where are the psychiatrists?…

Posted on Tuesday 27 December 2011

Therapists revolt against psychiatry’s bible
Mental health professionals say new diagnoses will lead to overmedication
By Rob Waters
Dec 27, 2011

… the DSM-5, is slated for publication in May 2013. As the task force producing it has posted drafts on its website, an undercurrent of dissatisfaction has exploded into a full-scale revolt by members of U.S. and British psychological and counseling organizations. The chief complaint is that the newest version will lower the criteria needed to diagnose some conditions, creating “subthreshold” disorders, and generally making it easier for healthcare professionals to label a person with a psychiatric disorder and medicate him or her.

The latest rebellion against the DSM-5 began with a salvo from across the Atlantic. In June, a special committee of the British Psychological Society complained in a letter to the APA that “clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences.” The committee criticized the proposed creation of an “attenuated psychosis syndrome”—a sort of poor-man’s psychosis with less severe symptoms — “as an opportunity to stigmatize eccentric people.” They also objected to a proposed reduction in the number of symptoms needed to diagnose adolescents with attention deficit disorder because it might increase diagnoses and the use of meds.

Then David Elkins, professor emeritus at Pepperdine University and president of the Society for Humanistic Psychology, a division of the American Psychological Association, formed a committee to discuss similar objections and draft a petition enumerating them. In October, he posted the petition online. “I figured we’d get a couple hundred signatures,’’ Elkins said. The response stunned him and his colleagues. The petition attracted more than 6,000 signatures in three weeks; as of mid-December it had topped 9,300 signatories and garnered the endorsement of 35 organizations. On Nov. 8, American Counseling Association president Don Locke jumped in with a letter to the APA objecting to the “incomplete or insufficient empirical evidence” underlying the proposed revisions and expressing “uncertainty about the quality and credibility” of the DSM-5. “This has become a grassroots movement among mental health professionals, who are saying we already have a national problem with overmedication of children and the elderly, and we don’t want to exacerbate that,” says Elkins…

David Kupfer, the University of Pittsburgh psychiatrist who chairs the task force overseeing the manual’s preparation, says he expects the final number of disorders included in the DSM-5 to be about the same as in the current book. He says he welcomes the criticism and that nothing is final. The task force has been testing proposed new diagnoses in 2,300 patients at seven adult treatment centers and four adolescent centers that are acting as field-test sites, he says. “There’s a myth that all the decisions have been made, when in fact, all the decisions haven’t been made,” he says. “Just because [things have] been proposed doesn’t necessarily mean they’ll end up in the DSM-5. If they don’t achieve a level of reliability, clinician acceptability, and utility, it’s unlikely they’ll go forward.”

The most surprising critic of the DSM is a one-time pillar of the psychiatric establishment. Allen Frances, professor emeritus at Duke University, chaired the task force that created the DSM-4. Now he’s railing against both the process and proposed content of the new DSM in blogs on the website for Psychology Today that blast the new revision as “untested” and “unscientific.”  Psychiatric diagnoses are loose enough already, Frances  told me, and that laxity has led to “epidemics of over-diagnosis in child psychiatry” causing huge numbers of children to be unnecessarily labeled with attention deficit disorder and bipolar disorder and treated with medications. “DSM has to be a safe, reliable and credible guide to current clinical practice,” he says. “It can’t be an untested program for future research.’’

The user revolt against the DSM-5 has emerged as a major challenge to the document, Frances says, and its future is looking unclear. He and Elkins are proposing that an independent committee of experts review the proposed draft and make recommendations. The fight over the DSM-5 pits some of the greatest minds and biggest egos in the world of psychiatry, but it’s more than a battle among 301.81s [narcissistic personality disorder]. For people seeking help for life’s problems who don’t want to be labeled mentally ill or have their treatment limited to medication, and for clinicians who want to help people without reducing them to a category, the stakes are high.

Not bad coverage for a holiday week. But it’s unclear to me why there’s so little psychiatric noise about the DSM-5. Are we simply settling for our lot and waiting to retire? My guess is that it’s a bit more complex than that. The everyday psychiatrist has been hammered for decades having to readjust to the role of medication manager for others – out of the role of primary care-giver. Hospital psychiatrists have only a few days to adjust medications before the "days" run out. My guess is that the general gist of attitudes might be in the range of "demoralized." Who cares about the DSM-anything? It’s just a number for the form. Office psychiatry has become more bureaucratic and administrative than medical. And the bruhaha about the DSM-5? Just some more anti-psychiatry. Create a specialty that is only allowed to medicate, then complain about medication. A specialty only reimbursed for short visits, then complain about short visits. I expect that’s how things must feel to many who have adapted to the modern world of medicine. It’s a shame…
    December 28, 2011 | 12:20 PM

    As a (relatively) young psychiatrist, I couldn’t agree more. I resent the fact that I’m seen as primarily (or, in some settings, solely) a source of (a) diagnoses and (b) medications, when in fact (a) our diagnoses are imperfect and always will be (hence the DSM-5 brouhaha) and (b) our medications are– well, your blog says enough about that. 🙂

    Are we “settling for our lot”? Judging by the attitude of most of my peers, colleagues, and teachers, yes. And I predict that our “lot” is to be defunct or irrelevant within my own generation.

