Despite some last-minute changes, there are big problems, says Allen Frances, who led the task force that produced D.S.M.-4.
[T]he 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. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts....
Frances rejects the accusation that the D.S.M. is "shilling for drug companies":
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....
Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists....
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The author of the NYT writes, "We need some equivalent of the Food and Drug Administration to mind the store and control diagnostic exuberance."
That's the ticket. Control and govern. The FDA, after all, is such a stellar organization. Now let's build a control structure over the touchy-feely, wobbly, pseudo-science of psychiatry.
Oh, damn... It looks like we're fast approaching the end of psychiatry.
Anyone have a suggestion for our new shamanistic class?
Read "The Psychopath Test" by Jon Ronson and be terrified about the havoc the DSM can and does wreak.
Another priesthood collapsing under its own corruption.
See anything Thomas Szasz has written or said over his professional lifetime.
I assume school which identify ADHD behavior and recommend doping up kids on Ritalin and other drugs use DSM criteria as its bible.
First we had real honest-to-gods shamans and their enforcers who liked to be called kings. It was fork over your goods and chattels and your virgin daughters an we'll give you rubes the skinny. Then we got philosophers for a while and things began to improve, until some nitwit got himself nail to a post and we got priests and kings again. Only this time the priests took a few lessons from the philosophers they'd displaced and things weren't so bad as Priests and Kings I -- at least we weren't building pyramids. We were building temples and palaces and castles. At least you can get out of the rain in a temple. But then we got philosophers again and thing got brighter for a while, but then that guy Rousseau showed up and it began to stink a bit. The stink got worse with Marx. Then we got a whole new class of shamans, the psychiatrists. They had a stink about them as well, but it wasn't as bad as the miasma hanging about Marx -- like mild BO versus five day old fish. Now the BO has ramped up to sewer-worker-who-hasn't-showered-in-a-month level. What next?
This incredibly self-serving article only mentioned insurance companies in passing; yet if mental health care wasn't paid for by them, the DSM would have little reason to exist.
Every healthcare provider dances to the tune of the insurance companies. The DSM is the sheet music for the mental health care gavotte.
Hmmm,
The only thing I can say is that every discipline needs a standardizing body. Computer languages are usually standardized, even some proprietary languages such as C#, and it's a good practice.
I note the writer is all for the last 2 standards, which rejected the influence of psychoanalysis, so maybe he has an axe to grind.
But if you admit that it is possible for a point to be improperly moved from one side of the line to the other, you've thereby tacitly admitted that it is possible for a point to be improperly moved from the other side of the line to the one.
Think about it.
It renders the entire D.S.M. meaningless except as a weather vein for popular sentiment.
Which, to historians and philosophers of science, is no great revelation.
People seem really angry about psychiatry.
I agree that we should resist medicalizing what is normal, but that abomination is not limited to psychiatry.
The government and NGOs require medical workers to ask about all sorts of things that are not medical, like whether you have a gun, if you wear seat belts, use bike helmets, have an advance directive, what your sex life is like, etc. arguments can be made for all of it, but much of it is data gathering for no good purpose other than nanny-ism.
No one can seriously argue that there are no depressed or psychotic people, or ignore that there are people desperate for help, trauma survivors literally unable to leave their beds, and deny that medicines and therapy can be helpful for them.
Expanding the scope of psychiatric oversight is stupid, but that is not evidence that no one is mentally ill.
When I was beginning medical school, I met one of the two or three most impressive people in medicine I have ever known. He was a psychiatrist and clinical professor at UCLA. His name was George Harrington and many of his ideas were written down by one of his residents, named William Glasser in a book titled "Reality Therapy." When my wife was teaching in the early 60s it was highly recommended in the Los Angeles school district. That, of course, was before teachers' unions. The book is still in print.
After my experience with Harrington, I decided that psychiatry was a field I was very interested in. Then I met other psychiatrists. I quickly lost interest.
