Popular Posts

Total Downloads Worldwide

Tuesday 31 July 2012

DSM-5 Follies, As Told in Its Own Words - with annotations by Professor Allen Frances the Editor in Chief of the DSM-IV Task Groups + SIGN PETITION TO TRY TO RESIST DSM-5'S INFLUENCE



The DSM 5 Follies, As Told in Its Own Words

By Allen Frances Posted: 02/ 9/2012 

Nothing can illustrate how far DSM 5 has gone off track better than the words spoken in its defense by DSM 5 leadership. Dayle Jones and Suzy Chapman have assembled (from among many others) the 10 most wrong-headed quotations, and I have annotated them with my own thoughts.

1. "And that's what the DSM is -- a set of scientific hypotheses that are intended to be tested and disproved if the evidence isn't found to support them."
No! DSM 5 is most decidedly not "a set of scientific hypotheses"; it is an official manual that will influence people's lives for better (and sometimes for worse) in enormously consequential ways. DSM 5 is not a research agenda "intended to be tested" after its publication; it must hit the ground safe and scientifically sound. Any DSM 5 proposal for change that lacks strong evidence should be considered "disproved" right now, without further ado before publication, not after. Our patients are not guinea pigs for reckless DSM 5 experimentation.

2. "However, a lot of this has not been tested as well as we would like... Our plan is that these will be immediately tested once the DSM is official, and then one will be able to see if revisions can be made."
Again a resounding no! Allow entrance into DSM 5 only for changes that have already passed muster. Exclude everything that "has not been tested as well as we would like." DSM 5 is not a place for the untried speculations and the pet theories of the assembled experts. Add new suggestions only if they are well studied and of proven worth and safety.

3. "Our intent with the DSM-5 is to make it a much more fine-tuned, fine-grained system so that we have a better assessment with repeated research, like we have for blood pressure or cholesterol estimates."
DSM 5 is introducing a variety of dimensional measures. Dimensions are more accurate than categories in describing continuous variables (e.g., IQ, height, weight, blood sugar). Providing dimensions could have been a useful advance if done well. But the measures suggested by DSM 5 are ad hoc, untested, and so impossibly time-consuming and unnecessarily complex that they will never be used in clinical practice. A premature and poorly done dimensional system will have no result other than to give dimensional diagnosis an undeserved bad name. And it makes no sense to compare assessing mental disorders to assessing cholesterol or blood pressure so long as psychiatry has no objective biological tests. Our diagnoses are now, and will remain for some time, necessarily far less precise than those in the rest of medicine.

4. "The revision should be a living document. That's so we can convene expert panels more frequently in the future."
Please spare us a future filled with frequently convened expert panels; their fickle suggestions will likely do far more harm than good. Expert panels are largely responsible for the mess DSM 5 is in now. Why so? Experts live in an ivory tower world and don't appreciate how suggestions that may work for them can be so badly misused in the real world. We should avoid making changes arbitrarily and instead wait until scientific discovery makes it clear that change is necessary. There are no prospects for quick breakthroughs in psychiatric diagnosis in the near future except for Alzheimer's, where diagnostic tests may be available in several years.

5. "The idea of medicalising normality comes from a perspective that there are no psychiatric disorders, and you need to avoid stigmatizing people by giving them one."
Not so! The fear that DSM 5 is conducting a "wholesale imperial medicalization of normality" originated with me, and I am a great defender of psychiatric diagnosis and treatment -- but only when it is done well and within its proper sphere. Most of the widespread criticism of DSM 5 is not directed toward psychiatric diagnosis in general, but toward the careless way DSM 5 has been prepared, and toward its disregard for the harmful unintended consequences it will most certainly cause.

6. "Our intent is not to increase or decrease prevalence, but to make something that is more accurate and scientifically based."
DSM 5 will dramatically increase prevalence by adding five new, very common "disorders" that together will mislabel many millions of people now considered normal. Also, DSM 5 plans to lower thresholds for many of the existing disorders, turning normal grief into depression and dramatically increasing rates for attention-deficit disorder and generalized anxiety disorder. It is simply irresponsible not to be concerned about or measure the major impact this will have on the over-use of medication, on stigma, and on the misallocation of scarce resources.

