 |
| Salvador Dali*: The Average
Bureaucrat |
A few weeks ago, I reported on an
open letter to the American Psychiatric
Association, calling for it to reject three controversial expansions of sexual
paraphilia diagnoses that are being promoted by government evaluators in civil
commitment cases.
A lot has happened since then. The only one of the three
controversial diagnoses still in the running for official status has been
altered for the umpteenth time. An esteemed journal is issuing a scathing
critique. And the open letter is generating buzz in the blogosphere.
The
open letter has
garnered more than 100 signatures, many from prominent forensic psychologists
and psychiatrists in the U.S. and internationally. If you intend to sign on but
haven’t yet, act now because I understand it will be submitted very soon. (Click
HERE to review the text; click
HERE to email your name and professional
title to co-author
Richard
Wollert.)
Hebephilia gets yet another makeover
This week, the Sexual Disorders Workgroup for the upcoming
fifth edition of the APA's diagnostic manual
toned
down its proposal to turn sexual attraction to young teens into a mental
disorder. As psychiatrist Allen Frances
explains
at his
DSM5
in Distress blog, hebephilia is still there -- you just have to read the
small print to see it:
 |
| Dali: Enchanted Beach with Three Fluid
Graces |
Confronted
by universal opposition from the rest of the field, the DSM 5 group has been
forced progressively to whittle down their pet, but they so far have refused to
just drop it altogether. 'Hebephilia' first lost its free-standing independence
and was cloaked as Pedohebephilia. When this didn't fly, the term was dropped
altogether in the title but the concept was slipped into the definition of
Pedophilia -- which was expanded out of recognition by having a victim age
cut-off of 14 years. No one accepted this outlandish suggestion and now finally
the work group comes back with ‘early pubescent children' and tries to keep
'hebephilia' as a term in the subtype. The instability of the criteria sets
associated with this concept is additional evidence that the fervor for its
adoption stems from emotional loyalty rather than reasoned review of its weak
conceptual and research base. How can the group vouch for the reliability of the
diagnosis when the concept and criteria are changing every month? This is no way
to develop a diagnostic system.
The staunch insistence on this transparent attempt to turn
statutory rape into a mental disorder owes in large part to the makeup of the
sexual disorders workgroup. As
Frances
notes, "the most wayward of all the DSM 5 work groups" is "lopsidedly
dominated" by psychologists from a sex clinic up in Toronto, whose ambition is
"to find a place in DSM 5 for their pet diagnosis."
Although the group's other outlandish proposals, Paraphilic
Coercive Disorder and Hypersexuality, have been shelved for the time being,
Frances worries that putting them in the appendix "for further study" is still
risky:
Recognizing
that the jig is up on the grand design, members of the DSM 5 sexual disorders
work group have been heard saying they may have to settle for an Appendix
placement for their three hothouse creations. This would create forensic
dangers. We have learned from the abuse of "Paraphilia Not Otherwise Specified"
in Sexually Violent Predator cases that any (even remote) legitimization by DSM
5 is certain to be misconstrued and misused in the courtroom.
Come on
guys. This is absolutely absurd just on the face of it…. So back to the drawing
board, DSM 5 sexual disorders work group. The grand dream is lost -- now at
least make sure you don't mess up on the fine print.
On the professional listservs today, some conspiracy
theorists were speculating that the new wording signifies a plot to enhance the
standing of physiological testing in sex offender assessment. The
latest
proposed criteria for "pedophilia, hebephilic type" require "equal or
greater sexual arousal from prepubescent or early pubescent children than from
physically mature persons." How to determine that fuzzy standard? Enter the
penile plethysmographer, a new
niche career track, penis cuff at the ready to measure who is aroused by
what.
"There is withering criticism already that the DSM is being
expanded to sell more drugs," wrote one colleague. "Now it appears that
psychiatry and psychology are conspiring to use the DSM to spur PPG tests --
tests which risk leaving patients with traumatic and indelible memory traces. Do
most psychiatrists really want to open this door?!"
Orwellian thought police?
The mere idea of allowing the American Psychiatric
Association to dictate "normal" sexuality frightens English Professor
Christopher
Lane. Lane, whose book
Shyness:
How Normal Behavior Became a Sickness exposed the unscientific inner
workings of the DSM-III committee, expressed shock over the first listed
criterion for the shelved disorder of hypersexuality: "Excessive time is
consumed by sexual fantasies and urges, and by planning for and engaging in
sexual behavior." On his
Side
Effects blog, Lane
mused:
 |
| Dali: Femme a Tete de
Roses |
"Excessive time"? What exactly does that
mean, and according to whose standards? That's not a small or trivial matter to
settle when the APA is talking in vague generalities about the nation’s libido
-- how much sex it wants and how much sex the APA thinks it should think about
wanting. The APA is talking about how much time Americans can devote to sexual
fantasy before it suggests that we’re mentally ill if our preoccupations are
stronger than those set by the relevant task force.
Does that initiative
seem to overreach a bit, even to the point of sounding almost Orwellian? It does
so to me. If we're to have criteria, are quotas next, including for fantasy?
It’s as if the East Coast offices of the APA had morphed into those of the
Thought Police in Orwell's 1984, warning citizens that they’d overstepped their
"sexual thought quota" for the week and must be rationed -- or punished
accordingly.
Lane analyzed hebephilia through his characteristic
historical lens:
It's an
archaism, a throwback literally to 19th-century psychiatry, but refers to
practices that were as central to the Classical age -- and thus to Western
democracy -- as were Socrates, Plato, and especially Plato’s Symposium,
one of the foundational books in the West on eros and love.
The APA is
already trying to determine how long normal grief should last before it’s
thought pathological. Its brisk, jaw-dropping answer: two weeks. Do we really
want the same organization dictating how often we can think about sex? These
kinds of proposals can only end badly.
