, chemical, neuropsychological, or neurophysiological, will result in a solution of the problem of whether patients described by different groups are comparable. This first and crucial taxonomic step should expedite psychiatric investigation.

Diagnosis has functions as important in psychiatry as elsewhere in medicine. Psychiatric diagnoses based on studies of natural history permit prediction of course and outcome, allow planning for both immediate and long-term treatment, and make communication possible between psychiatrists and other physicians, as well as among psychiatrists themselves. Such functions are of obvious importance in research. In contrast to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders [DSM-II], in which the diagnostic classification is based upon the "best clinical judgement and experience" of a committee and its consultants, this communication will present a diagnostic classification validated primarily by follow-up and family studies…
Here’s a sampler of the Feighner Criteria [that might look real familiar]:
Primary Affective Disorders.

    —For a diagnosis of depression, A through C are required.
    A. Dysphoric mood characterized by symptoms such as the following: depressed, sad, blue, despondent, hopeless, "down in the dumps," irritable, fearful, worried, or discouraged.
    B. At least five of the following criteria are required for "definite" depression; four are required for "probable" depression.
    1. Poor appetite or weight loss (positive if 2 lb a week or 10 lb or more a year when not dieting).
    2. Sleep difficulty (include insomnia or hypersomnia).
    3. Loss of energy, eg, fatigability, tiredness.
    4. Agitation or retardation.
    5. Loss of interest in usual activities, or decrease in sexual drive.
    6. Feelings of self-reproach or guilt (either may be delusional).
    7. Complaints of or actually diminished ability to think or concentrate, such as slow thinking or mixed-up thoughts.
    8. Recurrent thoughts of death or suicide, including thoughts of wishing to be dead.
    C. A psychiatric illness lasting at least one month with no preexisting psychiatric conditions such as schizophrenia, anxiety neurosis, phobic neurosis, obsessive compulsive neurosis, hysteria, alcoholism, drug dependency, antisocial personality, homosexuality and other sexual deviations, mental retardation, or organic brain syndrome. (Patients with life-threatening or incapacitating medical illness preceding and paralleling the depression do not receive the diagnosis of primary depression.)
    —For a diagnosis of mania, A through C are required.
    A. Euphoria or irritability.
    B. At least three of the following symptom categories must also be present.
    1. Hyperactivity (includes motor, social, and sexual activity).
    2. Push of speech (pressure to keep talking).
    3. Flight of ideas (racing thoughts).
    4. Grandiosity (may be delusional).
    5. Decreased sleep.
    6. Distractibility.
    C. A psychiatric illness lasting at least two weeks with no preexisting psychiatric conditions such as schizophrenia, anxiety neurosis, phobic neurosis, obsessive compulsive neurosis, hysteria, alcoholism, drug dependency, antisocial personality, homosexuality and other sexual deviations, mental retardation, or organic brain syndrome.
So to no a priori principles, descriptive criteria, follow-up, and family studies, they’ve added mutual exclusivity [see C. in each case]. There’s essentially no comorbidity allowed in these criteria. Robert Spitzer and Statistician Joseph Fleiss added Kappa to the mix two years later – concretely including reliability in the mixture [see box scores and kappa…, self-evident…]:
A Re-analysis of the Reliability of Psychiatric Diagnosis
British Journal of Psychiatry. 1974 125:341-347.

… With respect to improving the nomenclature, the St.Louis group has offered a system limited to 16 diagnoses for which they believe strong validity evidence exists, and for which specified requirements are provided. Whereas in the standard system the clinician determines to which of the various diagnostic stereotypes his patient is closest, in the St. Louis system the clinician determines whether his patient satisfies explicit criteria. For example, for a diagnosis of the depressive form of primary affective disorder the three requirements are dysphoric mood, a psychiatric illness lasting at least one month with no other pre-existing psychiatric condition,and at least five of the following eight symptoms: poor appetite or weight loss; sleep difficulty; loss of energy; agitation or retardation; loss of interest in usual activities or decrease in sexual drive; feelings of self-reproach or guilt; complaints of or actually diminished ability to think or concentrate; and thoughts of death or suicide.

A consequence of the St. Louis approach is the necessity for an ’undiagnosed psychiatric disorder’ category for those patients who do not meet any of the criteria for the specified diagnoses. In actual use, this category is applied to 20-30 per cent of newly-admitted in-patients. These two approaches, structuring the interview and specifying all diagnostic criteria, are being merged in a series of collaborative studies on the psychobiology of the depressive disorders sponsored by the N.I.M.H. Clinical Research Branch. We are confident that this merging will result not only in improved reliability but in improved validity which is, after all, our ultimate goal.
In this 1974 paper, they did a meta-analysis of previous inter-rater reliability studies using their Kappa for comparisons [see box scores and kappa…]. In talking about the Feighner Criteria, Spitzer mentions one of the consequences of having such a tightly defined system, "In actual use, this category is applied to 20-30 per cent of newly-admitted in-patients" speaking of his own study. There were people left over that didn’t fit anybody’s diagnostic criteria. They were unsullied by using undiagnosed psychiatric disorder, adding yet another item to the list. He mentioned an N.I.M.H. collaborative study on the psychobiology of the depressive disorders, where he next focused his attention. And it expanded outside the boundaries of depressive illness. Like the Feighner Criteria, the N.I.M.H. Research Diagnostic Criteria [RDC] were advertised as research criteria, but they were headed for your town sooner rather than later as the new DSM-III.
One can only be awed by Robert Spitzer’s industry in those years. At the time, I was in analytic training in his building, the New York Psychiatric Institute. I had no idea of the flurry of activity going on upstairs. The building was always too hot, complicating staying alert in those after lunch classes. I now suspect that it was overheated by Spitzer’s energetic activities and endless debates.
This next study was published as the time for the release of the DSM-III neared. The Research Diagnostic Criteria were a refined subset from the earlier Feighner Criteria. It was to be the reliability study for the coming release of the new diagnostic manual.
Research Diagnostic Criteria Rationale and Reliability
by Robert L. Spitzer, MD; Jean Endicott, PhD; and Eli Robins, MD
Archives of General Psychiatry. 1978 35:773-792.

