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  May 13, 2012                  
     

DSM-5: On Dr Frances' article on the DSM-5 in the NYT

 
The mild and the long-suffering may suffer forever in this world. As long as the patient will suffer, the cruel will kick.

(The Reverend Sidney Smith.)
Profligacy in taking office is so extreme, that we have no doubt public men may be found who, for half a century, would postpone all remedies for a pestilence, if the preservation of their places depended upon a propagation of the virus.

(The Reverend Sidney Smith.)
 

Yesterday I quoted an article by Dr Allen Frances in the New York Times but did not discuss its text, which I will do today - and in case you got a surfeit of the Reverend Smith this month: I quote him because his quoted sayings are very apt and seem to me mostly correct about most men, if given the opportunity: They will abuse others, for profit or for fun:

"What are we, then, at present?" "We find that at present the human race is divided politically into one wise man, nine knaves and ninety fools out of every hundred. That is, by an optimistic observer. The nine knaves assemble themselves under the banner of the most knavish among them, and become 'politicians': the wise man stands out, because he knows himself to be hopelessly outnumbered, and devotes himself to poetry, mathematics or philosophy; while the ninety fools plod off behind the banners of the nine villains, according to fancy, into the labyrinths of chicanery, malice and warfare. It is pleasant to have command, observed Sancho Panza, even over a flock of sheep, and that is why politicians raise their banners. It is, moreover, the same thing for the sheep, whatever the banner. If it is democracy, then the nine knaves will become members of parliament; if fascism will become party leaders; if communism, commissars. Nothing will be different, except the name. The fools will still be fools, the knaves still leaders, the result still exploitation. As for the wise man, his lot will be much the same under any ideology. Under democracy he will be encouraged to starve to death in a garret, under fascism he will be put in a concentration camp, under communism he will be liquidated. This is an optimistic but on the whole scientific statement (...)" (T.H. White, The Book of Merlyn, p. 50-1)

As I said yesterday, I have been writing rather a lot about the DSM-5 lately, because I fear that it will function as a death-trap for many ill people, not just with ME/CFS but with virtually any disease, especially those diseases which are today's multiple sclerosis or peptic ulcers:

Psychiatrists, bureaucrats, politicians and journalists will in great majority blame the ill for being ill; accuse them of being insane; and try to force them to work or at least kick them out of the dole, thereby effectively condemning the really ill to a horrible and slow dead in a paper box, if they make it as far as that, after having been thrown out of the dole as a malingerer or a nut-case, and after having been thrown out of their houses for not paying the rent for lack of dole.

So I am quite glad that Dr Allen Frances, the chief editor of the DSM-IV (officially called its  "chair", it seems) found the courage and clarity of mind to write the article I reproduced yesterday, and reproduce today again, namely for the purpose of commenting on it.

Here it is again, split up and displayed in blue to make it easier to distinguish Dr Frances' text and my comments:


Diagnosing the D.S.M.
New York Times[op-ed]
By ALLEN FRANCES
May 11, 2012

At its annual meeting this week, the American Psychiatric Association did two wonderful things: it rejected one reckless proposal that would have exposed nonpsychotic children to unnecessary and dangerous antipsychotic medication and another that would have turned the existential worries and sadness of everyday life into an alleged mental disorder.

I can see and appreciate that longed for things, when they eventuate, appear "wonderful", but I may be - or may seem to be: diplomacy may also enter here - a bit more cynical or realistic than Dr Frances is, and I believe parts of the DSM-5 were meant to be bartering material ("we give you this, if you let us retain that"), and that many DSM-5 innovations, dreamt up in secret committees of psychiatrists, and without any input of other or more qualified persons, like psychologists, lawyers, social workers, counselors or philosophers of science, seem to have been proposed in the spirit of "let's find out whether we can trick the public in accepting this, since it is all so good for psychiatrists' income and power".

Then again, that is one major reason to feel thankful that Dr Allen Frances, the chief editor of the DSM-IV, found the moral courage to protest publicly against the dangers of the DSM-5 to whoever is not a psychiatrist, and risks to be judged in its terms, e.g. as being fit to work, because a secret committee of psychiatrists has decided that one is not really ill, even though many - real - medical doctors insist one is ill, with a real disease some secret committee of psychiatrists decided to ignore, deny or wipe their asses with:

But the association is still proceeding with other suggestions that could potentially expand the boundaries of psychiatry to define as mentally ill tens of millions of people now considered normal.

