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Sunday 19 May 2013

DSM-5 PUBLISHED ON 18th May 2013 : "Infighting, boycotts, resignations: Psychiatry faces another crisis of confidence" - By Sharon Kirkey, Courtesy of Postmedia News May 19, 2013 - TO SEE ALLEN FRANCES IN U.K. COME TO OLD TRAFFORD ON JUNE 28th 2013.

Infighting, boycotts, resignations: Psychiatry faces another crisis of confidence


By Sharon Kirkey, Postmedia News May 19, 2013

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In the early 1970s, psychologist David Rosenhan set out to answer a simple question: Can psychiatrists tell the sane from the insane?

Rosenhan and seven other perfectly rational “pseudopatients” went to a dozen U.S. hospitals complaining that they were hearing voices. All but one were diagnosed with schizophrenia and sent to a psychiatric ward. Each had been warned by Rosenhan that, to get out, they would have to convince the psychiatric staff they weren’t insane. So, immediately after they were admitted, they stopped mimicking symptoms of “abnormality” and behaved as they normally would.

Still, they were kept in the hospital for periods ranging from seven to 52 days, each finally discharged with a diagnosis of schizophrenia, “in remission.”

The Rosenhan experiment sparked a crisis of confidence in psychiatric diagnosis — a crisis that appears to be playing out again today.

This time the catalyst is the newest and fifth edition of the official guidebook of psychiatry: the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. The encyclopedic tome has undergone its first major revision in nearly two decades and makes its official debut May 18 at the annual meeting of its publisher, the American Psychiatric Association.

The rewrite has been rocked by boycotts and the resignations of some of the very experts tapped to give advice — including the former head of the department of psychiatry at the University of British Columbia, John Livesley, who says he quit the DSM-5’s personality disorders work group over a “disregard for evidence.”

Thomas Insel, director of the U.S. National Institute of Mental Health — essentially the country’s top psychiatrist — has announced that his agency is “re-orienting” its research away from the DSM over the book’s “lack of validity” while it pursues its own alternative diagnostic system, which Insel promises will be more firmly anchored in brain science.

The leaders of the DSM-5, such as Dr. David Kupfer, co-chair of the DSM-5 task force, have fired back, saying the book reflects the strongest means available today for cataloguing mental illness, and insisting that while genetic and other biological tests would be the ultimate holy grail of diagnosis, there’s no sign that such foolproof methods will be available anytime soon.

The public clash is making psychiatry look like “nonsense,” says Allen Frances, the man who led the task force that created the fourth edition of the DSM in 1994. “It’s bad for patients. This will discourage people who desperately need help from getting it.”

Frances has been the DSM-5’s most dogged and unapologetic critic. He says the book contains untested diagnoses on the “fuzzy boundary of normality” and that it recklessly lowers the thresholds for existing ones.

“I’m a strong believer in the value of psychiatric diagnosis and treatment when done well,” Frances says. “But it’s silly and harmful to be over-treating people who don’t need it, and tragic to be neglecting the needs of those who do.”

Psychotherapist Gary Greenberg is more blunt. “Even at its best … psychiatric diagnosis is fiction sold to the public as fact,” Greenberg writes in his new book, The Book of Woe: The DSM and the Unmaking of Psychiatry.

“There is a huge disconnect between what psychiatry claims for itself, and what it can actually do,” he says.

Canadian psychiatrist Joel Paris says that “no one really knows what a mental disorder is,” or how to clearly separate normal from abnormal. “It’s all very fuzzy.”

In other words, 200 years after psychiatry was recognized as a medical discipline, a stark question persists: Is psychiatry credible?

There is no doubt about the validity of psychological suffering. Mental illness, in its extreme, is undeniable. “With psychotic people, there’s very little argument,” says Paris, a professor and past chair of the department of psychiatry at McGill University in Montreal. Johns Hopkins clinical psychologist and writer Kay Redfield Jamison has described the  “profound horror of depression,” while chronic, intense anxiety is described as so totally absorbing a person’s consciousness, that every minute they feel as if they will die.

But our mental reactions to the smaller pieces of daily tragedy are more complex, Paris says. When does the sadness from a break-up become depression? When does normal human experience become somehow “sick”?

“You can diagnose almost anybody with the DSM, and unfortunately this is happening, with a lot of over-diagnosis going on clinically,” Paris says. “A lot of people are being given stimulants because they don’t pay attention, and mood stabilizers because they’re moody and antipsychotics for almost everything these days.”