A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria [RDC]. The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria…
This is a complex paper. I think it’s the one that justified ‘lumping’ the depressions so I’ll likely be back to it later. But for the moment, it’s a message from a time when men were men, and Kappa was KAPPA:
Little wonder Dr. Spitzer introduced his DSM-III in 1980 to a standing ovation at the APA. In a few short years, he had mustered the forces to create a new diagnostic system backed by a hard science – something new for the likes of Psychiatry. The assemblage was at least clapping for his and his colleagues’ accomplishment, and whether you agree with the product or not, you’ve got to give them credit for building it – a Rosie the Riveter level task extraordinaire. Here are the nuts and bolts for review:
  1. no a priori principles
  2. descriptive criteria
  3. follow-up
  4. family studies
  5. exclusivity
  6. reliability
  7. undiagnosed psychiatric disorder

via The Amazing World of Psychiatry: A Psychiatry Blog by Dr Justin Marley on 5/12/12

This week there has been a large media response to the discussion of DSM-V at the American Psychiatric Association’s (APA) 165th Annual Conference (see also Appendix I). Positive Psychiatry, DSM-V and Mental Health in the older adult population have all been important topics at the APA Conference. There are several videos from the APA Conference on the Webs Health Edge Channel.
Dr James Scully, CEO of the APA gives an overview of the 165th Annual Conference in this video
The President Elect Professor Jeremy Lazarus of the American Medical Association speaks in this video about a trend towards integrated care where Medical and Psychiatric services can work together
An important issue that was addressed at the conference was the criminalisation of people with mental illnesses and this is discussed by Dr Marcia Goin and Dr Ken Rosenberg in this video
In this video, Judge Steven Leifman talks about strategies for keeping people with mental illnesses out of prison
In this video there is a discussion of some of the research that is being presented at the conference
The APA is inviting people including non-APA members to submit comments in response to the draft version of DSM-V in the 6 week period from May 2nd 2012-June 15th. This means that interested individuals or groups can become stakeholders in the revision process. Professor Kupfer has indicated that there have already been more than 11,000 comments submitted from across the world. The APA is inviting people including non-APA members to submit comments in response to the draft version of DSM-V in the 6 week period from May 2nd 2012-June 15th. This means that interested individuals or groups can become stakeholders in the revision process. Professor Kupfer has indicated that there have already been more than 11,000 comments submitted from across the world.
The latest changes in draft version include a clarification on Bereavement Reactions, field trial data supporting the categorical diagnosis of Borderline Personality Disorder, a separation of Language and Speech Disorders, Somatic Symptom Disorder as a combination of two separate disorders and changes to the Neurocognitive and Anxiety Disorders. The more recent changes have also been covered elsewhere in the media.
The New York Times has several feature articles on DSM-V. In this article there is an examination of the Addiction category with the prediction that diagnosis rates will increase with the new criteria. This article looks at the decision to remove Mixed Anxiety and Depressive Disorder as well as the Psychosis Risk Syndrome. There is also a look at the proposed changes in the Autistic Spectrum Disorders and Asperger Syndrome along with recent research findings in this area. Time Magazine covers the proposed change of Post Traumatic Stress Disorder to Post Traumatic Stress Injury in response to the perceived stigma of the word disorder. There is also coverage of the removal of Psychosis Risk Syndrome at Nature. There is also a Reuters piece on some of the changes.
In the Blogosphere there is coverage of the APA Conference at ShrinkRap while in another post, Dinah responds to a critical post about DSM-V by Paula Caplan. There is a good round-up of DSM-V related news at Shrink Things. There is also a round-up which links to more critical views of DSM-V at the AltMentalities Blog which are broadly divided into camps which are either against the concept of a Diagnostic Manual or else are critical of some of the changes advocated in DSM-V.
Appendix I – Other DSM-V Articles on the TAWOP Site
Explaining DSM-V: Interview with Professor David Kupfer, Chair of the APA DSM-V Taskforce
Another Scientific American Article on DSM-V: Is This A Step Too Far?
The Debate on DSM-V with Scientific American Continues
The Day I Got Frustrated Reading An Article About Psychiatry In Scientific American
Asperger Syndrome Could Be Removed As A Diagnosis In DSM-V
Causality and DSM-V
Appendix II – Previous DSM-V Related News Items Discussed on the TAWOP Site
The news items below are unedited and must be interpreted in terms of the subsequent developments. They help to set the context for the current discussion.
DSM-V and ICD-11
The draft DSM-V criterion for a mixed depressive episode are being expanded to fit more closely with clinician’s experience and there are further details here. The new version of the World Health Organisation Classification of Disease (ICD-11) is displayed in draft version here. This is a work in progress with daily updates and it will allow people to comment from July 2011 onwards. I checked out the Mental and Behavioural Disorders section and there was just a little information there (relating to indexes for mortality) at the moment. The World Psychiatric Association have a very interesting paper on the use of the ICD-10 diagnostic system by psychiatrists. The researchers surveyed 4887 psychiatrists across the world using an internet based survey tool. The use of ICD-10 varied from 0% in Kenya and 1% in the USA to 100% in Kyrgyzstan, FYRO Macedonia and Slovenia. 71% of the psychiatrists surveyed used ICD-10 as their main diagnostic system. DSM-IV was the main diagnostic system for 23% of the psychiatrists surveyed (unweighted). 14.1% (unweighted) of the sample set ‘sometimes’ used a diagnostic system and 1.3% used the older versions of ICD-10 – ICD-9 or ICD-8 for diagnostic purposes. There is also a critical look at DSM-V at ‘Boring Old Man’ which highlights the wider debate in society.
The draft changes for DSM-V have been published by the American Psychiatric Association Draft Development Team for DSM-V here. I might have overlooked something but it looks as though it is an overview of the changes being suggested for specific conditions that are being presented.
