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  Apr 20, 2012                  
     

  DSM-5: The six most essential questions in psychiatric diagnosis - 0


 "Peu de personnes peuvent aimer un Philosophe. C'est presque un ennemi public qu'un homme qui, dans les différentes prétentions des hommes, et dans les mesonge des choses, dit à chaque homme et à chaque chose: "Je ne te prends que pour ce que tu es: et je ne t'apprécie que ce que tu vaux." Et ce n'est pas une petite entreprise de se fair aimer et estimer avec l'annonce de ce ferme propos."
-- Chamfort       
" If mankind had wished for what is right, they might have had it long ago. The theory is plain enough; but they are prone to mischief, 'to every good work reprobate.' "
As long as the patient will suffer, the cruel will kick."
        -- Rev. Sidney Smith

I said yesterday that I would try to review the series of articles that go by the comprehensive title "The six most essential questions in psychiatric diagnosis" and decided to do that - if possible: see below under ME/CFS if I can't get this done - in 7 parts, corresponding to its six questions plus the introduction.

This is the part that deals with the introduction, that I will cite fully, as allowed by the copyright, that I also cite. I cite and review as follows:

          • The original text is in blue and is indented, to keep a visual
            contras between the text of others and my own
          • My own text is in black and less indented and inbetween what
            I cite, since that seems the clearest procedure to me
          • I have converted the text from pdf to html, and have done my
            best to quote faithfully with one exception:
          • There are some added empty lines and breals for better readability
            in the html-format I use, and provide below a link to the original

Backgrounds:

The first is the original part 1, that included the introduction quoted in the text that follows; the other two sketch in some of my own backgrounds, next to an M.A. in psychology. Also, I have a B.A. in philosophy but have been denied the right to take an M.A. in that, since I was removed from the faculty of philosophy because of the crime of having opinions that differed from the Boards of Directors of that faculty and that university

For the same reasons I could not get the minimal help to help clean my house or do some shopping for me, that was required to write a Ph.D. in psychology, for which I had the promotor, the ideas and the notes: Persons like me are hated in the city were I live, because I have upset the moral and political and ideological pretensions of many.

Finally, my reasons to write about the DSM-5 and psychiatry are not, in the first place, my strong interests in science, philosophy and ethics, but the fact that I have found that the fact that I am ill with ME/CFS has been a reason for psychiatrists and clinical psychologists to slander and defame myself and millions of others with my disease:

According to psychiatric frauds like professors Wessely, Sharpe (also active in the DSM-5), White, Reeves, Bleijenberg (a clinical psychologist), both the World Health Organizations and thousands of medical researchers who are not psychiatrists, who have argued, in medical journals, on the basis of much research and evidence, that people afflicted like I am have a serious neurological disease, that is explicitly not psychiatric, must all, like me, be mad with "dysfunctional belief systems"... for which reasons I and many others with my disease have not received any help ill people do get for 34 years now, while scientific research - such as does not support the lies of the above mentioned frauds and medical malpracticians - into my disease also has been made impossible or very difficult where I live, because of what these frauds claim, and because politicians and bureaucrats want to save money, and do so preferably from folks who cannot defend themselves. (*)

My father survived almost 4 years of German concentration-camps - the link contains the text of his description of that - because he was a member of the Dutch resistance against Nazism. He could raise a family. I could not: I get no help; I have been consistently discriminated and slandered for saying I am ill; and I am denied the right on both help and research; in my country (Holland) at least tens of persons - according to a medical specialist in the disease - have committed suicide for this reason.

I must chalk this up to the claimed "sciences" of psychiatry and clinical psychology, that are hardly real sciences in the sense physics, chemistry and pharmacology are sciences, but instead are for the most part pseudosciences, that enable fraudulence, medical malfeasance, and the spread of bullshit in the name of "psychiatric science", and also to the depravity of some of its practitioners, that I see in the same light as the activities of the former president of the American Psychiatric Association Donald Ewen Cameron and the human-all-too-human motives that enabled the Action T4. (*)

So I have been empirically forced to see that psychiatry as practised and indeed as propagandized theoretically works as a strong force for evil: To harm ill people; to destroy their human rights; to save money by stultifying real scientific research into real diseases; to force GPs to abide by the opinions of the state's tame psychiatrists as to who is ill in what sense; and to abuse ill people.

And while not all psychiatrists or all psychiatry are bad or mad, most of its theories are bogus, deluded, pseudoscientific, or at the very best guesses in the dark with little empirical support, the facts about and around psychiatry, and its bureaucratic and governmental abuse have force me to conclude that a considerable part of is

"Malice (..) pleasure derived from another's evil (..)" (Cicero) (*)

which has been made possible by the sorry state of psychiatry as a science; the ease with with the majority of the public can be flummoxed; the - partially intentional - obscurity, untestability, and pretentiousness of its doctrines and prose; and the great financial advantages its abuse brings to psychiatrists, bureaucrats, governments and pharmaceutical companies.


