1. More on a sow's ears
2. Reformatting Nederlog
This is mostly about the
DSM-5, which is the sow's ear that can be as little turned into a silk
purse as crap can be changed to gold - except by flimflam, with a note
at the end on the present status of Nederlog.
1. More on a sow's ears
Dr Allen Frances did it again: He wrote another
courageous piece on the excrescence that is the DSM-5.
You'll find my own writings on the subject collected here:
but I do not
have the distinctions Dr Frances has:
He is an MD, a psychiatrist, an emeritus professor of psychiatry, and
the chief editor of the DSM-IV, and by my lights he has been quite
rationally and quite courageously been sayingv "No" to the DSM-5
ever since 2009 - which you find here:
The reasons I
appreciate his stance is that I mostly agree with him - except that, as
you may find in the first dotted link above - that I am more radical
than he is, but then indeed I am not a psychiatrist but a psychologist
and a philosopher of science; that I think the subject is quite
important, since good health care and honest and scientific psychiatry
are in the interest of - literally - billions of persons; and that I
know from my personal life and background that only a small percentage
of persons find it in themselves to take a moral stance if doing so is
not socially popular or currently fashionable, as indeed few persons
resisted Nazism actively, while being subjected to it (my parents and grandparents did,
though), just as relatively few had the courage to be dissidents in the
former Soviet Union.
So I have been following his writings about the DSM-5, that you can
find here, for the most part:
probably learned about from Ms Suzy Chapman's excellent site about the
and I have
also been quoting and commenting him quite extensively in my Nederlogs
about the DSM-5, linked above.
I will do so again, after making one clarification:
I never mailed or spoke with Dr Frances, and also not with Drs
Carroll and Nardo mentioned below, nor indeed did they with me, and
they are not responsible for my opinions nor am I
responsible for theirs, while the reason I write about the DSM-5 is
that I have ME/CFS
since 1.1.1979, when I was 28, and fell ill, like my ex-wife, with Epstein-Barr,
after which we never got healthy again, but that also turned out not
to give us any right on any help whatsoever, mostly
because psychiatrists - such as the execrable professor Wessely - had
decided to blacken the character, person, integrity, honesty and
intelligence of millions of persons with ME/CFS: I found to my astonishment, late in 2009,
that professor Wessely has been argueing in fact since 1988 that I must
be insane and/or a malingerer because my disease as no biochemical
marker. Professor Wessely claims to know, even though the
Wikipedia-article on Epstein-Barr, which is a common precursor to
A relatively complex
virus, EBV is not yet fully understood. Laboratories around the world
continue to study the virus and develop new ways to treat the diseases
Wessely and his psychiatric mates - none of them specialists in real
medicine - insist that they know that millions of persons like me are
not really ill but have "dysfunctional belief syndromes", that is, if
they are not malingering, and should be denied help - except, of
course, by paid psychiatrists.
That sounds scarcely sane to me, and grossly immoral, and indeed
confirmed what I have been thinking about psychiatry for decades, since
the 1960ies: That
it is not a real science, simply because there is
not sufficient knowledge of how the human brain generates its marvels.
This is also why I came to write about it: It turns out to have
seriously harmed my chances to live a bearable life; it turns out to
have sadistically blackened the characters of millions of
people with my kind of disease; while I have the academic degrees - in
psychology and philosophy - to be able to see through it: I write about
it not because I am or have ever been interested in psychiatry,
but because I have been harmed by it, it turned out, for the Dutch
government finds it easier to save on the likes of me for the benefit
of bankmanagers or for bureaucrats' incomes rather than to take a
moral and rational stance, and also because I fear the consequences of
the DSM-5 for millions of other persons with my kind of disease, and
indeed more than for me, simply because I am nearly at a
pensionable age and also am not easily bowled over by bullshit.
But millions of others do not have the sort of knowledge I have, and
that is why I write about the DSM-5.