Firstly I was interested in what amounts to a wholescale reclassification of the Dementias and related conditions into Major and Minor Neurocognitive Disorders. There are some nice ideas contained within this move including the consideration that it is not only memory which needs to be affected. However I was unclear on reading the descriptions of whether it would include the subtypes as I could find no mention of this. However it would be unusual if the various subtypes of dementia for which there is an abundance of evidence were not included as subtypes within this framework as this could be considered a step backward. Additionally I couldn’t find any mention of the term Mild Cognitive Impairment (although there are some broad similarities with minor neurocognitive disorder) and the various subtypes for which there is an emerging evidence base and which is the focus of research in the hope that a better understanding could lead to prevention or amelioration of subsequent dementia.
There were very few changes here. One suggestion was to use a catatonia specified elsewhere instead of catatonia secondary to a medical disorder.
There are some big changes in the Personality Disorders. These have been reduced from 10 to 5. One of the difficulties with the current Personality Disorder types is the diagnostic overlap. A person may fulfill the criteria for more than one type of personality disorder. There are a number of changes to the criteria which should improve reduce the number of comorbid personality disorder diagnoses. A simple Likert-scale is used for quantifying personality and personality traits and the five types are Borderline Personality Disorder, Antisocial/Psychopathic Type, Avoidant Type, Obsessive-Compulsive Type and Schizotypal Type.
There are a large number of new diagnostic labels being considered for inclusion and subsuming current labels. For instance alcohol dependence syndrome may be subsumed under Alcohol-use disorder. Cannabis withdrawal is another diagnosis being introduced. The discussions around the terms ‘addiction’ and ‘dependence’ are discussed below.
There are big changes to the diagnosis of Schizophrenia with a proposal for removing subtypes including Paranoid Schizophrenia, Disorganised and Catatonic schizophrenia. Changes are being suggested in order to bring DSM-V into closer alignment with ICD-10. Proposed changes to the criteria for Schizoaffective Disorder are meant to increase reliability. ‘Psychosis Risk Syndrome‘ is being introduced (see further discussion below) and a Catatonia Specifier is being suggested. This is apparently because catatonia is ‘often not recognised’.
Mixed anxiety and depression disorder is being introduced with criteria that avoid ambiguity. This is currently included in the appendix of DSM-IV. There is a proposal to rename Dysthymic Disorder as chronic depressive disorder. There is a proposal to replace Bipolar Disorder Most Recent Episode Mixed with a mixed specifier. There are a number of changes in the criteria of Manic Episode particularly around energy levels.
The proposal is to include Obsessive-Compulsive Disorder under a new category of ‘Anxiety and Obsessive-Compulsive Spectrum Disorders’. The changes here are further discussed in the ‘PsychBrownBag’ Blog and the ‘OCD Center of Los Angeles’ Blog below.
There is a proposed amalgamation of four conditions into ‘Complex Somatic Symptom Disorder‘ but for further discussion see the ‘OCD Center of Los Angeles’ Blog below.
The proposal is to reclassify Factitious Disorders under Somatic Symptom Disorders.
Theere is a proposal to subsume Dissociative Fugue under Disssociative Amnesia. Similarly there is a proposal to remove Dissociative Trance Disorder and integrate the criteria into the diagnosis of Dissociative Identity Disorder which has a number of other proposed changes.
There are a number of new diagnoses.
A new diagnosis of Binge-Eating Disorder is recommended (for further discussion see below). In Anorexia Nervosa there is the proposal to remove the criterion of amenorrhoea whilst in Bulimia Nervosa there are some proposed changes to the frequency of binge eating episodes and the purging criteria.
There are a number of new conditiosns (a number of which subsume other conditions) including Klein-Levin Syndrome, Primary Central Sleep Apnoea, Primary Alveolar Hypoventilation, Rapid Eye Movement Behaviour Disorder and Restless Leg Syndrome amongst others. There are a number of changes to the criteria for narcolepsy including hypocretin deficiency.
There are a large number of suggested changes including the removal of Rett’s Disorder, a number of proposed changes to the Attention Deficit and Hyperactivity Disorder criteria, the inclusion of Post-Traumatic Stress Disorder in school age children and Temper Dysregulation Disorder with Dysphoria which is further discussed below. Interestingly the wording for Separation-Anxiety Disorder may be changed so that it can be used with adults also. This is because there is evidence for an adult separation-anxiety disorder.
There is a proposal to include Pathological Gambling with substance-related disorders. There are proposed changes for Trichotillomania further discussed below.
There is a proposal to move Adjustment Disorder to a grouping of Trauma and Stress-Related Conditions.
Discussion of the Draft DSM-V Changes Elsewhere in the Media
Links to some of the discussions elsewhere in the media are given below.
The Time article looks at a number of proposed changes for DSM-V which includes the criteria for making a diagnosis of depression,use of a continuum and the case for autistic spectrum disorders, the possible grouping of non-dependence inducing substances together with dependence inducing substances in the addiction and related disorders, reducing the number of personality disorder types and making some amendments to some of the sexual disorders. Over at PsychCentral, Dr Grohol looks at a number of features of the DSM-V draft. He is encouraging of the inclusion of Binge Eating Disorder, but is critical of the criteria used in Minor Neurocognitive Disorder, Behavioural Addictions and also Temper Dysregulation Disorder which has a narrow time period fo 6 to 10 years for diagnosis. Over at the ‘Psyche Brown Bag‘ blog, Joyce Anestis comments on the restructuring of the multiaxial system as well as the arrival of a number of new disorders including ‘hoarding disorder’, ‘olfactory reference syndrome’, ‘skin picking disorder’ and ‘psychosis risk syndrome’ amongst others and is also confused by the proposed changes to the personality disorders. The Times has a look at a number of the proposed changes including ‘sluggish cognitive tempo disorder’. Web MD has an article on the changes and features an interview with Dr First who is critical of the utility of the diagnosis of ‘Psychotic Risk Syndrome’.
