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Wednesday, 31 October 2012

DSM-5 Debate: Let the Bereavement Exclusion in DSM-5 Die - Courtesy of nthe Psychiatric Times

  Debate: Let the Bereavement Exclusion in DSM-5 Die

By J. Sloan Manning, MD | 07 September 2012
Dr Manning is Codirector of the Mood Disorders Clinic at the Moses Cone Family Practice Center in Greensboro, NC. Dr Manning reports no conflicts of interest concerning the subject matter of this article.


The DSM-IV bereavement exclusion (BE) is a source of consternation—something to squint the eyes and cock the head at, and create wonder (See: "Ringing the Bell to Save the Bereavement Exclusion"). It is an anachronism, a failure to apprehend the terms “biopsychosocial” and “stress-diathesis,” based on a false dichotomy, an idea that academicians and philosophers might ponder, but not experienced clinicians.
Apart from purely academic questions addressed in studies summarized elsewhere, the

BE never enters my thinking except as a contextual marker for a broad and proper description of illness that precedes holistic treatment planning.1 It is not a deciding factor, or rule-out. It is of Axis IV importance, and not merely relegated as such.
I write this as one in the midst of bereavement, having lost my dear mother several months ago. I moved my family to North Carolina 9 years ago for the express purpose of joining my extended family here. We made the decision as a part of a mid-life “course correction.” Enjoying each other and supporting each other during the last years of my parents’ lives was of prime importance. My father died before we could make the move. My mother lived independently for 8 years—and we lived it to the hilt. During the last year of her life (in rehab facilities and briefly in a nursing home) we were never closer.
I still avoid driving by the nursing home. I still wake up at night occasionally tearfully thinking of her. I cook a lot of pot roasts in the old cast iron Dutch oven she made famous. I am converting a home office to a guest bedroom filled with family memories. I am not ill. I am grieving. It doesn’t look like illness. It doesn’t need to be treated like illness. I can’t believe anyone would mistake it for illness, especially an experienced clinician. But if I were ill and grieving, I would expect my health care providers to understand that the 2 concepts are not mutually exclusive, and I would expect them to offer help for my illness . . . all of it.

Part of my practice is in a mood disorders clinic in a family practice residency. I wish everyone could have a similar opportunity to assess and treat patients. This team approach, continually balancing the views of the psychopharmacologist, psychologist, social worker, family practice resident, and patient is the clinical Promised Land. During each intervention, we strive to leave no stone unturned, no problem unaddressed—and we keep each other honest. Often as not, it is the psychotherapist in the group who calls attention to a biological vulnerability and the opportunity to offer improvements in affective stability and emotional resilience with skillfully prescribed medication. The psycho-pharmacologist (me) gets to practice therapeutic conversation in the presence of passionate teachers. Patients hear thoughtful clinicians and begin to understand themselves and their situations as complex systems that may benefit from a variety of combined treatments.

All this is to say that I cannot remember a single instance in this setting where the BE saved the day, preventing the unnecessary use of medication for a nonillness. In situations in which previous ill episodes were absent, symptoms were mild, and cognition and function were preserved, we would always choose the path of supportive and cognitive psychotherapy, and bibliotherapy or other nonpharmacological means as primary interventions. However, in patients with severe symptoms or those with documented histories of Axis I illness, we would never ignore the reality that intact affective control systems are a requirement for successful negotiation of grief. And we would never sacrifice the patient’s life on the altar of our academic egos. We are clinicians first.

To the extent that DSM-5 is an evidence-based document, the BE should die or, perhaps preferably, take its proper place of importance in Axis IV. All passionate 5-axis egalitarians who understand grief in the broad context of depressive illness can now say, “Amen.” We are clinicians.


Reference
1. Lamb K, Pies R, Zisook S. The bereavement exclusion for the diagnosis of major depression: to be, or not to be. Psychiatry (Edgmont). 2010;7:19-25.

Anti-DSM Sentiment Rises in France Why French psychiatrists and psychoanalysts are opposed to the diagnostic manual - Courtesy of the Psychology Today website.

