636,120 Ways to Have Posttraumatic Stress Disorder

Hat tip to "Big Trends in Neuroscience" where I first came across the link. This made the rounds about a year ago while I was on hiatus, but it still deserves extra attention

Diagnosing mental illness: more than half a million reasons to worry

Here’s a fascinating article from Perspective on Psychological Science about the very troubling state of psychiatric diagnosis, using PTSD as the prime example (Galatzer-Levy and Bryant 2013). I know DSM bashing is all the rage (looking at you, Tom Insell), but this paper takes DSM to the woodshed in some new and exhilarating ways. I had my behavioral neuroscience students read it last semester, and it got them appropriately agitated.

Bibliography

Galatzer-Levy, I. R., and R. A. Bryant. 2013. 636,120 Ways to Have Posttraumatic Stress Disorder. Perspectives on Psychological Science. SAGE Publications, November 1. http://dx.doi.org/10.1177/1745691613504115

You can find the full paper in PDF format here

Bitterness To Be Classified As a Mental Illness

Some psychiatrists are trying to get excessive bitterness identified as a mental illness named post-traumatic embitterment disorder. Of course this has some people who live perfect little lives, and always get what they want, questioning the new classification. The so called "disorder" is modeled after post-traumatic stress disorder because it too is a response to a trauma that endures. "They feel the world has treated them unfairly. It's one step more complex than anger. They're angry plus helpless," says Dr. Michael Linden, the psychiatrist who put a name to how the world works. Reported in the LA Times, via Slashdot

Psychiatrists Do Not Know What Normal Sex Is.

Psychiatrists are trying to define what normal sex is for the next edition of the DSM, but will probably wind up making everything a for-profit treatable condition that be be treated with a pill.

As Seen on MSNBC

This month the American Psychiatric Association announced the names of “working group” members who will guide the development of the new Diagnostic and Statistical Manual of Mental Disorders, or DSM, the codex of American psychiatry.

Not surprisingly, given the DSM’s colorful history, particularly when it comes to sex, controversy erupted within days of the announcement, especially over membership of the Sexual and Gender Identity Disorders working group, which will wrestle with questions such as:

• Are sadomasochism or pedophilia mental disorders?
• Are dysfunctions like female hypoactive sexual desire disorder (low sex drive) psychiatric issues, or hormonal issues?

Perhaps the most important question is whether, when it comes to many sexual interests and issues, it’s even possible or desirable to create diagnostic criteria.

At least one petition, spearheaded by transgender activists, is being circulated to oppose the appointment of some members to the Sexual and Gender Identity Disorders work group and its chair, Kenneth Zucker, head of the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto, Canada. The petition accuses Zucker of having engaged in “junk science” and promoting “hurtful theories” during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy.

Zucker rejects the junk-science charge, saying that there “has to be an empirical basis to modify anything” in the DSM. As for hurting people, “in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.”

That sex is controversial comes as no surprise to Dr. Darrel Regier, the vice-chair of the APA’s DSM-V Task Force, based in Arlington, Va.

Sex, he says, in an understatement, “is an area that obviously has lots of emotion attached to it.” But the APA, he says, is doing its best to put science and evidence first, both in who it appoints to working groups and in the process it will use to create the DSM-V (so called because it is the fifth complete version). Each working group will accept input from many experts with varying views, reach a consensus on DSM content, and then put that work group’s product before the board of trustees of the APA and the APA assembly.

All that may be true, but Regier does not expect such reassurances to quell the forces already swirling around the DSM-V as it moves toward a 2012 publication date. Currently, the DSM-IV includes sex-related activities as varied as paraphilias like voyeurism, klismaphilia (erotic use of enemas) and sadism, and functional disorders like dyspareunia (pain with intercourse), erectile disorders and premature ejaculation.

'A set of scientific hypotheses'

The first DSM was issued in 1952. The idea was to create a more standardized way of talking about psychiatric disorders. As psychiatrist Dr. Gail Saltz, a TODAY Show contributor who also practices in New York, explains, the DSM is best viewed as “a language we have chosen to speak, a talking point we mental health professionals have created to communicate as well as we can with each other and with other professions.”

It is not a final arbiter of who’s crazy and who’s not. Saltz, who says she thinks the DSM can be limiting in clinical practice, prefers to take a holistic approach and look at each patient’s collection of symptoms and concerns without being restricted by the DSM’s various criteria.

Regier agrees that’s how doctors should use it, arguing that the DSM “really needs to be seen as a set of scientific hypotheses.” It is, he believes, “a living document” changeable with new research.

But if the DSM is a book of “hypotheses,” why the fuss? Does the DSM matter?

Yes. A lot.

The first reason why is prosaic. If you want your insurance to reimburse your visit to a mental health professional, you are probably going to need a DSM code signifying a diagnosis.

But the more profound reason is that it shapes how doctors, even the rest of rest of society, view sexuality.

“A psychiatric diagnosis is more than shorthand to facilitate communication among professionals or to standardize research parameters,” wrote Dr. Charles Moser and Peggy Kleinplatz in a 2005 paper published in the Journal of Psychology and Human Sexuality.

“Psychiatric diagnoses affect child custody decisions, self-esteem, whether individuals are hired or fired, receive security clearances, or have other rights and privileges curtailed. Criminals may find that their sentences are either mitigated or enhanced as a direct result of their diagnoses.

The equating of unusual sexual interests with psychiatric diagnoses has been used to justify the oppression of sexual minorities and to serve political agendas. A review of this area is not only a scientific issue, but also a human rights issue.”

A problem for whom?

There is no shortage of opinion on what ought to be changed, deleted or included in the new DSM-V. Sandra Leiblum, formerly a professor at New Jersey’s Robert Wood Johnson Medical School and an expert in female sexual health who is now in private practice in Bridgewater, N.J., says she wants to see a revision of diagnoses of female hypoactive sexual desire disorder, other female arousal disorders and sexual pain like dyspareunia. For example, she wants language that would separate arousal disorders into genital (more biological in origin) and subjective subtypes.