7: "The manual itself is not invested in representing any particular point-of-view or theory and is intent on reflecting the latest findings from scientific study."
Would that it were so. DSM 5 literature reviews are remarkably variable in quality; often one sided, incomplete, and unsystematic; and sometimes giving undue weight to unpublished papers or papers authored by DSM 5 work-group members. The DSM 5 changes are mostly unsupported by scientific evidence.

8. "A kappa for a DSM-5 diagnosis above 0.8 would be almost miraculous; to see a kappa between 0.6 and 0.8 would be cause for celebration. A realistic goal is kappa between 0.4 and 0.6, while a kappa between 0.2 and 0.4 would be acceptable."
DSM 5 is not-so-subtly warning us that the reliability results from its field trial came in so low that we should accept a level of diagnostic agreement far below the universally accepted minimum standards. It wants to include some definitions whose diagnostic agreements are barely better than chance -- which means they are useless. The unacceptably low reliability is caused by the remarkably imprecise DSM 5 writing. This was supposed to be corrected in a second stage of field testing, but DSM 5 so badly missed its deadlines for the first stage that Phase 2 had to be stealthily cancelled. Low reliability is unacceptable; DSM 5 should rewrite and retest its poorly performing criteria to ensure that they do not cause great confusion.

9. "When asked if he thinks the APA can adjust revisions by the end of this year, Regier says 'there is plenty of time.'"
Perhaps this casual attitude toward time explains why every DSM 5 deadline has been missed -- some by a whopping 18 months. The poor planning and execution of DSM 5 have already forced a postponement from its original publication in 2012 to 2013, and yet another postponement is now necessary if it is to meet even minimal standards of quality.

10. "There is in fact no outside organization that has the capacity to replicate the range of expertise that DSM-5 has assembled over the past decade to review diagnostic criteria for mental disorders."
This statement is in response to the request for independent scientific review contained in a petition endorsed by 47 mental health professional associations including the BRITISH PSYCHOLOGICAL SOCIETY(See Post - The Future of Psychiatric Diagnosis). Because it is internal, secret, and porous, DSM 5's own scientific review process has no credibility. But contrary to the quote, there is a very clear and highly desirable alternative. The Cochrane group is expert in conducting independent, evidence-based scientific reviews to guide medical decision making. Cochrane should be contracted by APA to review the most contentious diagnoses. There is no other way DSM 5 can possibly gain the public trust.
* * * * *

This is just a select sample from among any number of equally self-incriminating quotations that consistently hoist DSM 5 on its own petard. The public statements of the DSM 5 leadership consistently reveal just how insulated they are -- far out of touch with the proper purpose of their task and unable to see serious risks that seem perfectly apparent to everyone else. DSM 5 is probably stuck on its disastrous course unless it can finally be restrained by outside forces --some combination of press shaming, public and professional opposition, and/or governmental intervention. Time is running out.

Sarah Kamens’ role in DSM-5 reform - The American Humanistic Society.

A Rising Star in Humanistic Psychology: Sarah Kamens’ role in DSM-5 reform

Sarah R. Kamens, doctoral candidate in clinical psychology at Fordham University and Student Representative to the Division 32 Executive Committee, is featured
By David N. Elkins and Fredrick J. Wertz
Sarah R. Kamens

Sarah R. Kamens, doctoral candidate in clinical psychology at Fordham University and Student Representative to the Division 32 Executive Committee, is one of our "rising stars" in humanistic psychology.

When I formed the Division 32 Committee on the DSM-5 in August, 2011, I appointed Sarah, along with Brent Robbins, to serve on the committee because I knew she had studied the DSM-5 development and was highly knowledgeable about the problems with the proposed manual.  It quickly became obvious that Sarah not only had detailed, in-depth knowledge about the problems with the proposed DSM-5 but that she was also an excellent writer who was able to describe those problems in scholarly and convincing language. Although Brent Robbins and I have many years of experience and consider ourselves good writers, we stepped aside to let Sarah craft the "Open Letter to the DSM-5 Task Force and the American Psychiatric Association." To date, the Open Letter , which called for changes to the proposed DSM-5 and was posted on a petition website, has been signed by more than 8800 mental health professionals and 30 psychology organizations. Sarah also drafted other documents related to the DSM-5 effort. She has been, and remains, invaluable to our committee. In late November, 2011, she decided to leave the committee per se and to move to a consultancy position in which she will continue to work on an "as needed" basis with the committee to bring about changes in the DSM-5. Sarah will join other scholars at the 2012 Annual Conference of the Society for Humanistic Psychology (March 29-April 1, 2012) and also at the APA Convention in Orlando (August, 2012), to present papers in two similar symposia titled "The DSM-5 Controversy:  Division 32 President Symposium."