Anti-DSM Sentiment Rises in France

Why French psychiatrists and psychoanalysts are opposed to the diagnostic manual
PARIS — Anger and concern about the growing influence of the DSM in France, as well as over a number of related, prominent pharmaceutical scandals here, has culminated in the creation of Stop DSM, a professional and political group that is strongly opposed to the manual’s diagnostic power and what it sees as its negative social consequences.The group, comprising prominent French psychiatrists, psychologists, and psychoanalysts working “across the spectrum” of mental health, has organized a conference next month (its second) that will focus on the DSM’s practical and political consequences. Some panels will cite the diagnostic manual as increasingly a “world problem” while others are slated to invoke alternatives that aim to release France—and much of the rest of the world—from what critics say represents the worst of American psychiatry, including the unwanted but growing “hegemony” of the American Psychiatric Association.
Stop DSM was established two years ago, one of its organizers, Patrick Landman, told me at a planning meeting earlier this week, due to widespread concern about diagnostic trends in French and European psychiatry. In Europe, France has the highest prescription rates for antidepressants among adults. National concern about the widespread use of Ritalin among French children and teens also spiked after the National Consultative Ethics Committee (CCNE) for Life Sciences and Health noted in a report on addiction and on the amount of amphetamine (speed) comprising Ritalin that “the distinction between licit and illicit drugs is not based on any consistent scientific basis.” Excellent studies such as Maurice Corcos’s L’homme selon DSM: Le nouvel ordre psychiatrique (Man According to the DSM: The New Psychiatric Order, 2011) and La Folie √©valuation: Le malaise social contemporain mis √† nu (Madness Rating: The Contemporary Social Malaise Exposed, 2011) reach a broad audience here, and the short and powerful collection Pour en finir avec le carcan du DSM (For an End to the Yoke of the DSM), associated with Stop DSM, is also a bestseller.
You don’t need to look very far to grasp why—or, indeed, to understand why Landman and his colleagues are so concerned. The day after their planning meeting, the New York Times published a balanced op ed by Weill Cornell Medical psychiatrist Richard A. Friedman entitled, “A Call for Caution in the Use of Antipsychotic Drugs.” Abilify, Seroquel, “and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion,” Friedman noted, “a 13 percent increase over the previous year, according to the market research firm IMS Health. The number of annual prescriptions for atypical antipsychotics rose [in the U.S.] to 54 million in 2011 from 28 million in 2001,” he continued, “an 93 percent increase, according to IMS Health. One study found that the use of these drugs for indications without federal approval more than doubled from 1995 to 2008.” “Until recently,” Friedman concluded, “these drugs were used to treat a few serious psychiatric disorders. But now, unbelievably, these powerful medications are prescribed for conditions as varied as very mild mood disorders, everyday anxiety, insomnia and even mild emotional discomfort.” As this blog noted back in June 2009, Seroquel has even been tested in randomized trials on those with public-speaking anxiety.
Stop DSM not only is built on strong academic foundations, but also is well-organized, with a website that translates into up to ten different languages detailing its platform/manifesto, its objectives and activities, a forum for members, and articles from and for contributors detailing concerns and recommendations. Its membership includes prominent, highly acclaimed psychiatrists, psychologists, and psychoanalysts who have found common cause in their opposition to the language, nosology, and effects of the DSM. They are joining the now-global petition against DSM-5, organized by the Coalition for DSM-5 Reform and supported by numerous mental-health organizations around the world, including 15 divisions of the American Psychological Association.
Notes the manifesto of Stop DSM: “The nomenclature of the DSM, on which [the World Health Organization’s] ICD-10 has been modeled, has progressively become the single and obligatory classificatory reference of “mental disorders” [in France and around the world]:
—in epidemiology;
—in the field of research and scientific publications;
—for social protection systems and insurances;
—in order to collect statistical data for care policy and financing;
—as an unique reference manual in the teaching of psychiatry in medical and psychology schools, for the training of professionals and lecturers in health, social and special education fields;
—[and] finally, for physicians, who, having no other relevant training, prescribe more and more psychotropic drugs, based on questionable diagnostic criteria.”
“With the purpose of responding to specific and distinct requirements,” it continues, “the widespread use of this unique classification becomes a confusion, inadequacy and [source-risk]—especially since the WHO is not empowered to take decisions on scientific research, but instead … should recommend independence, diversity, and promote the coexistence of different approaches.”
“Moreover, far short of scientific rigor, the DSM is based on unambiguously partial conceptions. It neglects … clinical data; multiplies … pathological categories; and lowers the threshold of diagnostic criteria for inclusion, which leads to false-positives and pseudo-outbreaks (as, for example, hyperactivity, bipolar disorder, [and] autism). It is misused for predictive purposes in children and adolescents, taking the risk of harming their development and integration. It also promotes what has become, for a large part of the population, a real addiction to psychotropic drugs.”
The manifesto, supported by individual and group signatures, insists that the World Health Organization “stop promoting internationally the ICD-10’s monopoly condition, [derived] from the DSM, … [which is] imposing its dictatorship over … clinical practitioners and researchers that base their practice on other clinical criteria.” It reminds us “that multiple references could coexist, that a single model would not be imposed for all purposes on a simple statistical basis,” and calls on the WHO—and the American Psychiatric Association—“to stop the manipulation of diagnostic categorizations that, under the guise of ‘good practice,’ dictate to practitioners of therapeutic lines for economic or political goals.”
“A simplified nomenclature,” concludes Stop DSM, is not “sufficient to respond to the categorizations needed to satisfy social protection.”
The group’s upcoming conference will be held on Saturday, October 20th, from 9:00-5:30 pm, in the Maison des Cultures du Monde, 101 blvd Raspail, 75006, Paris. Further information is also available on its website here.

christopherlane.org

Tuesday, 30 October 2012

Pharmageddon - The Bitter Pill for the U.S. Population to Take - YOUTUBE VIDEO

http://youtu.be/d9Etb4s98V0

The United States has a passion for pills, being the world's biggest users of psychotropic drugs, consuming 60 per cent of them. And as RT's Marina Portnaya explains, pharmaceutical firms plan to keep cashing in even if it costs people their health.

Pharmageddon: how America got hooked on killer prescription drugs - Courtesy of the Guardian Website


A man protests against pill mills in Fort Lauderdale. 98% of doctors who prescribe oxycodone work in Florida, and Americans travel far to get the drug – many arriving on the ‘Oxycodone Express’



Pharmageddon: how America got hooked on killer prescription drugs-
White House declares prescription drug abuse in US 'alarming' as thousands flock to Florida – the home of oxycodone pill mills
      