Carol Queen, a sexologist, sexual rights activist and co-founder of San Francisco’s Center for Sex and Culture, believes the new DSM should stress that sexual variances are only a problem “if they are problems in the life of the person showing up” in a psychiatrist’s office “so that when somebody is eroticizing something, or doing something in a consensual way, that’s not a problem” even if it may seem odd to most of us.

She also proposes an addition, a diagnosis of “absexual” (“ab” meaning “away from”). This would include those who appear to be “turned on by fulminating against it.” Examples could include state governors who crusade against prostitution even while paying hookers for sex, and religious leaders who wind up trying to explain engaging in the sex acts they preach against.

Moser, who is affiliated with the Institute for Advanced Study of Human Sexuality in San Francisco, and Kleinplatz, from the University of Ottawa, argue that all paraphilias, like sexual sadism, sexual masochism, transvestism, should be removed from the DSM, insisting that “the DSM criteria for diagnosis of unusual sexual interests as pathological rests on a series of unproven and more importantly, untested assumptions.”

This does not mean, as opponents of this idea have suggested, that they somehow approve of sex between adults and children. “We would argue that the removal of pedophilia from the DSM would focus attention on the criminal aspect of these acts, and not allow the perpetrators to claim mental illness as a defense or use it to mitigate responsibility for their crimes," they wrote. "Individuals convicted of these crimes should be punished as provided by the laws in the jurisdiction in which the crime occurred.”

Most of these suggestions are inherently political, as much as the APA and most psychiatrists would wish to avoid politics. Sex exists as part of the culture, and it cannot be separated from it.

The DSM has reflected cultural shifts through its revisions and new editions. The most famous example is homosexuality. When the first DSM was created in 1952, homosexuality was declared a mental illness. By 1973, and after much heated debate and over objections from religious conservatives, the DSM-II excluded homosexuality as a disorder with the exception of one variant, and that was soon dropped in an interim revision.

Once deviant, now desirable

“Definitely a change in culture affects diagnoses,” Leiblum says. “We used to think oral-genital sex was deviant and we have embraced that. Masturbation was evidence of out-of-control behavior, now we see it as not only normative but to be encouraged.”

So if enough people start to do it, or are more public about doing it, does that mean it is no longer a disorder? “I think it probably affects the degree to which people are willing to look at scientific evidence,” Regier says.

This fuzziness is why, starting in the 1980s, the field moved toward adding the notion of “distress” to the DSM.

“We do not consider something a disorder unless there is a clearly defined description of this entity and there is clearly some significant dysfunction and distress associated with it,” explains Regier. “I would say also if there is no victim involved … this behavior is not imposing a person’s will on another person, that is a critical component when one looks at conditions in this area.”

If you aren’t distressed, and everyone is a consenting grown-up, then there probably isn’t a disorder. But things won’t be that simple for the creators of the new DSM.

“How do you make a criteria that does not pathologize low desire?” Leiblum asks rhetorically. You add the need to be distressed about it. “But then whose distress should be looked at?” she asks, referring to a sexual partner. “You can have hypertension and not feel any distress because there is objective criteria for what is high blood pressure. But there is none of that for sexual diagnoses, even premature ejaculation. What constitutes premature?”

(At a press conference Monday, the International Society of Sexual Medicine made a stab at a definition, saying premature ejaculation is "a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration; and, inability to delay ejaculation on all or nearly all vaginal penetrations; and, negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.”)

This problematic lack of clarity, Leiblum argues, is especially acute for the paraphilias. Does the criteria amount to “If it’s mine it’s OK, but if it’s yours it’s kinky? These issues need to be grappled with.”

Half of Americans are in some way mentally ill, and one-quarter of the population has taken anti-depressants, not including that one time at a rave

Another person is waking up to the fraud the is Modern Psychiatry. An Editorial in the NY Sun, by Christoper Lane

America has reached a point where almost half its population is described as being in some way mentally ill, and nearly a quarter of its citizens - 67.5 million - have taken antidepressants.

These statistics have sparked a widespread, sometimes rancorous debate about whether people are taking far more medication than is needed for problems that may not even be mental disorders. Studies indicate that 40% of all patients fall short of the diagnoses that doctors and psychiatrists give them, yet 200 million prescriptions are written annually in America to treat depression and anxiety.

Those who defend such widespread use of prescription drugs insist that a significant part of the population is under-treated and, by inference, under-medicated. Those opposed to such rampant use of drugs note that diagnostic rates for bipolar disorder, in particular, have skyrocketed by 4,000% and that overmedication is impossible without over-diagnosis.

To help settle this long-standing dispute, I studied why the number of recognized psychiatric disorders has ballooned so dramatically in recent decades. In 1980, the Diagnostic and Statistical Manual of Mental Disorders added 112 new mental disorders to its third edition, DSM-III. Fifty-eight more disorders appeared in the revised third edition in 1987 and fourth edition in 1994.

With over a million copies in print, the manual is known as the bible of American psychiatry; certainly it is an invoked chapter and verse in schools, prisons, courts, and by mental-health professionals around the world. The addition of even one new diagnostic code has serious practical consequences. What, then, was the rationale for adding so many in 1980?

After several requests to the American Psychiatric Association, I was granted complete access to the hundreds of unpublished memos, letters, and even votes from the period between 1973 and 1979, when the DSM-III task force debated each new and existing disorder. Some of the work was meticulous and commendable.

But the overall approval process was more capricious than scientific.

DSM-III grew out of meetings that many participants described as chaotic. One observer later remarked that the small amount of research drawn upon was "really a hodgepodge - scattered, inconsistent, and ambiguous." The interest and expertise of the task force was limited to one branch of psychiatry: neuropsychiatry. That group met for four years before it occurred to members that such one-sidedness might result in bias.

Incredibly, the lists of symptoms for some disorders were knocked out in minutes. The field studies used to justify their inclusion sometimes involved a single patient evaluated by the person advocating the new disease. Experts pressed for the inclusion of illnesses as questionable as "chronic undifferentiated unhappiness disorder" and "chronic complaint disorder," whose traits included moaning about taxes, the weather, and even sports results.