    But the spectrum of psychological/psychiatric problems (or, if you prefer a gentler term, “suffering”) is so vast, so intertwined with medical illness, and so amenable to psychological (and, at times, psychopharmacological) approaches, there must be a future for psychiatry.

    I would amend your question to ask: where are the psychiatrists to create that future?

    December 28, 2011 | 7:07 PM

    Dr. Balt,

    This all comes down to the issue of trust (lack thereof)…
    There has been a great betrayal on the part of psychiatry.
    Psychiatrists may be unable to build enough trust to “create the future.”

    IMO, it will likely be created without psychiatry.

    The facts are out.
    They are not pretty for anyone who studies them (anti-psychiatry or anyone else).
    It may be impossible to get the toothpaste back in the tube.

    Psychiatrists may soon be replaced with professionals (and non-medical people) who are able to offer safer, more effective treatment options.


    December 28, 2011 | 7:53 PM

    I wonder if sometime you might write down your thoughts about the work of Thomas Szasz and Peter Breggin? I would just appreciate a more informed and experienced point of view than my own about their perspectives.

    December 28, 2011 | 7:57 PM

    Just a quick head’s up. I was watching The Young Turks (Current TV) Wednesday evening. Host Cenk Uygur and regular Ana Kasparian took an oblique swipe at the DSM V, and what we (the dirty masses) can expect from the field of psychiatry when they team up with Big Pharma—ever watchful of the bottom line. Keep up the good work. Like the drip, drip, drip of the Chinese water torture, I guess the secret of getting the word out is just to keep on keepin’ on. Thanks for all your work, supporting documentation, and viewpoint from inside the field—even if the viewpoint is not shared by all.

    December 28, 2011 | 8:48 PM

    As an interested layperson, I find it worrisome that more professionals are not speaking up. The last time I went to see a therapist (an MFT), some of the first words out of her mouth were, “Do you want any drugs? I can connect you with someone to get some drugs.” I was stunned and then joked, “Know where I can score some meth? Heard it works wonders!” She wasn’t amused. My work with her lasted 6 sessions and each time she pushed medication. I just wanted to talk.

    December 29, 2011 | 11:41 PM

    re: “DSM has to be a safe, reliable and credible guide to current clinical practice,” he says. “It can’t be an untested program for future research.’’

    It appears unconsented medical experimentation has reared its ugly head in psychiatry and other fields in the 21st century, medicine having learned little to nothing from abuses of the 20th.

    Untested programs for future research rings a bell about another major healthcare initiative – healthcare IT. See http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=readinglist

    December 30, 2011 | 9:57 AM

    Dr. Silverstein makes a powerful argument about Medical IT on the blog Healthcare Renewal. The trip from science fiction to useful science is made by increments of hard work with more failed experiments than successes rather that by declarations laced with irrational exuberance. His analogy between Healthcare IT and the DSM-5 process is a powerful one. I appreciate the comment…

    Joel Hassman, MD
    December 30, 2011 | 4:58 PM

    As Stephany pointed pointed out in a prior link in another thread, the APA stands to profit $10 million from this monstrosity. Has obscene and intrusive become the slogan words of this organization?

    December 30, 2011 | 10:08 PM

    i was re-reading earlier “1borings” and went to look at mediguard website to learn more about them

    did you mention that mediguard was also a means of recruiting patients for clinical trials? “connecting researchers and patients”

    MediGuard was created by professionals with decades of experience in healthcare market research, clinical drug development, and drug safety to help patients take a more active role in their treatment.” Initially funded by Quintiles Transnational, the world’s leading provider of clinical research services, the primary purpose of MediGuard is to promote better communication and research about drug safety. Specifically, the goal was to create a community of patients profiled by medication and condition that are both accessible and motivated to participate in research.

    We believe that the patient can play an important role in improving drug safety. Today, public and private organizations spend millions of dollars on drug safety research and risk management programs-often with disappointing results. At MediGuard, we feel strongly that connecting patients and researchers will allow us to conduct better, faster and more cost-effective research. Our end goal is to publish data that ultimately improves patient satisfaction, safety, and health.

    December 31, 2011 | 3:06 AM


    Yeah. In fact, that’s what Mediguard seems to be at its core, a stealth recruitment tool. The pitch asking for access to Clinical Records strikes me as the ultimate trolling tool [http://1boringoldman.com/index.php/2011/11/23/an-invisible-empire-ii/] – just one of the reasons to oppose EMR [Electronic Medical Records]. See Dr. Silverstein’s posts on the Healthcare Renewal blog…

    Nancy Wilson
    December 31, 2011 | 7:04 PM

    “where are the psychiatrists?…”

    in hiding?

    The Dallas Psychoanalytic Center’s website now requires viewers to log in. So much for transparency. The general public can still access the center’s archived newsletters via the Wayback Machine. The URL is http://www.dalpsa.org/

Sorry, the comment form is closed at this time.