-

Previous IndexNL Next

Nederlog
Aug 19, 2011           

On confusions and misunderstandings concerning the DSM-5



In case you were looking for Mozilla Browsers i.e. yesterday's Nederlog (NL), with direct links to the download pages and six very useful Add Ons for Firefox 6.0 and SeaMonkey 2.3, use the link. (And the last Nederlog is always called both NL and exists with a dated name, that's its proper name.)

Now to the subject of my title - various
confusions and misunderstandings concerning the DSM-5 notably of methodological, statistical and scientific kind.

My general background as regards methodology, statistics, science and philosophy of science is here:
while gives quite a few links to material on this site. If you have read the books under the first link, and the texts under the second, I must suppose you are rationally qualified.

In fact, very few will have read any of the books under the first link, though all of these can be fairly regarded as classics in their fields (by many, not just me), and that mostly because few these days, also when they have an academic degree, have learned much about methodology, statistics, and philosophy of science, since this got quite widely out of fashion, since postmodernism became fashionable:
It so happens that I wanted to write about these confusions and misunderstandings anyway, and the reason I do so now is that I received a copy of a blog by a Ms K. Dayle Jones, who is a counselor and an associate professor, and who has been to some extent involved with the DSM-5 the past year, and who wrote an interesting blog about the DSM-5, with some good ideas and recommendations, but also with some confusions and misunderstandings.

As I've implied, I do not blame Ms. Jones for these, for in fact (1) she shares them with many academics, notably many psychiatrists and (2) the reason this is so is that few scientists are well educated in methodology and philosophy of science. Moreover (3) this can be excused to a considerable extent for scientists who are in fact mostly practicians of science rather than research scientists - GPs, surgeons, clinical psychologists, engineers etc.

So let us see - and yes, I will explain myself, and not argue by mere claims, as the DSM-5 editors do. The original is under the link in the title and was posted on August 16, and I quote in blue:

What Should Counselors do about DSM-5?

Dayle Jones

I’ve spent the last year writing about the DSM-5, which is slated for publication in May 2013. I admit, the more I’ve read and learned about the proposed revisions and how they’re being developed, the less optimistic I’ve become about the final product.

I’ve described several of the problematic proposed revisions in previous blogs and in the DSM-5 Update column in Counseling Today. The most worrisome proposals involve diagnoses with lowered symptom requirements and the inclusion of “subthreshold” disorders. For example, the DSM-5 proposals that reduce the symptom requirements in existing disorders – like Major Depressive Episode, Generalized Anxiety Disorder, Substance Use Disorder, ADHD, and others – have the potential consequence of dramatically increasing the prevalence rates of disorders.

Quite so - and that is the whole point as well: More power and money to the psychiatrist brotherhood.

The new “subthreshold” disorders – such as Attenuated Psychosis Syndrome (i.e., Psychosis Risk Syndrome), Mixed Anxiety Depression, Mild Neurocognitive Disorder, and Disruptive Mood Dysregulation Disorder (i.e., Temper Dysregulation Disorder) – have generated more concerns. A subthreshold disorder is not, by itself, considered a disease or disorder. Instead, it represents some, but not all, of the symptoms of a mental disorder. The problem with subthreshold disorders is that they blur the boundaries between pathology and normal behavior.

Not quite - I mean: I agree "they blur the boundaries between pathology and normal behavior" , and again I think this is intentional, but Ms Jones, like most people, seems to mistake operational definitions and conceptual definitions - a a confusion of a measuring tool and what it measures, as in the visible symptoms of measles and the disease measles.

Indeed, this confusion is very widespread:

Originally, at least the DSM-III was meant to offer operational definitions, i.e. in the present context: definitions of symptoms in behavioral or empirical  terms, that especially medical doctors could factually and practically agree on, as a way to have at least agreement on the terminology used, and on what a disease was supposed to show in the behaviour of those who had the disease.


That was good science, at least in principle, and it was
not meant that the operational definitions are definitions of the disease, but only of some behavioural symptoms that are supposed or known to go with it, typically or always, in theory. (All of that may very well be mistaken, but then again such mistakes are only empirically provable or plausible if the operational definitions are unambiguous and in observational terms.)