Phillips et al. Philosophy, Ethics, and Humanities in Medicine 2012,7:3
http://www.peh-med.com/content/7/1/3

REVIEW                                                  Open acces

The six most essential questions in psychiatric diagnosis:
a pluralogue part 1: conceptual and definitional issues in
psychiatric diagnosis

James Phillips, Allen Frances et al.

© 2012 Phillips et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

This is the beginning and top of the article as I found it in pdf, upon converting it to html. I have left out 23 authors, covered by "et al" because it's a long list, not easy to convert, while they are in the pdf I linked and most or all will be mentioned later in this series.

Also, I like to thank the editors of "Philosophy, Ethics and Humanities in Medicine" for making this Open Access under a Creative Commons Attribution, and like to remark that this is how science ought to be done, rather than hidden behind a publisher's paywall who thereby profits privately from research and education funded from public taxes while making the rational and fair practice of and access to science much more difficult.

Abstract

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

In the original the Abstract is boxed, and I reproduced that. Here are some remarks on the Abstract and I will start with a fundamental oddity many psychiatrists and psychologists who read the above may have missed, because it is not stated plainly:

Consider engineering, as in making buildings, ships, roads etc. which to a considerable extent, like psychiatry, is a practical science rather than a theoretical one: engineers make or repair things, as psychiatrists are supposed to diagnose and help people, that is based on one or several theoretical sciences: mathematics, physics and chemistry for engineers, medicine, psychology and pharmacology for psychiatry.

Now what would you think of the science of engineering if its practitioners and theoreticians assemble to consider the fundamental questions of the nature of the collapses of buildings and the definitions of such events, and indeed whether they are real or merely verbal entities, and how they should be classified, termed, recognized, and experimented with?

The rational guess is that you would infer these engineers either don't know their business or science, or are putting you on: How can they design and repair buildings if they agree among themselves that they don't understand the fundaments of their own practical science, even if this implies that their clients may have their roofs caving in for reasons no engineer can clarify in clear English?

In brief... the fact that these kinds of questions can and indeed have to be raised (have to, because psychiatrists (mis)treat real people, for money, with claims and promises, and often interfering in their bodies, lives and chances) strongly suggests psychiatry is not a real science - and see here the lemma pseudoscience in Wikipedia, that provides a useful spectrum of possibilities for locating a purported science on an axis that varies total nonsense to great physics or chemistry.

For if it is true that a set of presumably some of the best "invited commentators" of the science - say engineering, for a moment, to provide some mental clarity and perspective - have assembled, some 100 years after their supposed science started to be taught as if it were a real science in real universities, to consider the fundamental questions whether the object of their science, that they are professors and doctors in

represent real diseases/collapsed buildings that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders/collapsed buildings do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories/collapsed buildings are simply constructs with no evidence of psychiatric disorders/collapsed buildings in the real world.

I do not think town planners or citizens who want to live safely will employ engineers to construct their buildings if these engineers - after 100 or more years of subsidized and university-taught education and practice in their own craft - are still not even capable of rationally and reasonably answering the simplest of questions about their own subject.

Next, I have noted the 6 fundamental questions, which seem fair enough to me, although I can also think of other fundamental questions in this subject, e.g. concerning methodology, ethics and the law, and although I would probably have formulated differently. I will turn to problems related to formulations and terminology when discussing the questions and their answers in the body of the text.

It is well to keep the general set-up of the text in this series in mind:

James Phillips wrote the general introduction and the introductions and conclusions to the six specific questions; Allen Frances wrote the questions and responses to the commentaries by some or all of the 23 other authors; and the 23 other authors comment on and/or answer the questions posed. This is all in blue in my reproduction.

And in this reproduction of the original, Maarten Maartensz provides the comments in black.

Now to the General Introduction that I quote all of: 

General Introduction

This article has its own history, which is worth recounting
to provide the context of its composition.

As reviewed by Regier and colleagues [1], DSM-5 was
in the planning stage since 1999, with a publication date initially planned for 2010 (now rescheduled to 2013).

The early work was published as a volume of six white papers, A Research Agenda for DSM-V [2] in 2002. In 2006 David Kupfer was appointed Chairman, and Darrel Regier Vice-Chairman, of the DSM-5 Task Force. Other members of the Task Force were appointed in 2007, and members of the various Work Groups in 2008.

I think it should be remarked here that - as doctors Spitzer, the chief editor of the DSM-III and Frances, idem of DSM-IV, and quite a few others found - the actual making and design of the DSM-5 are hidden in secret, since it is designed by a plurality of committees, the members of which are sworn to secrecy, while very little real information is provided about the contents, the progress, or indeed the objections made against what is known about the DSM-5.

The generally best source of information about the goings on in the development of the DSM-5 are not provided by the obscure and ill-designed websites of the APA but by Ms Suzy Chapman, on a site that the APA tried to take down by SLAPPing Ms Chapman, that is, by threatening her with court cases, namely because she had used the five English characters "dsm-5" in the title of her excellent, fair, rational site.

