October 31, 2012

DSM-5: The sick comedy continues


1.  Excursus on the badness of modern psychiatry
2.  The latest DSM-5 bullshit
PS. My eye problems


This is mostly an update of the series on the DSM-5, that got started in Nederlog, in 2010, and that you can find summarized here and diagnosed here.

1. Excursus on the badness of modern psychiatry

The brief of it is that, considered as science, psychiatry is not a science but a pseudoscience, as it has been from its very inception, by Charcot and Freud, as argued very well by the late Richard Webster, summarized by me here (whose excellent site is being kept going: Thank you, whoever is responsible for that!)

Note that in itself this is not very bad: I consider large parts of psychology, sociology, political sciences aka politicology, some branches of medical science, and even some parts of physics as little better than pseudoscience or as protosciences of some kind, that eventually may pan out.

Also, there are considerable grey margins, and it may depend on authors, subjects, and treatments, as the mathematically inclined who have looked into cybernetics, general systems theory, or chaos theory may have found for themselves: These fields are based on mathematical notions, that are themselves hard to find fault with, but the way they are applied may be wacky, pretentious or just nonsensical.

In any case, none of this strikes me as very bad, even if I consider it nonsense, because these would be sciences, whether protoscience, pseudoscience, or wacky science, are generally limited to the field of ideas, a few universities, and a handful believers, as indeed is the case with most new scientific theories.

If you haven't read Martin Gardner's "Fads and fallacies in the name of science" and "Science: Good, bad and bogus", and are in any way interested in science at all, you should: He was a very sensible man, with lots of relevant knowledge, who wrote a very clear style.

Things start to get very bad only when pretended science becomes the agency or justification of social repression, as happened to the science Karl Marx believed himself to have discovered or when it becomes a justification for fraud and abuse on a large scale, as is the case with modern psychiatry, especially since that teamed up with large pharmaceutical companies, and started to prescribe all manner of dangerous drugs to all manner of people, without any good empirical and rational justification whatsoever.

That is ... apart from greed, to be sure: The basic reason psychiatry and Big Pharma teamed up is that psychiatrists are legally entitled to prescribe drugs, and Big Pharma makes drugs.

And here again a proviso or two have to be made: Many medicinal drugs that pharmacologists design do work - indeed to an extent, with variations, and often with unpleasant side-effects, but on the whole better than having no drugs.

Also, it is not uncommon that a drug works, as just stated, while there is no good medical or bio-chemical explanation why it does. If the potential risks and benefits have been charted in an honest, empirical and rational fashion, at least there is a choice, that can be made on the basis of some relevant evidence.

With psychiatric drugs, it is different: Whether they really work, as they are claimed to do, in the general population, and whether they really have no dangerous side-effects, is often unknown, for three basic reasons:

First, psychiatry - unlike most of the rest of medicine! - is NOT a science but a
pseudoscience, ever since it was invented as an easy way to make money for medical folks with little or no conscience.

Second, the trials and tests of psychiatric drugs often are not properly done, for various reasons, that include the first point and the next, besides simple financial reasons (i.e.: shoddy testing costs less and reveals no failures) and not so simple methodological and statistical reasons.

Third, because there is an unholy alliance between the people prescribing the drugs, that is here: the psychiatrists, in their role as "medical doctors", and the pharmaceutical companies, for there have been made many arrangements by which the psychiatrists profit in person, financially or otherwise, if they prescribe specific drugs.

In these circumstances, you have the wherewithal for a racket, a scam, a schema of fraudulence, where a
pseudoscience becomes the justification for prescribing each year billions of dollars of dangerous drugs to unsuspecting patients, not because these drugs are known to work, but because those making and prescribing them know they are profitable, and work for profit rather than for patients' interests or sound, honest and moral science.

They have turned themselves into sellers of snake oil, because selling snake oil is profitable, and hardly anyone knows enough biochemistry, medical science, or about psychiatry - the pseudo-science of snake oil selling, effectively a subset of Public Relations aka the art and science of conmanship - to stop them on legal, scientific or moral grounds.

Having reached this stage, which is the stage psychiatry reached already in 1980, with the DSM-III, the stage of very bad - dangerous, dishonest, fallacious, fraudulent -
pseudoscience has been reached.

For more on this topic - in part also related to ME/CFS, in part to philosophy of science and methodology - see the series I wrote on the DSM-5 and How to write like a psychiatrist (psychologist, psychotherapist)

2.The latest DSM-5 bullshit

There now are the latest PR-bids by the designers of the DSM-5 and the APA. You'll find the details on Ms Chapman's excellent site, including many links - though I should warn you that, since the APA is into pretended medical science, served with large doses of PR-sauce, only for the money, you'll have to pay a lot of money to get acces - for 24 hours, for $35, for each file of PR-crafted bullshit - to their baloney.