Social phobia, later dubbed "social anxiety disorder," was one of seven new anxiety disorders created in 1980. At first it struck me as a serious condition. By the 1990s experts were calling it "the disorder of the decade," insisting that as many as one in five Americans suffers from it. Yet the complete story turned out to be rather more complicated.

For starters, the specialist who in the 1960s originally recognized social anxiety - London-based Isaac Marks, a renowned expert on fear and panic - strongly resisted its inclusion in DSM-III as a separate disease category. The list of common behaviors associated with the disorder gave him pause: fear of eating alone in restaurants, avoidance of public toilets, and concern about trembling hands.

By the time a revised task force added dislike of public speaking in 1987, the disorder seemed sufficiently elastic to include virtually everyone on the planet.

To counter the impression that it was turning common fears into treatable conditions, DSM-IV added a clause stipulating that social anxiety behaviors had to be "impairing" before a diagnosis was possible. But who was holding the prescribers to such standards? Doubtless, their understanding of impairment was looser than that of the task force. After all, despite the impairment clause, the anxiety disorder mushroomed; by 2000, it was the third most common psychiatric disorder in America, behind only depression and alcoholism.

Over-medication would affect fewer Americans if we could rein in such clear examples of over-diagnosis. We would have to set the thresholds for psychiatric diagnosis a lot higher, resurrecting the distinction between chronic illness and mild suffering. But there is fierce resistance to this by those who say they are fighting grave mental disorders, for which medication is the only viable treatment.

Failure to reform psychiatry will be disastrous for public health. Consider that apathy, excessive shopping, and overuse of the Internet are all serious contenders for inclusion in the next edition of the DSM, due to appear in 2012. If the history of psychiatry is any guide, a new class of medication will soon be touted to treat them.

Sanity must prevail: if everyone is mentally ill, then no one is.

The Loss of Sadness: How psychiatry transformed a normal emotion into an "illness"

A snippet from this recent report in NewsWeek.

It's hard to say exactly when ordinary Americans, no less than psychiatrists, began insisting that sadness is pathological. But by the end of the millennium that attitude was well entrenched. In 1999, Arthur Miller's "Death of a Salesman" was revived on Broadway 50 years after its premiere. A reporter asked two psychiatrists to read the script. Their diagnosis: Willy Loman was suffering from clinical depression, a pathological condition that could and should be treated with drugs. Miller was appalled. "Loman is not a depressive," he told The New York Times. "He is weighed down by life. There are social reasons for why he is where he is." What society once viewed as an appropriate reaction to failed hopes and dashed dreams, it now regards as a psychiatric illness.

That may be the most damaging legacy of the happiness industry: the message that all sadness is a disease. As NYU's Wakefield and Allan Horwitz of Rutgers University point out in "The Loss of Sadness," this message has its roots in the bible of mental illness, the Diagnostic and Statistical Manual of Mental Disorders. Its definition of a "major depressive episode" is remarkably broad. You must experience five not-uncommon symptoms, such as insomnia, difficulty concentrating and feeling sad or empty, for two weeks; the symptoms must cause distress or impairment, and they cannot be due to the death of a loved one. Anyone meeting these criteria is supposed to be treated.

Yet by these criteria, any number of reactions to devastating events qualify as pathological. Such as? For three weeks a woman feels sad and empty, unable to generate any interest in her job or usual activities, after her lover of five years breaks off their relationship; she has little appetite, lies awake at night and cannot concentrate during the day. Or a man's only daughter is suffering from a potentially fatal blood disorder; for weeks he is consumed by despair, cannot sleep or concentrate, feels tired and uninterested in his usual activities.

Horwitz and Wakefield do not contend that the spurned lover or the tormented father should be left to suffer. Both deserve, and would likely benefit from, empathic counseling. But their symptoms "are neither abnormal nor inappropriate in light of their" situations, the authors write. The DSM definition of depression "mistakenly encompasses some normal emotional reactions," due to its failure to take into account the context or trigger for sadness.

That has consequences. When someone is appropriately sad, friends and colleagues offer support and sympathy. But by labeling appropriate sadness pathological, "we have attached a stigma to being sad," says Wakefield, "with the result that depression tends to elicit hostility and rejection" with an undercurrent of " 'Get over it; take a pill.' The normal range of human emotion is not being tolerated." And insisting that sadness requires treatment may interfere with the natural healing process. "We don't know how drugs react with normal sadness and its functions, such as reconstituting your life out of the pain," says Wakefield.

Even the psychiatrist who oversaw the current DSM expresses doubts about the medicalizing of sadness. "To be human means to naturally react with feelings of sadness to negative events in one's life," writes Robert Spitzer of the New York State Psychiatric Institute in a foreword to "The Loss of Sadness." That would be unremarkable if it didn't run completely counter to the message of the happiness brigades. It would be foolish to underestimate the power and tenacity of the happiness cheerleaders. But maybe, just maybe, the single-minded pursuit of happiness as an end in itself, rather than as a consequence of a meaningful life, has finally run its course.

There are no cures in modern Psychiatry. They wouldn't know a cure if it stood up and slapped them in the face.

While we are pointing to posts from Furious Seasons, here is a snippet from one post that points to one of the major flaws in that dysfunctional branch of medicine, psychiatry. That being ...

There are no cures in modern Psychiatry. In fact, they wouldn't know a cure if it stood up and slapped them in the face.

No one is ever pronounced cured. Once you get to this point, you are just a few baby steps from opening the door to an Alice in Wonderland fairy tale world where the "science" itself is found to be more and more fraudulent, what with their stew of pills, and their quicky and highly profitable diagnoses. And you wonder at the ethical problems people sidestep when they discover this, and then choose to ignore it.

To be fair, this is a radicalizing moment. But then you need to decide what is at stake.

Speaking of psychiatrists, I saw mine yesterday as I do every two months or so. Despite being off-meds at his urging, I continue to see him just to be on the safe side. But I'm beginning to wonder how safe that side is. You see, I've had almost two years of not just being subsyndromal, but of being virtually non-syndromal and the last five months of that has been without the aid of medications of any kind and so I had to ask him if I even passed muster as someone with bipolar disorder anymore. His answer discouraged me.

"Once diagnosed, never undiagnosed. But once diagnosed, not always symptomatic."