The site is here

Dx Revision Watch

and my own comments on the APA's - rather frightening and very irrational and unreasonable - attempt to SLAPP a private person who does the work they should have done better than they can or care to do it is here:

Is the American Psychiatric Association
a terrorist organization?

Since when both Ms Chapman's and my site have grown in psychiatric readership .

From the beginning of the planning process the architects of DSM-5 recognized a number of problems with DSM-III and DSM-IV that warranted attention in the new manual. These problems are now well known and have received much discussion, but I will quote the
summary provided by Regier and colleagues:

I will copy the quote, but - also in view of the apparent enormous cognitive confusions in psychiatric minds about the most fundamental questions concerning their subject (to the effect of: "does it exist?!", "do we describe it in the correct terms?!", "does it really work?!", "how could we answer these questions?!") I must ask: You write these gentlemen "recognized a number of problems" - but how do you know there was anything at all to be recognized? Isn't it better to say, rather than "recognized": "stated there were" or perhaps - but you never know nor (perhaps) can know, with a degreed psychiatrist - "sincerely believed"?

And I mention this because it has turned out that the terminology used is quite important in psychiatry, which indeed may be understood from the assumptions that they often do not know what they are talking about, and/or do talk about their subjects in decidedly odd, unclear and stilted ways.

But we now turn to the quoted prose of "Regier and colleagues", the very folks who want to impose the DSM-5 on the US and the world:

Over the past 30 years, there has been a continuous testing of multiple hypotheses that are inherent in the Diagnostic and Statistical Manual of Mental Disorders, from the third edition (DSM-III) to the fourth (DSM-IV)... 

Sorry to interfere but "a continuous testing " must be a misnomer, I suspect an intentional one, for Mr Regier knows as well as I do that there have been wide-ranging debates in these very same "30 years", some of which were know as "the Freud wars" in which two main concerns of most participants in  it who knew some of real science were precisely that (1) psychiatry does not really "test" its "multiple hypotheses" in the same way as real science test their hypotheses, and namely because (2) most of psychiatry is not a real science but is a pseudoscience.

Then again, as I have found out last year: The preferred method of "Regier and colleagues" is not rational argument but a combination of cant-ridden obfuscations and innuendo, which I concede is a generally more successful rhetorical instrument than is speaking honestly, truthfully and rationally, but which I am perverse enough to dislike and distrust.

The expectation of Robins and Guze was that each clinical syndrome described in the Feighner criteria, RDC, and DSM-III would ultimately be validated by its separation from other disorders, common clinical course, genetic aggregation in families, and further differentiation by future laboratory tests–which would now include anatomical and functional imaging, molecular genetics, pathophysiological variations, and neuropsychological testing. To the original validators Kendler added differential response to treatment, which could include both pharmacological and psychotherapeutic interventions... 

I know of Mr Kendler as a proponent of psychiatric genetics, and don't know of the others, but then I have read part of the DSM-III and it seemed to me that this is what it was all about: Empirical testing and eventual validation of psychiatric theories by making psychiatry amenable to scientific testing, through clear empirical definitions that could be used in both empirical research and univocal diagnosing.

That is the way of science, at least in principle, indeed also in psychology.

There is a little problem, though, according to "Regier and colleagues": It didn't work as planned and promised, in psychiatry:

However, as these criteria have been tested in multiple epidemiological, clinical, and genetic studies through slightly revised DSM-III-R and DSM-IV editions, the lack of clear separation of these syndromes became apparent from the high
levels of comorbidity that were reported... 

Having been exposed to the prose of "Regier and colleagues", I must remark I feel innuendoed and obfuscated upon, so to speak: "the lack" is asserted but not supported with reason or argument; the interposed "clear" sounds like the True Scotsman fallacy - i.e. the vastly learned Dr. Regier always wins: if he gets controverted he says the "separation" wasn't "clear" enough, as a "lack", and anyway he can say what he pleases about keeping "syndromes" apart, for their existence depends on some "lack of clear separation" between the various possibilities inherent in "syndromes".

And apart from that, "became apparent" again is a typical Regier or DSM-5 term: It means whatever one wants it to mean, depending (for it's a fallacy of comparison: if you leave out mentioning who this "became apparent" to and for what reason, on what evidence, you say nothing clear at all), while the claim that "the high levels of comorbidity that were reported" are such a reason again is a vague claim ("high" in what sense, "reported" by whom, for what reason) and besides skirts (hides, obfuscates) a question or premiss, namely that "levels of comorbidity" were at all relevant to "these criteria" that "have been tested".

But then I should add, for the benefit of those who don't know much about DSM-5 style APA-prose and APA-logic:

APA-logic

that this is the usual and clearly preferred style of "communicating" in those circles, so far as I can tell: They hardly can do better or different, and all seem as highly trained in verbal acrobatics as a Vatican diplomat.

