brain circuitry, rather than chemical imbalance…

Posted on Thursday 1 March 2012

    My Third Letter to the APA Trustees
    Psychiatric Times
    By Allen Frances
    March 1, 2012

    This letter was sent to the APA Trustees and to the DSM-5 Task Force on February 12, 2012, under the title, “Heads Up And Recommendations.”

    DSM-5 press coverage has suddenly exploded—more than 100 stories from all around the world were published in just the last three weeks (see title and links below). The press is uniformly negative and extremely damaging to DSM-5, to APA, and to the credibility of psychiatry.

    The APA responses have been few, unconvincing, and lacking in substance. Also troubling, 47 mental health organizations have expressed their opposition to DSM-5 by endorsing a petition requesting it to have a scientific review independent of APA. And many users are planning to boycott DSM-5 altogether by substituting ICD-10-CM (which will be freely available on the internet). It is fair to say that DSM-5 has become an object of general public and professional scorn.

    What would Mel Sabshin be doing in this time of crisis? Of course, Mel never would have allowed APA to get into this mess—but once in any crisis he was an expert in damage control. Were he here today, Mel would certainly recommend that you immediately cut the DSM-5 losses to prevent its inflicting further damage on APA, on psychiatry, and most importantly on our patients.

    Fortunately, there is an easy and obvious solution. Before more harm is done, simply reject the 5 most questionable DSM-5 proposals. This would mean:
       (1) keeping the bereavement exclusion in DSM-5 (turning grief into depression is by far the biggest object of public concern);
       (2) not reducing further the threshold for already swollen ADD; dropping both
       (3) ‘attenuated psychotic’ and
       (4) ‘disruptive mood dysregulation disorder’ (because they both risk furthering the already excessive use of off-label antipsychotics in kids and also lack sufficient research support); and
       (5) not allowing the expansion of pedophilia to include hebephilia (which would create a forensic nightmare).

    The many positive results of finally dropping these worst and most dangerous of the DSM-5 suggestions would be immediate—the press quiets down; mental health professionals find DSM-5 less unpalatable; the risk is reduced of having the government investigate APA’s exclusive control of psychiatric diagnosis; the credibility of psychiatry is less tarnished; patients receive fewer inappropriate medications (and I get to drown my cursed blackberry in the ocean).

    Other serious DSM-5 problems would certainly remain–highly questionable DSM-5 proposals, distressingly imprecise writing, and forensic risks. But these are less dangerous, less likely to completely discredit DSM-5, and can be addressed and corrected in a less fevered atmosphere. In contrast, the worst suggestions simply cannot be defended and need to be rejected quickly before DSM-5 is ruined by them.

    As the responsible leaders of the APA, you cannot avoid your fiduciary responsibility to regain control of the staff and to rein in a runaway DSM-5 process. Continuing to do nothing means further loss of public and professional faith, dramatically reduced DSM-5 sales, APA budget shortfalls, declining membership, and potential loss of the DSM-5 franchise.

    Time is running out and things are fast approaching a point of no return.

    All of this was absolutely predictable and completely preventable 3 years ago. The longer you wait, the harder it will be to produce an acceptable DSM-5. Unless you act soon to make DSM-5 safe, the press, public, and professional reactions will undoubtedly just keep getting worse; there will be less time for correction, necessitating yet another DSM-5 publication delay; and the risks mount that the DSM’s will no longer be considered the standard for psychiatric diagnosis. You are reaching the point of “now or never.”

I know little of the DSM-5 franchise, the APA’s budget or its membership, and have little energy for the specifics of the DSM-5’s current obvious bloopers. But I do feel something of a passion about this particular revision effort that I haven’t felt for the ones that came before. I had no use much for the DSM-II [yes I was alive then]. I don’t mean that negatively, what I mean is I didn’t use it. The traditional psychiatric Diseases [Schizophrenia, Manic Depressive Illness, Melancholia, Alzheimer’s Disease, etc.] can be listed on the back of an envelope. The remaining classification of people and their ills hasn’t been like that for me – discrete diseases. It is much more like a matrix with way too many dimensions to describe, and I’ll not try here. So the DSM-III when it showed up wasn’t my cup of tea and I largely ignored it except to show others that I could read. I only thought about it when I talked with colleagues or filled out forms – not when I was seeing patients.

I’ve changed my mind about that. I now think the idea behind the DSM-III was sound. I recant. The DSM-III was a crude outing, but the idea of consensually validated descriptive diagnoses and uniform coding was useful. I think what they did with depression was inexcusable and destructive – but that was a localized problem. The later iterations didn’t do much for me, pro or con. I don’t think they made much difference from the prospective of a single practitioner with a particular patient base. Little changed, and the depression mistakes just continued untouched by more rational hands. But this DSM-5 Version does upset me. I’m not close enough to know about all the administrative snafus, missed deadlines, and secrecy – although when Dr. Frances called them to our attention, they’re as plain as the nose on your face.

