Mike Nova: American Psychiatry At The Crossroads
Last Update: 8:55 AM 5/11/2012
"It should broaden its theoretical and conceptual outlook... it should assume its rightful leadership role in World Psychiatry... by discarding the outdated stereotypes, not reinforcing them" |
Thank you, Dr. Frances; for your previous work and for your courageous and independent stand now. |
James Phillips: "Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations." |
Did American Psychiatry sell its soul to profit-hungry (Psycho) Pharmaceutical Industry? Is it not the time to stop all this "DSM-s In Perpetuity" madness? And not to spend another $25 or more ml. for the next round of controversies and wide-spread public scepticism and criticism?" |
"Empirical explanation and treatment repeatedly fail for psychiatric diagnoses. Diagnosis is mired in conceptual confusion that is illuminated by Ludwig Wittgenstein's later critique of philosophy (Philosophical Investigations).
A diagnosis is a sort of concept that cannot be located in or explained by a mental process. Conclusion: A diagnosis is an exercise in language and its usage changes according to the context and the needs it addresses."
Psychiatric diagnoses are not mental p... [Aust N Z J Psychiatry. 2012] - PubMed - NCBI
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"Much less clear, even in the US, is whether
the approach is commonly used by clinicians in ordinary
practice, thus really resulting in an increase of the reliability
of psychiatric diagnosis in clinical settings. It has been, for
instance, reported that several US clinicians have difficulties
to recall the DSM-IV criteria for major depressive disorder
and rarely use them in their practice (e.g., 2). Furthermore,
some of the DSM-IV cut-offs and time frames have been
found not to have a solid empirical basis (e.g., 3) and to
generate a high proportion of sub-threshold and “not otherwise
specified” cases (e.g., 4).
The spontaneous clinical process does not
involve checking in a given patient whether each of a series
of symptoms is present or not, and basing the diagnosis on
the number of symptoms which are present. It rather involves
checking whether the characteristics of the patient
match one of the templates of mental disorders that the clinician
has built up in his/her mind through his/her training
and clinical experience."
Mario Maj
President, World Psychiatric Association
Psychiatric diagnosis: pros and cons of prototypes...
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Drug companies like Pfizer are accused of pressuring doctors into over-prescribing medications to patients in order to increase profits - GALLO/GETTY
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American Psychiatry should broaden its
theoretical and
conceptual outlook beyond the narrow professional concerns about diagnostic systems and classifications (at this time, with all the enormous importance of these issues, we are not ready for the true scientific approach towards resolving them; and the practical problems with "reimbursements" and "parities" should be left for
actuaries and medical records departments to resolve). Recent controversies about DSM-5 indicate that the whole conceptual direction of improving and perfecting diagnostic pseudonosological labeling system (and the professional and social power of labeling that comes with it) hit a roadblock and is in "no exit" blind alley. How can we introduce a true, medically scientific and evidence based classification system for mental disorders if we still know so little about their nature and origins? The attempts to codify the current clinical labels are
methodologically and
epistemologically dangerous because they reinforce the current clinical
belief system with its multitude of misconceptions. The history of
science and medicine in particular is replete with these kind of errors. Preoccupation with improving the reliability by forced agreement (which by itself proved to be impractical and next to impossible) does not affect the much more important issues of
validity of psychiatric diagnosis, and, if anything, leads to their neglect and displacement (not only in psychodynamic, but real sense) from our area of interests and scientific horizons, almost relegating these issues to the province of "conspiracy of silence". How can we agree on something, if we don't really know what this "something" is or if it even really and "truly scientifically" exists? And why should we agree on this "unknown something?"
Medicine and psychiatry are empirical and "practical sciences"; we are not just "talkers" and "labellers"; we are "doers": our task is to ease mental pain and suffering (of which this world is aplenty) for individuals, groups and societies. We do it in the dark, our knowledge is still limited and trues are hidden. We should not reinforce these limitations, presenting "blind spots" as medical facts, but should accept them, be aware of them and work further, relentlessly, and completely with an open mind to resolve them. Narrow professional concerns with "parities and reimbursements" should not be a consideration and should not stand in the way of scientific research and progress in modern psychiatry. This probably was the "primal and original sin" which lead the whole DSM improvement effort astray.
American Psychiatry should assume its rightful leadership role in World Psychiatry with its bold and broad, open and independent minded, scientifically eclectic stance, discarding the outdated stereotypes, not reinforcing them; the stance worthy of this great nation and its spirit.
References and Links:
Mike Nova: Breivik Trial and
The Crisis Of Psychiatry As A Science
Mike Nova
Breivik Trial and The Crisis Of Psychiatry As A Science
Breivik is not the only one who is on this trial. Psychiatry
as a science is on this trial also, just like on many other trials where
forensic psychiatric involvement is sought. This is highlighted by the two
contradictory psychiatric assessments of the accused, with their directly
opposing diagnostic impressions and directly conflicting main general
conclusions.
The first forensic psychiatric evaluation, completed on
November 29, 2011 by the psychiatrists Torgeir Husby and Synne Sørheim found
Breivik to be "paranoid schizophrenic" and "psychotic" at the time of the
alleged crime and presently and therefore legally "insane". A leaked copy of the
initial psychiatric examination described his crusader fantasy as a product of
the "bizarre, grandiose delusions" of a sick mind.
The second evaluation, about 300 pages long, made by the
psychiatrists Terje Toerrissen and Agnar Aspaas on a request from the court
after widespread criticism of the first one, was completed on April 10, 2012,
just six days before the trial, but was not released, and according to the
leaked information, found him afflicted with "narcissistic personality disorder"
with "grandiose self" and not psychotic at the time of the alleged crime and
presently and therefore legally "sane".
The latest psychiatric report was
confidential, but national broadcaster NRK and other Norwegian media who claimed
to have seen its conclusions said it described Breivik as narcissistic but not
psychotic.
Torgensen gets the impression that Breivik found an ideal place
to nourish his delusions of grandeur in the anti-Islamic scene full of crusader
fantasies. “This was coupled with an extremely sadistic disorder,” Torgensen
says. “This disastrous combination could explain the scale of his violence.”
The new report from forensic psychiatrists Terje Tørrissen and Agnar Aspaas
concludes that he did not have “significantly weakened
capacity for realistic evaluation of his relations with the outside world, and
did not act under severely impaired consciousness”.
"Our conclusion is that
he (was) not psychotic at the time of the actions of terrorism and he is not
psychotic now," Terje Toerrissen, one of the psychiatrists who examined Breivik
in prison,
told The Associated Press.
Thus, as it almost always
happens in complex forensic psychiatric cases, it was left for the infinite
wisdom and common sense of the court, unburdened by the "sophisticated" and
empty psychiatric jargon, to decide by itself, and rightly so, the "main
questions" of the accused's mental illness or mental health and his "sanity" or
"insanity" and to make its own, judicial decision regarding the issue of legal
responsibility. Both mutually conflicting (but not mutually exclusive) forensic
psychiatric evaluations, which, no doubt, were performed in good faith and with
utmost professional diligence, will be taken into account by the court, but were
rendered almost irrelevant by their contradictions. Once again, psychiatry,
pretending to be a medical discipline and a science, was humiliated and reduced
to the position of a laughing stock for the public and the media.
Mr.
Breivik's skillful and astute lead defense lawyer, Mr. Geri Lippestad, treating
his client with respect and at the same time with appropriate professional
distance and apparently convinced of his client's mental illness and "insanity",
chose a strategy of presenting Mr. Breivik to the court and to the public "as
is", letting him to reveal himself and his presumed mental illness fully as the
engine of alleged criminal behavior, apparently counting that it will be
convincing enough for both the judges and for the court of public opinion.
“This whole case indicated that he is insane,” Geir Lippestad told
reporters. “He looks upon himself as a warrior. He starts this war and takes
some kind of pride in that,” Lippestad said. Lippestad said Breivik had used
“some kind of drugs” before the crime to keep strong and awake, and was
surprised he had not been killed during the attacks or en route to Monday’s
court hearing.
Lippestad, a member of the Labour party whose youth wing had
been the target of Friday’s shooting rampage,
said he would quit if Breivik did not agree to psychological
tests.
Geir Lippestad said the new report means Breivik's testimony
will be crucial "when the judges decide whether he is insane or not." The trial
started on April 16 and is scheduled to last 10 weeks.
Mr. Breivik declared
himself undoubtedly and completely "sane" and consistently, if somewhat eerily
out of place and time, painted a self-portrait as a model and self-sacrificing
ideological warrior, taking as an insult any, albeit "professional" opinions
otherwise and dismissed them with anger and indignation.