In addition, treatment response became less specific asselective serotonin reuptake inhibitors were found to be effective for a wide range of anxiety, mood, and eating disorders 

Or a bit more precisely: With the discovery that fluoxetine improves depression in many, pharmacologists had found a much cheaper and much more effective treatment of depression than psychiatrists provided, thereby strongly suggesting all theories, models and treatments that psychiatrists had used were mostly ineffective - except of course in getting money from patients' bank accounts to psychiatrists' bank accounts.

So it became quite clear that psychiatrists who wanted to remain in the business of selling psychiatric services to laymen had to invent something new, also in view of the fact that: 

(..) atypical antipsychotics received indications for schizophrenia, bipolar disorder, and treatment-resistant major depression. 

Which is to say, in effect, that psychiatrists had been missing lots of things about what they did prescribe, and again had been overtaken by developments in pharmacology.

And more did not pan out according to psychiatric theories, teachings and practices:

More recently, it was found that a majority of patients with entry diagnoses of major depression in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D)study had significant anxiety symptoms, and this subgroup had a more severe clinical course and was less responsive to available treatments...

Which is to say, in effect, that psychiatrists had been missing lots of things in their theorizing.

Likewise, we have come to understand that we are unlikely to find single gene underpinnings for most mental disorders, which are more likely to have polygenetic vulnerabilities interacting with epigenetic factors (that switch genes on and off) and environmental exposures to produce disorders. [[2], pp. 645-646]

Yet one more psychiatric claim-or-delusion laid to rest, next to the bodies of those driven to suicide by being blamed for their stomach ulcers or homosexuality.

I have also arrived at the end of the prose of "Regier and colleagues" - which to my mind suggests psychiatry should have been given up as a science, having had it mostly consistently wrong in all its many schools from their inception, to the detriment of their patients, but to their own financial benefit, for one has to pay one's doctor for services rendered, also if these were based on delusions, nonsense, or bullshit.

Back to the prose of James Phillips:

As the work of the DSM-5 Tas Force and Work Groups moved forward, a controversy developed that involved Robert Spitzer and Allen Frances, Chairmen respectively of the DSM-III and DSM-IV Task Forces. The controversy began with Spitzer’s Letter to the Editor, “DSM-V: Open and Transparent,” on July 18, 2008 in Psychiatric Times [3], detailing his unsuccessful effort to obtain minutes of the DSM-5 Task Force meetings. In ensuing months Allen Frances joined him in a exchange with members of the Task Force. In a series of articles and blog postings in Psychiatric Times, Frances (at times with Spitzer) carried out a sustained critique of the DSM-5 work in which he focused both on issues of transparency and issues of process and content [4-16].

Note, in passing, how strange it is - apart from the gross impoliteness with which this was done, at least in dr. Frances' case - that precisely the editors of the current and previous editions were treated as naughty boys who have no need nor a right to know what the worthies of the secret committees of the DSM-5 are brewing in camera.

In any case, here is a link to a good and clear exposition by dr. Frances about the lack of merits of the DSM-5:

A Warning Sign on the Road to DSM‐5:
Beware of its Unintended Consequencences

Here is dr Phillips' summary of dr Frances' opinions:

The latter involved the Task Force and Work Group efforts to address the problems of DSM-IV with changes that, in Frances’ opinion, were premature and not backed by current scientific evidence. These changes included new diagnoses such as mixed anxiety- depression, an expanded list of addictive disorders, the addition of subthreshold conditions such as Psychosis Risk Syndrome, and overly inclusive criteria sets - all destined, in Frances’ judgment, to expand the population of the mentally ill, with the inevitable consequence of increasing the number of false positive diagnoses and the attendant consequence of exposing individuals unnecessarily
to potent psychotropic medications.

But think of all the great good this brought to the person, spouses, children and dependents of psychiatrists! And since when does a medical person work for his patients' interests and well-being rather than his own, if we are asking such questions of finances and motives for practicing what its practicians call "medical science"?

Or less cynically: Why have I never read a clear exposition of the earnings of medical and psychiatric doctors and clinical psychologists through the practice of their claimed sciences? Why is the ancient question "Cui bono?" always avoided, not answered, or disdainfully circumverted when asked about "a therapy" proposed by "a therapist" of what is always claimed to be "in the patients' interests"? Why are patients, who suffer the consequenes of misdiagnoses and maltreatments and are the folks who pay the diagnoses and treatments they get prescribed normally, given no insight in such fundamentally human questions as: What percentage do you earn from this?!

The changes also included extensive dimensional measures to be used with minimal scientific foundation. Frances pointed out that the NIMH was embarked on a major effort to upgrade the scientific foundation of psychiatric disorders (described below by Michael First), and that pending the results of that research effort in the coming years, we should for now mostly stick with the existing descriptive, categorical system, in full awareness of all its limitations. In brief, he has argued, we are not ready for the “paradigm shift” hoped for in the 2002 A Research Agenda.

This seems reasonable enough, given the above, and given the generally awful trackrecord of psychiatry and psychiatric theories. But it seems the APA and certainly the group that, in secret, designs the DSM-5 wants none of it, and I concede their proposals are likely to drive vastly more patients towards psychiatrists - which is to say that it strongly increases the chances of psychiatrists on a high income.

