c’est la vie…

Posted on Friday 2 November 2012

Dubrovnik CroatiaThe story of how my wife and I ended up on a Mediterranean Cruise in our early thirties on a ship filled with British "Holidaymakers" would take up several pages, but have nothing to do with why I mention it. The trip started in Split Yugoslavia in the days of Marshall Tito, and stopped in various places in that country before moving on to the Grecian Isles and Athens. We spent several days in Dubrovnik, a treasure of a walled city on the Adriatic. It was our first trip to a certified communist country, and if that was communism, I was all for it – great food and wine, a spectacular ancient city full of friendly animated people [who would barter and trade for anything, any time]. The Yugoslavians were little different from the Greeks or other Mediterranean people I met on other travels. I had no clue that there was no such entity as Yugoslavia, that it was really an amalgam, that the seemingly uniform culture of people were waiting for Tito’s communism to die so they could get back to the business of ancient ethnic wars and would be slitting each others throats in the not too distant future. We thought we were in a real place, but it was an illusion created in the aftermath of the World Wars – one that exploded as quickly as it was formed when circumstances allowed. We watched the destruction of Dubrovnik twenty years later on television in stunned disbelief.

The story of why I was reminded about that trip is as convoluted as the one that explains why I was there in the first place, or how I ended up on a french web site last night called stop-dsm.org. But once in a new place, there are often unexpected treasures. It’s the fun of traveling, even on the Internet. I recently mentioned that I was an anglophile, but I’m a closet francophile too. I love reading Sartre, Camus, Foucault, Derida, Lacan. I can rarely tell you clearly what they said later, but in the reading, I am captivated, and I do remember the music even if the lyrics fade away. Like my trip to Yugoslavia, it’s something of a magical mystery tour.

The stop-dsm site/group is a consortium of french mental health types – psychologists, psychoanalysts, psychiatrists – who are not just opposed to the DSM itself, but oppose its influence on the International Classification of Diseases [ICD-10] as well. Unlike other critics, they don’t pick at various diagnostic entities, or even the versions [III, IV, or 5], they’re opposed to the whole thing. They don’t say it quite this way, but they see Dr. Spitzer’s solutions and compromises as a ‘dumbing down’ of mental health diagnoses. Rather than trying to synopsize their points [and failing], I’ll point to their Manifest which summarizes all things. It’s called:

The term “psychical or mental suffering” cannot be confined to the traditional definition of “illnesses,” because it may impact anyone and everyone. The World Health Organization has deemed it a major priority, but then initially engaged itself in the struggle against it via a one-sided choice which views the Manual issued by the APA (American Psychiatric Association) as grounded in science. WHO’s restrictive choice bears the generic name of “DSM,” or Diagnostic and Statistical Manual of Mental Disorders, the third version of which stigmatizes conflicts that are important to psychiatric evaluation, and is contemporaneous with the treatment recommendations of the behavioralists and practitioners of CBT. Since its methods are not clearly delineated, they are also contributing to the promotion of an indispensable pharmacological accompaniment…
I recommend getting in a french frame of mind and reading the whole thing. If you read French, I’d suggest the french version. I can barely still read French, but English translation of french prose always loses some of the music.

So maybe now I can explain why I thought of that trip to Yugoslavia in my late youth. I saw something artificial but I didn’t know it. It was a false unity forged for reasons of historical necessity and maintained by force. It contained the roots of failed monarchies, ethnic and religious hatred, the early 20th century conflicts between fascism and communism – all unresolved for more than a generation until they could later see the light of day. Reading the stop-DSM Manifest, I felt the same way. The authors weren’t afraid to be psychoanalysts or psychologists. They scoffed at phrases like "evidence-based" as a trick. They openly pointed to the hegemony of the Cognitive Behaviorists and the Psychopharmacologists in the DSMs. It reminded me of the heated debates we had in the 1970s [and all enjoyed]. And while it felt very french, it also seemed very real.