"This incredibly self-serving article only mentioned insurance companies in passing; yet if mental health care wasn't paid for by them, the DSM would have little reason to exist."
Excellent comment. In the days I was referring to above, insurance did not cover psychiatry and most inpatient care was in state hospitals which no longer exist.
You are tempting me to wade in, Pogo, with that slipperiness of yours, tempting - but I gotta get on.
Pogo & Michael K represent opposite ends of the spectrum--spotlighting the dilemma of psychotherapy, i.e.,just when one needs it the most as a social guide, it is least useful. By this I mean that, just as in the Dylan lyric that one "doesn;t have to be a weatherman to know which way the wind blows" one doesn't exactly need a PhD in Psychology to spot the obvious extremes at either end of the mental spectrum--the Ozzie & Harriet "normals" on one end and the rubber-room candidates at the other. But as for those gray areas in between--when the "science" of psychology is most needed--psychologists are LEAST useful--either remaining silent or wildly disagreeing amongst themselves. (Remember the trial of Regan's would-be assassin in which the tyestimony of the "experts" was EVENLY split as between those describing him as sane and those who did not?) Based upon the observable track record of its practitioners, the general public is right to be wary and sceptical about the claims of the profession..
I do not agree that the middle area is where psychiatry is needed most.
It is needed somewhat, maybe not at all. Pathologizing normal human suffering as mental illness is mostly done to get paid for counseling. Health insurance demands discrete diagnoses for payment, and thus you get bullshit.
Sanity is a legal not a psychiatric definition, and psychiatrists are no better than anyone else at picking it out. Lawyers led us down that idiotic path, and some psychiatrists were glad to get paid for the charade.
@POGO/
Would tend to agree in terms of the legal systems' inability to come to terms with mental disorders. The Andrea Yates trial (the Texas lady who drowned her five children saying God told her to do it) is a classic case proving your point, Pogo.
@POGO II
And what do you think of the ethics of the state forcibly making a prisoner like Yates take her meds while in prison when the defense was claiming to use the insanity defense, thereby having the jury view the more "normal" Yates sitting before them on her meds, rather the un-medicated person Yates actually was at the time of her acts?
@virgil:
Yes; the Yates debacle exposed the incompetence of psychiatry in the legal realm. We are better served by removing the psychiatrist as an expert on issues that define legal culpability. They are no better at it than the man in the street.
And coercing her to take meds is shameful, another charade.
DSM-5 does something interesting that may or may not make sense. It says nobody is perfect. Everyone is weird. When-and only when--that becomes a serious problem, the weirdness becomes a disorder. At that point, money should be spent to hire an expert to help deal with it.
Of course, any lawyer realizes that determining when something is a serious enough problem will now become a big deal. Kind of like determining "negligence."
As psychology moves further away from a subjective discipline, and moves more towards a discipline that uses more reliable scientific methods, I hope the legal system matches the evolution of the profession. I'm not the most unbiased debater on the issue. I have a family member who I personally know to be both mentally retarded with an IQ around 70 and mentally ill, with frequent hallucinations and delusions, who ended up being convicted of a very serious crime. The shrinks split both ways, and the benefit of the doubt goes to the state in those cases. She was eventually granted clemency and released early into psychiatric care, and I look forward to the day when things like MRI brain scans and physiological tests can accurately describe mental disorders, especially for determining whether or not someone can have the mindset necessary to be criminally culpable in the first place.
I'm convinced that we're all fucked up and that's what makes life so rich. However, there is a minority who is dangerously and/or sociopathically fucked up and who genuinely need help (as do those often dealing with them.) Like so many other areas, those truly in need are lost in the mad rush to pathologize everyone.
Well. I've been reading THE EMPERORS NEW DRUGS by Irving Kirsch. The data are so compelling they are only eclipsed by the magnitude of guilty knowledge among the apparent orthodoxy that seems to have cartelized these clinical and market channels.