In fact, there are no valid definitions for many of the conditions so neatly laid out in the DSM, Paris and others argue, and no laboratory test exists that can confirm a diagnosis in psychiatry. Despite growing research into the convolutions and folds of the human brain, the science is revealing more about normal brain functioning than any kind of “psychopathology,” or sickness, Frances says.

Still, psychiatry keeps creating new illness categories, new ways the brain and mind can become “disordered.”

Major changes to the DSM include the addition of “disruptive mood dysregulation disorder,” or DMDD — defined as children who exhibit “persistent irritability” and frequent behaviour outbursts, a freshly minted diagnosis that observers say hasn’t been adequately studied yet and could make DMDD as entrenched in our vernacular as ADHD, or attention deficit/hyperactivity disorder.

Also new to the manual is hoarding (“persistent difficulty discarding or parting with possessions”), excoriating (skin picking) disorder, binge eating disorder (“frequent overeating at least once a week for three months”) and a loosening of the criteria for attention deficit/hyperactivity disorder.

Gone from the new manual is “bereavement exclusion” for a diagnosis of major depressive disorder. Under the old manual, people who recently suffered a loss could not be diagnosed with major depression unless their symptoms persisted beyond two months. Now, a diagnosis of depression can be made a mere two weeks after the loss of a loved one.

For the first time in the manual’s history, the total number of diagnoses will not grow, its leaders have said.  But the stakes, they say, are high: Writing in the Journal of the American Medical Association, David Kupfer and DSM-5 task force co-chair Darrel Regier state that approximately 30 to 50 per cent of patients who see a family doctor have “prominent mental health symptoms or identifiable mental disorders.”

In Canada, we are told that one in five of us will suffer from a mental illness in any given year. In the federal public service, nearly half of the long-term disability claims in 2010 were related to mental illness.

While the statistics may suggest that we’re in the grips of an epidemic of mental illness, experts say there is no evidence that we are getting sicker as a nation.

The one-in-five estimate is based on epidemiological studies in which large numbers of people are surveyed, usually by lay interviewers, not experts.

As well, as the surveys have grown more detailed, a larger number of disorders are being included, increasing the overall findings of apparent problems.

There are no blood tests or X-rays for mental illness, and no such tests, except for Alzheimer’s disease, are on the horizon. Doctors rely on what their patients tell them, Greenberg says, “which, in turn, is dependent entirely on what you ask, which, in turn, depends entirely on what you look for.”

The psychiatric guidebook, the DSM, assigns a name and number to each disorder, and provides a list of criteria that can be counted, leading to diagnosis.

For example, if a person exhibits three out of seven symptoms for a “hypomanic episode”  — “a distinct period of persistently elevated, expansive or irritable mood” — the person qualifies for that diagnosis. Having five out of nine symptoms adds up to borderline personality disorder.

The thresholds are essentially “best guesses” based on clinical experience and the consensus of expert panels. Greenberg tells the story of how, when the psychiatrist who first proposed the criteria for depression was asked why he set the threshold at six out of 10 symptoms, he said, “It felt about right.”

“I’m certainly not saying that they just pull this stuff out of the air for the sake of it,” Greenberg says. “It does match problems that you see coming into the clinic.” But there is a certain amount of arbitrariness to it, he says.

Take, for example, anxiety disorders. Jerome Wakefield says humans are hardwired by evolution to experience anxiety.  “There are ways that it appears we’re designed to experience anxiety that are now being labelled ‘disorder’ that are quite normal for our species,” says Wakefield, co-author, with Allan Horwitz, of All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders.

The essential feature of social phobia is defined as a “marked and persistent fear of social or performance situations in which embarrassment may occur” — the very situations in which fear can be perfectly normal and natural, says Wakefield, professor of social work at New York University.

Paris, of McGill, says DSM is imperfect, but necessary. “What I tell my students is, ‘Look, read this, learn it, use it. Don’t believe it’s a bible. Don’t take it too seriously. Don’t think it’s the be-all and end-all.’

Psychiatric diagnoses are based entirely on signs and symptoms, he says. “In medicine, we went beyond signs and symptoms 100 years ago. We had X-rays and blood tests, all kinds of things which allowed us to directly observe what was going on in various organs in the body. And we’re nowhere near that with the brain. We just can’t do it.” It could take another 50 years before the field even gets close, he says.