I personally loved the eclecticism of psychiatry when I arrived in the early 1970s from the world of Internal Medicine and hard science. I could and did read Freud, Kernberg, Beck, Kraepelin, Bleuler, Psychopharmacology Texts, Carroll’s Dexamethazone Suppression Test, Bateson, Bowlby, Ellis, Liang, etc. and learned something from each without having to resolve the unresolvable. In the morning I was a crisis intervener in the ER, then on to the wards where I was a biological psychiatrist. In the afternoon I was a psychodynamic psychotherapist with my outpatients, and that evening I ran a group and thought about Bion, help-rejecting complainers, and scapegoating. Early on, it was like there were a universe of ways to think, and my task was to find the one that fit the circumstance. Later, it became disconnected from its outside roots and became just the way I thought, my toolbox, constantly modified by cases and the new things I read. I got smarter and dumber at the same time, and it was just my cup of tea. The coming of the DSM-III and its revolution changed the world I lived in, but I’ll admit that it had no real impact on my thinking about people. I understood its political and fiscal roots, but it was clinically immaterial. And though I learned the nuts and bolts to take my boards and talk to trainees, I didn’t buy the book and I never thought about it in my decades of practice when I was in the room with an actual patient.

I’m now retired and pretty well versed in the DSM history, but that’s latter-day learning. I acquired used copies of the DSM II, III, IIIR, and IV that I bought and read as part of writing this blog. I get why it happened, what it was intended to be, what it became. I can explain and calculate kappa. I think Dr. Spitzer and Frances did some amazing things and have included them both in my pantheon of thinkers. But I still see patients and I can’t actually recall the DSM explicitly coming to mind when I’m in the clinic, even now. It’s an academic exercise for me, created to write this blog about the perversion of science in modern psychiatry, but the DSMs themselves are experience-distant from my doctor self. That’s just the way it is and always has been. I have lots of old friends who are Social Workers, Psychologists, Pastoral Counsellers, Biological Psychiatrists, etc. and have some new ones made in the course of writing this blog. I respect them all as clinicians and I think it goes the other way. I remain a part of the psychoanalytic community, but am hardly the cardboard Freudian I read about. The mind brain dichotomy lives in my head. I still go for bio-psycho-social as a model. I’m a decent Neurologist when the need arises. I’m sure I’m a different clinician than I was in 1980, but the DSM had no part that I know of in that. I write this paragraph in celebration of feeling somewhat liberated by this reading to be the mental health mongrel I really am.

So back to the stop-DSM Manifest. As I read through it, it had the french penchant for a certain kind of drama, sure enough, but I really enjoyed it [including the drama]. I found myself smiling along the way, once actually even laughing out loud. I personally see the kind of open-mindedness I called ‘eclecticism’ as an essential ingredient in working with the infinite variety of patients that come looking for help – a strength rather than a weakness. The DSM feels like a straight-jacket rather than an aid. Categories and classifications are essential to organizing all of the information needed for the task at hand, but there are so many of them and each one has a potential place in the preliminary meeting with a patient. They help get you in the ballpark, but none are up to the task as things progress and you get to know the unique person you’re with at the time. That may sound kind of hippy-dippy [or maybe even french], but to me it’s as scientific as Newton and Einstein. The DSM, particularly the DSM-5, is directive rather than classificatory. They even say it eg they want to include Grief with Major Depressive Disorder to make sure we treat it. Who needs that? It’s not a treatment guide. But I digress. Here’s a piece from the stop-DSM Manifest:
A methodology with zero clinical validity

The DSM’s repertories of “disorders” and “dysfunctions” only furnish psychical or mental suffering with surface level clichés. There is no branch of medicine in which a practitioner would diagnose an illness founded solely on the manifest expression of a symptom. Since information provided by regular patterns (invariances) are avoided on principle, surface descriptions are multiplied: this so-called “Evidence Based Medicine,” which claims to favor evidence in pursuit of greater effectiveness, reveals its true goal by limiting clinical explorations to the most superficial evidence, and by mixing up elements of otherwise heterogeneous orders (particularly the clinical and moral): take for example the comment by Dr. Roger Misès about “behavioral problems, “ which he refers to as “incivility” cum illness.