Dr Dan Carlat has a discussion of the proposed criteria on his blog and seems fairly positive on these (however I would just add that there are neurobiological criteria for a number of disorders in DSM-IV/DSM-V draft e.g Hypocretin Deficiency in Narcolepsy above). He notes that Temper Dysregulation Disorder is being favoured as it would avoid a diagnosis of Bipolar Disorder in children in a number of cases. He’s in favour the use of addiction in place of dependence or abuse and also the use of the concept of Binge-Eating Disorder. The New York Times has a piece featuring interviews with several psychiatrists and 230 comments at the time of writing. Integral Options cafe has links to a number of posts including those on the NPR site. An article at the NPR website examines the limits of the checklist approach and how severity might be measured when using a dimensional approach. The Economist has a piece on the history of the diagnostic criteria but also cover some of the disputes that have taken place. ‘DSM-V and ICD-11 watch’ have some interesting links as well as a brief look at suggestions for medically unexplained symptoms. Dr Finnerty has an overview of proposed changes as well as some useful links. Mind Hacks has coverage here and here. The APA have a facebook site that interested readers can join.
Stanton Peele covers the proposed use of the term addictions in this ‘The Huffington Post’ article. The ‘Join Together‘ website features an interview with Dr Charles O’Brien who is chair of the APA’s DSM substances related disorders workgroup. He explains the distinction between dependence and addiction and the consideration of including the term addiction in DSM-V. They also discuss the possibility of collecting behavioural addictions together with alcohol and other drug related disorders.
Anxiety Disorders and OCD
Tom Corboy director of the ‘OCD Center of Los Angeles’ writes about a number of proposed changes over at the ‘OCD Center of Los Angeles’ blog. Thus Corboy discusses the suggested use of an ‘Anxiety and Obsessive Compulsive Disorder Spectrum’. Corboy is also critical of the suggestion of agaraphobia without panic disorder, in favour of moving Body Dysmorphic Disorder into the ‘Anxiety and Obsessive Compulsive Disorder Spectrum’ and adding a muscle dysmorphia variant, critical of the aggregation of 4 somatoform disorders including hypochondriasis, in favour of the relabelling of trichotillomania as ‘hair pulling disorder’ and also for the inclusion of skin picking disorder.
Intellectual Disability
Over at the blog ‘Mental Incompetence and the Death Penalty‘ there is a guest post by Dr Watson. He criticises the proposed criteria for intellectual disability on the basis that there doesnt appear to be a consideration of the standard error for IQ testing meaning that there is what he describes as a ‘bright light’ cut-off point of 70 or below whereas in practice there is a group that are scored over 70 who would still be included amongst a number of criticisms.
Bipolar Disorder in Children
Over at the NPR website, there is a wider discussion of the diagnosis of Bipolar Disorder in children as well as the more recent ‘Temper Dysregulation Disorder’.
Autistic Spectrum Disorders
The Left-Brain Right-Brain blog compares the criteria in DSM-IV with those in DSM-V for autistic disorder and autistic spectrum disorders respectively and links to a number of other articles on the subject. There is another discussion of the autistic spectrum disorders proposition here. There is further coverage here and here.
Eating Disorders
Time has a piece on orthorexia which hasn’t made it into the draft version of DSM-V. There is also coverage of the proposed changes at the Ed-Bites blog (with 15 comments at the time of writing).
Dr Dan Carlat takes a further look at the DSM-V draft proposals here. Dr Charles Parker has further coverage here and also over at the Corpus Callosum blog. There is a look at grief in the draft DSM-V proposals at Psychotherapy Brown Bag.
DSM-V and ICD-11
In the BJPsych there is an interesting article by Professor Michael First who writes about the potential for harmonisation of DSM-V and ICD-11 which is a widely discussed topic (First, 2009). There are a number of points of interest in the article and he notes that there are investigators involved with revisions of both systems which should help to contribute to attempts to harmonise both systems. The discussions around these systems will no doubt increase.
There was discussion recently of the diagnosis of Asperger syndrome being dropped from the next edition of the DSM and this will mean an expansion of the autism diagnostic category. This was originally discussed in a New York Times article (which requires (free) registration). The article features an interview with Dr Catherine Lord, who is one of 13 members of the working group on autism and Neurodevelopmental Disorders. The group are considering a number of amendments to the autism diagnosis including the addition of comorbidity that have been associated with the condition including disorders of attention and anxiety. However the suggestion regarding Asperger syndrome has not yet been ratified by the group. There have been a number of responses in the media. This article contains interviews with a doctor who runs a clinic, a parent of a child with Asperger’s syndrome and the president of a non-profit organisation for raising awareness of the condition. There is some information on the DSM-V process here.
DSM-V is due to appear in 2012. A twitter campaign has been started to petition for the inclusion of Depressive Personality Disorder in DSM-V. Professor Simon Baron-Cohen has argued against the removal of the Asperger Syndrome label in this New York Times article. Dr Anestis offers his views on this article and Baron-Cohen responds in this blog post.
Michael First. Harmonisation of ICD-11 and DSM-V: Opportunities and challenges. The British Journal of Psychiatry. 2009. 195. 382-390.
An index of the TAWOP site can be found here and here. The page contains links to all of the articles in the blog in chronological order. Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link. Podcast: You can listen to this post on Odiogo by clicking on this link (there may be a small delay between publishing of the blog article and the availability of the podcast). It is available for a limited period. TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link. Responses: If you have any comments, you can leave them below or alternatively e-mail Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