It was late Summer and Fall before I figured out why I cringed whenever the DSM-5 Revision came up. It was reading things like this:

Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5
by David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.
American Journal of Psychiatry 168:672-674, 2011.

In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders,we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder. In A Research Agenda for DSM-V, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…

The seminal article by Robins and Guze on diagnostic validity, which proposed a classification of psychiatric illnesses based not on psychodynamic, a priori hypotheses but rather on external, empirical indicators, built a direct pathway to DSM-III. Their proposed classification steps included identifying core clinical features, conducting differential diagnosis to separate the condition from similar disorders, gathering laboratory data, assessing temporal stability of the diagnosis, and determining familial aggregation of the disorder. The resultant explicit criteria featured in DSM-III and subsequent editions have significantly improved our understanding of psychiatric disorders, but they did not come without a price. While diagnostic reliability has thrived, large-scale epidemiological studies have underscored the inefficiency of DSM’s criteria in accurately differentiating diagnostic syndromes, especially in community samples. With reification of the criteria through revised editions of DSM-III-R and DSM-IV, proliferation of diagnostic comorbidities and overreliance on the "not otherwise specified" category have continued…
Research Domain Criteria (RDoC)
National Institute of Mental Health
June 2, 2011

Over the past several decades, an increasingly comprehensive body of research in genetics, neuroscience, and behavioral science has transformed our understanding of how the brain produces adaptive behavior, and the ways in which normal functioning becomes disrupted in various forms of mental disorders. In order to speed the translation of this new knowledge to clinical issues, the NIMH included in its new strategic plan Strategy 1.4: “Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.” The implementation of this strategy has been named the Research Domain Criteria Project [RDoC]…

The field of mental health is on the cusp of a revolution, which is set to transform the diagnosis and treatment of mental illness and reverse the lack of major progress made in curbing associated ill health and death over the past 100 years, the director of the US National Institute of Mental Health, has claimed. “We are at an extraordinary moment when the entire scientific foundation for mental health is shifting, with the 20th century discipline of psychiatry becoming the 21st century discipline of clinical neuroscience,” Thomas Insel said before a meeting on the challenges facing mental health research at the Royal Society in London on 31 August…

The seismic shift had been driven by what he described as three “revolutionary changes” in thinking, the first of which was that mental illness was increasingly being recognised as a disorder of brain circuitry, rather than as a chemical imbalance, thanks to neuroimaging techniques and the discovery of some key biomarkers. Secondly, mental ill health was now recognised as a developmental disorder for which early intervention was vital, said Professor Insel, highlighting US research showing that 50% of study participants had reported the onset of mental health problems by the age of 14, and 75% by the age of 24. “We are still stuck with getting to the problem very late. The future will be about understanding the trajectory of illness so that we can identify the first signs before it develops into psychosis,” he said…
I’m a doctor that sees patients who show up because they hurt in their mentals. Most of them don’t have disorders of brain circuitry, I’m sure of that. Most of them will never be diagnosed with genetics, neuroimaging, cognitive science, and pathophysiology. I’m sure of that too. There are such patients, and I keep up so I won’t miss them when they come along, but they’re not the main stream of the patients that come for help. And I really enjoy reading about neuroscience, and hope that if they keep at it they’ll find some ways to use it effectively in some cohort of patients to help them get better. But right now, I’d kind of like the people who are constructing the DSM-5 to give us a classification we can use now, for patients we see now, with the conditions we treat now. This summer, I finally got it that this DSM-5 crew isn’t thinking about me or the patients I see. If I feel that way, one can only imagine how the vast majority of non-psychiatrist mental health professionals who are actually seeing and treating patients must feel. As a matter of fact, it was Dr. Frances’ efforts that brought a lot of them out of the woodwork to sign that petition at the upper left of this blog page, and their numbers are rising. How do the fantasies of clinical neuroscience types like Kupfer or Insel come across to them? They are like me. They use the DSM-whichever as a diagnostic manual too [at least they used to use it].

And the DSM-5 Task Force seems to have the idea that treatment is part of their charge. They want to eliminate "grief" as an exclusion because they want to remind me to treat patients if they get real sick – as if I wouldn’t know to do that. They want me to call weird people Attenuated Psychosis Syndrome because up to 30% of them might develop Schizophrenia. I know that, but I don’t want to pathologize the 70% that don’t. Might-be-gonna-be-something isn’t early detection, it’s labeling. They want me to call out-of-control kids disruptive mood dysregulation disorder as if they all have the same thing. I don’t think they do, but I don’t know. They don’t either. Two years ago, they wanted me to pretend the same kids were Bipolar and treat them with antipsychotics. Now they’re going to have DMDD to justify antipsychotics. I don’t question that some few of these kids are legitimately put on antipsychotics for behavior control, but I want that to be because there are no other options and I want the people using big medicines in this way to know what they’re doing and why, not hiding behind some faux diagnosis.