A man protests against pill mills in Fort Lauderdale. 98% of doctors who prescribe oxycodone work in Florida, and Americans travel far to get the drug – many arriving on the ‘Oxycodone Express’. Photograph: Alan Diaz/AP
The Kentucky number plate on Chad's pick-up truck, parked round the back of a doctor's clinic in Palm Beach, Florida, reveals that he has just driven a thousand miles, 16 hours overnight, to be here – and he's not come for the surfing.
"It's my back," he says, rubbing his lower vertebrae. "I'm a builder. I fell off the roof and hurt my back."
That's odd, as we have just watched him run out of the clinic and over to his truck without so much as a limp. He's clutching a prescription for 180 30mg doses of the painkiller oxycodone.
Chad is one of thousands of "pillbillies" who descend on Florida every year from across the south and east coasts of America. Some come in trucks bearing telltale number plates from Kentucky, Georgia, Tennessee, even far-away Ohio. Others come by the busload on the apocryphally named Oxycodone Express.
It's a lucrative trade. Chad tells us he has just paid $275 (£168) to the doctor inside the clinic, or pill mill, as it is pejoratively called. The doctor, who can see up to 100 people in a sitting, can make more than $25,000 in a day, cash in hand.
For Chad the profits are handsome too. He will spend $720 at a pharmacy on his 180 pills, giving him a total outlay of about $1,000. Back in Kentucky he can sell each pill for $30, giving them a street value of $5,400 and Chad a clear profit of more than $4,000. If he goes to 10 pill mills in Palm Beach on this one trip he could multiply that windfall tenfold. But then there's the other cost of the oxycodone trade, a cost that is less often talked about, certainly not by Chad or his accommodating doctor.
Every day in Florida seven people die having overdosed on prescription drugs – 2,531 died in 2009 alone. That statistic is replicated across the US, where almost 30,000 people died last year from abusing pharmaceutical pills.
It's an American catastrophe that has been dubbed pharmageddon, though it rarely pierces the public consciousness. Occasionally a celebrity overdose will attract attention – Anna Nicole Smith, Heath Ledger, Michael Jackson – but they are specks in a growing mountain of human mortality.
The White House last month said the abuse of prescription drugs had become the US's fastest-growing drug problem.
Declaring the trend an "alarming public health crisis", it pointed out that people were dying unintentionally from painkiller overdoses at rates that exceeded the crack cocaine epidemic of the 1980s and the black tar heroin epidemic of the 1970s combined.
At the heart of the disaster is the powerfully addictive painkiller oxycodone, which comes in various brands – OxyContin, Roxicodone and Percocet. It is a legitimate therapy for those in great pain but has spawned a generation of addicts and, in turn, attracted crooked doctors who massively expanded the prescription of the drugs in up to 200 pill mills, most in southern Florida.
The epidemic has affected people of all ages but is becoming more prominent among teenagers and young adults.
Ric Bradsaw, the sheriff in Palm Beach, said: "There's a culture that's taking hold among teenagers that because a doctor prescribes these pills they can't be bad. Kids don't have the fear of pharmaceuticals that they do of illegal drugs."
Eleanor Hernandez was introduced to "oxies" when she was 14. "I had no idea it was dangerous at all. Other people were taking it for pain, so why would I worry about it?"
Her mother had just died and Hernandez found that she felt care-free when she took a pill. "It took the pain away, of my mother's death, and physically too. It numbed you, made you feel like you were in a bubble."
By 15 Hernandez was selling oxycodone from the park across the street, making money to pay for her own habit. It was a downward spiral. She was in and out of rehabilitation clinics, in and out of custody. Then she overdosed twice and was resuscitated both times in hospital.
But Hernandez was one of the lucky ones. Now 20, she works in a treatment centre helping 14 to 17-year-olds beat addiction. "To this day I thank God that I found help because if I hadn't I probably wouldn't be here."
Rich Perry did not find help. He died aged 21 from a cocktail of oxycodone and other prescription and illegal drugs. He began taking prescription pills three years previously, in his last year at high school. He confided in his mother, Karen, that he had a drug problem and went into rehab.
He was clean for a year, but then, without his parents realising, he relapsed, obtaining oxycodone from three separate doctors. He overdosed once but carried on using the drug. The first Karen knew that her son had gone back to the pills was when two officers knocked at her door at 2am to tell her he was dead.
Now, like Hernandez, Perry seeks solace by helping others to avoid her son's fate. She runs the Florida group Narcotics Overdose Prevention and Education – Nope. Together with the American Society of Interventional Pain Physicians it is battling to persuade the state to introduce a monitoring database that would allow police and medical authorities to identify where the oxycodone is coming from, and in turn identify and shut down the pill mills. Though Florida is the epicentre of the oxycodone epidemic, with 98% of all the nation's doctors who handle the drug located here, astonishingly the state has no comprehensive database recording prescription histories.
Even more astonishingly its recently elected governor, the Tea Party favourite Rick Scott, has blocked the introduction of a database on grounds of cost.
That makes Perry see red. "Cost! For heaven's sake! What is the cost of a human life?"
The police are even more baffled. They point out that Florida's lack of regulation has allowed the pill mills to flourish.
Eric Coleman, a narcotics detective in Palm Beach, said the true cost of Florida's oxycodone disaster would surpass that of the database many times over if all costs related to the crisis – state subsidies for prescriptions, policing and incarceration of addicts, hospital visits for those who overdose, autopsies and paupers' burials for the dead – were added up.
The Palm Beach police force has many of the pill mills under surveillance and is steadily shutting them down. Over the past year 33 healthcare professionals have been arrested in Palm Beach alone and several have had their medical licences revoked.
Yet the police know that until a proper monitoring system is in place, the clampdown they are carrying out will only displace the problem. Pill mills are popping up in other parts of Florida, around Tampa and Orlando, as pill mill doctors move to new pastures.
"This crisis is going to get worse before it gets better," Coleman says. "It's heartbreaking to watch all the families ripped apart, the young lives ended, the damage these doctors – that honourable, esteemed profession that we trust to look after us – are leaving behind."

Monday, 29 October 2012

"Pharmageddon,"Q&A: Psychiatrist Dr. David Healy author of the book with that title - Courtesy of the Healthlands Website - SCANDAL = "Drug treatment induced death is the leading cause of fatality in the Mental Health field!"

 

"Drug treatment induced death is the leading cause of death in the Mental Health field."

 

"Pharmageddon,"Q&A: Psychiatrist Dr. David Healy Defines his fears about the overphamaceuticalisation of medicine.



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Dr. David Healy has spent decades delving into the dark corners of the pharmaceutical industry, where, for instance, drug companies have tried to hide the worrisome connection between antidepressant drugs and suicide. In the psychiatrist’s best-known previous books, The Antidepressant Era and Let Them Eat Prozac, Healy explored the often vexing history of the mental health field and its troubled relationship with Big Pharma. In his latest book, Pharmageddon, he presents an even bleaker picture of the way industry has co-opted medicine in general — not just mental health. Healthland spoke with Healy about his findings.

What do you mean by ‘pharmageddon’?
At the moment, treatment-induced death is the fourth leading cause of death [overall], and within the mental health field, it’s probably the leading cause of death.
It’s a little bit like climate change. It may feel great to have a car, the convenience you get is a thing we appreciate each time we hop in the car and drive down to the market. But the use of cars is contributing to the bigger picture of climate change. In the same way, quite a few medications we take produce good outcomes. But we’ve [had a] climate change in medicine, which runs the risk of completely destroying medicine as we’ve known it.
And the key tool in all of this is how companies use the scientific evidence. They construct trials to get the outcomes they want; they only publish positive trials. The study often shows the opposite of what the data actually shows.