via candidaabrahamson by rfinkel on 5/12/12
With the roll-out of Clozaril, in 1989, with its promise to treat recalcitrant schizophrenics, the era of the second-generation, or ‘atypical,’ antipsychotics, was born. And there is much the atypicals offer over the first-generation antipsychotics, including freedom from fear from the worst side effects: tardive dyskinesia, with its uncontrolled involuntary movements, uncontrollable tremors, akathisia, with its inability to [...]

via MOTHERBOARD by Amy_Teitel on 5/12/12
Lib_thumbAlliant Techsystems is poised to take first prize in the commercial space game.

via MOTHERBOARD by Amy_Teitel on 5/12/12
Liberty_page_1-500x647_thumbAlliant Techsystems is poised to take first prize in the commercial space game.

via The Amazing World of Psychiatry: A Psychiatry Blog by Dr Justin Marley on 5/12/12

There is an interview with the chair of the American Psychiatric Association’s (APA) DSM-5 taskforce, Professor David Kupfer on Web Edges Health channel. DSM-V is the pending fifth edition of the Diagnostic and Statistical Manual of Mental Diseases, the American diagnostic manual for mental illnesses which is used internationally. Professor Kupfer gives an insight into some of the DSM-V related activities taking place at the American Psychiatric Association’s 165th Annual Meeting. He also invites commentary on the draft edition of DSM-V and this invite is also open to non-APA members. There have already been 11,000 comments from individuals and groups from around the world.
An index of the TAWOP site can be found here and here. The page contains links to all of the articles in the blog in chronological order. Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link. Podcast: You can listen to this post on Odiogo by clicking on this link (there may be a small delay between publishing of the blog article and the availability of the podcast). It is available for a limited period. TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link. Responses: If you have any comments, you can leave them below or alternatively e-mail Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

via candidaabrahamson by candidaabrahamson on 5/12/12
In May, 2008, the House if Representatives voted to make May Borderline Personality Disorder (BPD) awareness month. Although not as well-known as bipolar disorder or schizophrenia, the disorder is actually at least as common, found in 1-2% of the adult population, most frequently women. Patients account for 20% of inpatient hospitalizations. According to the DSM-IV-TR, [...]

via MOTHERBOARD by Jenn_Frank on 5/12/12
Paprika_thumbDeveloped in 1994 and published the following year, <em>Chop Suey</em> was a cunning piece of multimedia edutainment, suited just as well to grown-ups — smirking hipsters and punk rockers, probably — as it was to the prescribed “girls 7 to 12” crowd.
But it wasn’t a computer game. It was something else: a loosely-strung system of vignettes; a psychedelic exercise in “let’s-pretend”; a daydream in which the mundanity of smalltown Ohio collides with the interior lives of its two young protagonists.
As the game opens, the Bugg sisters are idling on a grassy knoll, counting clouds and recalling the day’s events. Lily and June Bugg, we are informed, have spent the afternoon with Aunt Vera. The narrator — a yet-unknown <a href="">David Sedaris</a> — sets the scene in nasally twee, occasionally grating reeds.
<strong>“They didn’t know the names of the flowers in which they lay — pollen dusty daisies, wild violets, cornflowers — so June Bugg named them herself, touching a finger to the soft center of each.”</strong>
When Sedaris concludes his opening narration, our player immediately regains control of her cursor. From here she can survey Cortland’s landmarks in any order she chooses, repeating anything she likes. She might revisit lunch at the Ping Ping Palace, where the food is so exotic, it’s often tinted cyan or hot pink. She might play dress-up with Aunt Vera — whom, we suspect, is something of a lush and a man-eater.

. . . Lily and June’s own imaginations illustrate those stories in happier, more magical idioms

The player might go to the carnival to have her fortune read; she might play Bingo. Perhaps she might visit Aunt Vera’s second husband, Bob, or else she could visit Vera’s third husband, also Bob. (Tragically, it is impossible to visit Bob #1, except through occasional flashbacks.)
<strong>“‘A broken heart for every light,’ she said, and sighed, rearranging her pink flowered bathrobe.”</strong>
Most in-game stories are delivered secondhand from a reminiscing grown-up, while Lily and June’s own imaginations illustrate those stories in happier, more magical idioms. The game never oversteps, never makes “regret” its central concern; after all, this is a children’s game. But an adult player might be surprised at how wistful the game actually is.
Wry flourishes give <em>Chop Suey</em> its teeth: Dooner, an unemployed Gen-X slob, hides his girly mag in the dresser’s top drawer. And if our player puts on a pair of X-Ray Spex, Aunt Vera and boyfriend Ned are both reduced, tastefully, to their undergarments.
Were <em>Chop Suey</em> a literal, physical picturebook, it might resemble Richard Scarry’s <em>Busytown</em> as revised by Bratmobile. Alternatively, we might go along with <em>Entertainment Weekly</em>‘s description: “a little like <em>Alice in Wonderland</em> as performed by the B-52s for NPR.” (The magazine went on to name <em>Chop Suey</em> 1995’s <a href=",,300154,00.html">CD-ROM of the Year</a>.)
<em>Chop Suey</em>‘s nearest analog, though, is a very different edutainment title, <em><a href="">Cosmology of Kyoto</a></em>. Released the same year as <em>Chop Suey</em>, <em>Kyoto</em> is another interactive storybook designed to make good on the early-’90s’ promise of CD-based “multimedia.” But <em>Kyoto</em> is technically limited by Macromedia: the game itself feels strangely static, and while there’s lots to explore, there’s little to <em>do</em>.
<em>Chop Suey</em> suffers these failings and worse. All told, it takes only an hour to see everything in the game once, and then there is little incentive to play again, except to remember how the game went. The player can’t “save” her “progress,” because there is no such thing as progress. In 1995 at least one reviewer worried <em>Chop Suey</em> might frustrate children with its circular narrative.