Prior to her current doctoral work, Sarah studied media theory at the European Graduate School (EGS) in Switzerland, where her professors included Judith Butler, Avital Ronell, Slavoj Žižek, and Alain Badiou. Her MA thesis at EGS, published by Atropos Press, examined the intersections between traumatology and the “linguistic turn” in critical theory. Sarah also spent time in the Middle East, where she worked in film production and conducted psychosocial research. She was the associate producer on a fiction film set in a historical Israeli mental institution built atop a Palestinian village, and she produced a documentary about the nonviolent resistance movement for the liberation of Jammu-Kashmir. In the Middle East, she conducted research on psychosocial interventions for parents and their children with the Psychosocial Department of the Palestine Red Crescent Society (PRCS). With PRCS, she designed a study of the psychosocial correlates of political violence in children’s drawings. She also conducted an interview study of Palestinian psychologists that addressed unique aspects of their experiences, such as their reflections on living under the same violent circumstances as their clients and their views of Western mental health professionals. Sarah continues to collaborate on research with her Palestinian colleagues, with whom she recently published a follow-up study of a school-based psychosocial intervention for at-risk adolescents in Peace and Conflict.

At Fordham University, Sarah studies phenomenology and qualitative research methods under Dr. Frederick Wertz. Each semester, she works as a graduate teaching assistant/lab instructor for undergraduate psychology courses. In her MA thesis research, Sarah investigated psychiatrists’ discourse about the DSM-5 controversies. She analyzed written texts by psychiatrists as well as interviews that she conducted with Robert Spitzer, MD (Chair of the DSM-III Task Force) and Michael First, MD (Director of the DSM-5 Prelude Project), using an innovative integration of phenomenological-existential and discourse analytic methods. An early article that she wrote on controversial issues for the upcoming DSM-5 appeared in the Society for Humanistic Psychology Newsletter, and a more recent piece on the DSM-5 proposals for paraphilias and gender-related diagnoses was published in The Humanistic Psychologist. She is currently preparing a dissertation proposal for a cross-cultural, phenomenological study of schizophrenia based in New York and Jerusalem.

In her clinical work, Sarah is interested in urban community mental health, interdisciplinary approaches to psychosis, and the psychological effects of environmental stressors such as homelessness and political violence. She recently completed a year-long clinical externship at Kirby Forensic Psychiatric Center, and she is currently an extern at the Addiction Institute of New York, St. Luke’s / Roosevelt Hospital. In the future, she hopes to continue teaching and conducting research in the areas of psychiatric theory, cross-cultural phenomenology, and methodological issues in the development of clinical nomenclatures.

Sarah is already a brilliant scholar, deeply committed to the humanistic vision. I have no doubt that Sarah will be a major leader of the next generation of humanistic psychologists and that she will make substantive contributions to the humanistic movement.

Please join me in congratulating Sarah on her outstanding contributions to Division 32 and as the first person to be selected for " SHP Member Spotlight."




by Paula J. Caplan, Ph.D.

Many people have presented me with the following challenge: ‘People suffer. Often, good therapists can help relieve suffering, and suffering people deserve to have insurance pay for their therapy. But insurance companies won’t pay unless the person gets a psychiatric diagnosis. However, psychiatric diagnosis is unscientific and has often caused both direct and indirect, devastating effects in people’s lives. So what is the solution?”

Of course, I totally agree with all of the above statements. What do I think is the solution?
For years, my answer was: “I don’t know what the solution is, but I do know that we must not keep silent when we know that people are being harmed. So first we have to expose the harm, and then we have to brainstorm about a solution.”

However, the work of a student, Meadow Linder, in her brilliant undergraduate thesis at Brown University, combined with what countless therapists have told me over the years, suddenly revealed a solution to me. I will describe it here, but be aware that it may seem overly simplistic, and you may immediately think, “But that will never happen!” I do not believe it is overly simplistic, and as for whether or not it will ever happen, well, if we don’t aim for honesty and the repair of the world (what in Hebrew is called Tikkun Olam), then we can be sure we won’t get there.