Or indeed tens or millions now considered ill, e.g. with a serious neurological disease like ME/CFS, or indeed many other diseases some secret committee of psychiatrists, for mostly unknown reasons, on the basis of deliberations that, in so far they become known, are clearly bogus, and evidently very much in the financial interests of psychiatrists and pharmaceutical companies, but at least as much against the financial, legal, personal and financial interests of tens of millions persons who would not be misdiagnosed if there were no DSM-5, but whose lives or finances and personal integrity will be severely damaged if the editors of the DSM-5 get their way.

The proposals are part of a major undertaking: revisions to what is often called the “bible of psychiatry” — the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M. The fifth edition of the manual is scheduled for publication next May.

That name “bible of psychiatry” incidentally shows how irrationally psychiatry tends to be approached: A real science does not need a bible of any kind, and real science should not be considered as if it has some religious status, sanctity or certainty.

Then again, this sort of terminological abuse and irrational approach is very common, so I just registered it and move on to a very important conclusion of Dr Frances, who is the chief-editor of the DSM-IV:

I was heavily involved in the third and fourth editions of the manual but have reluctantly concluded that the association should lose its nearly century-old monopoly on defining mental illness.

Quite so: A private organization of professionals, who are into their profession like almost all professionals, for money, should not have the only or the dominant voice in making the decisions who is mentally unfit, fit for locking up on grounds of attributed insanity, or indeed in any other decision that effects the lives and chances of others, while also strongly benefiting those who make the decision.

Indeed, there also is a close analogy with religion: In a non-authoritarian democratic state there is no place for a state religion that decides who is a heretic and who is a faithful believer.

And the point of Dr Frances is in the moral, legal and commonsensical fields: NO professional group should have the final or dominant say so about its policies, practices, and norms wherever these effect the lives of others in the society: Butchers should not have the final say so on the standards of hygiene in slaughter houses; medical doctors should not have the final say so on what is moral or legal; salesmen should not have the final say so on the quality of what they sell, and so on.

Times have changed, the role of psychiatric diagnosis has changed, and the association has changed. It is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy.

Yes, indeed - except that I think that "times" never allowed other professions the rights psychiatrists have appropriated by presenting themselves as the sole authorities as to what madness is, and as the only ones qualified to decide whether a person is insane, or fit for being locked up, not for having committed a crime but for being "of unsound mind", according to some psychiatrist.

Also, I do not think psychiatry was ever "capable of being sole fiduciary" of judging other people's sanity, legal status, incarceration, or stigmatization as a mental case, nor do I think it could or should be "capable of being sole fiduciary: Those are totalitarian, authoritarian capacities no group of professionals and indeed no proper subset of persons should have in any free society where all citizens have equal rights. 

Psychiatric diagnosis was a professional embarrassment and cultural backwater until D.S.M.-3 was published in 1980. Before that, it was heavily influenced by psychoanalysis, psychiatrists could rarely agree on diagnoses and nobody much cared anyway.

It does not seem thus to me (who is a psychologist of 62), but I would agree that this may be mostly a matter of interpretation or perspective, and I do agree that until 1980 psychiatry was much less powerful and much less dangerous than since.

D.S.M.-3 stirred great professional and public excitement by providing specific criteria for each disorder. Having everyone work from the same playbook facilitated treatment planning and revolutionized research in psychiatry and neuroscience.

The first sentence in the above quotation  is both true and deplorable, in my view (and it is "DSM-III"): Most of what is claimed here seems to me to be bogus and public relations talk, although it is true this was the kind of talk that the APA abused when introducing the DSM-III.

In fact, the DSM-III and the DSM-IV were based on a major confusion that the DSM-5 also embodies: That the operationalized definitions of supposed mental disorders in these diagnostic manuals are a new - "theory free!" - science of psychiatry, while in fact the basic reason for operationalizing is not to remove theories, but to test theories.

Also, I simply disagree with Dr Frances that the DSM-III "facilitated treatment planning and revolutionized research in psychiatry and neuroscience": I don't think it did, and if it did this "news" did not reach the handbooks of psychology or neurology that I have read and passed examinations in, in the study of psychology.

I turn to Dr Frances' next paragraph:

Surprisingly, D.S.M.-3 also caught on with the general public and became a runaway best seller, with more than a million copies sold, many more than were needed for professional use. Psychiatric diagnosis crossed over from the consulting room to the cocktail party. People who previously chatted about the meaning of their latest dreams began to ponder where they best fit among D.S.M.’s intriguing categories.