The result is an inflation of “disorders,” an inflation which corroborates the aforementioned absence of scientificity, since an authentic scientific initiative enables us to delimit a large variety of manifestations to a few clinical types whose number has been reduced.  From the 106 pathologies listed in the version from 1952, the DSM’s current version now identifies 410 “disorders.” DSM-V, which is currently being developed, should log at least twenty-some additional categories. In terms of mental pathology, it has constructed various “false positives” whose sole beneficiaries would appear to be the pharmaceutical companies. What is more, this inflation is nurturing the birth of catchall concepts that justify sometimes dangerous and stigmatizing treatments for children.

In prior versions of the DSM, a clinical category as constant as hysteria, witnessed to by the experience of Antiquity even, was deleted. In similar fashion, neurosis has no longer been included since 1980, although homosexuality would have to wait until 1987 to no longer be viewed as a mental illness; the date when, paradoxically enough, sexuality itself lost its status…All this leaves us with the idea that these statistics refer more to American culture, its norms and its fashions, even as the DSM’s psychopathological categories reveal their international ambitions. Indeed the WHO plans to impose the application of the ICD on a global scale within the next few years.

As for the planned DSM-V of the future, new and entirely dimensional categories are being invented, based on the amplitude of the manifestations it deems pathological, such as “hypersexuality disorder” and “coercive paraphilia disorder.” Even more troubling still, the addition of “predictive factors” as portents of “future disorders.” Each of us will thus potentially be ill and thus candidates for preventative treatment. The pinnacle of this vertigo-inducing inflation is no doubt reached with the invention of “risk syndromes” such as “psychotic risk syndrome,” which goes from prevention to prediction by calling for the systematic prescription of psychotropic medications at non-negligible doses for adolescents who are deemed atypical. And all this despite the fact that no field test has even shown its usefulness. Such an expansion of pathology might even be deemed against Human Rights.

So I was freed up by the trip to stop-DSM. I found myself thinking later that the DSM-III and the earlier revisions were a negotiated peace among a diverse group of mental health practitioners in a time of war. It may have saved our asses in the initial encounter with Managed Care, but it created only an illusory Yugoslavia-esque unity – volatile but contained. And I’m thinking that the reason this DSM-5 has aroused such a specific explosion of opposition is that it breaks the unspoken treaty by being so heavily driven by one closed-minded group of compromised ideologues who don’t understand what it was for in the first place. To borrow my own metaphor, it’s an arrogant offering in a time for humility. They thought it was theirs to own, and I predict they’re going to end up doing just that – having it all to themselves.

C’est la vie
    Joel Hassman, MD
    November 2, 2012 | 3:09 PM

    Maybe I am the only one who thinks this way, or, maybe I am the only one who has intestinal fortitude to say it somewhat publicly at sites like this, but, most psychiatrists don’t care or don’t have strength to speak out against what surely is a small minority of colleagues who are pushing agendas that benefit few but disrupt many.

    I am at a point in my life when I hear someone say, “if only I knew this would be a problem/issue/conflict , I would have done something sooner”, well, to any and all who say that but don’t sincerely mean it because such person didn’t want to accept an overt truth or situation, or expend any energy to really take action look up the word “disingenuous” and if you have the ego strength to look inward, you’ll see it fits such attitude.

    Again, maybe I am the only one who sees the future as coming, but if PPACA stays as set, psychiatry is gone by 2016 at the latest. And all antipsychiatrists who might find that a wonderful outcome, well, get ready to redirect all that outrage to the non psychiatrists who will be substituting for our alleged transgressions who will do even more harm than we supposedly do now with even less training to handle mental health problems.