But in an attempt to strengthen its legitimacy, psychiatry is becoming increasingly enthralled with the promise of neuroscience – with linking psychiatric disorders to broken brain mechanisms. Lost, some fear, is a focus on the psychosocial factors that can help explain human distress.

The brain is undoubtedly involved, says psychologist Frank Farley, past president of the American Psychological Association. “But you can’t boil everything down to a laboratory measure. People do not live in laboratories — that’s not where the pain is, that’s not where the living is, that’s not where the relationships are. We need to bring the social side of life into diagnosis.”

Greenberg believes doctors are motivated “by a desire to relieve suffering. Their purpose in cataloguing our troubles is surely not to turn us into Shrink McNuggets,” he writes in The Book of Woe.

But not all mental suffering is a medical disorder, he says, “and nobody knows how to draw that line, but the DSM chugs along as if we did.”

Dr. Suzane Renaud, president of the Canadian Psychiatric Association, rejects the accusation that psychiatrists may somehow be over-diagnosing.

“Obviously we want to attend to the people who come in and say, ‘I’m not functioning well; I’m suffering.’ We want to treat the people who truly are sick.” But, she emphasizes, psychiatrists also reassure patients when their reactions to life’s stresses are entirely normal.

Frances sees it differently. Psychiatry, he says, is a “noble and essential profession.” But its diagnostic labels are too pliant and rubbery, “too elastic,” he warns.

As with Rosenhan’s experiments of 40 years ago, it’s still too easy “to make patients out of people who are basically normal.”


Psychiatry 101: a history, a glossary and what they say about it now

Here’s a short history of psychiatry:

Psychiatry comes from the Greek words “mind healing” and is the branch of medicine that focuses on the treatment and prevention of mental disorders.

1792 or 1793: French doctor Philippe Pinel is appointed director of the Bicetre Insane Asylum in France. He believed mental illness was a disease, not caused by demonic possession. His treatments included unchaining patients and access to the outdoors.

1808: First formal use of the term “psychiatry” attributed to German Prof. Johann Christian Reill in a long essay that justified the creation of this new medical specialty.

1840: “Idiocy/insanity” recorded in the U.S. census, the first attempt to gather information about mental illness in the United States.

1858: The Mount Hope Asylum for the Insane is founded in Darmouth, N.S.

1883: German Dr. Emil Kraepelin publishes the first edition of the Textbook of Psychiatry, arguing that many mental illnesses had biological causes and created a classification system for mental illness.

1899: Sigmund Freud publishes the Interpretation of Dreams, establishing the foundation of psychoanalyis and his theory that mental illness is shaped by the conflicts of childhood.

1893: Kraepelin defines “dementia praecox,” now known as schizophrenia.

1908: University of Toronto opens a department of psychiatry in the medical school.

1934: Insulin shock therapy is introduced, a precursor to electroconvulsive therapy (ECT). Up to this point, the main treatments for mental illness were institutionalization and psychotherapy.

1935: Portuguese neurologist Egas Moniz performs the first lobotomy (frontal leucotomy) believing certain behaviours can be stopped if the circuits in the frontal lobes of the brain are disconnected.

1943: McGill University opens psychiatry department, headed for the next 20 years by Dr. Ewen Cameron.

1949: Moniz wins the Nobel prize for medicine for inventing the lobotomy.

1950s: The first antipsychotic drug, chlorpromazine, is successfully used in France.

1951: The Canadian Psychiatric Association, a voluntary professional association, is formed.

1952: The first Diagnostic and Statistical Manual of Mental Disorders (DSM) is published, containing 106 disorders.

Late 1950s: The beginning of the “deinstitutionalization” movement to get people out of mental institutions and back into the community so they can receive outpatient care.

1970: Lithium is approved by the U.S. Food and Drug Administration for some illnesses.

1974: The American Psychiatric Association agrees to remove homosexuality from the DSM.

1975: The film adaption of the Ken Kesey novel, One Flew over the Cuckoo’s Nest, shows horrific, albeit fictional, conditions and treatments inside a psychiatric ward.

1980: Third edition of the DSM is published; the number of disorders grows to 265.

1987: Prozac is approved in the U.S.  It is launched in Canada a year later.

1994: Fourth edition of DSM is published, listing 365 disorders.