I agree that surprised me too, although I should add that, while I studied psychology in the 1970ies and 1980ies, the DSMs, including DSM-III were hardly mentioned and not discussed at all where and when I studied, and the only reason I did see the DSM-III in the 1980ies is that a professorial friend had a private copy of it.

Besides, all of the 1970ies were rife with psychobabble, so the DSM-III did fall in a fertile ground, that much helped the DSM-III's sales, next to its - false, Public Relations - pretension this was, at long last, the beginning of a scientific psychiatry.

The fourth edition of the manual, released in 1994, tried to contain the diagnostic inflation that followed earlier editions. It succeeded on the adult side, but failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children that has since occurred.

This is the edition Dr Frances was "chair" of, that I indeed never as much as saw, because it did not seem to have reached the faculty of psychology I got my degree in and because I was myself never much interested in psychiatry, that I have regarded as a pseudoscience ever since I was 17 and read a scholarly introduction to it.

I do appreciate Dr Frances' admission in he failed in some important respects to do the right things; and I think that his standing up to protest against the DSM-5 is admirable, and the more so since so very few of his nominal peers seem to have the character to own up their own failings or the courage to do something about them after they happened.

Indeed, the D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services.

Precisely: That is the problem - not that a small group of (supposed) health-professionals congregate to indulge in (let's say) speculations without real empirical foundations, but that they acquire the social and legal status of having the virtual monopoly on deciding who is sane and who is not; who is socially fit or unfit; who will be helped or hindered, maligned, manipulated, and "diagnosed" with what is slander and defamation in the mouths of any who is not of their kind.

No group of professionals of any kind merit that manner of social power, and no group has it, in a democratic state of law, not even non-psychiatric medical doctors. To which must be added the fact that the pronouncements and diagnoses of psychiatrists, in spite of their own claims, are not based on real empirical rational science, for the most part, but are sheer bogus or, at best, wishful thinking about the secrets brain-scientists may be capable of revealing in 25 or 50 years, but that today no one has the knowledge to decide, and no one should, therefore, be permitted to decide, and certainly not with what is often the force of law.

For if this happens what one has is no longer medical science nor science, but has taken the guise of a state-protected inquisition, that has been given the monopoly to decide who will be forced to work, who will be forced to be locked up, who will be forced to take or be injected with dangerous medicines, and who merits the labels of "insane", "mad", "perverse", "disturbed", all in the name of religion, pardon pseudoscience.

D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts.  Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true.

I guess the first statement may be true, but it seems to me more likely that such research as does happen is driven mostly by pharmaceutical companies, or would have happened anyway, as the DSM seems to me to be too general and vague to "drive" research, though it may be used to justify it.

As to the courts: I do not think psychiatry or psychiatrists or psychiatric diagnostic manuals should be used in courts. First, because psychiatry is not a real science, but a pseudoscience, for the most part. Second, because even if it were a real science, it should have no vote in determining who should be punished, locked up, or set free: Such moral and legal decisions should not depend on psychiatrists or a purported branch of medical science. Third, because it gives far too much power to a profession that should not have power to lock people up or impose judgements on them that are basically moral prejudgments served with a sauce of (pseudo-)science.

Next, it is definitely not true, in my judgement, that "the American Psychiatric Association" ever was "the entity best equipped to monitor the diagnostic system", though indeed Dr Frances wrote "seems". My reason to object is that the APA's and psychiatric judgements on or diagnoses of people go far beyond the boundaries of any real science, as they are explicitly moral, explicitly legal, and should be explicitly not be the near or total monopoly of the very persons profiting from it.

As to who is "to monitor the diagnostic system": "Society" at large, since it is society at large that is directly effected by it - and that means, in a case like this, that it are especially citizens with a scientific education whose task it is to monitor the pronouncements, decisions, diagnoses, ideas and ideals of a professional group like psychiatrists, and that especially because (1) every citizen may be misdiagnosed by a psychiatrist or medical doctor, while (2) no professional group should have the power to judge its own omissions and commissions, and (3) if a purported science like psychiatry (or scientology, also simultaneously a religion, as it happens) cannot explain its diagnoses, judgements, theories, lack of theories or terminology to scientifically educated laymen in clear commonsensical terms, this must be because either it is not a real science or because it proposes immoral or irrational things.

D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription.

Quite so - and I'd say that if an emeritus professor of psychiatry, who is the chief editor of the currently used DSM says so, something must have gone very wrong... unless indeed (as I would not be amazed to find) the APA wants to argue that Dr Frances is incompetent or is not sane.