What since then happened is that
almost everyone, including - it would seem - all 38,000 leaders of the APA (and I so much like the megalomania of that: 38,000 leaders, no less:)

APA-logo
                                  Click image for my submission to the APA

mistook and mistake operational definitions and conceptual definitions - and the latter would attempt to define a disease or aspect thereof in terms that are not necessarily limited to terms describing observable behaviours. (E.g. Alzheimer may be defined, provisionally, as a set of cognitive and related problems due to a certain type of lesions in the brain (conceptual definition), manifested behaviorally by lapses of memory especially in the elderly and old (operational definition) - and I am giving an example of a distinction, and am not seriously defining Alzheimer's here.)

So as far as I can see, almost everybody writing about the DSM does not understand its purpose, the reason it exists, and believes or pretends that its operational definitions are conceptual definitions.


One problem is that very few pronouncing on it have much of an idea of what science is like. Thus, few seem to realize science proceeds by testing guesses, which needs precise guesses (and no multi-dimensional vagueness), for only
precise guesses can be falsified and indeed verified. Imprecise, vague or ambiguous guesses are untestable. (The DSM-5 will make psychiatry totally untestable and unfalsifiable, and I think again that is intentional: That's why it is made "multi-dimensional" - to make it empirically untestable.)

Furthermore, the whole DSM-5 and indeed all ME-diagnoses, and it seems indeed many medical diagnoses, are based on the DSM-5 sort of way:
"Patient P has ailment A if P has m1 of n1 symptoms of category A, m2 of n2 symptoms of category B, and m3 of n3 symptoms of category C."

That sort of schema, that's used nearly everywhere, with its numbers, suggests great scientific precision and exact mathematical measurement, but in fact is quite otherwise:

Consider - for example - when some ailment is diagnosed across three dimensions or categories ("physical social psychiatric", for one example) and is required to have 4 out of 7, 3 out of 6 and 5 out of 8 to be diagnosed as having that ailment A. Now in mathematical fact these choices can be made in resp. 35, 20 and 56 ways, namely by elementary combinatorics.

The result is "a diagnosis" which is inherently extremely imprecise and vague, even though it looks as if it is the pattern of exactitude.

For in fact, that supposed pattern of exactitude implies in the example that  there are then 35*20*56= 39200 possible different patterns of this ailment thus diagnosed, of which patient P then manifested 1 of these 39200, all as "scientifically defined by evidence-based medical science".

If one were to object that I present an extreme case:

Consider "a simple diagnosis" that requires 4 out of 7 symptoms to be present. This can happen in 35 different ways. Which DSM-wizard has as much as thought these possibilities through, in any such case? Or tested their frequencies in a large enough population? None did.

It's rather elementary mathematics, but I have never seen this problem even mentioned, whereas it should be obvious for anyone who knows elementary combinatorics.

That's another reason why I can't take any DSM I have seen serious as empirical rational science:

Testing theories is best done by binary tests: it is so, or it is not so, and thus definitely confirmed or undermined given one of these. Theories which do not logically imply such tests are less testable or hardly testable, while something that is diagnosed as "X" and can be "X" in 39200 possible different ways is an "X" in an almost totally useless mass of vagueness and ambiguity, as indeed it also is next to useless if it were 35 or 18: Having "X" is then too ambiguous and imprecise, for its method of diagnosing logically implies the term "X" will cover too many distinct possibilities of having the ailment with that one name "X" - that also will make it much more difficult to test any therapies or treatments for "X".

In case of an empirically well-established kind of entities with real and known empirical properties (!!), it may be possible to research this - but in the DSM-5, where this procedure, with m1 of n1 symptoms of category A, m2 of n2 symptoms of category B, etc. being used to "define", "describe", or "diagnose" "mental ailments" that are mere labels or suppose very strong almost wholly untested - and indeed by the DSM-5-way wholly untestable - theories, this procedure is mere arbitrary doubletalk: A study in arbitrary vagueness presented as if it were a precise way of diagnosing, which it is not at all.