We talked about this and my original diagnosis in 1989--that was eight psychiatrists ago--and how I think I never was anything more serious than perhaps a bipolar 2, but I was diagnosed in the days before bipolar 2 existed. We talked about bipolar disorder as a personality disorder and how that may be far more applicable to someone like me than the big old ugly diagnosis of bipolar disorder 1, manic-depressive and mentally ill.

It became clear to me after a few minutes that there was no budging my doctor on his view of once-diagnosed, always-diagnosed.

So I told him something.

"What's the point of treatment and going through years of agony and finally getting vastly better only to be told that there is no goal line I can possibly cross that will lead to me being undiagnosed?"

He didn't have an answer for me. Our appointment was over. But my concerns are not.

How is it that I can go along with the rules of the mental illness paradigm for almost 20 years and actually meet almost every conceivable endpoint of recovery and still be told I have the disorder? That doesn't strike me as fair, logical or particularly humane. In fact, I am feeling rather screwed over by this whole process that has consumed my entire adult life.

What if we, as a culture, told that to cancer patients? Would there be a movement of cancer survivors? Or would their be hoards of former cancer patients huddled in the corner, well but still diagnosed? You know the answer: we'd never stand for that.

I think it's high time we started examining what personality issues psychiatrists might have--and if you know anything about the history of the DSM, you know they have loads of issues of their own--and began a push to stop this nonsense of labeling people for life. Oh wait, there's already a movement like that.

Is it any wonder it's had little success given that even fairly humane docs such as mine buy into the Dx'd for life nonsense and that there's a $250 billion industry very interested in keeping people like me sick for life even when I am more well than most normal people I can think of?

How Shyness Became a Mental Illness - Research reveals the importance of drug maker profits in the discovery of new diseases.

A Press Release from the News Office of North Western University

What's wrong with being shy, and just when and how did bashfulness and other ordinary human behaviors in children and adults become psychiatric disorders treatable with powerful, potentially dangerous drugs, asks a Northwestern University scholar in a new book that already is creating waves in the mental health community.

In “Shyness: How Normal Behavior Became a Sickness” (Yale University Press, October 2007), Northwestern's Christopher Lane chronicles the “highly unscientific and often arbitrary way” in which widespread revisions were made to “The Diagnostic and Statistical Manual of Mental Disorders” (DSM), a publication known as the bible of psychiatry that is consulted daily by insurance companies, courts, prisons and schools as well as by physicians and mental health workers.

“The number of mental disorders that children and adults in the general population might exhibit leaped from 180 in 1968 to more than 350 in 1994,” notes Lane, Northwestern's Herman and Beulah Pearce Miller Research Professor. In a book that calls in doubt the facade of objective research behind psychiatry's revolution, Lane questions the rationale for the changes, and whether all of them were necessary and suitably precise.

By labeling shyness and other human traits as dysfunctions with a biological cause, the doors were opened wide to a pharmaceutical industry ready to provide a pill for every alleged chemical imbalance or biological problem, he adds.

Lane, who meticulously and systematically researched the archives of the American Psychiatric Association, uses social anxiety disorder (first dubbed social phobia) as the lens through which to analyze American psychiatry's extraordinary shift in the last 30 years from a psychoanalytic orientation relying on talk therapy to its current emphasis on neuroscience and drugs.

He draws on previously neglected letters and memos written by the framers of the new disorders to argue that DSM revisions to social phobia or social anxiety disorder placed the diagnostic bar too low, turning social anxiety into a mental illness common enough to be considered, according to recent studies, third only to alcoholism and major depression.

The DSM continues to stipulate that social anxiety disorder (SAD) must be “impairing” for a diagnosis to occur. The problem, Lane argues, is that DSM-defined symptoms of impairment in 1980 included fear of eating alone in restaurants, concern about hand trembling while writing checks, fear of public speaking and avoidance of public restrooms.

By 1987 the DSM had removed the key phrase “a compelling desire to avoid,” requiring instead only “marked distress,” and signs of that could include concern about saying the wrong thing. “Impairment became something largely in the eye of the beholder, and anticipated embarrassment was enough to meet the diagnostic threshold,” says Lane.

“That's a ridiculous way to assess a serious mental disorder, with implications for the way we also view childhood traits and development, given the increased focus on reticence,” Lane adds. “But that didn't stop SAD from becoming what Psychology Today dubbed 'the disorder of the 1990s.'”

In addition to providing extensive documentation from the American Psychiatric Association archives, Lane includes previously confidential material from the drug companies themselves that present a worrisome history of the antidepressant Paxil.

The drug came onto the marketplace in 1996 despite the fact that its makers earlier had considered shelving it because of poor performance and early signs of side effects in clinical trials. Using a memo circulated among drug company executives, Lane presents evidence that a lot of information about the drug's poor track record was withheld from the public.

When Paxil became the first drug approved by the Food and Drug Administration for the treatment of social anxiety disorder in 1999, however, its makers launched a $92 million awareness campaign on the theme “Imagine Being Allergic to People.” This and other advertising campaigns helped change the way Americans think about anxiety and its treatment.

“Every marketer's dream is to find an unidentified or unknown market and develop it. That's what we were able to do with social anxiety disorder,” a product director for the drug told Advertising Age magazine. In 2001, with 25 million new prescriptions written for Paxil, the drug's U.S. sales alone increased by 18 percent from the year before.

Although psychiatrists insist that the line between ordinary shyness and social anxiety disorder (SAD) is sharply defined, Lane points to psychiatric literature that repeatedly confuses them, putting patients at risk of over-diagnosis and unnecessary, sometimes harmful treatment.

A professor of English in Northwestern's Weinberg College of Arts and Sciences, Lane previously directed a psychoanalytic studies program in Emory University's psychiatry department. Long interested in psychology, he presents evidence of a burgeoning backlash to psychiatry's current trends in the form of analyses of novels including “The Corrections” by Jonathan Franzen and “The Diagnosis” by Alan Lightman, as well as the film “Garden State” by Zach Braff.