Then again, my own suspicion is that the main cause of "glut of unnecessary and harmful drug prescription" is that pharmaceutical companies have succeeded in making many psychiatrists their effective executives, who chose to serve their own financial interests by serving the pharmaceutical companies interests rather than the public's or science's interests.

The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.  Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true.

The first statement is a very strong reason to block the using of the DSM-5 in the public interest: Psychiatrists should not have the only or the main say so as to their own scientific qualities or lack thereof. If they make it effectively impossible to have their manuals judged by other scientists, such as psychologists, lawyers, social workers, counselors, and medical doctors who are not psychiatrists, chances are they are trying to impose bullshit or pseudoscience on the public, and chances are that they will serve their own financial interests rather than making these subject to their serving the public interest honestly, fairly and rationally.

As to the rest of this paragraph: The relations between psychiatrists, especially those who are in DSM-5 committees or in the leadership of the APA, should be empirically and legally investigated by objective investigators who are neither psychiatrists nor paid by pharmaceutical companies.

What Dr Frances says next does not prove what he says in the last cited passage:

The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role.

All of this may be true, but it does not mean the pharmaceutical companies do not have a big hold over many psychiatrists, nor does it mean these companies do not have an undue influence on the contents or orientation of the DSM-5. And again, this needs objective empirical investigation rather than verbal assurances without evidence.

Then again, the start of Dr Frances next paragraph is true and important:

New diagnoses in psychiatry can be far more dangerous than new drugs.

The reason this is true and important is quite simple: It are the diagnoses in those diagnostic manuals that are considered - often falsely or with no or insufficient evidence - to be the legal, moral and scientific justifications for prescribing the drugs.

Now we come to another important conclusion by the chief editor of the present DSM-IV:

We need some equivalent of the Food and Drug Administration to mind the store and control diagnostic exuberance. No existing organization is ready to replace the American Psychiatric Association.

Quite so, and indeed for the same reason as there is an FDA: It cannot be left to the honesty, decency, and fair mindedness of the producers of goods to be the sole or final authorities on the qualities of their own products. That is - given how men are on average, and how psychiatrists have been shown to be the last 100 years or so - an open invitation to extensive corruption.

We have arrived at another important proposal and conclusion of Dr Frances, about the need for "some equivalent of the Food and Drug Administration to mind the store and control diagnostic exuberance"

The most obvious candidate, the National Institute of Mental Health, is too research-oriented and insensitive to the vicissitudes of clinical practice. A new structure will be needed, probably best placed under the auspices of the Department of Health and Human Services, the Institute of Medicine or the World Health Organization.

Yes, indeed: That is the way to go - with the added proviso that any such institution does need much more than only psychiatrists: Medical scientists from other branches of medicine (currently in the process of being sidelined as caretakers of "co-morbidities" of the plenitude of "psychiatric disorders" the APA hopes to profitably diagnose with the advent of the DSM-5), lawyers, psychologists, social workers, statisticians, economists: These are the sort of people to invite to judge the adequacy and practicality of diagnostic manuals that are going to be used on all persons.

Then again, Dr Frances has seen that as well:

All mental-health disciplines need representation — not just psychiatrists but also psychologists, counselors, social workers and nurses. The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts.

Quite so - and let me add that this is also the public way of honest and objective science in the public interest: It must be testable and must be investigated by other scientists than just those who hope to profit financially and socially if their manuals are adopted or allowed, and the trouble taken to this must be commensurate with its social importance, which is very large in the cases of medicine and of psychiatry. 

Primary care doctors prescribe the majority of psychotropic medication, often carelessly, and need to contribute to the diagnostic system if they are to use it correctly. Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.

Quite so, again because just as the leaders of the Ford Motor Company should not have the final word on the excellency or usage of Ford cars, so should the APA and psychiatry not have the final word on whether their diagnoses, their diagnostic manual, and the way their art or science is to be socially applied and why and wherefore, be left to the discretion of psychiatrists or their professional organizations: That way is the way of corruption.

Here is Dr Frances last statement:

Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots.

Precisely.


To end this long review: I wrote it for the same sorts of reasons as outlined in my DSM-5: The six most essential questions in psychiatric diagnosis - 0 :

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 malpracticianers - 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.

If the DSM-5 gets accepted in the way the APA seeks its acceptance, this means this kind of pseudoscientific moral degeneracy will be practiced on a much wider scale and on many more defenseless people than ever before.

It may well destroy millions of lives if it is not stopped before it can embark on its path of misdiagnosing.

 


P.S.    
Corrections, if any are necessary, have to be made later.
-- May 15, 2012: Fixed and added some 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

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 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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