Besides... for the extreme terminological vagueness with which these new mental ailments or theories thereof get introduced in the DSM-5, see:

Incidentally, for those who like to contemplate this manner of things: For most of the DSM-5 the following table suffices with instances of in how many ways x things can be taken out of y things, with x <= y, and 1 of x always in x ways and x of x in 1 way (calculated in Squeak):

2 of 3=3 2 of 4=6 2 of 5=10 2 of 6=15 2 of 7=21 2 of 8=28
  3 of 4=4 3 of 5=10 3 of 6=20 3 of 7=35 3 of 8=56
    4 of 5=5 4 of 6=15 4 of 7=35 4 of 8=70
      5 of 6=6 5 of 7=21 5 of 8=56
        6 of 7=7 6 of 8=28
          7 of 8=8

But that's a hopefully instructive aside, as to the number of distinct ways in which one can have an ailment "X" on the diagnostic schema the DSM-5 uses.

Back to Ms Jones:

The main fears about the inclusion of diagnoses with lowered symptom requirements and subthreshold disorders are
a. the potential for drastically increased prevalence rates;
b. the medicalization of normal behavior;
c. increased stigma; and
d. unnecessary treatment that frequently includes medications that sometimes cause harmful side effects and complications.

I agree - but add that almost no one seems to understand what the DSM was intended for, and seems to believe that its operational definitions, that were  originally framed to test psychiatric theories by having clear behavioural symptoms, are in fact the core and essence of modern psychiatry.

This is like mistaking behaviorism and psychology, and like insisting the visible outside is all there is to a thing, or like mistaking hell with Jeroen Bosch's pictures of it. (*)

But I wouldn’t have a problem with any of the DSM-5 proposed revisions if I was assured that they were supported by strong scientific evidence.

The whole set of ideas most of its users have about its purpose and content is fundamentally mistaken, and indeed unscientific: A science does not consist of its operational definitions - these are only introduced to test its theories.

Moreover, it now seems as if DSM-III, and more specifically DSM-IV and DSM-5 have been dreamt up quite intentionally and on purpose to satisfy the financial interests of psychiatrists (for: the more mentally ill, the rosier the financial future of the Physician Leaders Of Mental Health of the APA) by the committees of its editors, all operating secluded from the public and other psychiatrists, and also operating without any input from any real science, and even, it would seem, since DSM-IV at least, without any input from any one who knows philosophy of science or is at least aware what operational definitions are and why they exist.

Renowned researchers and experts in diagnosis have publicly expressed many concerns about the DSM-5, such as
a. lack of an independent, systematic, transparent, and evidence-based method for reviewing the empirical support for changes;
b. inadequate field trial research design; and
c. proposals to include untested dimensional assessments that lack information about scale development procedures or psychometrics

Yes, and I think it is rationally quite safe to conclude it happened all on purpose. I do not know how much the DSM-5 wizards of the APA know about philosophy of science and methodology - not as much as I, I am sure, but I doubt they are totally clueless - but I feel quite certain in assuming they know and welcomed the opportunity to redefine psychiatry so as to fit their own interests and prejudices, and in assuming they know, for the most part, it is all quite irrational and ad hoc, as indeed were DSM-III and DSM-IV, from what I have meanwhile read about how these came about, though perhaps these were at least considerably less dishonest, if not decidedly more rational. (**)

With over 500,000 mental health professionals in the U.S. that use the manual (197,000 social workers; 115,000 mental health counselors; 54,000 marriage & family therapists; 93,000 psychologists; 75,000 psychiatric nurses; 38,000 psychiatrists), the DSM greatly impacts counselors’ work in assessing, diagnosing, and treating clients.

It's interesting to get some numbers, and in fact strikes me as fairly crazy, given what the DSM is: NOT a book of definitions, NOT a handbook of psychiatry - but merely a list of lists of operationalized symptoms, put together to be able to agree at least on the empirical terms used to describe symptoms and then use that for the testing of real theories and unoperationalized concepts that are part of these theories (for any theory that is testable and worth its minimal salt must go beyond the known facts, if only to be testable, and if tested and not refuted, to be of some use).

Another major scandal is that these, as with the DSM-III, were never properly validated by any research: They were dreamed up by committees, essentially without rational evidence, for that requires the framing of conceptual definitions and theories to explain the operational definitions used to test them.