Lane, who was awarded a Guggenheim Fellowship to study psychopharmacology and ethics, audited medical courses and invited psychiatrists and pharmacologists to review his book, particularly a chapter on rebound syndrome. That term refers to a boomerang effect experienced by some patients on discontinuing Paxil that is more intense and dangerous than the turmoil that caused them to take the drug in the first place.

In examining the American Psychiatric Association archives, Lane -- who argues that psychiatry is using drugs with poor track records to treat growing numbers of normal human emotions -- even came across a proposal to establish “chronic complaint disorder,” in which people moan about the weather, taxes or the previous night's racetrack results.

“It might be funny,” he says, save for the fact that the DSM's next edition, due to be completed in 2012, is likely to establish new categories for apathy, compulsive buying, Internet addiction, binge-eating and compulsive sexual behavior. Don't look for road rage, however. It's already in the DSM, under intermittent explosive disorder.

Psychiatrist Group Names DSM Task Force

With a Tip of the Hat to the PharmaLot Blog

In a move that is likely to be closely scrutinized, the American Psychiatric Association today named its new task force for overseeing development of its 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-V. [...] The task force has 27 members, who rep scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates.

This task force, which will revise the DSM over the next five years, holds a great deal of sway, since their actions influence prescribing habits in the US and elsewhere. But it’s more than that. The DSM is where a condition is officially sanctioned as a disorder, which of course, also determines treatment. For these reasons, the APA has come under fire - as have other doctors - for ties to industry.

Of the 27 task force members, the APA says eight had no relationship with industry and 19 disclosed relationships with industry during any of the 36 months leading up to their nomination.

[...]

The APA, by the way, has been embroiled in the controversy over antidepressants and Black Box warnings, which the FDA mandated in early 2005 after the drugs were linked to suicide in youngsters. Since then, the APA has repeatedly urged regulators to rethink their position over concerns that patients and doctors are being scared away from using meds. As a result, though, some patient advocates charge the APA is too quick to side with industry.

The press release with the announcement can be seen here

The detailed list of members of the taskforce with their disclosures can be seen here

We remain extremely skeptical.

Leading American Psychiatrist Calls DSM IV Diagnostic Method Dehumanizing.

As reported here Contemporary American psychiatry has been dealt a shattering blow by no other than one of the most influential psychiatrists in academia.

Dr. Nancy Andreasen, Director of mental health clinical research at the University of Iowa, the editor of the American Journal of Psychiatry, and author of 500 publications, including the influential book, "The Broken Brain" (1984, recently released) in which she describes the "biological revolution" in psychiatry, has delivered a devastating blow to American psychiatry.

In her critical article in the Schizophrenia Bulletin, Dr. Andreasen makes some astounding acknowledgements--including the fact that American psychiatry is a veritable wasteland in need of "a reverse Marshall plan so that the Europeans can save American science by helping us figure out who really has schizophrenia or what schizophrenia really is..."

Dr. Andreasen points an accusing finger at psychiatry's reliance on an invalidated diagnostic guideline:

"The DSM has had a dehumanizing impact on the practice of psychiatry. History taking — the central evaluation tool in psychiatry — has frequently been reduced to the use of DSM checklists. DSM discourages clinicians from getting to know the patient as an individual person because of its dryly empirical approach. Third, validity has been sacrificed to achieve reliability. DSM diagnoses have given researchers a common nomenclature — but probably the wrong one. Although creating standardized diagnoses that would facilitate research was a major goal, DSM diagnoses are not useful for research because of their lack of validity."

Yet, she notes, the DSM-III and its successors, DSM III-R and DSM-IV were universally and uncritically accepted as if they were the ultimate authority on psychopathology and diagnosis. DSM forms the basis for psychiatric teaching to both residents and undergraduates throughout most of the United States.

Equally astounding--especially to those who didn't pay heed to critics who pointed out 20th century psychiatry's failings and decades of abusive "treatments"--is that Dr. Andreasen has to go back to the 19th century to find a period during which psychiatry resembled something close to a healing profession:

"the early psychiatrists attempted to develop therapies that might help to relieve mental pain in as humane and effective a manner as possible.

The picture of Pinel freeing the mentally ill from their chains is perhaps the most famous icon of their therapeutic approach. ‘‘Moral therapy’’ was developed in many countries in Europe, in Britain, and in the United States. In an era when no pharmacological treatments were available, it emphasized a variety of psychotherapeutic techniques that included personalizing the care to the individual’s needs, using nonintrusive and compassionate approaches, appealing to reason when possible, and giving the patient some responsibility for improving symptoms and behavior."

This firm conceptual and moral grounding, she acknowledges, is what psychiatry should strive to maintain--not the invalid, dehumanizing current practices.

She also acknowledges that the evidence has shown since the 1970s that "American psychiatrists were over diagnosing mental illnesses in comparison with the rest of the world and not doing systematic clinical assessments and that their diagnoses and clinical assessments were not reliable."

"Someday, in the 21st century, after the human genome and the human brain have been mapped, someone may need to organize a reverse Marshall plan so that the Europeans can save American science by helping us figure out who really has schizophrenia or what schizophrenia really is..."

In the meantime, psychiatry continues to expand its domain, devaluing those it labels as mental patients, subjecting them to harmful chemical interventions that undermine both their mental and physical health.

Dr. Andreasen is strangely silent about the all-pervasive influence the pharmaceutical industry has wielded on psychiatry during the second half of the 20th century. Conflicts of interest have been a dominant factor in the task force responsible for the formulation of DSM-III R and DSM-IV. Those conflicts of interest have been documented by Dr. Lisa Cosgrove and Dr. Sheldon Krimsky. [Link] and [Link]

Why Psychiatry's DSM should be abandoned

As seen in the Psychiatric Times - A decent article. Some overly technical points have been omitted. Of course, the question of whether the whole industry is rotten to the core is over looked. However, it is interesting to see a view on the inherent problems that are obvious even from the inside.

The American Psychiatric Association's DSM diagnostic system has outlived its usefulness by about two decades. It should be abandoned, not revised. [...]

Let me say at the outset that I do not wish to disparage all the hard and well-intentioned labors of the various work groups that developed the different sections of these books in their several editions or to deny the enormous amount of information summarized therein. But again, the aggregate is an awkward, ponderous, off-putting beast that discredits and diminishes psychiatry and the insight of those who practice it.