How interesting the latest DSM (typically conforming to the financial interests of the dominant university medical school cultures) seems ready to unleash an orgy of funding as the biological model of depression appears to have collapsed under years of data which impeach the gospelized clinical and academic liturgy about the physiology and nature of human depression and anxiety. Kirsch writes from the belly of the beast after a lifetime of amassing the credentials to do so.
This become even more troubling when one considers other data that indicated prescribed drug induced conflict avoidance resulted in arrested or otherwise failed trustee behavior.
Either way you look at it, it seems to explain much about the worsening aberrant behavior in Congress and professionals entrusted with significant institutional or corporate authority.
But could I have gotten all the above wrong? Maybe so. Just my opinion about what I recall having read so far. Still, it does seem like Kirsch and colleagues got it right. And they enormity of what that means says loads about the postmodern university med schools. Thanks to Ann and Meade we saw some of this culture last year when the university doc's handed out 'get paid today anyway' scripts to the Madison union protesters.
"It is needed somewhat, maybe not at all. Pathologizing normal human suffering as mental illness is mostly done to get paid for counseling. Health insurance demands discrete diagnoses for payment, and thus you get bullshit."
I agree completely. In the days I referred to, psychosis, which is real, was almost the only diagnosis accepted. Harrington said neurosis was just normal people being unhappy. He had a private practice that was almost all psychotics. I even remember him getting calls from the State Department about crazy relatives of diplomats.
When insurance entered the picture, all that changed. The state hospitals were closed by people who didn't think there was any real mental illness. Believe me, I've spent some time talking to really crazy people. The drugs that came along about 1960 made things worse because they worked but had severe side effects. Psychotic patients would stop taking them and get crazy again. The strange thing was that they knew they had been crazy (and that was the term they used) when they were taking the drugs but had no insight when they weren't.
The drugs are better now but the battle has been lost for a generation. Relatives of psychotic people beg for treatment of their family members but are powerless for the most part.
The insurance fraud is amazing. I was once on a panel reviewing claims for the military health care system. Psychiatrists would ship teenagers home from Guam and hospitalize them for typical teenage rebellion behavior. The cost was enormous.
Hmm, so the much mocked Tom Cruise wasn't completely wrong then?
This inability to reach a diagnosis seems to be symptomatic of generalized and intractable tomfoolery.
'promises to be a disaster... it will introduce many new and unproven...' if heard with the original operatic music might be more easily understood to be what in standard English might be "I have some concerns." The balance of Dr. Frances' comments might be taken as saying others have to participate in saying what the diagnoses might mean in their contexts, an ethical and democratic point. The innovation starting with, possibly, DSM-III is that diagnoses have one or two anchoring criteria that are pretty much sine qua non of diagnosis accompanied by other elements, a certain number of which but by no means all and varying with diagnosis should be found. Thus, for instance, a person with a certain diagnosis is likely to respond to drug that the FDA, responding to double blind data sets, has found indicated for that diagnosis. Errors more frequently are made by not following or perceiving the present diagnostic criteria.
It would seem that this discussion is akin to butchering a pig after determining that the carcass needs to first be frozen followed by submission to a band saw or the carcass should not be frozen and then submitted to disection by an experienced anatomist. The former arguements supported by the judiciary, the latter by medicalists, but in reality selected by the housewife.
"I look forward to the day when things like MRI brain scans and physiological tests can accurately describe mental disorders. . ."
Spect scanning can do much of that today. Psychiatrists, of course, generally reject the idea. Every other medical focus uses images of the affected organs, but Psychiatry actively resists the same.
You can look at some SPECT scans at brainplace.com
Trey
It is so weird to see it written DSM4 instead of DSMIV.
I think it's really easy to read the descriptions of mental illness and go all med school syndrome on them, but when you meet someone with real problems it's totally different from normal behavior.
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