To turn to Dr Frances. I will quote his text, that in fact consists
mostly of quotations of two other medical doctors and provide my
comments. Dr Frances' text is blue and sidelined or indented; mine is
black. The original is linked in the title:
Allen Frances, MD | 13 November 2012
recent Huffington Post piece titled Field
Trial Results Guide DSM Recommendations,1 DSM-5 Task Force Chair Dr
David Kupfer says, “What’s clear is just how well the field trials did
their job.” This surprisingly optimistic claim has inspired these
telling rejoinders from Mickey Nardo, MD, and Barney Carroll, MD, 2 of
the best informed critics of DSM-5.
Yes. It seems to me Dr Kupfer was plainly lying and knew he was lying.
His science isn't science: it is PR. But
read on in case you doubt.
Nardo first: “The absence of biological tests in psychiatry is unique
in medicine and sentences the classification of mental disorders to
Yes - as Szasz already insisted in the
1950ies. This was half of his basic argument that the concept of
'mental illness' is nonsense: If it is an illness, there must be a
provable pathology. The other half was that the mind is not an organ.
(I paraphrased in my term See the last link for considerably more,
including Szasz's own words.)
The problem with the first point is that someone may be quite clearly
not well, but one may lack the science to establish a provable
pathology. Then again, even if one grants that, insisting they are ill
doesn't make it science. But in my understanding, at least, it
used to be part of the job of a good GP to decide whether or not a
person was ill and not - say - malingering, but these days this can't
be done anymore, rationally speaking, at least not as GPs operate in
cities. (They don't visit patients at home anymore, and in Holland the
government has decided they normally have maximally ten minutes per
Also, "mental disorder" is even worse than "mental illness": It is a
term which should belong to Soviet psychiatry. At the very best it is
wildly metaphorical - and see the next remark.
The problem with the second point is that the mind is - part of - what
the brain does, like dancing is - part of - what a body may do. The
problem at the bottom of it is that no one has access to anyone else's
experiences, and the whole mentalese terminology is very imprecise,
precisely because there are no good factual criterions to decide what
someone else is thinking, feeling, desiring, imagining, etcetera. (This
is why behaviorism
was popular from ca. 1920-1970, especially with psychologists. But then
those were 50 years of dedicated throwing out of baby+bathwater.)
For me, this is all dishonest or
stupid bullshit. If you do not know what you are labelling or
classifying, seeking agreement on how the labels are applied makes
sense IF AND ONLY IF it can be tied to objective experimental
tests. But objective experimental tests require theories, and theories
is what Spitzer had done away with, I think on purpose, because
psychiatric theories had been made mince meat of in the Sixties and
Seventies, and had a bad public reputation.
1970s, Dr Robert Spitzer proposed we use inter-rater reliability as a
stand in for objective tests. His statistician colleagues developed a
simple measure (called ‘kappa’) to indicate the level of diagnostic
agreement corrected for chance. In 1974, Spitzer reported on 5 studies
that clearly exposed the unreliability of DSM-II, the official
diagnostic system at the time.
What Spitzer tried to do, I think, was to undo the anti-psychiatry
sentiments, and keep psychiatry profitable for psychiatrists. I can't
believe he was ever interested in science, for if he was he would have
operated quite differently: There was a lot of criticism to answer, but
he did no such thing:
What he did was to replace the refuted DSM-II's theories with
a descriptive category for fairies and elves and werewolves, that
couldn't be tested properly because there was to be no explicit theory
of any kind for fairies and elves and werewolves [or: schizophrenia,
manic depression and hysteria]: All the theories for them had been
scientifically disproven, and shown to be prejudice without factual
Instead, what the psychiatric pretended believers in fairies and elves
and werewolves now introduced was mocked up statistics - let people
fill out forms and move it through a statistical machine: 99 out of a
100 are flabbergasted because they can't understand - which let the pseudoscientists freely dogmatize
and argue any point whatsoever with "may be"s and "might be"s.
That is now called "evidence based medical science": They have no
testable theories; they pretend to do science by fitting their personal
financial interests and prejudices to such data as they somehow
gathered and dressed up as if it were real statistical testing. (They -
intentionally, I think, on the level of Kupfer and Regier - confused descriptive
statistics with statistical testing, and pretended the
former was the latter. What they are doing is the same sort of thing as
pundits and journalists and politicians do with election polls, which
are also descriptive statistics: "Explain" them so as to prop up and
serve their own interests and prejudices.)
correct this problem and obtain the diagnostic agreement necessary for
research studies, Spitzer then set about constructing sets of
diagnostic criteria meant to tap overt signs and symptoms, rather than
the more inferential mechanisms that informed DSM-II. He also developed
structured clinical interviews that provided a uniform method of
assessment. These approaches worked well to improve the poor kappas
obtained using the free form approach of DSM-II.