In fact, the American Psychiatric Association (APA) is the sole group that revises the DSM, despite representing only 7% of all mental health professions.

This seems not clearly expressed: In fact the DSM-5 is the work of editorial committees and sub-committees, altogether of some 150 or so who do it, and fundamentally by making it up from thin air, with lots of innuendo and vague bullshit, on the pattern "Evidence-based science has been found that suggests that it may be " a.s.o. (In fact, that they use this manner of verbal bullshit suggests strongly to me they know they are lying and imagining things.)

For years, counselors and other mental health professionals have relied on APA and the DSM for guidance in the diagnosis process. Yet, the DSM-5’s questionable research methodology leaves me wondering if we should continue.

My advice: Give it up. Give psychiatry up. Use your common sense, and such neurology and medical science as you understand, and insist that psychiatrists should not be in medical science but in theology, as doctors of the soul, and as evident frauds and flimflammers, at least since the DSM-5, if not since the days of the coke-snorting Freud and the schizoid paranoid Jung.

But what can counselors do if we don’t like the DSM-5 final product?

Use the DSM-III? Use some good handbooks of yore, like the books of Silvano Arieti, dean of the APA ca. 1970, who wrote good books on general psychiatry, schizophrenia, and creativity? (***) Use some Luria and Vygotsky, who at least were sensible psychologists? Rely on James's "Principles of Psychology" as basic text, supplemented by any of the far less clear and sensible but more up to date modern texts, used at Harvard or Stanford?

I’ve recently been writing about the International Classification of Diseases (ICD-10-CM). My purpose has been to educate counselors that DSM is not mandatory for most clinicians unless specifically required by their institutional settings.

And even there pseudoscience cannot be made mandatory except by abuse.

In fact, the ICD is the only classification system approved by HIPAA – not the DSM. As such, ICD codes meet all insurer-mandated and HIPAA coding requirements. The reason why mental health professionals can use the DSM-IV for diagnosis is because the DSM derives its code numbers from the ICD.

I suppose this is so, but have no definite knowledge. FWIW, I've only seen and read some in the DSM-III, somewhere in the 1980ies, as a student of psychology, and note that (1) this was not part of any of the courses I took (since I am not a clinical psychologist, it may have been used there, but I doubt it - see (3) and (4) below); (2) the book was owed by a professorial friend of mine, and that's why I saw it: He had it in his bookcase; and (3) all the psychologists I know, including many professors, did not take it serious, mostly for the reasons I have given: It's not a summary of the science of psychiatry in any way, but only - in so far as it is used properly and written properly - a book to make for uniform diagnosing of possibly ill people in terms of the same behavioural criterions. Besides (4) psychologists generally have a fairly to very low opinion of psychiatry, because they know psychiatry is not a real science, for lack of the requisite knowledge of how the brain produces conscious experience, and because they know most of psychiatry since Freud has been shown to have been bullshit, many times, and about many things, while psychiatry has harmed many persons, if not personally and medically, then at least financially, by pseudo-cures and nonsense-therapies and loads of expensive psychobabble.

Currently, the DSM-IV code numbers reflect the ICD-9-CM codes. However, the DSM-5 codes will have to reflect those from the ICD-10-CM because use of the ICD-10-CM becomes mandatory by all health professionals in October 2013.

I hope so. But if the understanding of what the DSM is for and contains is as lousy as it seems to be, I will not be amazed if they are made to agree in the mean while, simply because this is much in the financial interest of psychiatrists, probably much in the interest of powerful health-insurance and pharmaceutical companies, and also may be of great interest to governmental institutions, at least such as like to have a Soviet type of psychiatry: Whoever does not conform to the average, is eo ipso a nut case and a danger to society.

I’ve been publicizing the use of ICD as an alternative to DSM so that counselors know they are not confined to using the DSM-5 – especially if they find that the DSM-5 lacks credibility.

That's not really the point: It is not "lack of credibility" that matters, it is lack of scientific foundation that matters. (Whether that is "credible" to psychiatrists or counselors is of no concern to me, just as I am not concerned with the beliefs of devout uneducated Roman Catholics about Darwin.)