In the book, you look at how drug companies sell us on reducing risks — like say, high cholesterol — that may not actually do much to keep us healthy because high cholesterol itself is just a marker for cardiovascular disease risk, not an illness itself.
If you [look at] statins to lower cholesterol or drugs for osteoporosis, there’s no obvious benefit like there is from wearing a parachute when you jump out of a plane. You often just don’t feel good and you may feel a good deal worse. There isn’t even a proven benefit at the end. What you’ve got is proof in the sense of demonstrating that over a six-week period, you can show a marginal change that we have agreed to call a change for the ‘better.’ [The point is that the measure doesn’t necessarily mean your health will improve, but rather is just a marker linked with a reduction in risk.]
Trials get used as tool to persuade doctors to persuade you to have treatment. [And making drugs] available on prescription only is a means to persuade you to take things that if you were more naturally cautious, you’d be less inclined to take.

But don’t we need clinical trials to eliminate quack remedies and look systematically at the best treatments?
There’s two [situations] where trials are useful. There’s an area were you don’t need trials at all, where the treatment really works, such as antibiotics for serious infections. And they’re also really useful when they show that something doesn’t work.
What we’ve got is what’s in between, where in actual fact [some] people would say, for example, if you take all the trials of antidepressants, they actually show that the drugs didn’t work.

Yet many people say they experience profound changes after taking the antidepressant drugs like Prozac — some positive and some negative.
That’s not saying that they don’t work — a bunch of people swear that they’re working. The problem is that if we had all the data available [including the data that the drug companies hid], we ought to have said, ‘We’re not impressed by these drugs. We need to go to back to the drawing board and find the people who really benefit.’ There’s a bunch of people on [antidepressants] who clearly do well. But the companies have made whatever billions of dollars [selling them to a lot of people who don’t].

What do you think about the link between antidepressants and suicide? You’ve found some pretty damning evidence that healthy people may become suicidal or aggressive when they take these drugs.
There’s a group of people for whom antidepressants in general work awfully well, but there’s also a group for whom they don’t work well and they can become either violent or suicidal. The problem again comes back to the role of the doctor. If doctors can’t see that drugs may be good and may be bad, that they can be useful and problematic — if they aren’t experts and can’t handle a bit of complexity — they’re going to go out of business. The problem with doctors and antidepressants making people commit suicide is when it first came out about some children being suicidal, the American Psychiatric Association said that it believed that antidepressants save lives.
I’ve been trying to say to doctors, this is a professional suicide note. What they should say is, Psychiatry can save lives. We know that these pills are good for some and not others and it takes expertise to manage this. If don’t take that [perspective], well, there are cheaper people like nurses, and if pills have no risk and work well, there are cheaper people going to be prescribing.

Why do you emphasize the issue of prescribing privileges so much?
When you come to me for treatment, in sense you’re my hostage. If I ask you if something is wrong [in terms of side effects, you say], ‘No, things are fine.’ You may be having strange thoughts, you may be getting aches and pains you didn’t have before, but the problem is that you either want to keep me happy and so you don’t mention it, [or you say nothing] because I’ve told you that you have to be on these pills because otherwise you will have a heart attack or stroke. You may not even know that the problem is caused by the pill. As a doctor, I’m not trained to pick up that these things may be going on.
The other I’m thing not trained in is that when things are available by prescription only, it’s me, the doctor that ‘consumes’ the pill. I’m the consumer in the sense that companies market these drugs [to me] — in the case of pharma, they’re spending more on marketing than Apple spends or Microsoft or GM. [While those companies] market to all of us, the amount of dollars per head is small. But pharma markets to doctors. Direct-to-consumer ads are only a small part of budget and they’re designed not [just] to get you to believe in the pill, but get you to bring pressure to bear on doctors.

Wouldn’t a big part of the problem be solved simply by requiring drug companies to release all their data?
There should be a law requiring them to reveal all the data. I think that’s a key thing: there should be access to all of the data from the clinical trials. We take risks with new pills on an understanding that the data is going to be made available to experts to sift through and let us all know what the true profiles of these pills are.
If people entering into trials were asked to sign form saying, ‘Do you agree to have pharmaceutical companies sequester the data from this trial?’ they wouldn’t have signed it. Most assumed that because it appears to be science, that the scientific community will get to scrutinize the trials.

You’re personally working on a project to help bring more of the risks to light.
What we’re trying to do with our colleagues is to open up patient adverse event reporting. It’s called rxrisk.org, which will be a website where both people on pills and their doctors can go to report adverse events that may be happening. The idea is to give you a tool so that if things are going wrong, you can get an expert report from us about what is known about the links between the problem and the pills you’re on and by asking a few questions, try to pinpoint whether the pill actually causing the problem. That will give you a report to take to your doctor to make it easier to overcome the kind of hostage problem most people have when they go to the doctor and want to keep him or her happy. The idea is ultimately to create teamwork between doctors and patients and let them know in real time how many other people have reported this problem also.
We’re trying to put patients and doctors in the kind of position where, if they know that thousands of others have had this problem and then the pharmaceutical company says there’s no linkage, people won’t believe it and will say, This isn’t right. It’s in beta at moment.

So what else can be done?
There are ways to play with the system to get the outcomes we want. At the moment, we have a system that works well for the health of pharmaceutical companies but not so well for our health. I’m just trying to raise these issues. How best we solve them is a different matter, but we can’t begin to try to solve them if we don’t raise them. I’m not hugely hopeful but not entirely pessimistic either.

See more of Healthland’s ‘Mind Reading’ series.
Maia Szalavitz is a health writer for TIME.com. Find her on Twitter at @maiasz.