I think it's a bit different: What Spitzer did was throwing out
theories, as indeed the behaviouralist
psychologists had been doing since the 1920-ies (who made up a
whole jargon to speak about the mind nevertheless: they called it
"intervening variables", "latent variables") and replacing them by
behaviourist recipes: "sets of diagnostic criteria meant to tap overt
signs and symptoms".
However... that is totally useless pseudoscience
without any theories to test. What Dr Nardo calls "inferential
mechanisms that informed DSM-II" in fact was their attempt to do
science. It didn't work because their theories were false for the most
part, but at least the DSM-II had the scientific merit that it
could be tested and falsified.
Also, it seems to me that "structured clinical
interviews that provided a uniform method of assessment" in fact
probably means that the doctor did not need to think for himself or
herself any more, but merely needed to check some score-cards. Well...
that also will improve the agreements on naming fairies and elves and
werewolves, but doesn't make it any more scientific. Wide agreements on
bullshit categories prove nothing, and can be found in
Catholicism and Marxism as well (and both of these "sciences" decided
that in the end you could torture the required diagnosis from those you
had declared dissidents: By golly, it worked!).
There is a parallel here with the show trials of
Stalin, that tricked many, including G.B. Shaw.
But it wasn't "a research tool", although it was pretended to
be. And I fear in practice "criterion based
method of diagnosis" means check lists: If so, it is no
miracle at all that suddenly the consensus seems to improve! You can do
the same for Rorschach
tests - I mean introduce the technical terms "brillig", "slithy",
"gyre" and "gimble" to distinguish the wabes from the toves, and come
to agree with 95% accuracy, thereby proving to the psychiatric mind
that Rorschach pictures have been proved, by evidence based medical
science, no less, to come into two scientific categories, namely the
wabes (requires psychotropic drugs) and toves (may be cured with CBT
1980, Spitzer took the next big step of introducing the criterion based
method of diagnosis into DSM-III. What had originated as a research
tool now informed all clinical practice.
an important milestone for psychiatry when DSM-III field testing showed
that the system achieved good kappas.
On what was and are basically Jabberwocky
descriptions of imaginary worlds, designed to
be the apparently "evidence based medicine" to sell dangerous expensive
drugs to laymen.
new manual was an instant success throughout the mental health
professions and brought a measure of objectivity to a field previously
dominated by warring subjective opinions. Later, in 1994, DSM-IV was
also able to demonstrate good kappas in its much more extensive field
No, it wasn't. First, it was a success mostly in the US and in
psychiatry. Second, it was a success because it was well
marketed and ill understood. Third, psychologists in Europe
were not impressed: it was hardly mentioned and not read at all in my
study of psychology (and neither was DSM-II), and what I was told about
it showed me - long after the fact - that those informing me had been deceived
by the pretensions of its designers that they had developed a manual
for doing research, while what they had developed in fact was a manual
of pseudoscience enabling pseudoscientists to do "evidence based"
trickery that is no testing and therefore can seemingly prop up
anything that pays well. (See the technique of deriving wabes and toves
from Rorschach tests described above, and my DSM-5:
Medicine is a very sick
business in the US - 2.)
DSM-5 Task Force originally planned two sets of field trials, the
second of which was meant to provide quality control to correct
whatever weaknesses would be exposed in the first. But along the way,
the field testing got far behind its schedule and the quality control
step was quietly cancelled. No explanation was ever offered, but it
seemed likely that DSM-5 was being rushed to press so that APA could
reap publishing profits.
Hence it is pretended "evidence based medical science" with no basis of
evidence. My explanation is - as is supported by all bullshit about
kappas and the shifting of standards - that they could not even
generate verbal agreements on consistent bullshit, so they decided to bluff and brazen it out.