In her thesis, Meadow Linder (see her chapter in Bias in Psychiatric Diagnosis, Caplan & Cosgrove, Editors) found through interviews with some really fine, ethical psychotherapists that when a traumatized, suffering person comes to them for help, they do not worry about whether or not the person meets the number of criteria for Post-traumatic Stress Disorder that it says they must meet in the psychiatric diagnosis manual. Because the person is traumatized, and they think they can be of help, they assign the PTSD label, and then the insurance company will pay for the therapy. They do this on the most humane grounds, and many of them are even more comfortable doing this because they are aware that the psychiatric diagnostic manual is not grounded in good science, so it does not make sense to stick to unscientific rules when it means sacrificing the welfare of the patient. As a member of two of the committees that wrote the current version of the diagnostic manual, the DSM-IV (until I resigned after seeing how unscientific and how politically motivated the writing of this manual is), I saw firsthand that good scientific research is ignored, distorted, or lied about when it suits their purposes, and poorly done research is used to support whatever they want to put in or keep out of their manual.

I have been working with therapists since 1969 and cannot count the number of times that excellent, compassionate, ethical therapists have told me that they don’t worry about what psychiatric diagnosis to give patients, because they know that that rarely, if ever, is of any help. Instead, they consider what the insurance company will and will not pay for and how the companies often agree to pay for more or fewer therapy sessions, depending on the diagnostic label given to the patient. Then they, to a greater or lesser extent, base their choice of labels on what will enable them to provide the best and most appropriate kind of help. So many therapists do this, and know that others do it, and even the insurance companies are surely aware that this goes on. So what is happening in fact is that, once a person has been licensed as a psychologist or psychiatrist (in some states, people from other disciplines can be licensed therapists), right now, the therapist's judgment of the patient's needs is what is really the basis of insurance coverage. In spite of this, insurors and some therapists throw up their hands and ask, "Without diagnosis, how would we know whose therapy to pay for?!"

My Proposed Solution:
In light of what I have just described, my solution is simply that everyone involved -- therapists, insurance companies, the DSM authors — start being completely candid about what is happening, and we all skip the step of assigning a diagnostic label. In addition to the importance of an increase in honesty and ethical conduct all around that this would entail, there is an added, important clinical advantage that would accrue; the advantage is that, as the brilliant psychologist Jeffrey Poland has described in one of his chapters in the book Bias in Psychiatric Diagnosis, therapists would be encouraged and even liberated to try to learn about the whole patient, including their strengths and resources, instead of focusing too much (as many do today) on figuring out which set of DSM symptoms the patient most closely fits.

Monday 30 July 2012

DSM-5 : Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists....


May 13, 2012

The D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts....
Frances rejects the accusation that the D.S.M. is "shilling for drug companies":
The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role....

Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists....

Sunday 29 July 2012

DSM-5 - Public Relations Fictions Trying to Hide DSM-5 Facts

Public Relations Fictions Trying to Hide DSM-5 Facts
Posted: 05/31/2012 

Recently APA recruited a public relations guy from the Department of Defense to respond to my concerns that DSM-5 is way off track. He immediately went on the offensive and (in an interview for Time magazine) made the obvious PR mistake of calling me "a dangerous man." This provided me the opportunity to pose yet again the troubling questions about DSM-5 that APA repeatedly refuses to answer. The DOD guy hasn't surfaced since.
Instead, APA has adopted a much smoother, soft sell approach. It has hired GYMR -- an expensive PR firm. GYMR actually brags in its mission statement that it can "execute strategies that include image and alliance building, public education campaigns or media relations to harness the formidable forces of Washington and produce successful results for clients."
We now have the first fruits of GYMR's "image building" misinformation campaign. It has launched a PR website with the claim it will provide "the facts on DSM-5 development process. Read recent news stories & opinion pieces, along with our responses, to correct the record, highlight key omissions -- and provide essential perspective, so that the public has a complete and accurate view of this important issue."
Unfortunately, the site is very short on accurate facts, very long on misleading (or just plain wrong) "image building" fiction. It is all pure PR fluff -- a way to avoid answering the substantive questions that need addressing before DSM-5 is prematurely rushed to press. Let's compare GYMR fiction versus DSM-5 fact:

