the court of public opinion…

Posted on Thursday 15 November 2012

Leading psychiatrists question psychiatry’s diagnostic manual
Fox News
By Dr. Keith Ablow
November 12, 2012

With the new American Psychiatric Association Diagnostic and Statistical Manual V [DSM V] slated for publication next year, leaders in American psychiatry are criticizing the volume as unreliable. The DSM is the compendium of conditions psychiatrists use to diagnose their patients and, to a great extent, determine what treatments would benefit them.  The DSM also has extremely important implications for what kinds of psychiatric problems insurers will cover and even which ones schools and employers will consider disabilities. Dr. Allen Frances, professor emeritus at Duke University, who was actually the chairman of the DSM-IV task force, asserts in a recent blog published that the clinical trials that supposedly determined whether the new DSM V is a good and accurate guide “have been a pure disaster from start to finish.”  He calls the trials a “fiasco” and accuses the American Psychiatric Association of having “lost its competence and credibility”…

Given the concerns of leading psychiatrists like Frances, with whom I happen to agree, it is time to give real consideration to fundamentally changing the way psychiatrists use the DSM and encouraging them to think much more about what caused the disorders they are diagnosing. This is the proposal of one of the most influential psychiatrists of our time, Dr. Paul McHugh.  McHugh is Chairman Emeritus of Psychiatry at Johns Hopkins.  He and his esteemed colleague Dr. Phillip Slavney have written in the New England Journal of Medicine that the DSM is just a list of conditions with signs and symptoms and offers “no way of making sense of mental disorders.”  Making sense of mental illnesses—describing the patient’s actual suffering and disability—is imperative because pretending that people can be understood by giving them a label like major depressive disorder misses the fact that many actually complain mostly about anxiety, many others are actually grieving the loss of a loved one, and many others have pervasive low mood, low energy and low self-esteem that came “out of the blue.”  

McHugh and Slavney correctly wonder whether this sloppiness in simply labeling rather than truly understanding patients explains why antidepressant medicines — if they are being given to a very diverse group of people artificially lumped together by the DSM — don’t seem to work much better than placebo.  Why would they, if half the people who meet the criteria for major depression actually have other, central issues to address? Focusing on causes would reawaken psychiatry’s commitment to looking at people’s life stories as relevant to their suffering…

McHugh and Slavney say it is time to enrich and augment the checklist method of making diagnoses by starting to group mental disorders into the underlying causes:  [roughly translated from their wording] brain diseases, personality problems, behavioral problems and life stresses.  The McHugh and Slavney perspective is a valuable one.  Given the rising chorus of concern about DSM V, their thoughts, as well as those of Dr. Frances and of autism advocates and of many others should translate into delaying publication of the DSM-V, until it can incorporate a new respect [which is a very old idea, indeed] for how patients got sick, to begin with, and how, therefore, they can get well.

Having weighed in on the DSM-5 on this blog and as a recent contributor to another commentary, I found Dr. Lieberman’s response to Dr. Ablow today disappointing, perhaps even kind of sad:
The truth about DSM-5
Fox News
By Jeffrey Lieberman
November 15, 2012

The vast majority of psychiatrists and health care professionals understand that the "Diagnostic and Statistical Manual of Mental Disorders" aka "DSM" is a handbook to help clinicians and researchers to evaluate and communicate about mental disorders, described through common symptoms and behaviors exhibited by patients. The upcoming edition, commonly referred to as "DSM-5," will update the diagnostic categories and criteria that describe them, integrate dimensional measures into several disorders to help provide a fuller diagnostic picture, and revise the book’s organizational framework to signal potential underlying vulnerabilities as well as symptom characteristics of many conditions. Most importantly, the changes proposed to diagnostic criteria reflect the best scientific evidence since the current version was published nearly 20 years ago.

Fox News Medical A Team contributor Dr. Keith Ablow’s lack of information, or disregard for it, about the DSM-5 is apparent in his comments on FoxNews.com and Fox News Channel. The motivation and basis for his criticisms are obscure, but the counterproductive effects of his opinions are clear. By attempting to undermine the credibility of the DSM, and casting aspersion on the American Psychiatric Association – which represents the majority of the medical specialty of which he purports to be a member – he misleads people who may be affected by mental disorders and potentially discourages them from seeking care. This disregard for factual information is evident in his comments on the proposed criteria for Major Depressive Disorder and Generalized Anxiety Disorder. As currently proposed, these diagnoses’ criteria remain exactly the same as they were in DSM-IV, authored during Allen Frances’ tenure as DSM task force chairman. In fact, the Work Group and Task Force have been conservative in their approach to revisions aiming to bring the mental health field closer to a true understanding of mental disorders and – to quote his own words – “how patients get sick to begin with, and how, therefore, they can get well.” We wish that Dr. Ablow would be more thoughtful about expressing such reckless statements.