“On this day,”
he said, “I was waging a one-man war against all the regimes
of Western Europe. I felt traumatized every second that blood and brains were
spurting out. War is hell.”
"Breivik told the court that "ridiculous" lies
had been told about him, rattling off a list which accused him of being a
narcissist who was obsessed with the red jumper he wore to his first court
hearing, of having a "bacterial phobia", "an incestuous relationship with my
mother", "of being a child killer despite no one who died on Utoya being under
14".
He was not insane, he repeated many times. He claimed it was Norway's
politicians who should be locked up in the sort of mental institution he can
expect to spend the rest of his days if the court declares him criminally insane
at the end of the ten-week trial. He said: "They expect us to applaud our ethnic
and cultural doom... They should be characterised as insane, not me. Why is this
the real insanity? This is the real insanity because it is not rational to work
to deconstruct ones own ethnic group, culture and religion."
All this is
fine and dandy, and, no doubt, the aforementioned infinite wisdom of
Scandinavian level headed justice (embodied in a stern but motherly demeanor of
the presiding Judge Wenche Elisabeth Arntzen) will eventually emanate from its
somewhat obscure, slowly but surely turning and unstoppable wheels, hopefully to
almost every one's satisfaction. And eventually, this horrendous crime, the purp
and the trial will be almost forgotten and placed into archives for further
studies.
But the nagging questions remain and will remain for some,
and probably a long time: is psychiatry really a science? Or is it just a
collection of "professional" opinions, mixed with convenient labels and outdated
jargon? What is "sane" and what is "insane"? And how far should the justice go
in its modern "humane" stance?
"Grete Faremo, Norway’s justice minister,
has said that it plans to establish a committee to examine the
role of forensic psychiatrists. She told Norwegian daily
Aftenposten on April 13 the
committee would have a “broad mandate” that would examine three key questions:
What is sanity? What is the role of the forensic psychiatrist? And how do we
take care of security when an insane man is sentenced?
“Much suggests that
the medical principle is inadequate,” said Faremo. “It is a historic step we are
now taking. It is an important step in light of the terrible incident and the
trial we face and in consideration of people's sense of justice.”
“This is a
big thing,” says Abrahamsen. “If it hadn’t been for Breivik, we wouldn’t have
discussed this.”
___________________________
Response to Dr. Wessely
Normality or psychopathology of belief or belief
system is determined first of all by the intrinsic qualities of belief in
question. It is not determined by the fact that belief is shared or not shared:
"Delusions are beliefs that are not only wrong, in the sense of not
corresponding to the world as we know it, but they must also not be shared with
others of the same cultural background."
There are many delusional beliefs
that are or were shared, and some of them on a rather large scale. For example,
the ancient Maya believed, that for the sun to rise they had to offer human
sacrifices (of their best and brightest) every day, otherwise all kind of life
on earth would come to a halt. This belief was shared very widely
in precolumbian Maya culture, which does not make it less delusional.
Breivik's ultra nationalist anti-immigrant ideology is shared by great many
people of various cultural backgrounds. The goal of his forensic psychiatric
evaluation is to assess his own particular belief system, with all its
peculiarities and idiosyncrasies, in order to determine its nature, qualities
and psychopathological aspects, regardless of other similar beliefs. In the end,
it was him, not others, who took these ideas to their logical (or rather
illogical and "sick") extreme, although the (possibly facilitating) role of
"significant others" in his case still has to be determined.
Neither the
"monstrosity" and "grievous consequences" of his actions nor "popular
misconceptions" should cloud the picture. The most important factor in his
forensic psychiatric assessment is the presence or absence of identifiable and
diagnosable mental illness and the degree of its causal relationship with the
crime. In my opinion, whatever it is worth, psychopathological qualities of
Breivic's beliefs: their highly systematised, structured, all embracing "world
view" quality, along with their unshakable, messianic conviction and "call for
action", indicate with high degree of probability the presence of Delusional
Disorder, mixed, persecutory-paranoid type, and the direct and overwhelming
causal connection of his psychopathology with the criminal act.
The
cognitive aspect in psychopathology of Delusional Disorders (abnormalities
and/or dysfunctions in concept selection, elimination and confirmation),
indicating possible subtle but decisive organic involvement is much
under-researched area, probably due to our neglect or inattention to biological
aspects of these disorders and overestimation of its psychodynamic
aspects. Delusional jealousy, secondary to chronic alcoholism (a very discrete
and specific syndrome) is the case in point.
"The... misconception... that
the purpose of psychiatry is to “get people off”" might be as wide spread as any
other misconception, which does not make it any less of a misconception. The
historically formed legal concept of "NGRI: not guilty by reason of insanity" is
a witness of humanity and rationality on the part of society, not to mention
other, less important but present factors, such as political and social
convenience, expediency and cultural traditions. (E.g.: Disraeli to Queen
Victoria: "Only the madman can think about assassinating your Majesty...").
Modern psychiatry, very likely, was born out of the M'Naghten rules, as some
psychiatric historians suppose.
And last, but certainly not least, is the
difficult and complex subject of "Schizophrenia", its clinical concept (and/or
misconcept) and diagnosis (and/or misdiagnosis). The diagnostic label of
"Schizophrenia" became so wide spread and all encompassing (because it is so
easy to apply, and is applied almost indiscriminately), as to loose its meaning
and clinical value. In our rush to nosological (and reimbursement) parity with
the rest of medicine we jumped over our heads too soon, introducing the (man
made) diagnostic criteria based "nosological" system, which leads to premature
ossification and codification of clinical concepts and experience, impeding the
independent minded research greatly and precluding the normal development
(albeit slow and lagging) of psychiatry as a medical science. Is it not more
correct and probably clinically more productive, especially in the field of
psychopharmacology, to return to syndromologically based classification system
and to try to define, refine and research these historically formed clinical
syndromes further, before rushing to judgements about their pseudonosological
"pigeon holes"?
This is what Breivic trial, along with other issues, brings
to the front. And these issues deserve a deep and long thought.
Michael
Novakhov, M.D.
References and Links
References and Links
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Psychiatrists
say diagnosis manual needs overhaul ...
Psychiatrists
say diagnosis manual needs overhaul - (Reuters) - chicagotribune.com
http://forpn.blogspot.com/2012/05/psychiatrists-say-diagnosis-manual.html
And the rest is history – a three year long debate ensued, often contentious, about the whole process - 1 Boring Old Man » quite a week…
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theoretical and conceptual outlook - Google Search
theoretical outlook - Google
conceptual outlook - Google Search
theory - Google Search
Theory - From Wikipedia, the free encyclopedia
concept - Google Search
Concept - From Wikipedia, the free encyclopedia
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methodology - Google Search
Methodology - From Wikipedia, the free encyclopedia
Methodology is generally a guideline system for solving a problem, with specific components such as phases, tasks, methods, techniques and tools.
[1] It can be defined also as follows:
- "the analysis of the principles of methods, rules, and postulates employed by a discipline";[2]
- "the systematic study of methods that are, can be, or have been applied within a discipline";[2]
- "the study or description of methods".[3]
A methodology can be considered to include multiple methods, each as applied to various facets of the whole scope of the methodology.
Why Most Published Research Findings Are False by
John P. A. Ioannidis
Why Most Published Research Findings Are False
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PLoS Med. 2005 August; 2(8): e124.
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PMCID: PMC1182327
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Copyright : © 2005 John P. A. Ioannidis. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Why Most Published Research Findings Are False
John P. A. Ioannidis
Summary
There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research.
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epistemology - Google Search
Epistemology - From Wikipedia, the free encyclopedia
Stanford Encyclopedia of Philosophy articles:
*
belief system - Google Search
Belief system - From Wikipedia, the free encyclopedia
*
errors in history of science - Google search
errors in history of science - Wikipedia Search
Philosophy of science - From Wikipedia, the free encyclopedia
Scientific method - From Wikipedia, the free encyclopedia
Pseudoscience - From Wikipedia, the free encyclopedia
Karl Popper - From Wikipedia, the free encyclopedia
errors in history of medicine - Google Search
*
http://www.historyworld.net/wrldhis/PlainTextHistories.asp?groupid=474&HistoryID=aa52>rack=pthc
www.historyworld.net/.../PlainTextHistories.asp?...474&HistoryID...Cached - Similar
You +1'd this publicly.
Undo
The influential errors of Galen: 2nd century
AD
The
newly appointed chief physician to the gladiators in Pergamum, in AD 158, is a
native of the city. He is a Greek doctor by the name of Galen. The appointment
gives him the opportunity to study wounds of all kinds. His knowledge of muscles
enables him to warn his patients of the likely outcome of certain operations - a
wise precaution recommended in Galen's
Advice
to doctors.