GYMR Fiction: "We have extensive data from the field trials that on average there is a slight decrease in the overall rates of DSM-5 in comparison to DSM-IV disorders."
DSM-5 Fact: This is simply wrong -- APA has no such data. Except for autism, all of the DSM-5 changes will dramatically raise the rates of mental disorder and mislabel normal people as psychiatrically sick. The field trial provided no data on this crucial question because it made an unforgivable error -- not including head to head prevalence comparisons between DSM-IV and DSM-5. This makes it impossible to estimate how explosive will be the DSM-5 rate jumps. Moreover, false epidemics are often nurtured in the primary care settings that were untested in the DSM-5 field trials.
GYMR Fiction: The PR claim is that DSM-5 has provided a transparent process.
DSM-5 Fact: DSM-5 has been peculiarly and self-destructively secretive from its early confidentiality agreements (meant to protect "intellectual property") to its current failure to make public any of the results of its "scientific" reviews. Real science can never be confidential. None of this secrecy makes any sense.
GYMR Fiction: "APA takes very seriously its responsibility in developing and maintaining DSM and has devoted $25 million to the DSM-5 update process thus far."
DSM-5 Fact: The $25 million has been a colossal waste of poorly spent money. We did DSM IV for one-fifth the price and never missed a deadline or stirred much controversy. The difference in expenditure and outcome has nothing to do with us being especially competent. It has everything to do with DSM-5 being poorly conceived and organized and spending lavishly on silly things like public relations.
GYMR Fiction: "There are several proposals in DSM-5 that aim to more accurately describe the symptoms and behaviors of disorders that typically present in children."
DSM-5 Fact: The epidemics of excessive diagnosis in children will be muddled further by DSM-5. The threshold for ADHD is being lowered despite the tripling of rates. Temper Dyregulation (AKA DMDD) is being suggested based on just a few years of work by just one research group -- despite the risk it will exacerbate the already inappropriate and dangerous use of antipsychotic drugs in kids. And DSM-5 somehow persists in not understanding how its suggestions will necessarily have a profound impact on rates of autism.
GYMR Fiction: "There are actually relatively few substantial changes to draft disorder criteria."
DSM-5 Fact: Dead wrong -- how did GYMR ever come up with this one? My guess is that the DSM-5 changes would affect the diagnosis of tens of millions of people. APA has no way of refuting this estimate since it unaccountably failed to ask the crucial prevalence question in its $3 million field trial.
GYMR Fiction: "Those that have been recommended are based on the scientific and clinical evidence amassed over the past 20 years and then are subject to multiple review processes within the APA."
DSM-5 Fact: Most of the reviews are poorly done and none of the suggestions would stand up to the kind of impartial, independent scientific review demanded by a petition supported by 51 mental health associations. The APA internal review lacks any credibility because it is done in secret and has somehow found a way to approve DMDD and the removal of the bereavement exclusion -- both of which have little or no scientific support. To be credible, APA must both make public its own scientific reviews and also contract for external and independent reviews on all the most controversial topics.
GYMR Fiction: "The APA governance attention to this is far greater than anything that ever occurred with DSM III or DSM-IV."
DSM-5 Fact: Absurd on the face of it. If there had ever been anything resembling proper internal supervision, DSM-5 would not be in this deep mess and would not require expensive PR fig leaves to try to cover it up.
There is more, but you get the idea. DSM-5 is in a paradoxical position. Publishing profits pressure it toward premature publication, but its close to final draft is the object of almost universal opposition. On one side we have APA and its new hired gun GYMR -- on the other side we have 51 professional organizations, the Lancet, the New England Journal of Medicine, the international media and outraged segments of the public. It is far too late for any superficial "image building," however clever, to restore DSM-5 credibility. Saving DSM-5 requires radically reforming its mistakes, not covering them up with a PR smokescreen of misinformation.
The last and only hope for a safe and credible DSM-5 now resides in the new APA leadership -- it is within its power to thoroughly reform DSM-5 before it is too late.
The stakes are high. A DSM-5 at war with its users will wind up losing many of them. Disillusioned members (each of whom has involuntarily sunk almost $1,000 in this lavish but misdirected DSM-5 effort) will speed up the already rapid exodus of APA members. APA will eventually lose its monopoly on psychiatric diagnosis. Psychiatry will be unfairly discredited. And, worst of all, the patients who need our help will suffer.
DSM-5 is in such public trouble now because it heedlessly missed every prior private opportunity to self-correct. The solution is not the production of more public relations pablum. Instead, DSM-5 needs to regroup, solve its problems, and avoid racing over a cliff.

DSM-5 DANGERS - Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder when its rates have already tripled in just fifteen years?