Read more: http://healthland.time.com/2012/03/28/mind-reading-psychiatrist-dr-david-healy-defines-pharmageddon/#ixzz2AfTtesGX

Sunday, 28 October 2012

DSM-5 - Psychologists fear US manual will widen mental illness diagnosis - due to huge growth in 'False Positive' identification using DSM-5 - Professor Peter Kinderman speaks out.Courtesy of the Guardian online website



Professor Peter Kinderman



Psychologists fear US manual will widen mental illness diagnosis
Mental disorders listed in publication that should not exists, warn UK experts
Hundreds of thousands of people will be labelled mentally ill because of behaviour most people would consider normal, if a new edition of what has been termed the psychiatrists' diagnostic bible goes ahead, experts are warning.
Psychiatrists and psychologists in the UK are speaking out against the publishing of DSM-5, an updated version of the Diagnostic and Statistical Manual that categorises every type of mental disorder, including some that the psychologists say should not exist.
A petition condemning the new manual circulated by psychologists in the United States attracted 11,000 signatures. Its predecessor, DSM-4, is used in research worldwide, and has an influence, for example, in naming conditions that pharmaceutical companies devise drugs to treat.
However, the DSM's influence is uniquely strong in the United States, where the private healthcare system requires a diagnosis recognised by the manual for the patient to be considered legitimately ill and be reimbursed by the health insurer for any treatment.
Among the anxieties to be labelled mental disorders if DSM-5 is published in May by the American Psychiatric Association are shyness in children and uncertainty over gender. Loneliness could attract a diagnosis of chronic depressive disorder, and so could unhappiness following bereavement. A serial rapist could be classified as mentally ill, given a diagnosis of paraphilic coercive disorder.
Under the DSM-4, last revised 12 years ago, children who argue and refuse to obey parents can be classified as having oppositional defiant disorder.
Professor Nick Craddock, consultant psychiatrist in Cardiff and director of Wales' National Centre for Mental Health, said: "Somebody who is bereaved might need help and even counselling, but they did not need a label saying they had a mental illness. I believe that a large proportion of psychiatrists in the UK and Europe are sceptical about DSM-5."
Peter Kinderman, professor of clinical psychology and Head of Institute of Psychology at the University of Liverpool, said the revisions "could only make a bad system worse". The diagnostic approach, a tick-box list of symptoms leading to a label, was always "hugely problematic", he said. What is termed "oppositional defiant disorder" is dubious, he said: "Since my children say 'no you are an idiot, dad' repeatedly to me, by definition my children are ill." He also disagreed with the label of paraphilic coercive disorder: "In my view, rape is a crime and should not necessarily be regarded as a disorder. It gives people an excuse for that behaviour," he said."
Til Wykes, professor of clinical psychology at Kings College London, said: "The proposals in DSM-5 are likely to shrink the pool of normality to a puddle with more and more people being given a diagnosis of mental illness."
The American Psychiatric Association strongly defends DSM-5. In response to criticism from the British Psychological Association last year, Darrel Regier, vice-chair of the DSM-5 task force. wrote: "While we agree that human feelings and behaviors exist on a spectrum that contains some overlap of normal reactions to disease states, psychiatry also recognizes that there are real and discrete disorders of the brain that cause mental disorders and that can benefit from treatment."

DSM-5 - Diagnostic disarray - Courtesy of the British Association of Counselling website

  •  

     

    Diagnostic disarray

  • by
  • Catherine Jackson
  • A diagnosis is fundamental to medical treatment: doctors need to be able to agree on what is wrong with us in order to prescribe treatment and cure us.

    That, at least, is how physical health care works. But what if the experts frequently fail to come up with the same diagnosis for the same sets of symptoms in the same person? What if there are two completely different understandings of the disease, its risk factors and causes and how it should be treated? What if there is little objective scientific and physical evidence underpinning the diagnosis? What if the validity of the diagnostic system itself is questionable, precisely because there is weak scientific evidence to back it up?

    Disagreement over the validity of medical diagnoses of mental illnesses and the efficacy of psychiatric medications runs through mental health practice like the San Andreas Fault. The publication by the American Psychiatric Association of a draft fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM, first published in 1952) has further widened the crack between the two camps.

    On one side is a rapidly growing international group of critics, led by UK and US psychological and counselling organisations. Some 12,800 people have so far signed an international online petition against the draft DSM-5 that was launched by the Society for Humanistic Psychology, a division of the American Psychological Association. The petition itself was inspired by the British Psychological Society’s (BPS) polite but scathing critique of the draft.

    On the other side is an embattled American Psychiatric Association and its DSM-5 Task Force, whose revision has been criticised by many psychiatrists outside the US, and even by the chair of the task force that produced DSM-IV.

    The main criticisms of the draft DSM-5 are that it applies psychiatric diagnoses to an even greater number of what might be considered normal ranges of human emotions and behaviours and that it ignores almost completely any factors that might contribute to mental illness other than the biological and neurological. Critics say it extends still further the medicalisation of human distress and difference, without the scientific and biological evidence to support it.

    The BPS says that, without this evidence of physical signs or biological causation, DSM-5’s diagnostic categories ‘rely on subjective judgments’ and are influenced by ‘current normative social expectations’ of what is and is not perceived as ‘abnormal’.

    The BPS also highlights what it sees as the individualisation of mental disorder. By locating the problem in the individual, the BPS argues, medical diagnostic systems such as the DSM overlook potential social and environmental causal factors. If a mental illness has (as research clearly shows) a social cause, such as poverty, warfare trauma, sexual abuse or social inequality, the cure lies not in antidepressants or even cognitive behavioural therapy; it lies in reducing disparities in income, improving welfare benefits, avoiding wars and improving childcare and child protection through community and public health interventions. This is a very different world to that of DSM-5.

    Peter Kinderman, Professor of Clinical Psychology at the University of Liverpool and spokesman for the BPS on the DSM debate, says DSM-5 is making a bad system worse. ‘It’s trying to pathologise a vast swathe of human nature and social problems as symptoms of mental illness. It makes people look for biomedical solutions to social problems, and it allows people to prescribe medical solutions to social problems. We should be identifying people’s problems, formulating an intelligent hypothesis about why they have them, and then doing something about them. That is different from diagnosis.’