Consider the fact that your clinical practice is governed by a diagnostic system that:

• is a laughingstock for the other medical specialties;
  
• requires continual apologies to primary care doctors, medical students, residents, and the occasional lawyer or judge;
  
• most of our thoughtful colleagues privately rail against;;
  
• insists upon rigid categories that often serve only to confuse and misinform patients and their clinical workers (sometimes abetted by televised drug advertising);
  
• is so intellectually incoherent as to raise eyebrows among the well-educated, critical thinkers in our own psychotherapy clientele;
  
• persuades the world at large that psychiatry no longer has anything of interest to say about the human condition.

If it were within your power to do so, wouldn't you get rid of this system?

Let us make a tour of some of the diagnostic categories we all use and abuse. Schizoaffective disorder comes immediately to mind. Some argue that schizoaffective disorder should be a rare diagnosis. As unhappy as I am with the DSM-IV description, they reach an opposite conclusion to my own. Rightly criticizing the arbitrariness of the current criteria for this disorder (two weeks of hallucinations or delusions in the absence of prominent mood symptoms, but prominent mood symptoms for a "substantial portion" of the illness), one authority has even speculated that the confusion about schizoaffective disorder deters medical students from entering psychiatry!

I rather think that it is today's incarnation of the DSM, the DSM-IV, that deters medical students from entering psychiatry. Strict diagnostic criteria (which some want to repair by making them still stricter) reflect neither biological nor clinical reality. These realities simply will not yield to anyone's desire for precision. On the research front, recent studies suggest that there is considerable overlap in the genetic vulnerability for schizophrenia and for bipolar disorders. What is the point of false precision when the genes themselves are imprecise? [...]

Another reason is that the clinical syndromes we treat, whatever their genetic underpinnings, are themselves changing. If the reader will permit a brief digression, the schizoaffective debate reminds me of debates over whether black lung disease was a real illness when I was in general practice in East Kentucky years ago. Some physicians, particularly those hired by mining companies' liability insurers, held that it was simply chronic obstructive pulmonary disease (COPD). Indeed, most of the miners who suffered from it were also smokers. But the fact was that black lung behaved differently than typical COPD. At least in my care, it seemed to have a restrictive, as well as an obstructive, nature and needed more and earlier steroid treatment. These men had spent their lives breathing coal dust.

Today, our young bipolar patients are spending their lives ingesting antidepressants, cocaine, methamphetamine, methylenedioxymethamphetamine (MDMA) and hallucinogens over prolonged periods. These chemicals change their brains, just as coal dust changes lungs. Inter-episode recovery, a hallmark of classic bipolar disorder, becomes a thing of the past. Delusions, hallucinations and mood-cycling become entrenched, and antipsychotic maintenance essential. I could try to be strict and pile up two or three Axis I diagnoses to describe this entity, thereby confusing everyone else involved in the patient's care. Instead, and with no apology, I call it schizoaffective disorder, which is more easily explained to nonpsychiatrists as a nonhomogeneous in-between category.

One can leaf through the DSM-IV and find countless howlers and paradoxes, as I am sure many readers have already done. [...]

Primary care physicians never use these diagnoses, instead sticking with the clinical presentations they see, such as fibromyalgia syndrome. Anxiety disorders are artificially separated from the mood and psychotic disorders with which they are usually intertwined, yielding the frequent question, "If I have an anxiety disorder, why are you treating me with an antidepressant?" How many cases of pure generalized anxiety disorder have you seen? Of isolated social phobia? And so on. [...]

In fact, psychiatrists who specialize in any one of the major subject areas in the DSM-IV seem almost universally frustrated by "their" section of the book. This is equally true of analysts specializing in personality disorders, clinical researchers in major mental illness, traumatologists and neurobiological investigators. Overlapping dimensions, or spectra, of pathology much more accurately reflect clinical reality, whether we are talking about the narcissistic/borderline personality spectrum or the bipolar, schizophrenia, obsessive-compulsive or autistic spectra. When they can, biologically oriented researchers come up with their own criteria (like the negative/positive symptom clusters in schizophrenia), while psychodynamic and cognitive-behavioral writers put forward alternative ways to look at personality function in therapy settings. The DSM-IV's relationship to all this is as a Berlitz phrase book is to the Tower of Babel. [...]

Two questions arise from this situation, and the first is, Why? Why maintain and elaborate a diagnostic system that no one is happy with? A skeptic need look no further than the catalogues full of DSM-IV treatment guides and companions, DSM-IV-keyed textbook editions, DSM-IV software and the like that fill every psychiatrist's mailbox. The DSM-IV is a big moneymaker for the APA. Who dares practice--indeed who can practice--without the reigning bible close at hand? I maintain that the APA is holding back the development of the profession it represents by maintaining its income and its institutional hegemony over American mental health care with the DSM system. [...]

The IDC-9 or ICD-10 would provide a perfectly good alternative for billing and coding purposes, and perhaps the APA could let the World Health Organization take back the job of developing future code bibles, rather than duplicating the task. While we will always need an administrative diagnostic system, the APA's resources are better spent finding ways to get people excited about--and interested in--the rich scope of the field it represents, instead of endlessly rehashing an arid and intimidating set of menus.

As clinical psychiatrists communicating among ourselves and to other specialties and concerned parties, we need not take diagnostic categories literally. We can save the major valid diagnostic syndromes like paranoid schizophrenia, or panic disorder with agoraphobia, but append other features freely and, most important, change our basic diagnostic stance to a dimensional rather than a categorical one. Arbitrary checklists and time cutoffs ("more than two weeks," "less than six months") can be dispensed with in favor of our best global diagnostic impressions. The focus of psychiatric treatment should be a single diagnosis--a single person--in most cases, with no tiresome Axes involved. Impressions of personality contributions, "stressors" (how I hate the word--its generic tone invites us to leave the patient's story out!), relevant medical illness and so on can go back into a narrative note to be discussed in a nuanced way. Attempts to quantify functioning can be confined to research and otherwise left to lawyers, government agencies, insurance companies and the psychiatrists they employ.