But it is Galen's dissection of apes and pigs which give
him the detailed information for his medical tracts on the organs of the body.
Nearly 100 of these tracts survive. They become the basis of Galen's great
reputation in medieval medicine, unchallenged until the anatomical work of
Vesalius.
Through his experiments Galen is able to
overturn many long-held beliefs, such as the theory (first proposed by the
Hippocratic school in about 400 BC, and maintained even by the physicians of
Alexandria)
that the arteries contain air - carrying it to all parts of the body from the
heart and the lungs. This belief is based originally on the arteries of dead
animals, which appear to be empty.
Galen is able to demonstrate that
living arteries contain blood.
His error, which will become the established
medical orthodoxy for centuries, is to assume that the blood goes back and forth
from the heart in an ebb-and-flow motion. This theory holds sway in medical
circles until the time of Harvey.
Read
more:
http://www.historyworld.net/wrldhis/PlainTextHistories.asp?groupid=474&HistoryID=aa52>rack=pthc#ixzz1uDtUF4Ls
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16 Feb 2012 by Brennen McKenzie
A brief reference on the web site The Quackometer recently drew my attention to a very short book (really more of a pamphlet, in the historical sense) by Dr. Worthington Hooker, Lessons from the History of Medical Delusions, which I thought might be of interest to readers of this blog. ... However, the focus of this booklet is to illustrate more generally the sorts of errors in thinking that lead even otherwise intelligent and reasonable people to believe such nonsense.
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errors in history of medicine - Pubmed Search
- Performing your original search, errors in history of medicine, in PubMed will retrieve 930 records.
Lessons from the history of medicine.
Source
Lyman Briggs College at Michigan State University, East Lansing, Michigan 48824, USA. Wallerj1@msu.edu
Abstract
What is the point of teaching the history of medicine? Many historians and clinicians find it regrettable that some medical students today will graduate knowing almost nothing of such "greats" of the past as Hippocrates, Galen, Vesalius, Harvey, Lister, and Pasteur. But does this really matter? After all, traditional history of medicine curricula tended to distort medicine's past, omitting the countless errors, wrong turns, fads, blunders, and abuses, in order to tell the sanitized stories of a few scientific superheroes. Modern scholarship has seriously challenged most of these heroic dramas; few of our heroes were as farsighted, noble, or obviously correct as once thought. Joseph Lister, for example, turns out to have had filthy wards, whereas William Harvey was devoted to the Aristotelianism he was long said to have overthrown [1]. But as the history of medicine has become less romanticized, it has also become much more relevant, for it promises to impart useful lessons in the vital importance of scientific scepticism.
errors in history of medicine - Wikipedia Search
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- Performing your original search, validity of psychiatric diagnosis, in PubMed Central will retrieve 13290 records.
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Psychiatry (Edgmont). 2005 September; 2(9): 48–55.
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PMCID: PMC2993536
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The Validity of Psychiatric Diagnosis Revisited
The Clinician's Guide to Improve the Validity of Psychiatric Diagnosis
Ahmed Aboraya, MD, DrPH,  Cheryl France, MD, John Young, MD, Kristina Curci, MD, and James LePage, PhD
All from Department of Behavioral Medicine and Psychiatry, Robert C. Byrd Health Sciences Center of West Virginia University, Morgantown, West Virginia
Background: The authors reviewed the types and phases of validity of psychiatric diagnosis. In 1970, Robins and Guze proposed five phases to achieve valid classification of mental disorders: clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study. Objectives: The objectives of this paper are to review what has been learned since Robins and Guze's influential article as well as examine the impact of the new discoveries in neurosciences and neuroimaging on the practicing clinician. Method: The authors reviewed the literature on the concept of validity in psychiatry with emphasis on the role of clinical training, the use of structured interviews and rating scales, and the importance of the new discoveries in neurosciences. Results: Robins and Guze's phases have been the cornerstone of construct validity in psychiatry at the level of researchers. In the absence of the gold standard of psychiatric diagnosis, Spitzer proposed the “LEAD,” which is an acronym for longitudinal evaluation, and is done by expert clinicians utilizing all the data available. The LEAD standard is construct validity at the level of experts; however, guidelines are lacking to improve the validity skills of the practicing clinicians. Conclusions: The authors propose the acronym DR.SEE, which stands for data, reference definitions, rating scales, clinical experience, and external validators. The authors recommend that clinicians use the DR.SEE paradigm to improve the validity of psychiatric diagnoses.
Validity and reliability are two important topics vital to the development of modern psychiatry. Reliability refers to the extent to which an experiment, test or any measuring procedure yields the same results on repeated trials, 1 and is the topic of another paper. Validity is a more difficult term to define because its meaning differs based on the context. Validity, in a very general sense, refers to examining the approximate truth or falsity of scientific propositions. 2 When applied to measuring instruments, validity refers to how well the instrument measures what it purports to measure. 1 When applied to a disease entity, such as bacterial pneumonia, validity refers to the evidence that bacteria is the cause (verified by sputum culture), lung pathology exists (confirmed by x-ray findings), the symptoms (shortness of breath, fever, and cough), and signs (tachpnea, rales) are compatible with etiology and the disease responds to appropriate antimicrobial treatment. In a psychiatric illness, the patient comes with a subjective complaint (e.g., anxiety, depression, paranoia), and the trained clinician elicits signs of the illness through observation of the patient's demeanor, behavior, and thought process. However, there are fewer definitive objective measures (akin to x-ray and sputum culture) that confirm the diagnosis
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Psychiatric Mislabeling Is Bad For Your Mental Health
And DSM 5 will make it much worse
An accurate
diagnosis is wonderful thing—a giant step toward explaining what previously
seemed unexplainable and starting what is very likely to be an effective
treatment. An inaccurate diagnosis can be a disaster—leading not only to
inappropriate
medication
but also to stigma, ruined self confidence, reduced ambition, needless worries,
despair about the future, and a deeply injured sense of self.
Every week, I
receive one or two emails describing the pain inflicted by careless diagnosis.
And when I give talks, almost invariably someone in the audience (often a mental
health professional) will come up afterwards to describe their own personal
ordeal—being misdiagnosed, mistreated, and given up as too ill to be
productive.
The diagnoses that are most often harmfully misapplied are
schizophrenia,
bipolar
disorder, schizoaffective disorder,
ADHD, and
autism. The most
frequent cause of over-diagnosis is a clinician jumping to a rash conclusion
based on insufficient evidence. Risk factors for mislabeling on the patient side
are youth, a short track record of symptom evolution, an atypical presentation,
drug use, and family or environmental
stress. Risk factors on
the system side are evaluator inexperience, diagnostic exuberance, and external
pressures (eg whether insurance, disability, or needed school services depend on
having the diagnosis).
Read more on this blog:
Comment:
Mike Nova:
Thank you, Dr. Frances; for your previous work and for your courageous and independent stand now.
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James Phillips: "Indeed,
psychiatric nosology and the DSMs provide a vast arena for what are, explicitly
or not, hermeneutic deliberations. The progression from one DSM to the next is
itself a strong reminder that these are historical documents that do not
transcend their historical conditions."
Nowhere in contemporary psychiatry does this
hermeneutics of historicity, of multiple perspectives, [End Page 66] and of the
exposure of hidden assumptions, emerge more forcefully than in the area of
diagnosis. It is appropriate then that the first AAPP sponsored monograph should
be entitled Philosophical Perspectives on Psychiatric Diagnostic
Classification (Sadler, Wiggins, and Schwartz 1994). Indeed, psychiatric
nosology and the DSMs provide a vast arena for what are, explicitly or not,
hermeneutic deliberations. The progression from one DSM to the next is itself a
strong reminder that these are historical documents that do not transcend their
historical conditions. Hermeneutic considerations are engaged at the opening
bell with the famous (or infamous) statement that the DSM's diagnostic
statements are atheoretical. The notion of an atheoretical diagnosis is, of
course, an oxymoron hermeneutically.
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Mike Nova:
Is it not the time to stop all this "DSM-s In Perpetuity" madness? And not to spend another $25 or more ml. for the next round of controversies and wide-spread public scepticism?
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The subject of Industry Ties of DSM Workers
PsychiatryOnline
| Psychiatric News | News Article
Psychiatric News |
April 20,
2012
Volume
47 Number 8 page 1a-14
American
Psychiatric Association
Professional News
Article Misrepresents Industry Ties of DSM
Workers
Mark Moran
More than 70 percent of DSM-5 Task Force and work group
members now have no ties to industry.