Then again, some real specialists did, such as dr. Allan Frances, who has the considerable merits of being the chief editor (sorry: I don't believe in animated chairs) of the DSM-IV, who for moral and scientific reasons objects to the DSM-5, and 1boringoldman, who is in fact a psychiatrist with a good mind and moral courage, who feels flummoxed by quite a few of his colleagues in the DSM-5, and rightly so, and arguably so, as he does himself, quite well, here.

So I'll go through some of their latest posts, and start with Dr Frances, whose latest in his series DSM-5 in distress in Psychology Today can be found here.

I'll quote parts of it, in blue, and give my comments in black.

To start with, I like his opening quote:

        "You can't turn a sow's ear into a silk purse."

Put otherwise: Bullshit is bullshit whatever form, shape or sauce you present it in.

Next, I am afraid I must disagree with his
"Second problem- the design of the DSM 5 field trial had a byzantine complexity that could be dreamed up only by people with no experience in real life field testing."
My reason is quite simply that I think they know what they are doing. Not all of them, but the top. The public, including Dr Frances and me, are being skilfully flimflammed, Phil Parker style, but by smarter folks than PP. (Then again, I do know it may be risky for Dr Frances to say so, seeing the scurvy way Ms Chapman was treated by the APA - see: Is the American Psychiatric Association a terrorist organization? - while speaking for myself, I don't care, since I have nothing to loose, a very sharp mind, and sites in countries where it is difficult to take sites down for expressing opinions distasteful to frauds.)

I agree with Dr Frances about this:
"According to the authors, 14 of the 23 disorders had “very good” or “good” reliability; 6 had questionable, but 'acceptable' levels; and just three had “unacceptable” rates. Sounds okay until you look at the actual data and discover that the cheerful words used by the DSM 5 leaders simply don't fit their extremely disappointing results. The paper is a classic example of orwellian 'newspeak'."
Thus it seems to me, and indeed the APA and DSM-5 have done so before, and effectively it comes to this:
       old rules    - crapulous       - unacceptable - insufficient - tolerable - fair   - good
     new rules  - unacceptable   - insufficient   - tolerable     - fair       - good - excellent
You simply shift the standards, while pretending everything is the same.

The reason Dr Frances gives is also good:
" In fact, only the 5 of the 23 DSM 5 diagnoses that achieved kappa levels of agreement between 0.60–0.79 would have been considered 'good' in the past. DSM 5 cheapens the coinage of reliability by hyping these merely okay levels as 'very good'. Then it gets much worse. The 9 DSM 5 disorders in the kappa range of 0.40–0.59 previously would have been considered just plain poor, but DSM 5 puffs these up as 'good'. Then DSM 5 has the chutzpah to call acceptable the 6 disorders that achieved lousy, absolutely unacceptable reliabilities with kappas of 0.20–0.39. "
I agree, though for me there is a BUT...: I am not much interested in "reliability" - which after all is merely some sort of consensus on labels, that are not based on anything clear or coherent. (As it happens, I am re-reading "Gulag" by Anne Applebaum and noticed that the reports of inspectors of Gulags also worked that way, as did the CCCP: They invented (made up from thin air) whole categories of opponents, just for the purpose of terrorizing the Soviet population and filling the Gulags with cheap labour. No doubt they mostly agreed on the labels - but the labels classified a chimaera, not reality, and classified it for political profit, not for descriptive accuracy. Not surprisingly, they also used the shifty trick I illustrated above.)

Next, I supose I agree with Dr Frances'
"It is sad that the American Journal Of Psychiatry agreed to publish this sleight of hand interpretation of the remarkably poor DSM 5 field trial results. Clearly, AJP has been forced into the role of a cheerleading house organ, not an independent scientific journal. AJP is promoting APA product instead of critically evaluating it."
As it happens, I know much less than he does about them, but I'd guess they are not so much "forced" as - from their perspective - "collaborating". (Yes, that can be read in two tones.)

I also agree with his conclusion:
"A diagnostic system that affects so many crucial decisions in our society cannot be left to a small professional association whose work is profit driven, lacking in scientific integrity, and insensitive to public weal."
Then to 1boringoldman (who in fact is a psychiatrist I could name, which I do not do because he writes pseudonymously): He names and partially quotes what looks like a very good article by Marcia Angell in the New York Times, The Illusions of Psychiatry, and I will see if I can find more.