And, to use ICD-10-CM, counselors do not have to learn a whole new classification system. In fact, counselors can continue to use their DSM-IV and simply look up and use the new ICD-10-CM codes numbers (available free online).

See above for my recommendations. However, Ms Jones has a point, namely that counselors would have a need to speak the accepted officialese lingo, crazy as it is, for several reasons, and this is a way to do it.

Personally, I want the DSM-5 to be a quality product that I can trust for diagnosis.

Forget it, is my advice. It was, is and will be pseudo-scientific bullshit. And most of that is so by design. And no one ever could trust any DSM for diagnosis: It's end was not to facilitate diagnosing, but to facilitate the testing of conceptual diagnoses, arrived at by a real knowledge of the patient and of science.

I’ve used the DSM during my entire career as a counselor, and I feel some allegiance to this classification system. But the inclusion of potentially dangerous, scientifically unfounded diagnoses scares me enough to possibly abandon the DSM.

I do have some recommendations for APA and the DSM-5 Task Force that would assure the credibility of the DSM-5.

Not to me. It is either intentionally designed bullshit, or bullshit based on extensive ignorance of science and methodology. (****)

I suggest that for mental health professionals to endorse and purchase the DSM-5, that APA should take the following actions:


1. All evidence from the DSM-5 Task Force should be (a) immediately made public and (b) submitted for independent review. The DSM-5’s credibility will remain questionable unless it is subjected to systematic, comprehensive, independent, and multidisciplinary external review. As such, all evidence and data needs to be reviewed by experts in evidenced-based decision-making who are completely independent of the DSM-5 process. This includes all evidence and data from (a) the DSM-5 Scientific Review Group, (b) the work groups, (c) the field trial data, and (d) the dimensional assessments development procedures. The Cochrane Collaboration, an international network recognized for its high quality reviews of health care research, would be the ideal group for conducting this independent review.

This is fair enough, but it is clear as daylight that the APA and the editors of DSM-5 do not want this and never wanted it. What they wanted was the chance to make a supposed diagnostic manual in camera, by a small committee, dreaming up its nonsense without any real responsibility to anyone but the other members of the committee.

2. Any suggested DSM-5 revisions deemed to lack strong empirical evidence by independent review should not be approved for DSM-5.

Again fair enough in principle, but it may be safely assumed that one of the major ends of the DSM-5 is to make psychiatry untestable. Anybody who knows anything about statistics and methodology cannot conclude anything else given the craziness of what they call "multi-dimensional classifications", which in fact amounts to "anything an APA-member asserts must be accepted as gospel, unless he or she has been thrown out of the APA or lost the medical license".

3. Eliminate the untested dimensional assessments from DSM-5 and publish them as a separate document.

Knowing statistics, my informed highly probable guess is that is there by design to make psychiatry a mock "evidence based science", where the prejudices of its psychiatric priesthood are "evidence based science" because that's what they chose to call it, and few had the wit or courage to cry "This is evident dangerous bullshit! This is not science: this is flimflam!".

Again, check out

Especially the volumes in item 9 there explain all the fundamentals of mathematical logic, statistics, probability theory and methodology, also in clear and informed terms, and with many useful references and explanations of points rarely discussed in ordinary handbooks (that tend to be for practicians, and to be inexact and unreliable as to fundaments).

4. Delay publication of DSM-5. If having external review means that DSM-5 cannot be completed on schedule, the DSM-5 publication date will have to be delayed.

Again fair enough in principle, but I do no see it happen, though I'd love to be refuted here. Also, no external review by methodological or statistically or logically knowledgeable persons will leave it standing, for it's bullshit, and at least some of its editors should know enough of methodology and statistics to add that they must be mala fides.

I believe these recommendations are critical to producing a credible and safe DSM-5 that all mental health professionals can use and support.

In summa: Ms Jones clearly means well, and also has some good recommendations, although I do fear it is very unlikely they will be followed. But unfortunately, like most pronouncing on the (de-)merits of the DSM-5, she does not know enough of methodology and statistics to know how much she and others have been flimflammed and hoodwinked by the APA, but then, as I said above, she shares this lack of knowledge with most.

And this also is an important reason that fraudulent flimflam such as the DSM-5 gets accepted and receives credit: Very few are able to judge its pretensions rationally, and on the basis of a good knowledge of philosophy of science, methodology, and statistics.