Abstract
Teaser
An article in the online journal Public Library
of Science (PLoS) has misrepresented facts about conflicts of interest
among members of the DSM-5 Task Force and work groups, according to
APA.
And it ignored the extent to which industry
influence has been eliminated or greatly reduced because of strict financial
disclosure requirements mandated by APA.
In a statement, APA President John Oldham, M.D.,
said the article, written by Lisa Cosgrove, Ph.D., and Sheldon Krimsky, Ph.D.,
“does not take into account the level to which DSM-5 Task Force and
work group members have minimized or divested themselves from relationships with
the pharmaceutical industry.”
Cosgrove is a research lab fellow at the Edmond J.
Safra Center for Ethics at Harvard University. Krimsky is an adjunct professor
in the Department of Public Health and Family Medicine at the Tufts School of
Medicine
The article, “A Comparison of DSM-IV and
DSM-5 Panel Members’ Financial Associations With Industry: A Pernicious
Problem Persists,” states that APA’s financial disclosure policy for
DSM-5 has not resulted in a reduction of conflicts of interest and
concludes that “transparency alone cannot mitigate the potential for bias and is
an insufficient solution for protecting the integrity of the revision
process.”
The article appeared online March
13.
But Oldham said the authors of the article drew
comparisons to DSM-IV—for which there were not the stringent
requirements for financial disclosure that exist for DSM-5
contributors—to suggest erroneously that there has been an increase in conflicts
of interest.
“[S]ince there were no disclosure requirements for
journals, symposia, or the DSM-IV Task Force at the time of the 1994
release of DSM-IV, Cosgrove and Krimsky’s comparison of DSM-IV
and DSM-5 Task Force and work group members is not valid,” Oldham said.
“In assembling DSM-5 ’s Task Force and work groups, APA’s Board of
Trustees developed an extensive process of written disclosure of potential
conflicts of interest. These disclosures are required of all professionals who
participate in the development of DSM-5. An independent APA committee
reviews these disclosure documents, which are updated annually or whenever a
member’s financial interests change.”
Oldham’s response noted that currently, 72 percent
of the 153 members reported no relationships with the pharmaceutical industry
during the previous year. Moreover, the scope of the relationships reported by
the remaining 29 percent varies:
-
12 percent reported grant support only, including funding or
receipt of medications for clinical trial research.
-
10 percent reported paid consultations including advice on the
development of new compounds to improve treatments.
-
7 percent reported receiving
honoraria.
These figures contradicted those cited by Cosgrove
and Krimsky, who wrote, “Currently, 69 percent of the DSM-5 task force
members report having ties to the pharmaceutical industry.”
They went on to add, “This represents a relative
increase of 21 percent over the proportion of DSM-IV Task Force members
with such ties (57 percent of DSM-IV task force members had
ties).”
When queried for a response to APA’s challenge to
the PLoS article, Cosgrove said their data for DSM-IV were
“based on objective information we obtained from published sources since
DSM did not disclose at that time the financial interests of panel
members.”
She added, “We used the same methodology in the
current study although the sources of information were different because
DSM-5 did a lot of work for us by disclosing the financial
ties.”
With regard to the apparent discrepancy in reported
industry ties, Cosgrove said in her response that the figures she derived for
the DSM-5 group include the full three-year period prior to each
person’s nomination to the task force or work group, as was required for
participation in DSM-5.
She added, “It is important in reporting financial
interests that one chooses a time period prior to the publication of the
document. Thus, in order to compare the commercial ties of the DSM-IV
and DSM-5 groups, we relied on the best available data for each group:
published disclosures (for example, in peer-reviewed medical journals) of
financial ties for DSM-IV and the disclosure forms for the
DSM-5 groups.”
But Darrel Regier, M.D., M.P.H, APA’s director of
research, said that using the entire three-year reporting data and presenting
the data as current ignores the degree to which DSM-5 reporting
requirements have resulted in minimization or divestment of industry ties over
time.
“As documented in their previous publications, these
authors take the position that if there was ever any kind of relationship with
the pharmaceutical industry, the clinician should be excluded from
DSM-5 participation—an extreme position with which we disagree,” Regier
told Psychiatric News. “As a result, they counted all disclosures for
all years that were posted for DSM-IV Task Force members after 1994
publication of DSM-IV and contrasted that with DSM-5 Task
Force member disclosures for three years prior to their appointment—without
recognizing the substantial decrease in member affiliations as the DSM
process progressed over five years.”
Regier added, “It is clear that there has been a sea
change in how academic investigators related to industry over the past seven
years since 2005—three years before the work group members were reviewed for
their 2008 appointments to the DSM-5 Task Force. A good number of
investigators were providing lectures at industry-sponsored symposia at the APA
[annual meeting] and other meetings from 2005 to 2007, when those who were
invited to participate in DSM-5 agreed to limit and often end such
relationships.
“The use of the words ‘a pernicious problem
persists’ in the headline is unfortunate and highly inaccurate,” Regier said.
“The implication is that the relationships continue to exist as previously, when
in fact there has been a marked drop in industry relationships—which the authors
fail to recognize or acknowledge.”
______________________________________________________________
Tuesday, July 12th, 2011
ALJAZEERA – July 12, 2011
by James Ridgeway
Drug companies like Pfizer are accused of pressuring doctors into
over-prescribing medications to patients in order to increase profits
- GALLO/GETTY
Has America become a nation of psychotics? You would certainly think so, based on the explosion in the use of antipsychotic medications. In 2008, with over $14 billion in sales, antipsychotics became the single top-selling therapeutic class of prescription drugs in the United States,
surpassing drugs used to treat high cholesterol and acid reflux.
Once upon a time, antipsychotics were reserved for a relatively small number of patients with hard-core psychiatric diagnoses – primarily schizophrenia and bipolar disorder – to treat such symptoms as delusions, hallucinations, or formal thought disorder. Today, it seems, everyone is taking antipsychotics. Parents are told that their unruly kids are in fact bipolar, and in need of anti-psychotics, while old people with dementia are dosed, in large numbers, with drugs once reserved largely for schizophrenics. Americans with symptoms ranging from chronic depression to anxiety to insomnia are now being prescribed anti-psychotics at rates that seem to indicate a national mass psychosis.
It is anything but a coincidence that the explosion in antipsychotic use coincides with the pharmaceutical industry’s development of a new class of medications known as “atypical antipsychotics.” Beginning with Zyprexa, Risperdal, and Seroquel in the 1990s, followed by Abilify in the early 2000s, these drugs were touted as being more effective than older antipsychotics like Haldol and Thorazine. More importantly, they lacked the most noxious side effects of the older drugs – in particular, the tremors and other motor control problems.
The atypical anti-psychotics were the bright new stars in the pharmaceutical industry’s roster of psychotropic drugs – costly, patented medications that made people feel and behave better without any shaking or drooling. Sales grew steadily, until by 2009 Seroquel and Abilify
numbered fifth and sixth in annual drug sales, and prescriptions written for the top three atypical antipsychotics totaled more than 20 million. Suddenly, antipsychotics weren’t just for psychotics any more.
Not just for psychotics anymore
By now, just about everyone knows how the drug industry works to influence the minds of American doctors, plying them with gifts, junkets, ego-tripping awards, and research funding in exchange for endorsing or prescribing the latest and most lucrative drugs. “Psychiatrists are particularly targeted by Big Pharma because psychiatric diagnoses are very subjective,” says Dr. Adriane Fugh-Berman, whose PharmedOut project tracks the industry’s influence on American medicine, and who last month hosted a conference on the subject at Georgetown. A shrink can’t give you a blood test or an MRI to figure out precisely what’s wrong with you. So it’s often a case of diagnosis by prescription. (If you feel better after you take an anti-depressant, it’s assumed that you were depressed.) As the researchers in one study of the drug industry’s influence put it, “the lack of biological tests for mental disorders renders psychiatry especially vulnerable to industry influence.” For this reason, they argue, it’s particularly important that the guidelines for diagnosing and treating mental illness be compiled “on the basis of an objective review of the scientific evidence” – and
not on whether the doctors writing them got a big grant from Merck or own stock in AstraZeneca.
Marcia Angell, former editor of the New England Journal of Medicine and a leading critic of the Big Pharma, puts it more bluntly: “Psychiatrists are in the pocket of industry.” Angell has pointed out that most of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of mental health clinicians, have
ties to the drug industry. Likewise, a 2009 study showed that 18 out of 20 of the shrinks who wrote the American Psychiatric Association’s most recent clinical guidelines for treating depression, bipolar disorders, and schizophrenia had financial ties to drug companies.