David Kupfer now wants us to believe that the recently published
results of the DSM-5 field testing somehow serve to justify the
inclusion in DSM 5 of extremely controversial and much feared changes.
This is a terribly misleading claim.
In my understanding of the law as applied to medicine it is and ought
to be actionable. I think he is lying and is doing it for the money. My
own view is that such people ought to be in jail: We are effectively talking about what will be millions
of phony diagnosis, bullshit prescriptions, and destroyed lives and
And note that I think that is criminal
because it happens in the name of science: If it were explicitly
presented as opinion or religion it still would be bullshit, but at least it would not get dressed up as if it
were based on science, and people could simply chose between
Catholicism, the Salvation Army, Scientology, and Psychiatry, all
schemes to cope with the problems of life.
of all the other criticisms of DSM-5 (and there are plenty), the poor
results of the field trials must have been a major disappointment to
the Task Force. Dr Kupfer is now making a desperate attempt to salvage
the failed project by putting an unrealistically positive spin on its
I really can't believe these folks are honest. Also, they did not need
to read me to know they are bullshitting: The 2011 BPS
report and statement were quite good, and contained no
forty-year experience in reliability testing for DSM-II, the RDC,
DSM-III, and DSM-IV makes clear what are acceptable and what are
unacceptable kappa levels.
That is: "Trust Us! Trust Your Mumbo-Jumbo Man! He Knows! He Has Been
Serving You Suckers Selflessly For Forty Years! He Would Not Lie! He
Means Well! Trust Us! You Know You Can!"
It seems considerably worse to me, since the DSM-II
folks (1) did have theories to inform their judgments and (2) did not
use check-lists to precook agreements. Also, as it happens, some of the
most useful psychiatry I read is the German "Kompendium der
Psychiatrie", that managed to compress the diagnoses and theories
of psychiatry of the 1950ies and early 60ies within 120 smallish pages.
My guess is that it was derived from one of the earliest DSMs, but I do
not know. (In the last link - in German - you'll find it was first
published in 1961, and last reprinted in 2002.)
disturbing, three of the eight diagnoses tested at multiple centers had
widely divergent kappa values at the different sites—hardly a vote for
their reliability. Even worse, two major diagnostic categories [Major
Depressive Disorder and Generalized Anxiety Disorder] performed
terribly, in a range that is clearly unacceptable by anybody’s
standard. [see http://1boringoldman.com/index.php/2012/10/31/but-this-is-ridiculous/].
What it shows is that they have shown that they do not know what the
hell they are talking about - which is probably where it's at, but then they are in their business for money, and
they make a lot of money prescribing drugs.
Kupfer has been forced to drastically lower our expectations in an
effort to somehow justify the remarkably poor and scattered DSM-5 kappa
Actually, he shifted the standards dishonestly, as explained in my text of October 31, so now it appears as
if things worked out tolerably OK. In fact, it was a dishonest
is, in fact, only one possible explanation for the results—the DSM-5
field trials were poorly designed and incompetently administered.
Now here I have a problem. I like it that Dr Frances or Dr Nardo take a
stand, and I think this is fairly courageous, but my own guess is that
they were competently designed and administered, namely as pseudoscience. I really can't believe Kupfer and Regier are honest -
and if they are, they are too stupid for their function, and
frightfully ignorant about real science. (This is remotely possible. I
met already in the early 1980ies people preparing to be teachers of
mathematics who didn't know shit about mathematics, and to whom I could
not even explain Euclid's proof that there is an infinity of prime
numbers so that they could understand it. I was very amazed then, and
no: I was not taken in. They really did not know maths - and would soon
be teaching it.)
integrity requires owning up to the defects of the study, rather than
asking us to deviate from historical standards of what is considered
acceptable reliability. It is not cricket to lower the target kappas
after the study results fail to meet reasonable expectations.
I quite agree, with the addition that I am not much interested in the
agreement of bullshitters on terms that classify bullshit. Even if they
were to agree, testably and reproducibly, on their terminological
applications, it still would be agreement on how to apply
bullshit terminology to talk "scientifically" about the wabes and toves
that gyre and wimble, in a consistent intersubjective fashion. Well...
anyone who knows anything about politics knows this is neither
difficult nor proof of anything beyond consensus in terminology (and
agreement is the bedrock of our system—a non-negotiable bottom line.