    Oh yeah, that is already happening now, sorry, I didn’t want the truth and facts to hurt peoples’ feelings. The road to hell is paved with good intention. Well, guess what folks, the US government is paving that road with human flesh as we speak!

    November 2, 2012 | 5:33 PM

    1 boring old man is the most enlightening of psych-blogs, certainly not boring. Thanks to Mickey from an old woman up north in Norway, naively trusting the reigning bio-bio-bio shrinks who then drugged and killed my kind, loving, deeply unhappy young son, pretending that they were experts, without asking about his life his relationsships.
    Learned Hand, the American judge, once said that things have gone too far when lay-people can see what professionals don’t see – or won’t see…
    Our saddest experiences are validated by honest, courageous professionals, and
    heralds – hopefully – a new area without the rampant abuses and corruption of medicine and of psychiatry,

    November 3, 2012 | 2:17 PM

    As a fairly new reader, I’m very appreciative of your analyses.

    I attempt to use reason and look for plausibility and evidence to evaluate claims but, as a psychiatrist, I have to face the fact that evidence is lacking in much of our field. And that’s mighty uncomfortable.

    Part of my work involves reviewing the practices of other psychiatrists. My impression is that many jump on the DSM-bible bandwagon in order to relieve ambiguity. That involves putting aside what we know about the “leaders'” ego and financial motivations and about the lack of evidence for their claims. The DSM religion is more comfortable than not knowing. And once it’s published, it becomes “truth”. When I speak with them, I hear very little about the patient.

    Interestingly, as a Canadian, I frequently read French psychiatry reports. The further the writer is from U.S. culture (Franco-African/Parisian>French-Canadian from francophone provinces>French-Canadian from anglophone provinces> anglophone), the more likely I will come away with an understanding of the patient as a person in trouble.

    November 3, 2012 | 2:37 PM

    Thanks for that analysis. I expect what you say is dead on, though sad to this just plain American. We’ve headed down some wrong roads here in the States. Capitalism and Medicine aren’t the best of mixes.

    November 3, 2012 | 8:46 PM
    November 3, 2012 | 8:48 PM
    November 3, 2012 | 10:15 PM

    Lacanians seem to me to have controversy-itis in remembrance of their founder who never met a person he wouldn’t fight. It’s a shame Lacan’s flamboyance and innate contrarianism is the legacy his latter day saints carry forward. He was actually a remarkable thinker…

    November 4, 2012 | 1:22 AM

    I am not familiar with Lacan’s work. However, the discussion of some of his work in Fashionable Nonsense (Alan Sokal) was concerning. Several pages of Chapter 2 (page 18) are available online on Google Books (search Lacan within the book). Worth a look, though I know it’s off topic.
    Speaking of off-topic, couple of other articles you might find interesting:
    That also talks about this:
    The dichotomy of “non-hippocratic” vs “hippocratic” seemed useful, as did the description of the ascendancy of the former in American psychiatry.

    November 4, 2012 | 2:35 AM

    Non-Hippocratic vs Hippocratic

    Primum non nocere

    That brought me back to these 2 paragraphs from that amazing editorial in The Spine Journal:

    “Clearly, the entire concept of peer-reviewed literature, systematic topic reviews, and evidence-based clinical decision-making rests on the assumption that the published literature being reviewed has sufficient integrity to make the exercise worthwhile.”
    “The core of our professional faith, as Spengler points out, is to first do not harm. It harms patients to have biased and corrupted research published. It harms patients to have unaccountable special interests permeate medical research. It harms patients when poor publication practices become business as usual.”

    It was righteous. In a good way.

    But, is righteousness effective?

    Is seems that doctors value feeling “skilled” and “effective,” and having a feeling of mastery, over feeling “virtuous” or “righteous,” and having a feeling of uncertainty.

    Dr. Stahl appears to be a master at helping people feel the former. Understand the mechanisms and be a master psychopharmacologist. In a way the DSMs support the former. As does the attitude that the psychoatric literature has NOT become deeply biased and corrupted.