Clearly, if first things come first, and if psychiatrists, just as if they were ordinary men and women, would consider their own income as a first thing, dr. Frances' reception by the APA and DSM-5 worthies was to be expected and is clearly - yea: psychodynamically - explained.

We should note that as the DSM-5 Work Groups were being developed, the Task Force rejected a proposal in 2008 to add a Conceptual Issues Work Group [17] - well before Spitzer and Frances began their online critiques.

That is: the "Task Force" did not want clarity about conceptual issues, and I agree that if one's real - unstated: psychiatrists should understand why, it seems to me - end is the making of money by what is in real scientific terms mostly bullshit (seasoned with a few crumbs of real science, is true) or speculation with little empirical foundation, then this decision of the "Task Force" finds again a humanly quite understandable explanation.

In the course of this debate over DSM-5 I proposed to Allen in early 2010 that we use the pages of the Bulletin of the Association for the Advancement of Philosophy and Psychiatry (of which I am Editor) to expand and bring more voices into the discussion. This led to two
issues of the Bulletin in 2010 devoted to conceptual issues in DSM-5 [18,19]. (Vol 17, No 1 of the AAPP Bulletin will be referred to as Bulletin 1, and Vol 17, No 2 will be referred to as Bulletin 2. Both are available at http://alien.dowling.edu/~cperring/aapp/bulletin.htm.)

I have to to thank dr. Phillips for doing this, do so hereby, and must admit I have not yet seen his earlier named productions.

Interest in this topic is reflected in the fact that the second Bulletin issue, with commentaries on Frances’ extended response in the first issue, and his responses to the commentaries, reached over 70,000 words. Also in 2010, as Frances continued his critique through blog postings in Psychiatric Times, John Sadler and I began a series of regular, DSM-5 conceptual issues blogs in the same journal [20-33].

I have not seen these either, so far.

With the success of the Bulletin symposium, we approached the editor of PEHM, James Giordano, about using the pages of PEHM to continue the DSM-5 discussion under a different format, and with the goal of reaching a broader audience. The  new format would be
a series of “essential questions” for DSM-5, commentaries by a series of individuals (some of them commentators from the Bulletin issues, others making a first appearance in this article), and responses to the commentaries by Frances. Such is the origin of this article.

OK: That's nice to know, and a very commendable project - and I write not as one who makes money through psychiatry, but as one who lost money and chances through psychiatry - which makes me quite different, I must suppose, from any of the authors.

(The general introduction, individual introductions, and conclusion are written by this author (JP), the responses by Allen Frances.
For this exercise we have distilled the wide-ranging discussions from the Bulletin issues into six questions, listed below with the format in which they were presented to commentators. (As explained below, the umpire metaphor in Question 1 is taken from Frances’ discussion in Bulletin 1.)

This clarifies things. I turn to a consideration of these questions in a moment, but first like to remark that I am not against psychiatry as a form of paid help to people with particular kinds of problems.

What I am against are pseudoscience, fraud, deception and delusion in the name of (medical) science, of which I think there is and has been a lot in both psychiatry and clinical psychology, and also more broadly in therapies and therapists selling psychobabble treatments of all kinds.

Also, I am firmly convinced of the fact that a psychiatry designed as help to patients with problems of life - to use a broad and none to precise but useful phrase - that is freed from most theories that I have read in psychiatric and psychological handbooks, and that is more like social work or counseling than like psychoanalysis or cognitive behavorial therapy, both of which are mostly fraud, bullshit or delusion, will be vastly more helpful and honest for patients, besides being less expensive and more effective.

I do concede this may very well be just the reason psychiatrists in majority disagree with me about this:

Yes, it will not make you and your colleagues richer. But yes, you will be able to make a decent living, and more honestly so, simply because you will have a lot less to pretend and defend: You know really about as little as any of your patients about how the human brain produces meanings, ideas, selfs, ideas, art, motives, ideals, values and the feeling of mutual love in spring - say - but that does not mean you cannot help them with common sense, experience, a knowledge of realistic alternatives, and indeed sometimes with medicines too.

On to the questions.

1) How to Choose Among the Five Umpires of
Epistemology?
Are DSM diagnoses more like constructs or more like diseases? We would like to have the positions of each of the five epistemological umpires stated as clearly as possible.
Umpire 1) There are balls and there are strikes and I call them as they are.
Umpire 2) There are balls and there are strikes and I call them as I see them.
Umpire 3) There are no balls and there are no strikes until I call them.
Umpire 4) There are balls and there are strikes and I call them as I use them.
Umpire 5) Don’t call them at all because the game is not fair.

Could you please state the position of the umpire which you endorse?

As I have said before and above: These are justified philosophical questions, formulated in a clever, if slightly misleading way - but a supposed "science" - existing and taught in universities for some 100 years! - that still has no cogent, rational, plausible answers to these questions for its own field cannot be more of science than alchemy or astrology, that indeed have or should have similar problems: Do our hypotheses correspond to anything real? If so, how do we know? If not, is it all arbitrary or is their a kernel of fact? In either case: How can one possibly pretend one was taught and is practising a science - knowledge, you see - if one cannot even rationally or empirically answer the most basic questions about the subject of the supposed "science"?