The simple truth is that by historical standards, the DSM-5 field
trials did not pass muster. Dr Kupfer can’t expect to turn this sow’s
ear into a silk purse.”
Yes and no. Yes, in the sense of Dr Frances's or Dr Nardo's criterions
for psychiatric science. No, in the sense that I disagree with the
criterions, and indeed insist that diagnostic agreement is only
important if one is trying to empirically test theories
- but that is precisely what psychiatry does not do ever since
Carroll adds this: “The purpose of DSM-5 is to have criteria that can
be used reliably across the country and around the world.
Yes and no. Yes, in the sense that this is one of the pretensions. No,
in the sense that they have their built in obfuscation and weasel word: If
things are "biopsychosocial", as they nearly all claim, they can use
the "social" to explain away all failures (on the well-known
pattern "Too bad: These were not True Scotsmen"). Incidentally, my
own view is that they should introduce the concept of "biopsychotheosociaĺ":
A "science" like psychiatry should not deny the omniscient omnipotent
divine eye! And God
is everywhere, and no doubt also comes with excellent kappas! In fact,
I think I can prove that it is more honest and scientific to say that
God or Satan did it, and that one needs 30 lashes, than to say it is a biopsychosocially caused
dysfunctional belief system requiring stiff doses of anti-psychotic
medicine (with an excellent profit margin and perks for the
psychiatrists who prescribe it).
puzzling variability of results across the sites in the DSM-5 field
trials is a major problem. Let’s take just one of many examples—for
Bipolar I Disorder, the Mayo Clinic came in with a very good kappa
value of 0.73 whereas the San Antonio site came in with a really lousy
kappa of 0.27. You can’t just gloss over this gaping discrepancy by
reporting a mean value.
Dr Carroll does understand how statistics work! (I did not doubt that,
indeed, but this is one of the basic tricks, that now has been shown to
be much used by pharmaceutical companies, to manufacture "evidence" for
inconsistencies across sites have nothing to do with the criteria
tested—they are instead prima facie evidence of unacceptably poor
execution of the study protocol. The inconsistent results prove that
something clearly wasn’t right in how the study was done.
I don't know, but I agree there is a problem, indeed as Dr Carroll
says: If the DSM-5 is what it is claimed to be, it should at least
show high agreement in its verbal diagnoses. It doesn't, so it totally
fails as scientific diagnostic system.
appropriate response is to go back to the drawing board by completing
the originally planned quality control second stage of testing—rather
than barreling ahead to premature publication and pretending that
everything is just fine when it is not. The DSM-5 leaders have lowered
the goal posts and are claiming a bogus sophistication for their field
trials design as an excuse for its sloppy implementation. But a low
kappa is a low kappa no matter how you try to disguise it. Dr Kupfer is
putting lipstick on the pig.
Indeed, but since it remains a pig even if shrinks come to agree on how
to name its parts, I'd prefer to remove all of the pig out of science.
Then "what has to happen with the poor patients?!?!" drs Kupfer and
Regier may ask, suggesting they are moral human beings much concerned
with the well-being of patients.
Well, first they are less likely to be misdiagnosed. Second,
they learn that those who help them know little more than they do.
Third, I am not against helping people with problems, nor against
people who have some education to do so: I am against dressing up bullshit as if it science, and I am also against using bullshit to push dangerous well-paying
drugs onto and into patients. Fourth, I see no problem of principle
in medical or psychologically qualified folks trying to help people
with problems: The problem I have and see is with their pretensions to
know things about the human mind that I don't know. Sorry: It is a lie,
and I studied both the "science" of psychology and philosophy, and should
know if there is any solid knowledge about the human mind people with
my qualifications know, that layman don't know. Well, here it is: What laymen generally don't know is that those
they turn to for help don't know how the brain manufactures its
miracles, such as conscious experience, empathy, selves, the
understanding of meaning and language, and much more.
people experience a glazing of the eyes when the term kappa appears,
but it’s really a simple idea. The kappa value tells us how far we have
moved from completely random agreement (a kappa of 0) to completely
perfect agreement (a kappa of 1.0). The low end of kappas that DSM-5
wants us to find acceptable are barely better than blind raters
throwing random darts. If there is this much slop in the system when
tested at academic centers, imagine how bad things will become in the
real world of busy and less specialized clinical practice.