Will this ever happen? As my French-Canadian grandmother used to say, "Don't hold your breath!"

(Interested readers are advised to go to the Web site by Paul McHugh, M.D., [www.hopkinsmedicine.org/jhhpsychiatry/perspec1.htm] and read his systematic and cogent 1992 discussion of these same issues. From his lofty position as chair of psychiatry at Johns Hopkins University, he has long advocated for change in our diagnostic system.)

Dr. Genova, a clinical associate professor of psychiatry at the University of Vermont, has practiced in Maine for 21 years and is author of The Thaw: Reclaiming the Person for Psychiatry (The Analytic Press, 2002).

How 'junk science' has put a lot of disorders into the DSM for dubious legal reasons

In 2005, David Feige explained in an article in Slate Magazine how "junk science" has put a lot of disorders into the DSM for dubious legal reasons. "[This syndrome] is part of an ever widening matrix of criminal-justice-related mental-health syndromes whose main goal seems to be to explain away otherwise damaging evidence." This was in the context of a variety of 'expert witnesses' during the Michael Jackson trial, which was taking place at the time.

Here are some bits from that article

Urquiza, called earlier in the trial as an expert witness for the prosecution, testified about something called "child sexual abuse accommodation syndrome," or CSAAS.

He had never examined Mr. Jackson's accuser. He didn't need to.

As it turns out, CSAAS … explains everything.

CSAAS is part of an ever widening matrix of criminal-justice-related mental-health syndromes whose main goal seems to be to explain away otherwise damaging evidence. Rape trauma syndrome (or RTS), battered-woman's syndrome (or BWS), and CSAAS are all examples of this burgeoning field.
Etiologically, all three syndromes are the stepchildren of post-traumatic stress disorder (first diagnostically validated by inclusion in the 1980 version of the psychologist's bible — the Diagnostic and Statistical Manual of Mental Disorders, Third Edition). And, much like their parent, they all share flexible criteria easily applied to … well, pretty much everything.

And that's the whole problem.

Unlike diseases or disorders in which signs (physical phenomena like bruises) or symptoms (subjective complaints like "my elbow hurts") imply a specific cause (you injured your elbow), syndromes (which are also groups of signs and symptoms) may—but don't necessarily—imply a specific cause. As a consequence, although syndromes may sound scientific, their diagnostic value varies wildly.

CSAAS is, simply put, not diagnostic. First named and described in 1983 in an article by Dr. Roland Summit that described five general attributes of child sexual victims (secrecy, helplessness, denial, delayed disclosure, and retraction), Summit himself has conceded the lack of compelling empirical research support for the syndrome. And when lawyers start importing these scientific curiosities into the courtroom, we all have a serious problem.

[...]

CSAAS is a prosecutorial silver bullet and a fabricator's best friend. Every mistake you make is consistent with it; every mistake you don't make further confirms your credibility. No wonder prosecutors rely on it to bolster disintegrating cases. By making credibility tautological, CSAAS makes it nearly impossible to present a defense or attack an incredible witness. To make matters worse, CSAAS testimony is deeply appealing to jurors because of its soothing reassurance that otherwise inexplicable or incredible behavior is merely a manifestation of the actual trauma they all expect to see in a victim.

According to CSAAS experts, not reporting abuse is consistent with suffering from child sexual abuse accommodation syndrome. So is bad behavior, trouble in school, the failure to tell an accurate story, and even the recantation of the entire allegation of abuse. In other words, every criterion usually used by the defense to discredit a witness is actually transubstantiated into evidence that is perfectly consistent with abuse.

And here's the genius: Not exhibiting these signs of CSAAS doesn't mean a child wasn't abused—just that he or she didn't get the syndrome. In other words, a noncredible witness is suffering from the syndrome, but a credible one is merely a credible witness who was legitimately abused.

[...]

Ultimately, though, damage from this pseudoscientific syndrome testimony undermines far more than the fairness of Michael Jackson's trial. By creating the ability to explain away any behavior, syndrome testimony threatens to erode our ability to hold both the alleged victims and the alleged perpetrators to account for their actions. With syndrome testimony we find ourselves in a frictionless world where up is down, falsehood is truth, and there is an excuse for everything.

Ultimately, the problem with the Orwellian world of syndrome testimony is that anything goes, and everyone goes to jail. Don't like my tone? Blame angry author syndrome. Fail to follow my argument? Maybe you have an abstract reasoning deficit disorder. Getting angry? Want to stab me? Fear not, I'm sure a doctor (maybe even Urquiza himself) will be willing to testify that you are simply suffering from overreactive reader's syndrome.

And so it goes

New psycho-diagnostic manual no better than the old

Summarrized from here

A coalition from various psychodynamic associations has produced a new diagnostic manual as an alternative to the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), the main one currently used by psychiatrists and therapists to give patients a code number for purposes of treatment, research, and prognosis — but mostly health insurance reimbursement.

The new group's manual is the Psychodynamic Diagnostic Manual (PDM), which allegedly “attempts to characterize the whole person — the depth as well as the surface of emotional, cognitive, and social functioning.”

The PDM editors also claim to “require a fuller description of the patient's internal life to do justice to understanding his or her distinctive experience.”

Yeah, well, okay. Beautiful thought. But how it actually executed?

Actually, it seems to be more of the same old thing, with slightly shinier packaging, and an overly complex design philosophy.

We don't live under NORMAL CONDITIONS

A documentary film about depression and suicide

There is a tendency afoot today to blame the epidemic sweep of clinical depression in the US on bad genes or screwy brain chemistry. But what if the causes of depression, suicide, or other mental illnesses, do not emanate from biology?

This artful documentary film brings six people together for three days of emotional, and at times heated, discussion about the sources of their despair.

Intermixed are hard-to-find facts which challenge the psychiatric industry's claims that depression is a biological disorder. Fundamentally about empowerment and the resilience of the human spirit, this surprisingly inspirational new movie will change the way you think about "normal."