Next, a brief remark on the shortcomings of question 1), that I will consider in more detail in my next part of this series. Here I make three fairly general points:

          • First, I have read a fair amount of psychiatry, not as a
            psychiatrist but as a philosopher and psychologist, and I
            remark that I have rarely read a psychiatrist who was
            informed about philosophy of science and methodology,
            logic, and philosophy or psychology in general, in any
            great detail at least.
          • Second, as Frances himself will admit: In real science and
            indeed in psychology and psychiatry, sometimes all five
            distinguished alternatives apply, if perhaps not - as in
            psychiatry - simultaneously, and about all fundamental
            tenets of the supposed "science".
          • Third, the fact that these kinds of questions are not
            mostly settled in psychiatry (as in physics and chemistry,
            apart from quantum mechanics) shows psychiatry has not
            yet reached the level of verifiable empirical knowledge to
            be founded or capable of being founded as a real science.

2) What is a Mental Disorder?
It has been difficult to reach agreement on a definition of mental disorder. Could you comment on this problem, or offer what you think is an adequate definition of the concept, mental disorder?

It's a good question - but the fact that it needs to be asked and cannot be rationally answered by psychiatrists again shows they do not practice a real science but only practice some set of beliefs they succeeded in getting accepted by laymen and courts as if it is science, and that largely not on the basis of relevant knowledge, but only because psychiatrists got a basic training in medicine.

3) What are the Benefits and Risks of
Conservatism?
Given the state of the science of psychiatric disorders, should we design DSM-5 in a conservative manner, with minimal change, or do the state of psychiatric science and the problems in DSM-IV dictate major change?

It's a fair question, though I don't think there is a "state of the science of psychiatric disorders" since there is no real science of these entities, whose existence and correct terminology/definition is also a matter of deep epistemological confusion amongst the very folks practicing the claimed "science", on others, for money.

My own answer is along the lines that either there should be no DSM-5 as planned at all, or the whole field of psychiatry should be deleted from medicine as a science, for lack of real knowledge of the brain to answer its questions in an empirical, testable and rational way.

Incidentally, whilst I deny that psychiatrists have a science of "psychiatric disorders", I concede that a good practising psychiatrist (and these exist, just as there are good Catholic monks, even though both Catholicism and psychiatry are both fundamentally mistaken) will have acquired, through his or her practising, a considerable mostly intuitive and personal knowledge of human suffering and of human responses to suffering, and also of what ways of coping with suffering - in the society the patient and the therapist live - are likely to succeed or fail.

Then again, most of this will be intuitive and personal, and not properly testable or generalizable - which makes psychiatry, in a good practitioner of it, more like an art than like a science.

Also, I should remark that this needs not be a shortcoming: What is a huge moral and rational shortcoming is to pretend to be a scientist when one is not and should and could know one is not. Also, people are for the most part quite capable of helping other people without having a supposedly scientific training to do so: Mostly all this requires is some common sense, some empathy, some intelligence, and some knowledge of relevant circumstances.

4) Is Pragmatism Practical?
What roles do science and pragmatism play in the construction of DSM-5? Does our science allow us to make major decisions on a scientific basis? What role do pragmatic considerations play, both when the science is strong and when the science is weak?

I understand the reason for the question, but it is too fanciful in its formulation:

"Pragmatism" has a specific meaning in philosophy, where it refers to doctrines of W. James, F. Schiller, C.I. Lewis and others, or perhaps to doctrines of C.S. Peirce (who was a good friend of James, but so abhorred by James' interpretation of his ideas that he decided to rename the latter as "pragmaticism", a term "ugly enough to be safe from kidnappers", he hoped), but dr. Frances means neither of these, and in view of what follows means something like the usual meaning of pragmatism outside philosophy: practically useful - which makes the question redundant, strictly speaking.

So I think this is a bit too misleading, and what he should have asked concerning the several distinct uses of psychiatry are several questions relating to its being a source of income for psychiatrists; an instrument that is part of the law for governments, politicians and bureaucrats; and something that may be in various ways useful, useless, or harming for patients (who tend to have to make it financially useful to psychiatrists to even consider to help them, if such they indeed do, to start with).

But yes, the cynical brief answer is that psychiatry is very useful for psychiatrists and Soviet style or authoritarian governments, and also for comedians, satirists and cartoonists, and as a general illustration of how easy it is to flummox and flimflam most people, including those with degrees, and as illustration of the adagium "Mundus vult decipi, " and its Machiavellian, cynical, manipulative, egoistic addition "ergo decipiatur".

5) How Compatible are All the Purposes of DSM?
Is there a conflict over utility in the DSMs? The authors of DSM-III, DSM-IV, and DSM-5 intend the manuals to be useful for both clinicians and researchers. Is there a conflict between what is useful for clinicians and what is useful for researchers? Which group is served better by DSM-III and DSM-IV, and by the prospective changes in DSM-5?