Leading journal tackles the
controversy
The good news this week, which should have all of us
jumping up and down with joy, is that the APA has caved in under massive public
pressure and dropped its plan for a new psychosis risk disorder. This disorder
would have put thousands if not millions of youngsters at risk of being dosed up
with dangerous antipsychotic drugs based on a suspicion that they might go crazy
in the future. Mixed Anxiety Depression has also bit the dust.
 |
| Dali: Daddy Longlegs of the Evening
Hope |
But, as featured in a
special
issue of the esteemed
Journal of Nervous and Mental Diseases due out
in June on the raging diagnostic controversies, there are still many battles
ahead as the bloated DSM-5 enters the final stretch. The special issue will
tackle diagnostic inflation, pharmacological conflicts of interest,
controversies with the newly revamped personality disorders, and problems with
diagnostic reliability in the recent field trials. Hebephilia, often neglected
amidst controversies with wider impact such as psychosis risk syndrome and the
pathologization of normal grief, merited an article in this special issue.
In "Hebephilia and the Construction of a Fictitious
Diagnosis," forensic psychologists
Paul Good and the late
Jules
Burstein make a strong case for abandoning this faux disorder, which will
only make the APA more of a laughingstock in the future.
Good and Burstein catalog an assortment of empirical
problems. These range from the difficulty of reliably measuring "recurrent and
intense" sexual arousal to problems determining the pubertal status of a young
teenage victim. They also challenge the very idea that sexual attraction to
pubescent minors is a mental illness, rather than merely illegal.
Although the Sexual Disorders Workgroup hides behind a
fictive notion of a pure and ethereal "science," Good and Burstein clearly
believe that hebephilia, if added to the DSM-5, will be mainly invoked in a
partisan manner in forensic proceedings, in order to justify harsher punishment
and involuntary civil detention. Because of its power to do harm, they say, its
scientific grounding should be especially strong. If it does manage to worm its
way into the DSM, they say, it should still be challenged in court:
We believe
the admissibility of the proposed revision to DSM-5 that would include
Hebephilia as a type of Pedophilia could be challenged in a court of law based
on current legal standards. For example, since there is no professional
consensus or general acceptance in the scientific community to support the
notion of Hebephilia as a mental disorder, it would have difficulty passing the
Frye test for admissibility. Similarly, without a widely established body
of peer-reviewed, validation research and repeated studies showing inter-rater
reliability in the laboratory and among clinicians in the field, Hebephilia
would also have difficulty meeting the criteria specified in the Daubert
standard.
Indeed, this is just what has been happening to hebephilia
in federal court, where
at
least three civil detention petitions in a row have been thrown out due to
the level of controversy in the field over this purported condition.
With all of this tumult, it seems that the DSM-5 excesses
are producing a backlash against the American Psychiatric Association and,
indeed, fueling disenchantment with the whole enterprise of psychiatric
diagnosis.
As
Frances
writes, the turnaround on psychosis risk syndrome came about due to a
combination of:
- extensive criticism from experts in the field
- public outrage
- uniformly negative press coverage
- abysmal results in DSM-5 field testing
For the
first time in its history, DSM 5 has shown some flexibility and capacity to
correct itself. Hopefully, this is just the beginning of what will turn out to
be a number of other necessary DSM 5 retreats. Today's revisions should be just
the first step in a systematic program of reform.… This is certainly no time for
complacency. Much of the rest of DSM 5 is still a mess. The reliabilities
achieved for many of the other disorders are apparently unbelievably low and the
writing of the criteria sets is still unacceptably
imprecise.
Who
needs reliability?
Frances calls for slowing down the process to allow for
additional field testing and, more importantly, an independent scientific review
of all the remaining controversial DSM-5 changes. But the DSM-5 folks are taking
a different tack. Faced with field trial results showing very poor reliability
-- not much better than chance -- for many of their proposed diagnoses, they
want to change the definition of what counts as minimally adequate.
 |
| Dali: Autumn
Cannibalism |
It’s pretty ironic: The DSM-III went down in history for
elevating
the importance of reliability at the expense of validity. Remember,
diagnostic reliability just means that similarly trained raters see a certain
symptom presentation and call it by the same label. It says nothing about
external validity, or whether the label is meaningful in explaining a real-world
phenomenon. But reliability is basic. If a diagnostic label cannot be reliably
applied, you can't even start talking about its validity. And now, the same
psychiatric organization that reified the kappa reliability statistic as the
be-all, end-all of science is trying to tell us that traditional kappa levels
are unrealistically high for psychiatric research.
Historically, psychiatric reliability studies have adopted the
Fleiss standard, in which kappas below 0.4 have been considered poor. In the
January issue of the American Journal of Psychiatry, Helena Kraemer and
colleagues complained that this standard is unrealistically high, and lobbied
for kappas as low as 0.2 -- traditionally considered poor -- to be deemed
"acceptable."
Former DSM-III guru Robert Spitzer and colleagues object to this
proposal in
a letter in
the latest issue of the
Journal. "Calling for psychiatry to accept kappa
values that are characterized as unreliable in other fields of medicine is
taking a step backward," they state. "One hopes that the DSM-5 reliability
results are at least as good as the DSM-III results, if not better."
Alas, just wishing won't make it so. Despite its grandly stated
ambitions, the DSM-5 will likely go down in history as a major gaffe by American
psychiatry in its continuing struggle for world dominance.
Further reading:
*Salvador Dali: "One day it will have to be
officially admitted that what we have christened reality is an even greater
illusion than the world of dreams."
___________________________________________________________________
See also:
*
_______________________________________________
General Psychiatry News
Comments
(
Printable
Version
Email
This
Font