So I don’t like the science fiction neuroscience bent to the DSM-5, and I don’t like them directing treatment, and by the way, I don’t like them. They act as if their little corner of the world is the whole arena. They don’t make room for people like me who believe that the lives and minds of our patients are a big deal. And they make no room for the majority of our patients or our colleagues in other disciplines. I don’t like the way they‘ve responded to Dr. Frances, or Suzy Chapman, or anyone outside the clique. I know that some pretty known people have tried to get them to think about the inadequate way they‘ve dealt with depression, and have been ignored. I don’t like that a majority of them have been involved with industry and drug companies in inappropriate financial ways. It’s not just Allen Frances being ignored. He’s a proxy for the majority of mental health practitioners, the majority of our patients, and people like me – the psychiatrist who sees patients. That ought to be their constituency, not their neuroscience obsessed, future-think pals.

Our forefathers thought there were too many psychoanalysts in the upper halls of psychiatry – too much influence. Well, they were probably right. But they’ve been replaced by something much worse – a class of arrogant and controlling neuroscience insiders who have lost touch with the point of their being there in the first place. Dr. Frances ends with the phrase, "now or never." I expect they don’t even know what he’s talking about [that will mean "never"]…
    March 1, 2012 | 9:25 PM

    Okay, about this “disordered brain circuits” thing. Let’s follow it through grief.

    So your beloved partner of 25 years dies, week 3 goes by and you’re still weeping. At what point do your brain circuits become disordered?

    Are they normal, but when grief hits you an hour after your partner dies, they become disordered? Maybe they’ve always been disordered, but further damaged by this emotional shock?

    How about sociopaths, they may not feel grief, their brain circuits are okay?

    Or can your brain circuits be okay, but after you grieve for 14 days, they become disordered? Does this mean people with non-disordered brain circuits grieve only 13 days?

    Still trying to figure out where the disease process kicks in. Is feeling sad itself the brain circuit disorder?

    March 1, 2012 | 9:32 PM

    “They don’t make room for people like me who believe that the lives and minds of our patients are a big deal.”

    Unfortunately, “they” are not alone. There are plenty of psychiatrists who have drunk the Kool Aid and know absolutely nothing about the “lives and minds” of their patients. And it’s not surprising. It’s much too frightening to venture into that territory, when the DSM, pharmaceutical companies, and our teachers have given us such little guidance in how to handle it.

    March 2, 2012 | 8:19 AM

    These days I think neurologists care more about the lives and minds of patients than psychiatrists. Go figure.

    March 2, 2012 | 2:28 PM

    Attributed to Thomas Insel “mental illness was increasingly being recognised as a disorder of brain circuitry, rather than as a chemical imbalance.”

    Interesting how revisionism is progressing. How is the vast Talmudic commentary on “monoamine imbalance” going to be integrated with this new “brain circuitry disorder” idea? The authors of mountains of psychopharmacology nonsense, now that they’re neuropsychopharmacologists, have to claim they were actually talking about brain circuits. Looking forward to all kinds of sophistry as they attempt to maintain expert status.

    Having doubled-down on the monoamine theory for 20 years and lost the bet, psychiatry has lost all intellectual credibility. Serious clinicians don’t know what experts or research to trust. Brain circuits? Inflammation? SPECT scans? It all sounds like grasping at straws now.

    In the meantime, lousy drugs are being thrown at patients in stupid combinations for far too long. I hope everyone reading this supports universal health care, because the rise in iatrogenic diabetes alone is going to impoverish the patients you care so much about.

    March 2, 2012 | 4:04 PM

    Outstanding posting on the DSM-5 wrt bereavement can be found on this blog:

    Joel Hassman, MD
    March 2, 2012 | 5:31 PM

    I offer reading Olympia Snowe’s piece in the Washington Post regarding her decision to leave the Senate.

    I highlight the following comment in that piece I think applies to the way our alleged leaders in psychiatry seem to operate that mirrors what goes on in politics in general: “For change to occur, our leaders must understand that there is not only strength in compromise, courage in conciliation and honor in consensus-building — but also a political reward for following these tenets.”

    When you deal with people who are just outwardly narcissistic and paternalistic and have no interest in dialogue when legitimate concerns are raised, what do you do? Make them irrelevant. But, can people of substance and character take the risk to do what is right? So far, doubtful is the only fair term to use.

    March 2, 2012 | 6:50 PM

    Altostrata, you state: Serious clinicians don’t know what experts or research to trust. NEITHER DO PATIENTS AND LAYMEN.

    Further: In the meantime, lousy drugs are being thrown at patients in stupid combinations for far too long. I hope everyone reading this supports universal health care, because the rise in iatrogenic diabetes alone is going to impoverish the patients you care so much about. AMEN! (But as the anechoic effect is operant . . . the echo is very, very soft.)

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