In a
recent article in
The New York Review of Books, Angell deconstructs what she calls an apparent “raging epidemic of mental illness” among Americans. The use of psychoactive drugs—including both antidepressants and antipsychotics—has exploded, and if the new drugs are so effective, Angell points out, we should “expect the prevalence of mental illness to be declining, not rising.” Instead, “the tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007 – from one in 184 Americans to one in seventy-six. For children, the rise is even more startling – a thirty-five-fold increase in the same two decades. Mental illness is now the leading cause of disability in children.” Under the tutelage of Big Pharma, we are “simply expanding the criteria for mental illness so that nearly everyone has one.” Fugh-Berman agrees: In the age of aggressive drug marketing, she says, “Psychiatric diagnoses have expanded to include many perfectly normal people.”
Cost benefit analysis
What’s especially troubling about the over-prescription of the new antipsychotics is its prevalence among the very young and the very old – vulnerable groups who often do not make their own choices when it comes to what medications they take. Investigations into antipsychotic use suggests that their purpose, in these cases, may be to subdue and tranquilize rather than to treat any genuine psychosis.
Carl Elliott reports in
Mother Jones magazine: “Once bipolar disorder could be treated with atypicals, rates of diagnoses rose dramatically, especially in children. According to a recent Columbia University study, the number of children and adolescents treated for bipolar disorder rose 40-fold between 1994 and 2003.” And according to
another study, “one in five children who visited a psychiatrist came away with a prescription for an antipsychotic drug.”
A remarkable
series published in the Palm Beach Post in May true revealed that the state of Florida’s juvenile justice department has literally been pouring these drugs into juvenile facilities, “routinely” doling them out “for reasons that never were approved by federal regulators.” The numbers are staggering: “In 2007, for example, the Department of Juvenile Justice bought more than twice as much Seroquel as ibuprofen. Overall, in 24 months, the department bought 326,081 tablets of Seroquel, Abilify, Risperdal and other antipsychotic drugs for use in state-operated jails and homes for children…That’s enough to hand out 446 pills a day, seven days a week, for two years in a row, to kids in jails and programs that can hold no more than 2,300 boys and girls on a given day.” Further, the paper discovered that “One in three of the psychiatrists who have contracted with the state Department of Juvenile Justice in the past five years has taken speaker fees or gifts from companies that make antipsychotic medications.”
In addition to expanding the diagnoses of serious mental illness, drug companies have encouraged doctors to prescribe atypical anti-psychotics for a host of off-label uses. In one particularly notorious episode, the drugmaker Eli Lilly pushed Zyprexa on the caregivers of old people with Alzheimer’s and other forms of dementia, as well as agitation, anxiety, and insomnia. In selling to nursing home doctors, sales reps reportedly used the slogan “five at five”—meaning that five milligrams of Zyprexa at 5 pm would sedate their more difficult charges. The practice persisted even after FDA had warned Lilly that the drug was not approved for such uses, and that it could lead to obesity and even diabetes in elderly patients.
In a
video interview conducted in 2006, Sharham Ahari, who sold Zyprexa for two years at the beginning of the decade, described to me how the sales people would wangle the doctors into prescribing it. At the time, he recalled, his doctor clients were giving him a lot of grief over patients who were “flipping out” over the weight gain associated with the drug, along with the diabetes. “We were instructed to downplay side effects and focus on the efficacy of drug…to recommend the patient drink a glass a water before taking a pill before the meal and then after the meal in hopes the stomach would expand” and provide an easy way out of this obstacle to increased sales. When docs complained, he recalled, “I told them, ‘Our drug is state of the art. What’s more important? You want them to get better or do you want them to stay the same–a thin psychotic patient or a fat stable patient.’”
For the drug companies, Shahrman says, the decision to continue pushing the drug despite side effects is matter of cost benefit analysis: Whether you will make more money by continuing to market the drug for off-label use, and perhaps defending against lawsuits, than you would otherwise. In the case of Zyprexa, in January 2009, Lilly settled a lawsuit brought by with the US Justice Department, agreeing to pay $1.4 billion, including “a criminal fine of $515 million, the largest ever in a health care case, and the largest criminal fine for an individual corporation ever imposed in a United States criminal prosecution of any kind,”the Department of Justice said in announcing the settlement.” But Lilly’s sale of Zyprexa in
that year alone were over $1.8 billion.
Turning people into zombies
As it turns out, the atypical antipsychotics may not even be the best choice for people with genuine, undisputed psychosis.
____________________________________________________________________________
Read more on this subject on this blog:
How
American Psychiatry Can Save Itself: Part 1 - ...
___________________________________________________________________________
How
do controversial revisions in psychiatry's guidebook make you feel?
Posted: Fri, May. 4, 2012, 3:01
AM
How do controversial revisions in psychiatry's guidebook
make you feel?
By Stacey Burling
Inquirer Staff Writer
When upward of
10,000 members of the American Psychiatric Association meet here this weekend,
they'll be met by protesters - there are always protesters - and tough questions
about where their profession is headed and how it will define normalcy for the
rest of us. The official theme of the annual meeting, which opens Saturday at
the Pennsylvania Convention Center, is integrated care, a nod to the
increasingly interdisciplinary nature of medicine in the health-reform era. But
many sessions will also focus on the association's highly controversial overhaul
of the Diagnostic and Statistical Manual of Mental Disorders, the dominant
guidebook to mental maladies and a key factor in determining insurance
payments.
The current tome, the DSM-IV, was published in 1994 and updated in
2000. The book now in the works, the DSM-5 (yes, they dropped the Roman
numerals), is due out by next year's APA meeting.
Supporters say the
revisions incorporate more current science into the highly influential book. It
also strives for diagnoses that show how seriously ill patients are.
Critics
say the changes jump ahead of the science and expand what is considered mental
illness. While the association tries to detect illnesses earlier and possibly
prevent their most tragic symptoms, it risks calling essentially normal people
mentally ill, needlessly exposing thousands to stigma and strong medicines, and
handing drugmakers a bonanza.
One hot-button proposal allows grieving people
to be considered depressed after two weeks of symptoms. Another addresses
children who were being labeled bipolar by creating a different diagnosis:
disruptive mood dysregulation disorder. Some worry that diagnoses meant to
identify thinking problems in the elderly will turn normal aging into a
disorder.
The University of Pennsylvania was one of 11 academic medical
centers that field-tested the book's new approach. It looked at five diagnoses,
including three new ones: hoarding disorder, binge-eating disorder, and mixed
depression and anxiety.
In what is surely biting criticism in the
mental-health world, David N. Elkins, a psychology professor emeritus at
Pepperdine University, said the APA "should listen. They don't listen very well.
They need to listen to the outcry and take it seriously."
The APA must have
listened a little. It announced this week that it had moved the new attenuated
psychosis syndrome, which attempted to identify young people likely to develop
psychosis, and mixed anxiety and depression to a book section for conditions
that need more research. They also tried to better differentiate normal grief
from depression.
Last fall, Elkins, president of the Society for Humanistic
Psychology, helped draft an open letter critiquing proposed changes. It got
13,000 signatures online, he said.
His and other groups are so miffed that
they plan to write their own book. "We are calling for a summit in New York City
in the summer of 2013 of all the mental-health professions," Elkins said. "We
need a manual that is produced in an egalitarian way."
One of the most vocal
critics is psychiatrist Allen Frances, who edited the DSM-IV. He said that
overdiagnosing and overprescribing of antipsychotic drugs, particularly in
children and the elderly, were already big problems. Psychiatry, he said, should
be asking, "How can we put a governor on this? What DSM-5 will do, instead, is
open up the flood gates."
The new approach, he said, gives "drug companies a
free pass to convince everyone in the world that they have one disorder or two
or three."
There's also the matter of autism. Its proposed definition is
more restrictive. That has caused an outcry from autism advocates, who
fear children will lose school services.
Frances thinks his group has made
the current definition too broad. If fewer children with mild symptoms are
diagnosed, "that's a good thing."
He also thinks the APA has too much money
at stake to be objective. He says it makes $5 million to $10 million a year on
sales of the manual.
The APA says it has invested $25 million in developing
the new DSM over the last 12 years. It deflected a question about how much
income the book generates.
David Kupfer, a University of Pittsburgh
psychiatrist who heads the DSM-5 task force, said nothing was set in stone. A
third six-week comment period opened Wednesday. The APA already has received
close to 10,800 comments.
"We do want more public commentary," Kupfer said.
"We are carefully examining this with some of our review groups. We certainly do
not want to make changes for the sake of making changes."
For the record, he
said, the number of diagnoses is dropping from 280 to 220.