Every moment in the game, however connected, is also suspended in time

But the game’s perpetual loop of story is deliberate: “It works the same way that <em>Alice in Wonderland</em> does, where she leaves home and then she has adventures,” designer Theresa Duncan <a href="">explained in 1998</a>, “but if you took everything in between the beginning and the end of <em>Alice in Wonderland</em> and scrambled up every chapter, it would make no difference to the development of the story.” Every moment in the game, however connected, is also suspended in time.
In an industry glutted by worthless “games” for “girls” — the mid ‘90s begat a tide of titles like <em>McKenzie & Co.</em>, <em>Let’s Talk About Me!</em>, and <em>Barbie Fashion Designer</em> — <em>Chop Suey</em> really did get it right.
<em>Wired</em>‘s Greg Beato was <a href="">certainly impressed</a>. “With its sly whimsy and tactile, folk-art imagery,” Beato writes, "<em>Chop Suey</em> brings a whole new sensibility — quirky, poetic, almost bittersweet — to a medium that’s often lacking in such nuance."
The game’s visual charm owes no small debt to collaborator Monica Lynn Gesue, whose handmade art is at once childlike and sophisticated. Every screen is a frenetic hodgepodge; every animated painting, all squiggles and loop-de-loops.
Nevertheless, <em>Chop Suey</em>‘s main star was Theresa Duncan, whose competence as a game designer inspired a flurry of magazine profiles. But Duncan was celebrated as much for her audacious wardrobe as she was for her intellect. Salon, in 1998, called her <a href="">“a predatory businesswoman,”</a> taking extra care to note how well-dressed she was. In a 2000 issue of <em>Shift Magazine</em> she was heralded "Silicon Valley’s It Girl"; this proclamation was accompanied by a photo spread. <em>Paper</em> <a href="">profiled Duncan</a> as well: “Theresa wears a top by Ashley Pearce.”
In a 1997 issue of <em>Bitch Magazine</em>, Doreen Hinton — who presumably had never seen a glamor shot of Duncan — succeeded in praising <em>Chop Suey</em> itself, saying, “This is the least gender-specific game of all the ones labeled ‘for girls’ by marketers and writers.”
Indeed, where many developers were briefly, madly obsessed with giving pre-teen girls their own tier of games, <em>Chop Suey</em>‘s real accomplishment was that it seemingly targeted nobody. It’s “feminist,” albeit in a 1990s way: subtly, subversively. Not so long ago, girls’ books, girls’ music, and girls’ games demanded to be taken as seriously as the boys’, simply by being <em>better</em> than the boys’ stuff. A ’90s kid could opt to trade Sweet Valley High for <em>Weetzie Bat</em> or a Blake Nelson novel, say.
“[Duncan is] clearly the one to watch among developers of any gender,” Hinton’s article continued. “I can’t wait to see and hear and play her next offering.”
But Theresa Duncan managed only two more games. <em>Smarty</em> (1997) starred an eponymous heroine, Mimi Smartypants, and garnered a fast cult-like following. <em>Zero Zero</em> was released the very same year (“It’s good,” <a href="">conceded the Associated Press</a>, “but it’s no <em>Chop Suey</em>”).

The Internet has been an unkind documentarian, slowly turning <em>Chop Suey</em> from a “has-been” into a “never-was.”