Thirty years ago, the DSM-III Revision of the diagnostic code was used to radically change the specialty of psychiatry, an unprecedented move for a professional organization. It seems that the DSM-5 Revision leaders had the same kind of thing in mind – to move psychiatry the rest of the way to a neuroscience based classification. They failed to meet that goal [Neuroscience, Clinical Evidence, and the Future of P sychiatric Classification in DSM-5]. And since the Task Force was formed, the specialty has been rocked by scandals involving prominent psychiatrists, the integrity of our scientific literature, and the overt and covert pharmaceutical industry influence over academic and organized psychiatry. Dr. Allen Frances has been a tireless critic of the DSM-5 Task Force along with a throng of others. Dr. Ablow is coming from another direction, psychiatry’s abandonment of the patient’s life experience as a cause of their mental suffering.

But the point for the moment is that Dr. Lieberman, like the DSM-5 Task Force leaders before him, only counterattacks, "Fox News Medical A Team contributor Dr. Keith Ablow’s lack of information, or disregard for it, about the DSM-5 is apparent in his comments on FoxNews.com and Fox News Channel… The motivation and basis for his criticisms are obscure, but the counterproductive effects of his opinions are clear. We wish that Dr. Ablow would be more thoughtful about expressing such reckless statements." The responses of Dr. Schatzberg, Dr. Kupfer, Dr. Regier. and Dr. Scully to criticisms have been similar defensive counterattacks. And Dr. Lieberman sees Dr. Ablow’s as destructively motivated, "By attempting to undermine the credibility of the DSM, and casting aspersion on the American Psychiatric Association – which represents the majority of the medical specialty of which he purports to be a member – he misleads people who may be affected by mental disorders and potentially discourages them from seeking care."

I guess they’re going to go through with it and release the DSM-5 this May as planned, expecting that it will automatically replace the DSM-IV, that the APA’s authority is assured and will carry the day. I doubt that will happen. There are two kinds of authority: an authority of power, and an authority of wisdom. The power of psychiatry has been deeply eroded in the last several years by scandal and disillusionment, and the wisdom of the DSM-5 is apparent to very few – most of them on the Task Force itself. In so far as I know, the thrust of the waves of criticism generated by the DSM-5 have been earned by the Task Force itself, and they’ve been unable to see that. Likewise, they have been unable to adapt to the dramatically different climate that has developed since they started. That’s the sad part.

So, in a couple of weeks, the Board of Trustees is likely to approve it and send it on to the printer and to the court of public opinion. That seems to me a colossal mistake at the wrongest of times. We’ll see…
  1.  
    Tom
    November 16, 2012 | 8:32 AM
     

    It is obvious that a paranoid mind set has taken hold in the “leaders” of APA.

  2.  
    Joel Hassman, MD
    November 16, 2012 | 10:20 AM
     

    Iraq revisited, instead of weapons of mass destruction, the APA has a bunch of buffoons focused on weapons of mass destraction, and who dares challenge the great wizards?! Yeah, we get it APA Poo-bahs, pay no attention to the men behind the curtain. Must be nice to be retired and ruin other peoples’ lives at the same time!

    Although, Dr Ablow is not the kind of role model for dissenters, this being a colleague who makes psychiatric diagnoses of people on air he has never met!

  3.  
    Nathan
    November 16, 2012 | 12:27 PM
     

    I wouldn’t hold up Ablow’s critique too high, and I don’t know what he has said that already hasn’t been. He has certainly unethically used his credentials for financial gain with his work as a Fox News pundit, using psychiatric jargon to buttress social conservative moralizing as something justified and scientific (ex. his highly criticized pathologizing of Chaz Bono during his appearance on Dancing with the Stars and fear mongering about the harm children seeing him TV would experience). He was basically kicked out of the APA (whether being kicked out of the APA matters to us here is a different story) for doing so. Like many others on all sides the crises Psychiatry faces, Ablow pushes a worldview that despite not having the support to actually push such views, does so because his prestige, livelihood, and reputation depend on it. I feel that is what this whole field is now: asserting ideologies that frame the providers asserting such ideologies as meaningfully knowledgeable, helpful, and deserving of respect and money.

  4.  
    November 16, 2012 | 12:54 PM
     

    Truly pathetic. The APA leadership never has any response to criticism other than buzzwords and ad hominems, suggesting their reasoning ability is poor. This is consistent with the quality of their publications.

  5.  
    November 17, 2012 | 7:34 AM
     

    I share your disappointment in Dr. Lieberman’s response. I wrote about another one of his articles which I found equally hollow in its attempts to address some recent failures in pharma research:
    http://www.madinamerica.com/2012/09/on-drug-development-lucrative-markets-and-the-future-of-psychiatry/
    There is an inability to question the fundamental paradigms.

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