I suppose this may be a practically important question, that is mostly about "being all things to all men": Can one diagnostic manual - let's for the moment suppose: of any kind, in medicine - be useful both for academic research and for diagnosis by GPs, psychiatrists, in law courts etc.?

My own take is that this is very likely not to be so, regardless of one's criterions, because the demands and needs of a researcher are rather different from those of a clinician, to choose a term: The researcher wants tools to test and formulate hypotheses; the clinicians wants tools that have been validated and are reliable to use for diagnosing.

Having worked once for a large medical firm I have seen quite a few medical handbooks, encyclopedias and medical journals, and my own impression that the Dutch "Codex Medicus", that was a handbook designed for the use of GPs especially, that was meant to serve the diagnostic needs of practising medical doctors, was a better instrument than medical encyclopedias and handbooks. (Indeed, I have one, and it is quite useful for me.)  

My guess is that it is similar for psychiatric diagnosing - and indeed that a lot could be done or have been done to make a manual like the DSM-III or IV more useful and understandable to people without training in psychiatry, psychology or medicine.

6) Is DSM the Only Way to do Diagnosis?
Given the problems in DSM-III, DSM-IV, and (likely) in DSM-5, would you argue for an alternative, more rational diagnostic system than the DSM? Could you describe it? Would your alternative system simply replace the DSM or restructure it in a major way?

That is a very good question, and given what I have seen from the DSM-III, IV and 5 I most definitely would "argue for an alternative, more
rational diagnostic system than the DSM
" and it certainly would both "replace the DSM" and "restructure it in a major way". And the least it would be is: Clearly written, less pretentious, more practical, and with far fewer untested, untestable or plain wacky classifications, definitions and (implied) theories.

As will become apparent in what follows, these six questions are in multiple ways interrelated, and for that reason a response to one of the questions is often relevant to another of the questions. This is, for instance, quite obvious with Questions 1 and 2. What you think a mental disorder is will affect how you define the notion of mental disorder. Question 4 quickly enters this discussion. Should pragmatic, in addition to purely scientific, considerations enter into your effort to describe and define mental illness? Under Question 1, for instance, Harold Pincus offers a “pragmatic” response that could easily be placed under Question 4.

I suppose this should be mostly self-evident for intelligent people, and I will see about Mr Pincus' opinions when I discuss Question 1 and its answers.

And now let’s bring in Question 3 - whether to take a conservative or activist attitude toward changes in DSM-5. Don’t forget that threading its way through all of these questions is the dissatisfaction and disappointment  with the scientific status of DSM-III and IV. 

No, I will certainly not forget it - and once more: I find it rather disappointing, speaking very diplomatically, to see so many supposed scientists who are treating and classifying people, or helping to lock them up, on the basis of a science that they know or should know is not a science in the way physics and chemistry are, and which is doubtful or false - and has been shown to be so, in many of its central tenets, while clearly causing much harm to many people, and that mostly because they are misclassified and misdiagnosed, and therefore mistreated, which in case of psychiatry may mean that they end up in a mental hospital, with little chance of getting out. Is that consistent with rational medical ethics?

That troubled status clearly played a role in the epistemological (and ontological) discussion in Question 1, the definitional issue of Question 2, and the pragmatic aspect of Question 4. It is emblematic of the complexity of these discussions that the same troubled state of the current nosology will lead Scott Waterman in an activist direction in Question 3 and Michael Cerullo in a conservative direction.

Indeed. I'll see about the specific positions of specific contributors later, so here and now I agree that psychiatry is in a mess.

The final two questions take us in somewhat other directions, but both are related to the discussions that precede them. Question 5, about utility, raises major issues concerning how the manual is actually used, and for whom it is really designed - again, questions related to those of scientific status, definition,  pragmatic considerations, and finally attitudes toward change. 

Yes, but as I said: I found Question 5 too vague. Also, if we speak about "utility": Whatever psychiatrists may believe about themselves and their supposed science, if it is a real medical science, or if it should be one but isn't, the first "utility" should be in helping patients rather than researchers and clinicians - and yes, it is my considered opinion that the DSM-5 will not help but harm patients, and I fear the same is true of the other DSMs, for the simple reason that self-interest, prejudice, ignorance and pretense dressed up as "medical science" is a very bad and immoral idea.

With this question it’s hard to find anyone wanting to defend the premise of DSM-III and IV (and apparently DSM-5) that the manuals are equally useful for clinicians and researchers.

As I argued and I think effectively showed above this can be proved on logical grounds alone, almost: It's quite unlikely that two quite distinct groups with distinct motives, distinct standards, distinct ends, and distinct practices find a manual that was originally designed - in the DSM-III case - to help make - psychiatric diagnosing uniform (the same diseases identified by the same symptoms in the same terms), with the hopes of making a schema like the DSM empirically testable.