By Allen Frances - editor in chief of DSM-4


Am I a Dangerous Man?

No, but I do raise twelve dangerous questions
According to this week's Time magazine, the American Psychiatric Association has just recruited a new public relations spokesman who previously worked at the Department of Defense. This is an appropriate choice for an association that substitutes a fortress mentality and  warrior bluster for substantive discussion. The article quotes him as saying: "Frances is a 'dangerous' man trying to undermine an earnest academic endeavor." Fresh from DOD, it may be difficult for the new spokesman to leave behind combat cliches and perhaps he is not the best judge of academic endeavors. He enthusiastically extends the APA policy of shooting the messenger because it can't argue the message. Who knows—I may have become a picture card in his deck of high value targets.
The piece in Time magazine manages to raise again the silly APA suggestion that my objections to DSM 5 are motivated by a feared loss of royalties. Let's set the record straight—hopefully for the last time. The royalties on my DSM IV handbook are about $10,000 a year—not at all commensurate with all the time I have spent trying to protect DSM 5 from making all its repeated mistakes.

My motivation for taking on this unpleasant  task is simple—to prevent DSM 5 from promoting a general diagnostic inflation that will result in the mislabeling  of millions of people as mentally disordered. Tagging someone with an inaccurate mental disorder diagnosis often results in unnecessary treatment with medications that can have very harmful side effects. I entered the DSM 5 controversy only because I had learned painful lessons working on the previous three DSM's, seeing how they can be misused with serious unintended consequences. It felt irresponsible to stay on the sidelines and not point out the obvious and substantial risks posed by the DSM 5 proposals.

I don't consider myself a dangerous man except insofar as I am raising questions that seem dangerous to DSM 5 because there are no convincing answers. My often repeated challenge to APA—provide us with some straightforward answers to these twelve simple questions:

1) Why insist on allowing the diagnosis of Major Depressive Disorder after only two weeks of symptoms that are completely compatible with normal grief?
2) Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder when its rates have already tripled in just fifteen years?  
3) Why include a psychosis risk diagnosis which has been rejected as premature by most leading researchers in the field because it risks exacerbating what is  already the shameful off-label overuse of antipsychotic drugs in children?
4) Why introduce Disruptive Mood Dysregulation Disorder when it has been studied by only one research team for only six years and risks encouraging the inappropriate antipsychotic drug prescription for kids with temper tantrums?
5) Why sneak in Hebephilia under the banner of Pedophilia when this will create a nightmare in forensic psychiatry?
6) Why lower the threshold for Generalized Anxiety Disorder and introduce Mixed Anxiety Depression when both of these changes will confound mental disorder with the anxieties and sadnesses of everyday life?   
7) Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?
8) Why label as a mental disorder the experience of indulging in one binge eating episode a week for three months?
9) Why introduce a system of personality diagnosis so complicated it will never be used and will give dimensional diagnosis an undeserved bad name?
10) Why not delay publication of DSM 5 to allow enough time to complete the previously planned and crucial second stage of field testing that was abruptly cancelled because of the constant administrative delays in completing the first stage?
11) Why should we accept ambiguously worded DSM 5 diagnoses whose reliability barely exceeds chance?
12) And most fundamental. Why not allow for an independent scientific review of all the controversial DSM 5 changes identified above—proposed by forty-seven mental health organizations as the only way to guarantee a credible DSM 5? What is there to hide and what harm is done by additional careful review?  

If I am a dangerous man, it is because I am exposing DSM 5's carelessness and thus putting at risk APA's substantial publishing profits. During the past three years, I have made numerous attempts, private and public, to warn the APA leadership of the troubles that lay ahead and to implore them to regain control of what was clearly a runaway DSM 5 process. This has had no real effect other than delaying publication of DSM 5 for a year and the appointment of an oversight committee that turned out to be toothless. I am reduced now to just one means of protecting patients, families, and the larger society from the recklessness of the DSM 5 proposals—repeatedly pointing out their risks in as many forums as possible.

Previous APA responses to criticism provide the bland and unsatisfying reassurance that we should trust DSM 5 on faith because it has been prepared by experts who have toiled long and hard. This simply won't wash—this emperor really has no clothes. It is long past time for DSM 5 to abandon phoney attempts at public relations and instead allow itself to be subjected to a rigorous independent scientific review. We need a safe and scientifically sound DSM 5—not a third rate product that is universally opposed and lacks all credibility.   