The following informational text slates that are presented in the film are listed here with their sources:

Title	Source
In the U.S., 30,000 people kill themselves each year, one every 17 minutes.	National Center on Health Statistics
One million adolescents attempt suicide each year	Centers for Disease Control
Suicide is the 2nd leading cause of death among youth ages 15-24.	National Mental Health Association
As many as one-third of teenage suicides are gay/lesbian youth.	Department of Health & Human Services
Identical quadruplets develop schizophrenia. A renowned geneticist proclaims them proof of a biological cause, discounting the girls environment which included a father who banged their heads together to stop them from crying, abused them sexually and mutilated their genitals with acid.	Toxic Psychiatry, Peter R. Breggin, M.D.
In 1952 the American Psychiatric Association published the first Diagnostic and Statistical Manual listing 60 types of mental disease. By the 1990s the 4th revision of the DSM listed 374 ways to be mentally ill.	DSMs
In 1967 several prominent psychiatrists wrote in a prominent medical journal that brain dysfunction was a cause of urban violence.	JAMA
In the 1970's government agencies funded psychiatrists who advocated psychiatric brain surgery for rioters and their leaders.	War Against Children, Peter R. Breggin
In the 1990's, the U.S. government conducted research on inner-city youth believed to be genetically pre-disposed to violence. The goal: to identify them at an early age and use drug treatment before they become criminals.	In Genes we Trust, Barry Mehler
While 75 percent of all attempted suicides are women, 80 percent of all completed suicides are men.	National Center for Health Statistics
In 1997 Prozac became the No. 2 overall selling drug in the U.S. bringing Eli Lilly 1 billion, 492 million dollars in revenue	The Plymouth as reported in the San Francisco Chronicle.
Lilly and other drug companies fund research at institutes where their products are tested and provide speaking fees, consulting deals and free travel to the psychiatrists in charge of the studies.	New York Post, 1998
Biopsychiatrists have long touted brain scan evidence as proof that schizophrenia is a biological disorder. Researchers recently discovered that the brain abnormalities are found only in neuroleptic-treated patients and are in all likelihood medication-induced.	American Journal of Psychiatry December, 1998
Estimates suggest that 5 million children take Ritalin for ADD, a "disease" that has never been proven to exist.	There Is No Disease Fred Baughman, Jr. M.D.
Since 1980 the number of private, for-profit psychiatric hospitals has more than tripled. Over 300,000 children and adolescents are placed in these hospitals each year. In Kentucky in 1990, 80% of the kids in one hospital were there with a diagnosis of "conduct disorder."	Bedlam, Joe Sharkey

Do psychiatrists even know what they are doing?

Serious flaws in the way doctors classify psychiatric disorders have sent drug development way off track, two scientists assert in a paper in the British Medical Journal

As seen in this news report one of the scientists puts it this way:

"We need to take all of our copies of the DSM and throw them into the sea," cries Edward Shorter, lead author of the article and a professor of the history of medicine at the University of Toronto in Canada. "There are such fundamental flaws that the whole thing needs to be rethought. We need to have indications that correspond to natural, underlying disease processes."

The research paper has this take on who defines the diseases in the first place:

Who defines psychiatric diagnoses?

Officially, diagnostic decisions are made through scientific consensus by the World Health Organization and the American Psychiatric Association. Small committees of experts decide whether, for example, schizophrenia is one disease or several, and the process of decision making should be transparent and based on good scientific evidence. But sometimes the evidence is poor and influenced heavily by the pharmaceutical industry. The industry exerts a major influence through publication of sponsored supplements to journals, which are often poorly peer reviewed and promote unapproved treatments.8 Such supplements are particularly common for drugs for anxiety and depression as these are the most common treated conditions. Worldwide sales of antidepressants dwarf sales of drugs for all other psychiatric disorders.

Industry is said to prefer the disease based approach of DSM-III to any dimensional approach to illness definition. This is because the separate DSM-style diseases represent tidy diagnostic market niches. Every new diagnosis represents a new licensing opportunity. Companies only have to show the effectiveness of an existing drug over placebo for the new diagnosis in large clinical trials. This is expensive but not difficult if the same methods can be used as for previous studies with the old diagnoses.

But the basic symptom for all this is seen as the lack of speedy development of more drugs, instead to acknowledging the more fundamental problem:

Ultimately, the same original problem returns: deficits in the understanding of the basic science of psychiatric disorders. Both the DSM and drug developers are hampered by the same deficiency. In other words, they don't know what they're doing.

Of course, the news article tries to end on an upbeat note for psychiatry. Almost sounds like whistling in the dark.

Fears Grow Over Academic Efforts to Normalize Pedophilia

Caught this column on the fears some people have on the apparent effort to normalise pedophilia (originally published here)

Cultural experts who agree with claims that the Supreme Court may have opened the door to legalizing pedophilia in its Lawrence v. Texas decision on private homosexual behavior point to the growing movement within academia to de-stigmatize pedophilia.

of course there are protests that this won't happen.

Importantly, it is also noted that

During its annual convention in May, the American Psychiatric Association hosted a symposium discussing the removal of pedophilia along with other categories of mental illness (collectively known as paraphilia) from its Diagnostic and Statistical Manual of Mental Disorders (DSM).

After much criticism following CNSNews.com coverage of the symposium, the APA issued a statement reiterating its position on pedophilia.

But in his 1999 article "Harming the Little Ones: The Effects of Pedophilia on Children," Timothy Dailey, senior analyst for cultural studies with the Family Research Council, chronicled the APA's treatment of pedophilia in the DSM and compares it to the APA evolution of homosexuality.

In DSM revisions, Dailey explained that APA "adds a subjective qualification similar to that which appeared with regard to homosexuality: The individual must be 'markedly distressed' by his own pedophilic activity to be considered needful of therapy," Dailey wrote, adding that in the latest revision, pedophilia "is to be considered a paraphilia when the behavior causes 'clinically significant distress or impairment in social, occupational or other important areas of functioning.'"

Mary Eberstadt, research fellow at the Hoover Institute, told CNSNews.com: "The evidence is plain: there is indeed an ongoing attempt from within the psychiatric and psychological communities to de-stigmatize pedophilia by de-classifying it as a paraphilia in the first place."

You can read that full report here

So if I feel comfortable with my criminal activity, what am I?