John Oldham, the
psychiatric association's president, said one of the DSM's roles has been to
provide definitions that lead to better research. Mental health and illness are
on a continuum with no clear lines of demarcation, but scientists need to find
the earliest signs of dysfunction. "It's important for us," he said, "to be
trying to understand when the right time is to intervene."
Thomas R. Insel, a
psychiatrist who directs the National Institute of Mental Health, sees
psychiatry heading toward what he calls "clinical neuroscience." Psychiatrists
should study the brain the way cardiologists study the heart, he said.
While
people assume that thinking of mental illnesses as brain disorders will lead to
more medication, Insel said his agency has funded research into cognitive
training, therapy that uses the brain's ability to change. It also is studying
diet and family support.
"There is no biochemical imbalance that we have ever
been able to demonstrate," he said. "What we think about are changes in
circuitry and how the brain is processing information."
It makes sense to him
to try to identify at-risk youths before they develop symptoms that can
devastate their ability to work or have fulfilling relationships. The most
debilitating of the mental illnesses, schizophrenia and bipolar disorder, often
are diagnosed in early adulthood, but researchers are studying signs that emerge
years earlier.
Critics say that lots of teens have eccentric behaviors but
won't become mentally ill. This is true, Insel said, but "science entirely
supports" figuring out who's going to become psychotic and preventing it. "That
doesn't mean medicate earlier," he said.
The institute has embarked on its
own attempt to classify mental illnesses based on what's happening in the brain
rather than on symptoms.
Asked whether the association should delay rewriting
the DSM until the science advances, he said, "That's a fair question. I'm not
going to answer it." Then he said, "I think the DSM-IV is extremely
helpful."
Mahendra Bhati, a psychiatrist who headed the Penn field trial, is
confident that the new disorders his clinic tested are genuine mental illnesses.
They don't necessarily need drug treatment.
But he found the new approach to
personality disorders "clinically impractical."
Overall, he said, "I
honestly don't think it's going to make a huge difference in how I practice
psychiatry." His prescriptions, he said, are based on symptoms, not
diagnoses.
On Saturday, as psychiatrists inside the convention center discuss
proposed DSM changes, protesters outside plan to "Occupy the American
Psychiatric Association." They'll have a "label rip," where they tear up the
very diagnosis names that the psychiatrists are intent on defining.
"We'd
have to be Don Quixote to think we're going to stop it at this point," David
Oaks said of the DSM-5. A veteran of many such protests, Oaks, a Harvard grad
who has been called schizophrenic and bipolar, is executive director of
MindFreedom International and one of the event organizers. He says psychiatrists
have not listened enough to their "customers," who often find peer and social
support more helpful than drugs.
Read more:
http://www.philly.com/philly/health/20120504_How_do_controversial_revisions_in_psychiatry_s_guidebook_make_you_feel_.html?viewAll=y#ixzz1tts42VMT
Watch sports videos you won't find anywhere else
_____________________________________________________________________________
DSM-5
Debate: Committee Backs Off Some Changes, Re...
__________________________________________________________________________
Psychiatric diagnoses are not mental process: Wittgenstein on conceptual
confusion.
Source
Centre for Mental Health Research, Australian
National University, Canberra, Australia.
Abstract
Background: Empirical explanation and treatment repeatedly fail
for psychiatric diagnoses. Diagnosis is mired in conceptual confusion that is
illuminated by Ludwig Wittgenstein's later critique of philosophy (Philosophical
Investigations). This paper examines conceptual confusions in the foundation of
psychiatric diagnosis from some of Wittgenstein's important critical
viewpoints.Argument: Diagnostic terms are words whose meanings are given by
usages not definitions. Diagnoses, by Wittgenstein's analogy with 'games', have
various and evolving usages that are connected by family relationships, and no
essence or core phenomenon connects them. Their usages will change according to
the demands and contexts in which they are employed. Diagnoses, like many
psychological terms, such as 'reading' or 'understanding', are concepts that
refer not to fixed behavioural or mental states but to complex apprehensions of
the relationship of a variety of behavioural phenomena with the world. A
diagnosis is a sort of concept that cannot be located in or explained by a
mental process.Conclusion: A diagnosis is an exercise in language and its usage
changes according to the context and the needs it addresses. Diagnoses have
important uses but they are irreducibly heterogeneous and cannot be identified
with or connected to particular mental processes or even with a unity of
phenomena that can be addressed empirically. This makes understandable not only
the repeated failure of empirical science to replicate or illuminate genetic,
neurophysiologic, psychic or social processes underlying diagnoses but also the
emptiness of a succession of explanatory theories and treatment effects that
cannot be repeated or stubbornly regress to the mean.Attempts to fix the
meanings of diagnoses to allow empirical explanation will and should fail as
there is no foundation on which a fixed meaning can be built and it can only be
done at the cost of the relevance and usefulness of diagnosis.
PMID:
- 22528975
- [PubMed - as supplied by publisher]
Free full text
_______________________________________________________________________________
World
Psychiatry Journal - World Psychiatric Assoc...
Psychiatric
diagnosis: pros and cons of prototypes...
World
Psychiatric Association / English
Psychiatric diagnosis: pros and cons of prototypes
vs. operational
criteria
EDITORIAL
Mario Maj
President, World Psychiatric
Association
The development of operational diagnostic criteria
for
mental disorders in the 1970s was a response to serious concerns
about
the reliability of psychiatric diagnosis. Initially
intended only for
research purposes, the operational approach
was subsequently proposed also
for ordinary clinical
practice by the DSM-III. That this approach increases
the
reliability of psychiatric diagnosis in research settings is now
well
documented.
Much less clear, even in the US, is whether
the approach is
commonly used by clinicians in ordinary
practice, thus really resulting in an
increase of the reliability
of psychiatric diagnosis in clinical settings. It
has been, for
instance, reported that several US clinicians have
difficulties
to recall the DSM-IV criteria for major depressive
disorder
and rarely use them in their practice (e.g., 2).
Furthermore,
some of the DSM-IV cut-offs and time frames have been
found
not to have a solid empirical basis (e.g., 3) and to
generate a high
proportion of sub-threshold and “not otherwise
specified” cases (e.g.,
4).More in general, it has been maintained that a “prototype
matching”
approach is more congruent with human (and
clinical) cognitive processes than
a “defining features” approach
(e.g., 5).
The spontaneous clinical process
does not
involve checking in a given patient whether each of a series
of
symptoms is present or not, and basing the diagnosis on
the number of
symptoms which are present. It rather involves
checking whether the
characteristics of the patient
match one of the templates of mental disorders
that the clinician
has built up in his/her mind through his/her
training
and clinical experience.Moreover, some recent research focusing
on various
classes of mental disorders (i.e., personality disorders,
eating
disorders, anxiety disorders) suggests that a diagnostic
system
based on refined prototypes may be as reliable as one
based on
operational criteria, while being more user friendly
and having greater
clinical utility (e.g., 6).
World
Psychiatric Association / The WPA-WHO Global...
___________________________________________________________
Money
Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine |
candidaabrahamson
Money Motivates Mental Health Moves: DSM-5, Meet Makers of
Medicine
In the interest of full disclosure, let me be perfectly
clear.
As a therapist, I use the
DSM (
Diagnostic and Statistical
Manual of Mental Disorders), the ‘mental health bible’ that helps diagnose
and define treatment, frequently. I find it pivotal in making diagnoses, and
then in providing a shared language to discuss those diagnoses with consulting
psychiatrists, with other treaters, with educators. I share it with clients to
assist them in understanding their illnesses and potential treatments, and it’s
a useful tool to help third-party payers understand the needs of the
patients.
Really, overall I’m a fan, and I rely upon it.
Which is probably why I find myself so frustrated with the
current process of updating the (ready for this one?) DSM-IV-TR (don’t
ask) to the DSM-5.
Perhaps I’m an innocent (highly unlikely), but I had counted on
the American Psychiatric Association (APA), the group responsible for the
updating of the DSM (soon this will be an alphabet soup), to keep the
process relatively untainted.
I had counted wrong.
Again in the interest of full disclosure, I had
already found myself frustrated with several of the committee on the
DSM-5‘s decisions. In an act of tremendous restraint, I won’t go over
again my opposition to doing away with the bereavement exclusion [but won't
deprive you of a
hyperlink
to my mini-rant], nor will I carry on again about the potential inclusion of
Hypersexuality and Internet Addiction [ok--
link
here if you can't keep yourself away]. But the APA’s process of updating
‘the mental health bible’ crawled under my skin once again–not for its lack of
full disclosure, really, as much as its seeming indifference to what the
disclosure indicated.