    The debate is not simply medical versus non-medical: ‘I am not totally against drug treatment,’ Kinderman says. ‘Where medication is helpful, it should be identified as such. But attaching the label “major depressive disorder” to someone doesn’t tell us if the drug is going to help the person or not, and the vast majority of people with a mental health problem would benefit more from therapy than from drugs. The label carries stigma; it means they haven’t got problems that are part of normal life.’

    Blurring the distinctions
    Criticism of DSM-5 is also coming from the psychiatric profession. Nick Craddock, Professor at the Department of Psychological Medicine and Neurology at Cardiff University School of Medicine, is also concerned that DSM-5 has travelled too far along the road to medicalisation. ‘Psychiatry is based on the idea that there are both normal, and abnormal experiences and there is value in recognising the abnormal, because then you can help. But the corollary is that it is also important to recognise when an experience is part of normal behaviour, and not to broaden what is regarded as illness and not to intervene. What psychiatrists generally don’t think is helpful is labelling more normal experiences because then you are blurring the distinctions.’

    He cites the DSM-5 revision on bereavement as an example. DSM-IV specified that there should be a four-month ‘bereavement exclusion’ following a death: if a person continues to experience symptoms of low mood, loss of appetite and loss of interest in life (basically, depression) beyond four months, then they should be referred for psychiatric treatment. DSM-5 removes that exclusion period, which could result in a very normal period of mourning and loss being diagnosed as clinical depression. ‘That is a change that moves us towards medicalisation and that is something most psychiatrists don’t agree with,’ Craddock believes.

    He argues that there are some positive developments in the DSM-5 revisions, such as the inclusion of ‘dimensions’ of symptoms, which means people can be diagnosed with greater sensitivity to their specific symptoms. But the main weakness of DSM-5 is that it has come too soon, he argues: there has, quite simply, been too little that is new emerging from research to warrant this new edition. He says many psychiatrists in the UK and across Europe ‘would have some skepticism’ about the benefits of the DSM-5 revisions.

    There are financial dimensions to the DSM debate. DSM is the American diagnostic manual; most of the rest of the world uses the World Health Organisation’s International Classification of Diseases (ICD) system (currently at ICD-10). ICD-10 is free, unlike the DSM manuals, which are sold by the APA. The DSM is also inextricably bound up with the US medical insurance system: without a DSM diagnosis, US health insurers won’t pay for treatments.

    Craddock is sympathetic to the dilemmas facing the DSM-5 Task Force. ‘In the US, if a professional wants to help someone, they need to label the problem as something that justifies giving the help. At the moment in the UK we don’t have to do that. You can get help with a milder mental health problem that needs social or psychological intervention without a psychiatric diagnosis.’ This may partly explain why the diagnostic thresholds have been lowered in DSM-5, and why the list of disorders has been extended. However he warns that, with the introduction into the UK national health service of payment by results (PbR), ‘we in the NHS are going down that path’.

    The extent of the drug industry’s influence over the content of DSM is a highly contentious issue. The New Scientist recently reported that more than half the individuals in the DSM-5 Task Force have some financial link with the pharmaceutical industry. These connections have even greater resonance in the context of revelations in recent years of the misrepresentation by drug companies of the outcomes of psychotropic drug trials.

    More than biology

    David Elkins is Professor Emeritus of Psychology at Pepperdine University and, as President of the Society for Humanistic Psychology, chaired the committee that wrote the open letter to the DSM-5 Task Force to which the 12,800 signatories have put their names. He says the research evidence is crystal clear that mental and emotional distress cannot be explained in terms of biology alone. ‘After many years of neurobiological research, there are still no biological markers for most mental health problems. The medical model has worked well for physicians when treating biological disease. It doesn’t work well when it is superimposed on psychological difficulties. We already have a problem in the US with misdiagnosis and the overzealous prescribing of psychiatric drugs. This is not to question the motive or intentions of those on the DSM-5 Task Force, but it is deeply troubling to think that they may indeed invent new disorders and lower thresholds on existing disorders in such a way that more and more individuals will be misdiagnosed and treated with drugs.’

    He is not anti-psychiatry or anti-drugs, he says: ‘Medication is sometimes a helpful part of therapy but it has potentially dangerous side effects and should not be used except when truly necessary. Unfortunately the US public [direct advertising of pharmaceuticals to the public is allowed in the US] is being trained by advertisements from pharmaceutical companies to think that emotional problems can be solved with a pill. This is an appealing perspective and, unfortunately, seems to be increasingly supported by psychiatrists.’

    He also questions the hegemony of psychiatry over the other mental health professions, which he believes may explain some of the ‘backlash’ against DSM-5. ‘Many psychiatrists receive a great deal of money from pharmaceutical companies and this alliance may cause some, intentionally or unintentionally, to become more “biological” in outlook and emphasis. I think neither profession should have authority or monopoly over the other.’

    Validating

    Elkins raises another important factor in the complex debate: the value the general public places on a psychiatric diagnosis. It can be the one way people can access help, or even give themselves permission to seek it.

    Andrew Reeves, counsellor and supervisor and editor of Counselling and Psychotherapy Research, says that counsellors and psychotherapists cannot ignore the influence and impact on a client of a medical diagnosis, even if they don’t use diagnoses or recognise them as in any way valid. ‘I see a lot of people who come to the service where I work who are wanting a therapist a couple of weeks after a major bereavement and are quite disappointed when I say what they are going through is really quite normal, that it’s not pathological. A diagnosis can give someone a sense of validity for what they are feeling, particularly around emotional distress.’

    But, he says, he questions the whole psychiatric diagnostic process: ‘I would subscribe to the main criticisms around the medicalisation of human experience. Diagnoses can be reductionist: they can boil down someone’s complex experience to one label. So a diagnosis can open doors in one way but close doors in another.’

    Reeves shares Elkins’ critcism that DSM-5 is the product of psychiatrists, with no robust scientific evidence base: ‘DSM-5 is a collection of opinions of what is essentially a closed group of people. There are concerns about the validity and reliability of the diagnoses in real world situations.’