Notes

(*) Psychiatrists like Wessely are sure to want to insist at this point that their Cognitive Behavioural Therapy is the way to proceed with a biosocialphysical approach. I reply they are systematically and on purpose confusing matters terminologically, logically and empirically, by inventing bullshit theories that promise to be all things to all, whereas what they in fact offer is mostly lies and nonsense to help psychiatrists make money without being found out.

(**) Again and again what people without extensive knowledge of psychology and psychiatry fail to realize is how awfully LITTLE is known about how the brain produces experience - for which reason all theories explaining human experience must be mere guesses, almost certainly bound to be refuted by later research, as indeed has happened for much of psychiatry.

Psychiatrists, including the honest well-intentioned ones, that also exist, really have no special knowledge about human experiencing, thinking and feeling, for there is hardly any such real knowledge. They pretend to knowledge they do not really have to get paying patients, as men dealing in medicine seem to have always done, through at least 25 centuries, in which only the last 150 years or so saw anything in the way of a rational science of medicine based on real physics and bio-chemistry.

(***) I have read four of his books, and unfortunately there is little about him on the internet. "The Intrapsychic Self" is his general introduction to psychiatry, and was published by Basic Books. It is available second hand on the net, and I like it, since Arieti undertook to do what Freud and other psychiatrists failed to do: Propose a theory of thinking and feeling (that goes beyond mere empty verbosities).

(****) To quote professor Frankfurt on the subject, and to clarify why I use the very appropriate term bullshit for postmodern psychiatry and the DSM-5:

In his essay On Bullshit (originally written in 1986, and published as a monograph in 2005), philosopher Harry Frankfurt of Princeton University characterizes bullshit as a form of falsehood distinct from lying. The liar, Frankfurt holds, knows and cares about the truth, but deliberately sets out to mislead instead of telling the truth. The "bullshitter", on the other hand, does not care about the truth and is only seeking to impress:

It is impossible for someone to lie unless he thinks he knows the truth. Producing bullshit requires no such conviction. A person who lies is thereby responding to the truth, and he is to that extent respectful of it. When an honest man speaks, he says only what he believes to be true; and for the liar, it is correspondingly indispensable that he considers his statements to be false. For the bullshitter, however, all these bets are off: he is neither on the side of the true nor on the side of the false. His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says. He does not care whether the things he says describe reality correctly. He just picks them out, or makes them up, to suit his purpose.

 
P.S. Corrections, if any are necessary, have to be made later.


As to ME/CFS (that I prefer to call ME):


1.  Anthony Komaroff Ten discoveries about the biology of CFS (pdf)
2.  Malcolm Hooper THE MENTAL HEALTH MOVEMENT: 
PERSECUTION OF PATIENTS?
3.  Hillary Johnson The Why
4.  Consensus of M.D.s Canadian Consensus Government Report on ME (pdf)
5.   Eleanor Stein Clinical Guidelines for Psychiatrists (pdf)
6.  William Clifford The Ethics of Belief
7.  Paul Lutus

Is Psychology a Science?

8.  Malcolm Hooper Magical Medicine (pdf)
9.
 Maarten Maartensz
ME in Amsterdam - surviving in Amsterdam with ME (Dutch)
10.
 Maarten Maartensz Myalgic Encephalomyelitis

Short descriptions of the above:                

1. Ten reasons why ME/CFS is a real disease by a professor of medicine of Harvard.
2. Long essay by a professor emeritus of medical chemistry about maltreatment of ME.
3. Explanation of what's happening around ME by an investigative journalist.
4. Report to Canadian Government on ME, by many medical experts.
5. Advice to psychiatrist by a psychiatrist who understands ME is an organic disease
6. English mathematical genius on one's responsibilities in the matter of one's beliefs:

7. A space- and computer-scientist takes a look at psychology.
8. Malcolm Hooper puts things together status 2010.
9. I tell my story of surviving (so far) in Amsterdam with ME.
10. The directory on my site about ME.



See also: ME -Documentation and ME - Resources
The last has many files, all on my site to keep them accessible.
 


        home - index - top - mail