    The former must be a greater comfort to doctors when faced with a patient. The belief that there is a literature that, filtered through their critical professional acumen, supports proper treatment. That you’re a master pharmacologist. Versus the message of this blog that seems to be: you’re a chump. A well meaning doctor who would be outraged if you realized what had been happening to the field for the last 10-15 years and how your literature has become biased and corrupted to a very large degree. Doesn’t that still make them a chump? And it’s not like there is a vast storehouse of trustworthy studies of highly effective treatments out there just waiting to be set free. It’s going to take a long time to build up a literature that can be trusted to a greater extent. A very long time. That’s got to feel terrible.

    Who wants to feel ineffective?

    Dr. Stahl and his ilk make doctors feel more effective and more confident. You’re putting forward a message that doctors, particularly psychiatrists, can’t trust most of their literature or most of their expert peers. A lot of doctors probably have the sense that there is influence out there. But that is qualitatively different than realizing just how deep and pervasive that impact actually has been, and continues to be. How much that is truly warping mental health care.

    KOLs like Nemeroff and Stahl make doctors feel good. Drug reps make doctors feel good. Etc.

    The red pill or the blue pill?

    “Actually, I’ve been thinking it ever since I got here: Why, oh why, didn’t I take the Blue pill?”

    berit bj
    November 4, 2012 | 6:46 AM

    Cargo cult science versus integrity, personal integrity, scientific integrity, that is the question.
    The late Richard Feynman’s commencement address at Caltech ages ago, in the seventies set the standard in plain words.

    November 4, 2012 | 12:18 PM

    Berit BJ, Thank you very much for this reference. It really does set out the choice in plain words. It’s a “must read”:
    I still stand by the concerns I raise above. Those driven to take the red pill already have. KOLs, pharmaceutical companies, marketers, anyone seemingly who succeeds at influencing others on a large scale seem to work through extending what people already want to believe and using that to their advantage. Who wants to feel shame? “You can be even more super than you already are” seems much more attractive. Take the blue pill AND it’s good for you.

    Ben Goldacre’s Bad Pharma, Bernard Carroll at Health Care Renewal, even this blog seem I have part of the equation: they are a hell of an entertaining read. If there were a way to have physicians come away with the feeling of enhanced effectiveness and that things are right with the world, AND move them in the direction that things need to go that would be a neat trick.

    Stahl uses the term “pharma scold.” Stahl is a very intelligent man who chooses his words carefully. He’s knows that the message of psychiatrists unfairly besieged by pharma scolds will work better than the message of psychiatrists being “pharma dupes.” he’s offering the blue pill. And you’re offering the red, with the added bonus of personal responsibility for not having woken up to the problem sooner and being part of the group that inflicted it.

    And it’s surprising there aren’t more paychiatriats lining up asking where do they sign up?

    Someone needs to take what is on this site, at Heath Care Renewal, and in Ben Goldacre’s new book and figure out how to MARKET IT to psychiatrists.

    It seems like this site is predicated in part on the idea that things will play out better if physicians as a whole become a constructive part of promoting true data transparency and truly effective disclosures. Rather than simply having it forced upon them over and over.

    That will take more than preaching to the converted. That’s necessary, in order to give the converted some hope that they are not alone. But the fact that the vast majority of psychiatrists are CHOOSING to stay blind to how bad things are (buy into Stahl’s beseiged by pharma scolds argument, even of just slightly) is saying something important.

    The truth will set you free to feel crappy doesn’t seem to have been a very successful approach with physicians. N’est pas?

    November 4, 2012 | 3:09 PM

    Oh, the French. So very excellent at incendiary philosophical thought.

    Annonymous’s proposal above is what the Carlat Report could be if it weren’t …. commercial.

    Somebody needs to wade through the manure and find the tiny gold nuggets hidden therein and, if I might extend this metaphor to a nauseating extent, spoonfeed them to the psychiatric profession, which has gotten so used to being spoonfed.

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