Just for some background: There are 141 panel members on the 13
DSM-5 panels and 29 task force members. The members of these 13 panels
are the ones in charge of revisions to diagnostic categories and inclusion of
new disorders.
So far, so good.
Until you look a bit further, and realize the DSM-5
process has enough ties to big money (pharmaceutical money, of course), to make
good old Bernie Madoff, who, it turns out, had very few ties to actual money,
squirm with jealousy.
In “A Comparison of DSM-IV and DSM-5 Panel
Members’ Financial Associations with Industry: A Pernicious Problem Persists,”
Lisa Cosgrove, PhD, from the Edmond J. Safra Center for Ethics at Harvard
University, and Sheldon Krimsky, PhD, from the Department of Public Health and
Community Medicine at Tufts University, write the following astonishing facts
about the DSM’s financial connections to big pharm:
Three-fourths of the work groups
continue to have a majority of their members with financial ties to the
pharmaceutical industry. It is also noteworthy that, as with the
DSM-IV, the most conflicted panels are those for which pharmacological
treatment is the first-line intervention. For example, 67% . . . of the panel
for Mood Disorders, 83% . . . of the panel for Psychotic Disorders, and 100% . .
.[Note to reader: this 100% is a personal favorite of mine. How can you beat
it?] of the Sleep/Wake Disorders (which now includes “Restless Leg Syndrome”)
have ties to the pharmaceutical companies that manufacture the medications used
to treat these disorders or to companies that service the pharmaceutical
industry.
So if I’ve got this right [and I have a good
sense that I do; it isn't as difficult as the proverbial rocket science], and if
I return for the moment to the
DSM-5′s exclusion of the bereavement
clause, which means, just to sum up, that after two weeks of grief symptoms
(which, it is already known and accepted, overlap with depressive symptoms), a
bereaved person can be diagnosed with depression, I could be looking at
something like this, if I were take the most Machiavellian view. Depression, as
opposed to grief, can be treated with and has found to be responsive to
psychotropic medications. Thus turning grief into a depression yields more
prescriptions, which could potentially benefit any of that high percentage of
doctors sitting on the committee with connections to the companies that make
these meds.
I don’t really think that the 67% of the Mood Disorders
committee members insisted on turning grief into a mood disorder with the
thought that they would profit financially, hoping that the pharmaceutical
companies they’re connected would step in to provide psychotropics to the
bereaved. Not for a moment. But it might be difficult for those committee
members to completely keep that idea out of their heads. That’s why
conflicts of interests are problems.
Krimsky himself clarified that his article was not meant to be a
‘witch hunt.’ He said, “I don’t believe that anyone on the panel is purposefully
making decisions that favor industry. The issue is more subtle and just as
impactful. We all have the potential for bias in a conflicted situation, and
we’re all really defended against looking at those biases, and therein lies the
danger.”
I enjoyed some of the APA’s responses to the Krimsky-Cosgrove
article. Take David Elkins, president of the American Psychological
Association’s Society for Humanistic Psychology (a society I, myself, had never
heard of until the other day, but one with a title that piques my interest.
And–who knew?–it’s division #32 of the American Psychological Association. I
think my time could be well spent finding what the first 31 divisions
are.).
When asked what he had to say in response to the fact that
seven in 10 DSM-5 task force members have drug company ties, Elkins was
eloquent.
He was, not to put too fine a point on it, “dismayed.”
I love a man of few words.
But it gets better. The APA medical director and CEO is one Dr.
James Scully. And he says–and I don’t want people to miss this:
We wanted to include a wide variety
of scientists and researchers with a range of expertise and viewpoints in the
DSM-5 process. Excluding everyone with direct or indirect funding
from the industry would unreasonably limit the participation of leading mental
health experts in the DSM-5 development process.
Ok, I admit it. Those are my own italics. I can’t help it; it’s
priceless.
So, according to Scully, it’s worse than we even thought.
Looking for a mental health expert? Just know she’s connected to the
pharmaceutical companies. So much so, that if you keep anyone connected to the
drug makers out of a given process, you’ve lost your expertise base.
Now I feel better about the whole thing.
And the truth is that this isn’t as much of a shock to me as it
might have been. One incident proves little, but it made an impression on me,
and, woven into the tapestry of the Scully argument, bolsters my concern about
the infiltration of the drug companies into clinical practice.
The consulting psychiatrist and I met together with a patient to
get all views on the table at once, and to present a cohesive treatment plan. We
met in the psychiatrist’s office, where the doctor kindly proffered me a pen as
I searched my purse for one I couldn’t find [of course, now that I didn't need
them, I could locate my glasses, my bottle of baby aspirin, and the
receipt for the panty hose I'd been meaning to return--but couldn't find the
receipt].
This was no plain pen–it was a Paxil pen–with the medicine’s
name and logo written large upon it. The pad of paper he provided was dominated
by Effexor’s name–and, I kid you not, he had a Seroquel mug. My patient and I
sanitized our hands from a plastic bottle emblazoned with ‘Pristiq,’ and I
actually watched time pass on a cheap plastic clock with Abilify’s name
plastered across the face.
I stayed put, for I was certain, had I gone to the restroom, I
would have been met with toilet paper carrying Zyprexa’s name, and that, really,
was the limit.
And here’s the thing: This office isn’t unusual
in its collection of tchotchkes advertising psychotropics or other meds. It’s
all over.
In the interest of full disclosure, let me clarify: I thought
this was an excellent psychiatrist. Probably he’s sitting on the Mood Disorders
committee of the DSM-5, offering his expert opinion, and writing down
notes on his Zoloft clipboard.
Because if you cut him out of the DSM-5 process just
because he’s connected to the pharmaceutical companies–really, who do you have
left?
You know what? In the interest of full disclosure I tell you:
I’ve never heard of the APA’s society for humanistic psychology, but I’m right
there with its president. When it comes to how the DSM-5 is being
compiled, I too am–in a word–”dismayed.”
What You Really
Shouldn’t Miss
-
Please forgive the sacrilegious quality to this–but it is truly
hilarious. No need to count on the
DSM-5 to invent more psychiatric
illnesses with which you might one day be labelled. Oh no–there’s the “Disease
Mongering Engine.” It asks: “Why let the drug companies have all the fun?
YOU can invent diseases, too! Click the “Generate” button below
to create your very own disease, disorder, or syndrome.” See what you can
invent, patent and diagnose others with at
http://www.naturalnews.com/disease-mongering-engine.asp
-
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Psychiatry’s
bible, the DSM, is doing more harm th...
Psychiatry’s
bible, the DSM, is doing more harm than good - The Washington Post
Psychiatry’s bible, the DSM, is doing more harm than
good
By Paula J. Caplan, Published: April
27
About a year ago, a young mother called me, extremely
distressed. She had become seriously sleep-deprived while working full-time and
caring for her dying grandmother every night. When a crisis at her son’s
day-care center forced her to scramble to find a new child-care arrangement, her
heart started racing, prompting her to go to the emergency room.
After a
quick assessment, the intake doctor declared that she had bipolar disorder,
committed her to a psychiatric ward and started her on dangerous psychiatric
medication. From my conversations with this woman, I’d say she was responding to
severe exhaustion and alarm, not suffering from mental illness.
Since the
1980s, when I first made public my concerns about psychiatric diagnosis, I have
heard from hundreds of people who have been arbitrarily slapped with a
psychiatric label and are struggling because of it.
About
half of all Americans get a psychiatric diagnosis in their lifetimes.
Receiving any of the 374 psychiatric labels — from nicotine dependence disorder
to schizophrenia — can cost anyone their health insurance, job, custody of their
children, or right to make their own medical and legal decisions. And if
patients take psychiatric drugs, they
risk developing physical disorders such as diabetes, heart
problems, weight gain and other serious conditions. In light of the subjectivity
of these diagnoses and the harm they can cause, we should be extremely skeptical
of them.
Psychiatric diagnosis is unregulated, so the doctor who met
briefly with the aforementioned patient wasn’t required to spend much time
understanding what caused her heart to race or to seek another doctor’s opinion.
If he had, the patient would have realized that her bipolar diagnosis wasn’t
necessary or appropriate. Neither on her ER trip nor in later visits to
therapists did anyone explain how sleep deprivation impairs the body’s ability
to handle pressure.
In our increasingly psychiatrized world, the first
course is often to classify anything but routine happiness as a mental disorder,
assume it is based on a broken brain or a chemical imbalance, and prescribe
drugs or hospitalization;
even electroshock is still performed.