    The diagnoses are also not value-free, he argues. He points to Gillian Proctor’s work on borderline personality disorder diagnosis and its links with childhood sexual abuse. ‘She argues that borderline personality disorder is often applied to women who are very vocal and challenging and seen as difficult, because that doesn’t fit with how we expect women to behave. And you can move that out to whole range of diagnoses in DSM-5, including sexuality. We end up pathologising large groups of people who behave in ways that don’t conform to the norm or to social expectations.’

    As someone who has had six different psychiatric diagnoses in his lifetime, David Crepaz-Keay, Head of Empowerment and Social Inclusion at the Mental Health Foundation, could be forgiven for his ‘jaundiced view’ of the usefulness of diagnostic systems. But, based on the Foundation’s current research with people with a range of diagnoses for very severe mental health problems, including psychosis, schizophrenia, severe depression and bipolar disorder, he argues that a diagnosis can be helpful.

    ‘In our work in Wales we have found a distinct difference in people’s relationships with their diagnoses. People with bipolar disorder find it helpful to have a diagnosis because it also provides them with a sensible framework with which to self-manage their condition. But the others, and particularly those with schizophrenia, find it unhelpful. They say it narrows the treatment options to things that don’t work and actively excludes them from things they do find helpful.’

    He conjectures that one reason is the greater consensus in the psychiatric profession about the symptoms of bipolar disorder, which is absent in the case of schizophrenia. ‘A schizophrenia diagnosis is much more clinician-dependent. So the differences seem to be accuracy and reliability of diagnosis and efficacy of treatment, particularly from the perspective of the person receiving the treatment.’

    From this he concludes: ‘If you have to have a diagnosis, and treatment is helpful, then yes, it is useful. If, however, it is inconsistently applied and doesn’t yield any benefits to the patient and if, having tried it, it hasn’t helped the patient, you should give up and do something more useful.’

    Anne Beales, Director of Service User Involvement at the mental health charity Together, says that a clinical diagnosis attracts and perpetuates stigma, rather than offering a rational explanation for what might appear to others as irrational and potentially frightening behaviours. ‘Research in New Zealand, in their Like Minds, Like Mine campaign, found that if you use a diagnosis as part of an anti-stigma campaign, it actually increases stigma. Diagnoses become a means for society to set us apart and then set us aside and then set us under. There is little proof that the medical model helps us long-term, it simply contains us.’

    She would like to see people’s experience of mental illness unpacked into everyday language. She cites a booklet published by Together called Talking About Mental Health that compares different ways of describing symptoms of various diagnoses, including the DSM definitions and those used by other, non-western cultures. Its aim was to encourage people with mental health problems to find their own ways of articulating their experiences in a common framework of understanding. So, for example, a bipolar ‘high’ might be described in lay terms as, ‘When I am high I have boundless energy, experience a flood of creative ideas and have no social inhibitions’. In West Africa people use the phrase ‘Arctic hysteria’ to describe an episode of high excitement when someone may take off their clothes, run outside, break things, shout and put their safety at risk, while Greenland Kalaallit use the word ‘zar’ to describe behaviours including laughing, shouting, singing, weeping and withdrawal, which are linked with spirit possession.

    ‘We shouldn’t get wound up with the diagnosis, we need to look at the person,’ Beales says.

    Another way
    Sami Timimi is a consultant child psychiatrist with Lincolnshire Partnership NHS Trust. He has recently launched a campaign to abolish all formal psychiatric diagnoses. ‘It isn’t just that they lack validity and reliability. They’re a distraction,’ he says. ‘Today, when a diagnosis is made, the psychiatrist thinks they have done their job. But none of the diagnostic categories provide an explanation.’

    He cites as an example the diagnosis of ADHD, which is increasingly applied to children whose behaviour is hard to manage. ‘You end up with a circular argument. What is causing this child to be overactive and have difficulty concentrating? Answer: ADHD. How do you know it’s ADHD? Answer: Because the child is overactive and has difficulty concentrating. Then you get a narrative attached to that; it becomes a neurological problem and there is no consistent evidence for that. You invite everybody to stop looking beyond the label. You shut down an opportunity to understand the nature of the problem.’

    Indeed, he calls psychiatric diagnoses ‘iatrogenic abuse’ because of the absence of any scientific basis for the highly toxic treatments that a diagnosis permits doctors to prescribe to young children. ‘In psychiatry we simply have a system based on subjective judgments’. The result, he says, is a dangerous elasticity. ‘When you have a diagnostic category that can be expanded year after year, you should worry. And that is what is happening with quite a few of our diagnostic categories. So we are increasing antidepressant prescribing to children, despite guidelines telling us to limit them, and that is because it is a very subjective diagnosis and we are talking about areas in life where there is always going to be a market. There will always be kids with behaviour problems and kids who are unhappy and parents and teachers who want something to help them manage the situation.’

    And, he points out, we like the certainty of a medical diagnosis. ‘None of us like living in a world of uncertainties so it’s easy to see why doctors, teachers parents, children themselves get hooked on that. But if you look at the research, what makes a difference isn’t matching treatment to diagnostic categories. That has negligible effects. The main things are to do with external factors – socio-economic status, social inequalities, parental mental health, parental levels of education. The next biggest is what patients bring with them – their attitudes, feelings about the treatment and their motivation to engage with it. And the third, the biggest one, is the therapeutic alliance.

    ‘The explanation and the proposed course of treatment has to make sense to people. If we concentrate on that and develop a service that can work flexibly and doesn’t fall into diagnostic thinking, that is what will make the biggest difference,’ Timimi says.

    Timimi and his community CAMHS team in Lincolnshire are putting this to the test. They have launched what they call OOCAMHS – outcome-oriented child and adolescent mental health services. They are trying to work without diagnoses, looking at each individual child or young person in the round: their life, their family, their school and any other factors that might be affecting them. They are using the full range of psychosocial treatments available to them, and monitoring outcomes session by session. ‘If they aren’t improving, we try something else, or switch therapist,’ Timimi says.