Why isn’t <em>Chop Suey</em> better remembered?
Even as Duncan struggled to market her next two games independently, the 1990s edutainment craze had staggered to a halt.
Despite all its critical acclaim, it’s tough to say whether <em>Chop Suey</em> ever sold well. Anyway, how could it have? By 1997, when I first started searching for a copy, the disc was completely out of production. (I did eventually find the game, in its original box, eight years later.) Tech journalist Sam Machkovech explains that contemporary educational software has no shelf life: “Edutainment sellers quickly realized families would pass CD-ROMs along to friends once their kids had grown out of them,” he told me, “like used baby clothes.”
Computer gamers, too, had lost patience for so-called interactive fiction. The genre was quaint at best; at worst, adventure games were boring.
In the end, though, the Internet’s memory is not too long. A search for <em>Chop Suey</em> uncovers almost nothing, redirecting instead to endless, looping coverage of Theresa Duncan’s 2007 death — a suicide, and a <a href="">salacious one</a> at that. Circular narratives really are frustrating, it turns out.
By 2007, 40-year-old Duncan had reinvented herself as a blogger and filmmaker. As a result, most obituaries blithely skim Duncan’s contributions to children’s edutainment. <a href=""><em>New York Magazine</em> remembers</a> the erstwhile visionary as a “woman spurned by success.” Another article, this one <a href="">from <em>Vanity Fair</em></a>, describes a party at which Duncan “dragged out of a closet her old CD-ROMs”: the writer recasts Duncan’s computer games as some ancient football trophy the woman ought to have been embarrassed about. (The article continues, “‘Everybody kind of looked at each other like, Oh no, what is she doing?’”)
When Duncan reappeared in the news cycle, I thought <em>Chop Suey</em> might finally elicit more attention. I was wrong. A terrible, titillating death is far, far more interesting than an author or artist’s creative output.
Theresa Duncan’s death was assuredly a tragedy. But <em>Chop Suey</em>, like Duncan herself, was a critical darling of its time. The slow retcon of <em>Chop Suey</em> into anything less than a towering achievement is, in itself, tragic. The Internet has been an unkind documentarian, slowly turning <em>Chop Suey</em> from a “has-been” into a “never-was.”
In some ways, <em>Chop Suey</em> is very much a product of the ‘90s. It banked on that decade’s “girl game” boom. Its soundtrack screams alternative radio. Ornate scribbles and doodles glow as if they were lifted from MTV.
In other ways, <em>Chop Suey</em> is timeless. The technology holds up: the disc runs well, even on the latest computers. Duncan’s writing is still fresh, and Gesue’s artwork seems so alive. I’d venture to say that the game has aged “gracefully,” except that it has barely aged at all. <em>Chop Suey</em> is several perfect moments, suspended — “like shiny-dull pearls on a long, long necklace.”
Above all, <em>Chop Suey</em> was brave. It dared to represent the criminally underrepresented: that is, the wild imagination of some girl aged 7 to 12.
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via Faktensucher by curi56 on 5/12/12
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via rajpersaud by rajendra0 on 5/12/12
When doctors go on strike, patients stop dying
By Dr Raj Persaud, Consultant Psychiatrist, and Dr Peter Bruggen, retired Consultant Psychiatrist
As doctors vote on whether to strike in the UK, what’s the likely impact of withdrawing medical care on the health of the nation? The doctor’s union, the British Medical Association, seems to be throwing its chips on a gamble that the government doesn’t want to alarm the electorate.
But when doctors strike, the scientific evidence finds that patients stop dying.
The most comprehensive review of the medical impact of doctors’ strikes is published in the prestigious academic journal Social Science and Medicine. A team, led by Solveig Cunningham and Salim Yusuf at Emory and Georgetown Universities in the US and McMaster University in Canada, analysed five physician strikes around the world, all between 1976 and 2003.¹
In the different strikes analysed, doctors withdrew their labour for between 9 days and 17 weeks. Yet all the different studies report population mortality either stays the same, or even decreases, during medical strikes. Not a single study found death rates increased during the weeks of the strikes, compared to other times.
For example, in a strike in Los Angeles County, California, in January 1976, doctors went on strike in protest over soaring medical malpractice insurance premiums. For 5 weeks, approximately 50% of doctors in the county reduced their practice and withheld care for anything but emergencies. One analysis, quoted by Cunningham and colleagues, found that the strike may have actually prevented more deaths than it caused.
It’s the fact that elective, or non-emergency surgery, tends to stop during a doctors’ strike, which seems to be the key factor. It looks like a surprising amount of mortality occurs following this kind of procedure which disappears when elective surgery ceases due to doctors withdrawing their labour. Mortality declined steadily from week 1 (21 deaths/100,000 population) to week 6 (13) and 7 (14), when mortality rates were lower than the averages of the previous 5 years. However, as soon as elective surgery resumed, there was a rise in deaths. There were 90 more deaths associated with surgery in the 2 weeks following the strike in 1976 (ie when doctors went back to work) than there had been during the same period in 1975.
But, unlike Los Angeles, what about the impact of doctors’ industrial action where the majority of doctors participate, and the strike lasts several months?
Cunningham and colleagues report on a strike in Jerusalem from 2 March to 26 June 1983 due to a salary dispute between the government and the Israel Medical Association. 8,000 of Jerusalem’s 11,000 physicians refused to treat patients inside hospitals, though many of them set up separate aid stations where they treated emergency cases for a fee.
One analysis examined death certificates from several months surrounding the strike period, 16 February-3 September 1983, and from a control period the previous year, 17 February-3 September 1982. Mortality did not increase during or after the strike, even when elective surgery resumed. The pre-strike deaths for the control period and the strike period were identical at 89; there were six fewer deaths during the strike than during the control period, while in the 10 weeks following the strike, there were seven more deaths than there had been in 1982.
In an intriguing example of how a doctors’ strike can backfire, the authors of this particular mortality analysis argue that this apparent lack of impact of the strike on mortality suggests that there was an over-supply of doctors in Jerusalem at the time. The problem with drawing conclusions remains that the strike did not involve the whole scale deprivation of medical services. Cunningham and colleagues point out in their review paper that striking physicians opened aid stations, supplementing medical care and preventing people from mobbing the hospitals. While physicians were technically on strike during the 4 months of the dispute, most did not in fact adhere to the industrial action regulations. In truth, most doctors in Jerusalem provided care in a private or partially private context, so, while participating in spirit, they did not actually withdraw services.
Another intriguing study analysed changes in mortality by studying the Jerusalem Post’s newspaper reports of funerals during another Jerusalem doctors’ strike, this time between March and June of 2000. This one arose from the Israel Medical Association’s conflict with the government’s proposed wages. The hospitals in the area cancelled all elective admissions and surgeries, but kept emergency rooms and other vital departments, such as dialysis units and oncology departments, open.
The funeral study found a decline in the number of funerals during the 3 months of the strike, compared with the same months of the previous 3 years. One burial society reported 93 funerals during one month of the strike (May 2000) compared with 153 in May 1999, 133 in May of 1998, and 139 in May 1997.
Cunningham and colleagues summarise their review of research assessing the effects of doctors’ strikes on mortality, finding that four of the seven studies report mortality dropped as a result of medical industrial action, and three observedno significant change in mortality during the strike or in the period following.
There are several possible interpretations for this surprising finding. One is that as its elective or non-emergency surgery which is usually most effected in a doctors’ strike, it could be that the mortality findings reflect an impact of elective surgery. The findings could be important because they could illuminate the relatively high risks of elective surgeries, which may actually increase mortality. This might be a finding that would not have been highlighted if it wasn’t for doctors’ strikes.
Another sobering possible conclusion is that the public, and perhaps doctors themselves, overestimate the ability of medicine to stave off or have an impact on mortality.
The problem with interpreting the data, as Cunningham and colleagues point out in their review, in all medical strikes studied so far, not all doctors down tools. In the 1976 Los Angeles strike only 50% of physicians were involved. So doctors’ strikes don’t necessarily drastically reduce access to healthcare. Given the purpose of most strikes is to deprive management of the worker’s labour, and its benefits, this raises the question of how effective a doctors’ strike can ever be in comparison to other occupations. The very difficulty in getting physicians to withdraw their labour in the way other occupations can do hints at a fundamental difference between what it is to be a doctor compared to pursuing other ways of making a living. A doctor, the research on strikes illuminates, isn’t something you do, it’s something you are. This issue of identity is why it’s so much more difficult for doctors to simply discontinue practising medicine. It’s a character flaw prone to exploitation by governments and employers, effectively frustrating standard union tactics.
Another theory as to why patients live longer when doctors go on strike is that the profession finally shakes off the shackles of its employer’s restrictive practices, and returns, albeit temporarily, to practising medicine freely, as it would really like to. And perhaps, British Medical Association take note, that’s actually the most effective sort of industrial action doctors can ever take.
Cunningham S A, Mitchell K et al. Doctors’ strikes and mortality: a review. Soc Sci Med 2008;67:1784-1788