1994: The federal government settles the last law lawsuits related to brainwashing experiments conducted by Dr. Ewen Cameron at the Allan Memorial Institute in Montreal and partially funded by the American CIA.

2013: The fifth version of the DSM is released.

– Compiled by Kirsten Smith, Postmedia News

Sources: Canadian Encyclopedia; Encyclopedia Britannica, Psychiatry’s 200th birthday (British Medical Journal); Historical Synopsis – Department of Psychiatry at the University of Toronto; BBC; Wikipedia

Here’s a glossary of psychiatric terms:

Psychiatrist: A doctor who has completed a minimum of five years of additional accredited training following four years of general medicine training. There are about 4,100 psychiatrists in Canada. Demand continues to exceed supply.

DSM: Diagnostic and Statistical Manual of Mental Disorders. First published in 1952. First edition contained 106 disorders. DSM-IV, published in 1994, lists 356.

Binge eating disorder: Frequent overeating at least once weekly over the last three months.

Bipolar disorder: Extreme shifts in mood, from extreme highs or “mania” (talking very fast, jumping from one idea to the other, racing thoughts) to depression (feeling worried or empty; loss of interest in activities once enjoyed).

Brief psychotic disorder: Delusions, hallucinations, disorganized speech. Episodes last at least one day but less than a month.

Borderline personality disorder: A “pervasive pattern of instability of interpersonal relationships, self-image” and “marked impulsivity.”

Disruptive mood dysregulation disorder: Severe temper outbursts that occur three or more times per week that are grossly out of proportion to the situation.

Generalized anxiety disorder: Excessive anxiety and worry occurring more days than not for at least six months. People find it difficult to control the worry. The anxiety and worry are associated with three or more of six symptoms, including restlessness or feeling keyed up or on edge, irritability, and poor sleep.

Manic episode: Distinct period (at least one week) during which there is an abnormally and persistently elevated, expansive or irritable mood.

Major depressive disorder: Severely depressed mood and activity level that persists two weeks or more.

Obsessive compulsive disorder: Recurrent obsessions (persistent ideas, thoughts, impulses) or compulsions (repetitive behaviours such as excessive hand-washing) that consume more than one hour a day or cause significant distress or impairment.

Panic attack: Period of intense fear or discomfort that is accompanied by at least four of 13 symptoms, including pounding heart, sweating, trembling or shaking, and fear of losing control or dying.

Social phobia: Fear of social or performance situations in which embarrassment may occur.

– Compiled by Sharon Kirkey, Postmedia News

(Sources: DSM-IV; Centre for Addiction and Mental Health; Canadian Psychiatric Association; American Psychiatric Association)

What they’re saying about psychiatry:

From, “Saving Normal: An Insider’s Revolt Against Out-of-control Psychiatric Diagnosis, DSM-5, Big Pharma and the Medicalization of Ordinary Life,” by Allen Frances, MD, chair of DSM-IV Task Force:

“Normal needs to be saved from the powerful forces trying to convince us that we are sick.”

“Society has a seemingly insatiable capacity (even hunger) to accept and endorse newly minted mental disorders that help to define and explain away its emerging concerns.”

“The best way to deal with the everyday problems of living is to solve them directly or to wait them out, not to medicalize them with a psychiatric diagnosis or treat them with a pill.”

The “massive misuse of antipsychotics is crazy and shameful — a triumph of marketing might over common sense and good medical practice.”

From, The Book of Woe: The DSM and the Unmasking of Psychiatry, by Gary Greenberg:

“Their (psychiatrists) purpose in cataloging our troubles is surely not to turn us into Shrink McNuggets. But they are in the grips of forces bigger than they are, bigger than any of us. It’s not their fault that medicine is a service industry, that diseases are market opportunities and that a book of them is worth its weight in gold.”

“Even at its best…..psychiatric diagnosis is fiction sold to the public as fact.”

From, All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders, by Allan Horwitz and Jerome C. Wakefield:

“Perhaps the oddest thing about the DSM-IV definition of social phobia is that it classifies as disordered those people who are afraid in exactly those situations in which fear is most natural: social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.’”

“When are our fears normal and when do they reveal that something has ‘gone wrong’ with our minds? There is no precise answer to this question … No sharp lines divide natural sadness from depressive disorder, attention deficit disorder from boisterousness or bipolar disorder from ordinary mood swings.”

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