Saturday 28 July 2012

DSM-5 : New mental health manual is "dangerous" say experts. Courtesy of Reuters website.


New mental health manual is "dangerous" say experts and many Professors.



LONDON | Thu Feb 9, 2012 2:24pm EST
(Reuters) - Millions of healthy people - including shy or defiant children, grieving relatives and people with fetishes - may be wrongly labeled mentally ill by a new international diagnostic manual, specialists said on Thursday.

In a damning analysis of an upcoming revision of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM), psychologists, psychiatrists and other experts said new categories of mental illness identified in the book were at best "silly" and at worst "worrying and dangerous."
"Many people who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labeled as mentally ill," said Peter Kinderman, head of Liverpool University's Institute of Psychology at a briefing in London about widespread concerns over the manual.
"It's not humane, it's not scientific, and it won't help decide what help a person needs."

The DSM is published by the American Psychiatric Association (APA) and has symptoms and other new criteria for diagnosing mental disorders. It is used internationally and seen as the diagnostic "bible" for mental health medicine.
No one from the APA was immediately available for comment.
More than 11,000 health professionals have already signed a petition (at dsm5-reform.com) calling for the development of the fifth edition of the manual to be halted and re-thought.
Some diagnoses - for conditions like "oppositional defiant disorder" and "apathy syndrome" - risk devaluing the seriousness of mental illness and medical zing behaviors most people would consider normal or just mildly eccentric, the experts said.
At the other end of the spectrum, the new DSM, due out next year, could give medical diagnoses for serial rapists and sex abusers - under labels like "paraphilic coercive disorder" - and may allow offenders to escape prison by providing what could be seen as an excuse for their behavior, they added.


Simon Wessely of the Institute of Psychiatry at King's College London said a look back at history should make health experts ask themselves: "Do we need all these labels?"

He said the 1840 Census of the United States included just one category for mental disorder, but by 1917 the APA was already recognizing 59. That rose to 128 in 1959, to 227 in 1980, and again to around 350 disorders in the fastest revisions of DSM in 1994 and 2000.

Allen Frances of Duke University and chair of the committee that oversaw the previous DSM revision, said DSM-5 would "radically and recklessly expand the boundaries of psychiatry" and result in the "lexicalization of normality, individual difference, and criminality."

David Pilgrim of Britain's University of Central Lancashire said it was "hard to avoid the conclusion that DSM-5 will help the interests of the drug companies."

"Madness and misery exist but they come in many shapes and sizes," he said. "We risk treating the experience and conduct of people as if they are botanical specimens waiting to be identified and categorized in rigid boxes.
"That would itself be a form of collective madness for all those complicit in the continuing pseudo-scientific exercise."
Nick Craddock of Cardiff University's department of psychological medicine and neurology, who also spoke at the London briefing, cited depression as a key example of where DSM's broad categories were going wrong.

Whereas in previous editions, a person who had recently lost a loved one and was suffering low moods would be seen as experiencing a normal human reaction to bereavement, the new DSM criteria would ignore the death, look only at the symptoms, and class the person as having a depressive illness.
Other examples of diagnoses cited by experts as problematic included "gambling disorder," "internet addiction disorder" and "oppositional defiant disorder" - a condition in which a child "actively refuses to comply with majority's requests" and "performs deliberate actions to annoy others."

"That basically means children who say 'no' to their parents more than a certain number of times," Kinderman said. "On that criteria, many of us would have to say our children are mentally ill."
(Editing by Andrew Heavens)

Friday 27 July 2012


Do we need a diagnostic manual for mental illness?

Richard Bentall (above) and Nick Craddock discuss the controversial revisions to the US Diagnostic and Statistical Manual  +  WATCH THE VIDEO CLIP FOR 3 mins BELOW.



Mental illness
The main focus of the revised Diagnostic and Statistical Manual has been the broadening of psychiatric diagnoses. Photograph: Alamy

Richard Bentall: 'Who will benefit from the proposed revision?'