OK. My own guess - from a brief look - is that these kappas are
moonshine as well, qua statistics, but the essence of the matter is
that psychiatrists cannot and do not even agree on which patient merits
which label. If so, they are not doing science, and should be removed
from it. And again, I don't say they should not treat patients. All
that is necessary for effective treatment are common sense, some
knowledge of what is possible, in terms of ailments and treatments,
some basic medicine, psychology, law and social science, and some good
will. But such folks should not be able to hide their
dishonesty or incompetence behind a pseudoscietific bible only specialists can see through.
isn’t right . . . and when something isn’t right in a matter as serious
as psychiatric diagnosis the professional duty is to fix it. Having
shirked this responsibility, APA deserves to fail in the business
enterprise that it has made of DSM-5. If ever there was a clear
conflict of interest, this is it.”
I agree. But then that means they have failed as medical
people, and there is a legal side to that, and rightly so. ("Primum non nocere"
- and if you do so, knowingly, then get thrown out of medicine and pay
It's a good question, but I fear
the cynical realist answer is: They did ask themselves that
question, and started ecstatically gyring and gumbling in the wabes: "O FRABJOUS DAY! SO MUCH MONEY TO BE MADE! And the suckers fall
for it anyway, as long as you take care that your language is obscure,
pretentious, medicalese, and full of weasel words!"
are due to Drs Nardo and Carroll. There can be no doubt that the DSM-5
Field Trials were a colossal waste of money, time, and effort. First
off, they didn’t ask the most obvious and important question—What are
the risks that DSM-5 will create millions of misidentified new
‘patients’ who would then be subjected to unnecessary treatment?
the results on the question it did ask (about diagnostic reliability)
are so all over the map that they are completely uninterpretable. And
to top it off, DSM-5 cancelled the quality control stage that might
have cleaned up the mess.
That is a fair summary of the DSM-5's failing in its own terms.
almost certain that DSM-5 will be a dangerous contributor to our
already existing problems of diagnostic inflation and inappropriate
prescription of psychotropic drugs.
Yes indeed. It will very probably blight many lives, but then
at least "36.000 Physician Leaders In Mental Health":
families will thrive and prosper. (Again, my own
proposal is to remove the lot from science, and make it into a
religion, just like scientology: In the US that's even tax free!
Alternatively, remove it from science and train people who studied
medicine or psychology to help people with psychological problems, but honestly
so, and without either psycho-analytical or DSM bullshit.)
DSM-5 leadership is trying to put a brave face on its badly failed
first stage of field testing and has offered no excuse or explanation
for canceling its second and most crucial quality control stage. This
field testing fiasco erases whatever was left of the credibility of
DSM-5 and APA.
I agree it's a bad mess. My guess is that they will try to overcome it
doses of PR, and that they may very well succeed.
The best chances stopping them are via the US Senate or House,
legislation, and the law, but I would agree it also helps to target
medical people and psychologists, to the tune of: "You ought to
know this is bullshit, so do not refer
people with problems to psychiatrists, until they have been thrown out
of science or have retracted the bullshit they are currently basing
their bullshit prescriptions on. After all, you don't send people to
scientologists either, in the name of science."
1. Kupfer DJ. Field trial results guide DSM
recommendations. Huffington Post. November 7, 2012. http://www.huffingtonpost.com/david-j-kupfer-md/dsm-5_b_2083092.html.
Accessed November 13, 2012.
2. Reformatting Nederlog
I am still working on it and have today uploaded the
beginning of October, and two files from the end of that month that are
linked in this text, but it still is a work in progress, and not fully
P.S. My eye
There will be a new PS, probably with another name. In any case, the
eye problems are diagnosed as keratoconjunctivitis
sicca, quite possibly as a part of Sjoegren's
syndrome, which is a fairly common complication of ME/CFS, but
exists independently from ME/CFS.
necessary corrections have to be made later.