According to
the psychiatrists’ bible, the
Diagnostic and Statistical Manual of Mental Disorders
(DSM), which defines the criteria for doling out psychiatric labels, a patient
can fall into a bipolar category after having just one “manic” episode lasting a
week or less. Given what this patient was dealing with, it is not surprising
that she was talking quickly, had racing thoughts, was easily distracted and was
intensely focused on certain goals (i.e. caring for her family) — thus meeting
the requisite four of the eight criteria for a bipolar diagnosis.
When a
social worker in the psychiatric ward advised the patient to go on permanent
disability, concluding that her bipolar disorder would make it too hard to work,
the patient did as the expert suggested. She also took a neuroleptic drug,
Seroquel, that the doctor said would fix her mental illness.
Over the
next 10 months, the woman lost her friends, who attributed her normal mood
changes to her alleged disorder. Her self-confidence plummeted; her marriage
fell apart. She moved halfway across the country to find a place where, on her
dwindling savings, she and her son could afford to live. But she was isolated
and unhappy. Because of the drug she took for only six weeks, she now, more than
three years later, has an eye condition that could destroy her
vision.
This patient is well-educated and white, and before her illness,
she was wealthy. Research reflects that she was more likely to be diagnosed as
mentally ill than a man in her circumstances. Racism, classism, ageism and
homophobia can also affect who receives a psychiatric diagnosis.
It would
be less troubling if such diagnoses helped patients, but getting a label often
hinders recovery. It can lead a therapist to focus on narrow checklists of
symptoms, with little consideration for what is causing the patient’s
suffering.
The marketing of the DSM has been so effective that few people
— even therapists — realize that psychiatrists
rarely agree about how to label the same patient. As a
clinical and research psychologist who served on (and resigned from) two
committees that wrote the current edition of the DSM, I used to believe that the
manual was scientific and that it helped patients and therapists. But after
seeing its editors using poor-quality studies to support categories they wanted
to include and ignoring or distorting high-quality research, I now believe that
the DSM should be thrown out.
An undeserved aura of scientific precision
surrounds the manual: It has “statistical” in its title and includes a
precise-seeming three- to five-digit codefor every diagnostic category and
subcategory, as well as lists of symptoms a patient must have to receive a
diagnosis. But what it does is simply connect certain dots, or symptoms — such
as sadness, fear or insomnia — to construct diagnostic categories that lack
scientific grounding. Many therapists see patients through the DSM prism, trying
to shoehorn a human being into a category.
At a convention in
Philadelphia starting May 5, the DSM’s publisher, the American Psychiatric
Association, is due to vote on whether to send the manual’s next edition, the
DSM-5, to press. The APA is a lobbying group for its members, not an
organization with patients’ interests as its top priority. It has earned $100
million from sales of the current edition, the DSM-IV.
Allen
Frances, lead editor of the current DSM, defends his manual as grounded in
science, but at times he has acknowledged its lack of scientific rigor and the
overdiagnosing that has followed. “Our net was cast too wide,” Frances wrote
in a 2010 Los Angeles Times op-ed, referring to the
explosion of diagnoses that led to “false ‘epidemics’ ” of attention deficit
disorder, autism and childhood bipolar disorder. The current manual, released in
1994, he wrote, “captured many ‘patients’ who might have been far better off
never entering the mental health system.”
Frances has even said that “
there is no definition of a mental disorder. . . . These
concepts are virtually impossible to define precisely.”
Mental health
professionals should use, and patients should insist on, what does work: not
snap-judgment diagnoses, but instead
listening to patients respectfully to understand their
suffering — and help them find more natural ways of healing. Exercise, good
nutrition, meditation and human connection are often more effective — and less
risky — than drugs or electroshock.
Patients should not be limited in
their choices of treatment, but they should be better informed. If someone knows
about the many ways that suffering can be addressed, including a drug or a
treatment with potential benefits and harms, and they still want to try it, they
should be able to.
While patients who think they have been harmed by a
diagnosis can file a lawsuit or a complaint with a state licensing body, that
almost never happens. However, this weekend marks a big change, as some people
are speaking up: About 10 people who received diagnoses from the current DSM
edition are filing complaints against the manual’s editors. (I have worked with
the patients to prepare their complaints, and I’m filing my own as a concerned
clinician.)
The complainants allege that the DSM’s editors failed to
follow the APA’s ethical principles, which include taking account of scientific
knowledge and respecting patients’ welfare and dignity. They are asking the APA
to order the editors to redress the harm done to them — or in one case, to a
deceased relative — and to anyone else hurt by receiving a label. They want the
APA to hold a public hearing about the dangers of psychiatric diagnosis to
gather information about the extent of the damage and look for ways to minimize
it. Additionally, they are asking the APA to make clear to therapists and to the
public that psychiatric diagnoses are not scientific and that they often put
patients at risk.
As the patient labeled as bipolar told me: “If I had
never been diagnosed, I probably would still be married, would live close to
family and friends and not be so lonely, and would not be living on the
financial edge.”
outlook@washpost.com
Paula J.
Caplan, a clinical and research psychologist, is a fellow in the Women
in Public Policy Program at Harvard’s Kennedy School of Government. She is the
author of
“They Say You’re Crazy: How the World’s Most Powerful
Psychiatrists Decide Who’s Normal.”
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Books
on psychiatric diagnosis
Book
Review: Psychology's Ghosts - WSJ.com
__________________________________________________________________
Psychiatric Diagnosis:
Challenges and Prospects: Patterns and Prospects (World Psychiatric Association)
by Ihsan M. Salloum, Juan E. Mezzich
Detail:
Psychiatric Diagnosis: Challenges and Prospects: Patterns
and Prospects (World Psychiatric Association)
Product Description
Psychiatric diagnosis is one of the most important
topics within the broad field of psychiatry. Clear, accurate definitions of the
various disorders are essential for clinicians around the world to be confident
that they are classifying patients in the same way, thereby enabling comparisons
of treatment regimens and their outcomes. There are two major classification
systems in use, one produced by the World Health Organization, the WHO
International Classification of Diseases, Mental Disorders Chapter, and one by
the American Psychiatric Association, the well known Diagnostic and Statistical
Manual of Mental Disorders. Both of these are being revised so this book from
the prestigious World Psychiatric Association is especially timely.In this book,
leading experts in the field provide a broad and integrated coverage of the
concepts, structure and context of psychiatric diagnosis. It begins by
addressing mental health and illness around the world from historical,
philosophical and cultural perspectives. Health is approached comprehensively,
to include such aspects as resilience, resources and quality of life. The book
then covers major specific psychopathology topics in Section II, including new
categorizations and dimensional approaches. Section III concentrates on the
complex problem of comorbidity, a primary challenge for modern diagnostic
classifications in psychiatry. Finally, Section IV reviews emerging
international diagnostic systems in psychiatry, considering innovative models
and adaptations.This book will be essential reading for anyone involved in the
diagnosis of psychiatric disorders.
From the Back Cover
Improved diagnostic systems are necessary to enhance
clinical care, teaching and research. Written by leading experts in the field,
this book provides broad, integrated coverage of psychiatric diagnosis from
historical and conceptual roots to novel diagnostic approaches.Divided into four
accessible sections, the book covers: Concepts of mental health and illness
around the world from historical, philosophical and cultural perspectives.
Health is approached comprehensively, to include such aspects as resilience,
resources and quality of life Major specific psychopathology topics, including
new categorizations and dimensional approaches The complex problem of
comorbidity in mental and general health, a major challenge for modern
diagnostic classifications in psychiatry Emerging international diagnostic
systems in psychiatry, considering innovative models and adaptationsPsychiatric Diagnosis: Challenges and Prospects presents
innovative and helpful models for improved evaluation and care and should be
read by all mental health professionals, as well as practising clinicians,
researchers and postgraduate students in psychiatry and psychology.
___________________________________________________________
Esssential
Philosophy of Psychiatry (International...
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Can I sign a petition if I am unlicensed? (Probably not, hey?)
I had the worse deppresive episode of my life for about 6 months after my cat died. Luckily for me, my diagnosis is type-II bipolar which doesn’t have a (pet) bereavement exclusion clause, b/c I was suffering terribly and I was able to recover with the combination of medicine and therapy. I’m not saying that there aren’t potential negative consequences of removing the bereavement exemption, but I really don’t think you should lump it in with the negative consequences of undue involvement by the industry in the revision process.
If nothing else, removing the exemption, along with some other things like changing from a more categorical to dimensional approach, represents a change in the dsm-III/iv philosophy of mental disorders being discrete disease entities with an implied fully biological etiology. I’m not saying this will hamper the industry or slow down the monetezation of mental illness, but it is an interesting trend worth watching.