The way that we think and talk about psychiatric illness has implications for all of us – not only mental health professionals and their patients, but anyone with affected friends and family members, policy-makers struggling to know what services to provide and pharmaceutical companies considering future profits. So it's unsurprising that a proposed new edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), widely described as the "psychiatrists' bible", is causing much furore – but slightly more surprising that much of the dissent comes from within psychiatry.
Since the publication of the third edition in 1980, the DSM has employed a checklist approach to assigning diagnoses. By ticking off the symptoms listed under each disorder, a mental health professional can reach a diagnosis that is likely to be in agreement with the judgment of any other mental health professional. At the time, this seemed to be a huge step forward from earlier approaches, which were highly subjective and led to widespread disagreements about conditions (the diagnosis of schizophrenia, for example, was used much more widely in the US than in Britain). The fourth edition, in 1994, passed without much opposition, but the proposed fifth edition has attracted much criticism – not least from Dr Allen Frances, the American psychiatrist charged with editing its predecessor.
The main focus has been the broadening of psychiatric diagnoses, making an increasing range of behaviours targets of psychiatric concern. (As evidence this is already happened to an alarming degree: last year about one in four US citizens took a psychiatric drug.) For example, it has been proposed that grief should be dropped as an exclusion criterion for the diagnosis of depression, raising the risk that normal grief reactions will be considered evidence of illness. In the case of severe mental illness, the discovery that a large proportion of the population (about 10%) sometimes experience "subclinical" hallucinations and bizarre beliefs has led to the inclusion of an attenuated psychosis syndrome. (Research shows that only about 10% of people who meet these criteria will go on to become severely affected; clearly there is a risk that many will receive toxic drugs unnecessarily.)
Behind these concerns about the expanding scope of psychiatry lies a deeper problem. The proposed revision has been constructed on the basis of clinical consensus – psychiatric folklore institutionalised by committee – rather than scientific research. For example, despite evidence that "schizophrenia" and "bipolar disorder" overlap, they continue to be treated as separate illnesses.
Defenders of the DSM and similar systems argue that some kind of categorical method of diagnosing patients is required to allow communication between clinicians. Critics, such as myself, argue that it's better to communicate with a detailed and individualised list of a patient's problems. Either way, an important question is, who will benefit from the proposed revision? As there is no obvious scientific added value compared to the fourth edition of the DSM, and as there are some obvious risks associated with this expansion of diagnostic boundaries, one is bound to ask why there is a need for this revision, or who will benefit from it. It seems likely that the main beneficiaries will be mental health practitioners seeking to justify expanding practices, and pharmaceutical companies looking for new markets for their products.

Nick Craddock: 'Accurate and prompt diagnosis may be life-saving'

In my view, there are many problems with the DSM approach to diagnosis. There are too many categories, distinctions between diagnoses often seem arbitrary and it is largely driven by expert opinion, rather than solid scientific evidence. Like me, many other psychiatrists in the UK and Europe are similarly sceptical about the fifth edition of the DSM and its expansion of categories and consequent risks of over-diagnosis.
But we need to be clear: if someone is unwell, the first step to delivering effective care is to diagnose what the problem is. Making a diagnosis guides evidence-based clinical decisions. In most situations encountered in mental health, some level of diagnosis is essential to ensure effective help is provided (when needed) and that everyone can have some shared understanding of the situation.
For example, there are many reasons why an adult may develop lethargy, lose weight and become less active and interested in life. This could reflect temporary adjustment to a changing life situation (ie, a normal response to life's difficulties). The person might have cancer. The person might have heart failure. Alternatively, the person may be experiencing a severe depressive episode and be at immediate risk of suicide. The ways of helping are all very different – and not all medical – and diagnosis is needed to distinguish between the possibilities and implement the right help as early as possible. Accurate and prompt diagnosis may be life-saving.
A diagnosis can provide reassurance that a person's situation is not unique, mysterious or inexplicable and that there is a body of knowledge and experience that can be brought to bear in providing help. It can reduce stigma by explicitly acknowledging the presence of illness (and, thus, that the feelings or behaviour cannot be dismissed as character weakness or bloody-mindedness).
We should also remember that mental illness and physical illnesses very commonly occur together; this largely explains the fact that people with severe mental illness typically die 20 years earlier than do those without such severe mental illness. Thus, diagnosis of both mental and physical illness is a vital part of the care that those with mental health problems should expect.
The fifth edition of the DSM is an American development. In the UK we use the World Health Organisation's International Classification of Diseases (ICD), so the DSM does not directly affect NHS patients. Prompt and accurate diagnosis and recognition of mental illness and related health problems is the cornerstone of high-quality health services. That should be our focus in the UK.
• Follow Comment is free on Twitter @commentisfree