    They have compared their outcomes with those of a neighbouring CAMHS community team. ‘According to patient ratings – not our ratings – we have the lowest DNA [did not attend] ratings in the county and the lowest number of children and young people who have been in the service for more than two years and by far the lowest rate of referrals to inpatient services. We have devised a model that doesn’t invite people to think of themselves as long-term mental health patients.’

    He launched his campaign, No More Psychiatric Labels, because, he says: ‘We’ll never make progress using formal psychiatric diagnostic systems. People say this is crazy stuff, but the idea that we can come up with technical solutions to people’s problems is crazy. The problems we deal with are relational, not technical. That is where the solution lies.’

    Nick Craddock is hopeful that emerging research into the brain will lead to a better alternative to DSM. ‘The problem with DSM is it’s actually just a lot of descriptions of symptoms and we don’t yet have a full enough understanding of the biology, sociology and psychology to understand what is going on in terms of the risk factors for illnesses and the factors involved in developing an illness. There is a lot of information coming out now that is helping to link together biological understanding of the brain with psychological processes. The way we make diagnoses needs to relate to that knowledge. We should not be falling back on lists of symptoms.’

    Peter Kinderman and colleagues at the BPS are working on an alternative system for describing and treating symptoms of mental distress. They are starting with a descriptive list of symptoms of 250 DSM diagnoses and using a validated scale to identify the severity of their effects to provide a route to a range of treatments. He points to new research that shows very clearly a link between childhood sexual abuse and one of the chief symptoms of psychosis in adulthood, hearing voices.1 ‘What does a diagnosis of schizophrenia mean in that context?’ he asks. ‘It simply sends out an inappropriate message. Hearing voices is hearing voices: you simply need to recognise the truth of the situation. People hear voices for lots of reasons – if they go without food and drink, bereavement, one in ten of us hears voices quite regularly without it being a problem – that is hugely different from diagnosing schizophrenia and subjecting the person to psychiatric treatment.’

    Jumping off the bandwagon
    Kinderman believes that even psychiatry has recognised that a strictly biomedical approach doesn’t work. ‘They talk about the biochemistry of the brain. The same chemicals and processes are involved in falling in love, being sad, hearing voices, being anxious, failing to pay attention in school and turning a piece of wood on a lathe. They are all part of being human. The understanding of the brain should lead us to understand what it is to be human.’

    Pete Sanders, retired counsellor and trainer, a trustee of Soteria Network and founder of PCCS Books, is more blunt: ‘There is an ideological battle going on. We are seeing an alarming medicalisation of everyday life. You can’t be sad any more; you have to be depressed. You can’t be shy any more; you have to have social anxiety disorder. I am alarmed by the lack of reliability and validity in the way symptoms are clustered to create diagnostic categories out of thin air. But my real distress, my great disappointment and dismay is that psychiatry and therapists in general have jumped on the DSM bandwagon because it creates more “patients” for them to treat, and so we make money out of people’s distress.’

    He points to meta-analyses by psychiatrists Joanna Moncrieff and David Healy that have demonstrated not only that many psychiatric medications are no more effective than placebo but that some are actively dangerous. ‘They kill people. Maybe modern training tries to give a more balanced picture of mental distress; individual psychiatrists are doing the best they can in difficult circumstances, given the tools they’ve got, but biological psychiatry should carry a big danger label. We need a psychosocial model of mental health, not a biological one.’

    Sanders argues that the whole mental health care system has to change, and that this change will inevitably come from the bottom up. That, he says, is where counsellors and psychotherapists should focus their energies. ‘As a therapist, your hands are tied in a system that gives consultant psychiatrists all the power. You have no say and you can make things worse for your client if you go into battle with it.’ Instead, therapists should seek out their nearest mental health user or survivor group – for example the Hearing Voices Network or Mad Pride – and support them. ‘Some people are calling the mental health service user movement the last civil rights movement in the western world. For years academics argued for a social model for disability and it made not the slightest difference, but then disabled people started to take direct action and make a nuisance of themselves and that is what changed the law in this country.’

    The APA says it is still on course to publish the revised DSM-5 in 2013. The Chair of the Task Force was invited to contribute to this article, but declined.


    If the symptoms fit...
    These are two of the new diagnoses in DSM-5.

    Oppositional defiant disorder
    Symptoms of this childhood disorder include:

    ‘A. A persistent pattern of angry and irritable mood along with defiant and vindictive behavior as evidenced by four (or more) of the following symptoms being displayed with one or more persons other than siblings.

    Angry/Irritable mood
    1. Loses temper
    2. Is touchy or easily annoyed by others
    3. Is angry and resentful

    Defiant/Headstrong behaviour

    4. Argues with adults
    5. Actively defies or refuses to comply with adults’ requests or rules
    6. Deliberately annoys people
    7. Blames others for his or her mistakes or misbehavior

    Vindictiveness
    8. Has been spiteful or vindictive at least twice within the past six months.’

    Premenstrual dysphoric disorder
    Symptoms listed for this diagnosis include:

    • ‘Mood swings, feeling suddenly sad or tearful or increased sensitivity to rejection
    • Marked irritability or anger or increased interpersonal conflicts
    • Marked depressed mood, feelings of hopelessness or self-deprecating thoughts
    • Marked anxiety, tension, feelings of being “keyed up” or “on edge”
    • Lethargy, easy fatigability or marked lack of energy
    • Marked change in appetite, overeating or out of control
    • Other physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating”, weight gain.’

    The online petition against DSM-5 is at www.ipetitions.com/petition/dsm5. Details about No More Psychiatric Labels can be found at www.criticalpsychiatry.net


    Reference:
    1. Varese F, Smeets F, Drukker M et al. Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective and cross-sectional cohort studies. Schizophrenia Bulletin. 2012. Published online 29 March. doi: 10.1093/schbul/sbs050


Article quotes




‘I see a lot of people who are wanting a therapist a couple of weeks after a major bereavement and are quite disappointed when I say what they are going through is really quite normal’
‘We are increasing antidepressant prescribing to children, despite guidelines telling us to limit them, and that is because it is a very subjective diagnosis and there is always going to be a market’