Interestingly, it would seem from Regier's words quoted above that he believes these ends have not been reached - from which my logical conclusion must be that then this is strong evidence that psychiatry is not a real science, if it cannot even reliably classify and test its own subjects of research.

Finally with Question 6 we have an ultimate question - whether the current state of the DSMs warrants a total overhaul. With Roonald Pies we have an individually imagined overhaul; with Joel Paris we have a commentary on DSM-5’s effort at revision, and with Michael First’s presentation of the NIMH Research Domain  Criteria project (RDoC), we have NIMH’s response - that the diagnostic manuals of the future may not resemble the DSMs as we know them.

I am probably most interested - practically speaking, certainly - in this question, having such firm convictions on the badness of the DSM-5, and will see. Meanwhile, Mr First's conclusion that "the diagnostic manuals of the future may not resemble the DSMs as we know them" sounds very much like DSM-5 Speak, I am sorry to note: It differs from a tautology only in making a definite innuendo. (Any statement that is not a logical contradiction "may" be true, and the future "may" safely be assumed to be not quite like the past.)

We should not expect from this or any other publication final answers to the questions of psychiatric classification. The questions are too large, and our expectations have to be more modest. What we know is that the goals of DSM-III & IV have not been achieved and that we are left with more immediate questions as to how to proceed with the current revision, DSM-5. Responses to these questions are understandably mixed. What we hope from this article is to keep the discussion going, and perhaps to move it forward a bit.

This sounds a bit odd: "We should not expect from this or any other publication final answers to the questions of psychiatric classification." Why not? This is not philosophy: Many people are being and have been locked up, discriminated, or calumniated on the basis of diagnoses reached on the basis of a DSM. Why may patients not demand that such a diagnostic manual is for the most part predictively valid in its diagnoses, if these are used for the purpose locking people up or diagnosing them with fargoing consequences for their social chances?

To say that "The questions are too large, and our expectations have to be more modest" is to put on the cloak of a researcher, while forgetting or at least not mentioning that under it one also wears the cloak of a policeman, on the strength of whose judgements persons may or have been locked up for life.

Next, if I were to say that "What we know is that the goals of DSM-III & IV have not been achieved and that we are left with more immediate questions as to how to proceed with the current revision, DSM-5" I would add that this is very strong evidence that psychiatry is in fact not a real science, and psychiatrists do not know what they are talking about, and that consequently psychiatry should not be practiced any more as it has been. 

As to "Responses to these questions are understandably mixed. What we hope from this article is to keep the discussion going, and perhaps to move it forward a bit": First, the opinions of physicists about their science are not at all as " mixed" as those of psychiatrists about their science. (There are difficulties about the import and interpretation if quantum mechanics, but they have been there from the beginning, and it seems most physicists take that - quite rationally - as evidence that the subject is not fully understood.) Second, I agree the discussion is important and should proceed, mostly in the interests of patients and rational science than in the interests of psychiatrists or their incomes or power. Third, I would consider it a huge step forward if there would be a rationally tenable, practically useful and empirically testable diagnostic manual of psychiatry, but I have never seen one. Fourth, I am quite convinced that it may be written, on the basis of present knowledge of medicine, psychology, psychiatry, the law, and social work and counseling, provided the writers are rational and informed about real science and philosophy of science, and are honest and clear about what is hypothesis and what has predictive validity.

To turn to the last part of the introduction:

Finally, because of the total size of this exercise, “The Six Most Essential Questions In Psychiatric Diagnosis: A Pluralogue” will be published in four parts: each of the first three covering two questions and the final part a general conclusion. Thus this article, Part 1, covers the first two questions.

I see that this makes it probable my reviews of this effort will be in five parts, rather than seven, but then I may choose to divide things up according to the questions.

This was my review of the introduction of The six most essential questions in psychiatric diagnosis: part 1.




Note

(*) I am an atheist who is a child of atheists, who lives in what is claimed to be a Calvinist nation. Why is it that so many pretended or real Christians, lapsed Christians, and people in general in the West these days are not willing to face that human beings, if not born in sin, are flawed and dangerous animals? 

How do these folks who preach in public the equality and equal humanity of all men - as was the practice in my country for over 30 years - explain the rise and the deeds of Hitler, Stalin, and Mao and their millions of followers all eager and proud to do their biddings?

Anyway: If you can't see that two of the greatest problems man - intelligent men and women of good will - face are the stupidity of the average and the ease with which man practices inhumanity to man, especially if the latter are considered not to belong to one's own most excellent group, nation, religion, party or race, you are part of these two great problems and not part of its possible solution, for which I refer you to my

      On a fundamental problem in ethics and moral



P.S.     Corrections, if any are necessary, have to be made later.
-- Apr 21: The original Nederlog of yesterday got overwritten.
Explanation here. And the present version of this Nederlog has fewer
typos and more links than the former version.
-- Apr 29, 2012: This file got restored yesterday, and today I have
added some corrections, reformatting and links.

 

 

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

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:              &nb

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 understa, but nds 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.
 


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