via Observations by Gary Stix on 5/12/12
Google Glasses prototype
It would be nice if state governments went one step further and banned texting while walking. The law might require that anyone entering an emoticon into a smartphone would be required to stand (very still) within a foot of the sidewalk’s edge or cough up a $50 fine.
Going on foot from the Canal Street stop of the A train in lower Manhattan to the door of the huge former printing factory building where Nature Publishing Group has its offices has increasingly become a series of patterned avoidance maneuvers to skirt erratically moving objects immersed in text-crazed oblivion.
Mobile devices have succeeded in desensitizing a not insubstantial percentage of urban populations from their physical surroundings. How often have I experienced the desire to keep walking in a straight line and let the texter’s bowed head ram into my chest?
Technology giants are on the case. The purported solution is to eliminate the philosophical and physical dualism of things real and artificial. Google has come forward with Project Glass, which has demonstrated a prototype for a heads-up display that, in appearance, approximates a pair of glasses and, in function, places the capabilities of a smartphone literally in your face. Google Glasses, as they are informally known, work by sending text and images to a small sliver of a display attached to the frames, information that can orient the wearer to the immediate surroundings. They also can replicate a smart phone in other ways. Whenever it is released—and the company hasn’t specified a date—you would mouth, not finger, an “OMG,” which would then convert to a text message.
Some wags have suggested that Google Glasses and its ilk would lend a certain intimacy to the media exec’s vernacular of “searching for eyeballs,” pointing the way toward making up for the billions in advertising losses experienced by major media. Those same cynics have also suggested that walking down the street might be akin to getting spammed with a flurry of special offers—a free small coffee at Dunkin’ Donuts or a two-for-one sale at the Gap—even while you’re trying to get across a major intersection with life and limb intact.
The storied history of heads-up-displays stretches back decades. Projecting information onto a jet fighter’s windshield or even that of a two-door sedan makes some sense. Ubiquitous consumer acceptance of Google Glasses may be another story. In-your-face technology portends bringing processors and sensors closer and closer to the physical self, allowing them ultimately to be incorporated under the skin.
The next question, of course, is whether we really do want to merge with the machine. Wearable displays have been tested at universities for years. The videos of the guy at the supermarket looking at a grocery list on a display at the corner of one eye are well ensconced in the annals of geek history. My colleague George Musser, who must be one of the world’s leading first adopters of new tech (yes, that’s George on the iPhone line), always protests when we discuss this topic that he just hasn’t been able to procure a good wearable device. The argument: if you build one, people (or George) will buy one.
I wonder, though. Along with the search for an elixir for baldness, one techno trend that precedes the Internet by generations is the inexorable quest for ways to make eyewear obsolete, as witnessed by the billions channeled into contact lenses and Lasik surgery. True, fashion pays partial homage to the Coke-bottle lenses of yesteryear through the black 1950s retro frames popularized by the likes of Tina Fey.
For the most part, though, the trend has pointed toward keeping nose and eyes free of unneeded superstructure. You can even make an argument against Google Glasses by delving into the evolutionary psychology literature, with the caveat that it is filled with bubbe meises. (You can check that technical term here.) Symmetrical faces, or so we are told, are thought to be more attractive to the opposite sex. How does that jibe with the visibly noticeable display, microchip and sensor package that sits only over the right eyelid and temple. Will you want to wear those geek frames with a Todashi Shoji evening dress? Maybe not. Smartphones may be around for a while, and that means still weaving among the texters on the way to work—or at least until an irresistible force like social media meets an immovable object like me.
Source: Google

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