As to 1boringoldman's comments: I like his
" that psychiatry rapidly became a medication specialty rather than a medical specialty. The whole industry scenario described in Angell’s piece above from Robert Whitaker’s book was not apparent at the time – at least to me."
though I also find it a bit odd, especially because he knows statistics and seems to be a smart man. (I mean: There clearly was something rotten there. Then again, I am willing to suppose he was working hard and had little time - and as I have remarked before: While I don't believe psychiatry is a science, this does not mean that there are no psychiatrists who help people, indeed rather like religion: I disbelieve all religions, but some religious people have done fine things, perhaps indeed because of what I think are reasons not founded on facts or science.)

As to 1boringoldman's next paragraph:
"Now, it’s very easy to cast blame. Fibiger sees the last three decades as a massively failed experiment in which no new psychiatric drugs of note arrived because the academic scientists didn’t give industry enough to work with. It’s hard to even read that without laughing aloud. Organized and academic psychiatry has talked of little other than new drugs and advances in neuroscience for this whole period. The most lucrative pharmaceuticals for all time have been new psychiatric drugs. He makes no mention of the staggering profits, the ubiquitous corruption, or the fact that industry has owned a lot of the very people he’s blaming – academic psychiatrists. And all of those ads in our journals or on television didn’t mention that it was all just one great big experiment. His point is, however, correct in that "a massive experiment has failed: despite decades of research and billions of dollars invested, not a single mechanistically novel drug has reached the psychiatric market in more than 30 years.""
As it happens, I take a different - somewhat more cynical, some might argue: more realistic - perspective: It is not "a failed experiment" of 30 years: It was a huge success, financially speaking, that is, and also as pseudoscience: almost everyone, except Dr Szasz and a few lawyers, were effectively flimflammed, and enormous profits were made for 30 solid years.

Next, I sort of agree with 1boringoldman's
" The experiment that we didn’t know was an experiment has largely failed. The experimenters that we didn’t know were experimenting have fled the scene. And psychiatry proper is left in dubious straits, a position we earned by collusion. The gambles made by Dr. Sabshin’s medicalization, Drs. Robins’ and Guze’s neoKraepelinian Tenets, and Dr. Robert Spitzer’s DSM-III revision combined to solve a problem in 1980, but contributed to the one we have now in the process. "
However... as I see it the fight is not against poor science or against honest but spineless medicos, but against intentional fraud perpetrated by PR, in the name of "evidence based medical science", which is utter bullshit.

And that has been going on ever since Spitzer invented the DSM-III, from thin air, though he may have been just someone who found himself by chance in a position he couldn't responsibly fill, and who started making up things to save himself and his colleagues, having seen the incredible mess psychiatry had gotten in by the 1960ies and 1970ies (Remember Laing? Remember Szasz? Remember "The Freud Wars"? Remember Grünbaum?) and its effective refutation of almost every claim except that some did help some, for mostly obscure reasons?

Then there arrived the DSM-III, propelled with PR, advertisements and fanfares by many naive journalists, almost none with any qualification to rationally judge that book of biblical proportions and pretentions - and suddenly psychiatry was without any theoretical foundation, which made it both unfalsifiable and a
pseudoscience, but with an impressive seeming categorial set of labels, that - it seems - mostly were made up by Bob Spitzer himself.

Finally, I do agree with 1boringoldman's conclusion:
"How can psychopharmacology be in crisis? Psychopharmacology is in the same place it has been for much of its history. Psychopharmacologists may feel like they are in a state of crisis because industry has abandoned them to their own devices. But Psychiatry itself is what is in a real crisis, but not the one Dr. Fibiger is talking about. It’s the one Dr. Angell and Robert Whitaker write about – a crisis of conflicts of interest and ultimately medical ethics. And while we’re at it, we might just throw in a genuine crisis in leadership. Too many leaders are part of the problem…"
I suppose neither 1boringoldman nor Dr Frances would agree with my own view, which is that psychiatry should be cast out of science: It shows 30 years of systematic abuse, and has no real scientific foundations of any kind. But then I do agree that is a quite radical proposal and indeed I am not a psychiatrist - but somebody has to propose radical measures, and I am a psychologist and philosopher of science, severely discriminated for decades because of psychiaytric fraudulence, so I do believe I have a right to speak, and a right to insist on the maintenance rather than the obfuscation of scientific norms and medical morality.

For backgrounds, see my "How to write and think like a real psychiatrist (psychologist, psychotherapist) - aka how to become rich, famous and admired with a degree in a pseudoscience, and if you did not do so yet: The least it is is good informed satire.


Maarten Maartensz

P.S. My eye problems

                  PS: Any necessary corrections have to be made later.