a long and winding road…

Posted on Tuesday 14 May 2013

the road to Machu PicchuI don’t buy it. We are bombarded by articles making all kind of things out of Dr. Insel’s blog post, Transforming Diagnosis, an announcement that the NIMH will move away from the DSM-5 – coming just a couple of weeks before the DSM-5 even goes on sale. Like everyone else, I’ve joined in on the speculation and commentary on the reasons for this surprising move [old news…, a flair…, groundhog day…, replaces with…, damage control…, our jobs…, said it again…]. When I talk too much about the same thing, it’s because there’s something I’m trying to figure out but I haven’t gotten there yet. So for the last several days, I’ve been going over the history and rereading the articles trying to get the story clear in my mind rather than reacting to the media frenzy. I’ve done that now and here’s the conclusion. I don’t buy it. If you don’t either, and already know why, don’t bother to read further. It’s way too long. I just wanted to write it down so I didn’t have to keep mulling it over in my mind.

Since the release of the DSM-III in 1980, there have always been two versions of the paradigm for the diagnostic manual. The first one was in the DSM-III Manual itself and said:
For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed by evidence – not always convincing – to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors. The major justification for the generally atheoretical approach taken in DSM-III with regard to etiology is that the inclusion of etiological theories would be an obstacle to use of the manual by clinicians of varying theoretical orientations, since it would not be possible to present all reasonable etiologic theories for each disorder.
Robert Spitzer, in the DSM-III, p 6.
The second version, the background version, was from the group centered at Washington University in Saint Louis and was called – neo-Kraepelinian. It professed the same basis for classification [observed symptoms], but had nothing like the neutrality of Dr. Spitzer’s version. Their view has been summarized as the neoKraepelinian Tenets:
    1. Psychiatry is a branch of medicine.
    2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.
    3. Psychiatry treats people who are sick and who require treatment.
    4. There is a boundary between the normal and the sick.
    5. There are discrete mental illnesses.  They are not myths, and there are many of them.
    6. The focus of psychiatric physicians should be on the biological aspects of illness.
    7. There should be an explicit and intentional concern with diagnosis and classification.
    8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.
    9. Statistical techniques should be used to improve reliability and validity.

[1. & 2.] were directed against psychoanalysis and said that psychiatry was a medical enterprise, not involved in matters psychological. The next three [3.-5.] were a counter to the criticisms from Dr. Szasz and others who said that there was no such thing as mental illness and that psychiatry was not a medical specialty. Number 6. said that physicians were only to be involved with the biological aspects of mental illness. It didn’t say that all mental illness was biological, just that biology was the legitimate domain of psychiatric physicians. And the last three [7.-9.] were a call to use scientific methods in classification.

The Spitzer version [atheoretical, descriptive] was the official version, and under that definition, the DSM-III was used by mental health professionals of all disciplines. During the next decades, the other mental health professions became increasingly covered by health insurance as members of approved panels by the various insurers and the DSM-III [IIIR and IV] systems became the standard reporting system for mental health in America [cross referenced to the ICD-9CM, the official system by treaty].

The neoKraepelinian version was the nucleus for a dramatic change in academic psychiatry which became rapidly biomedical and psychpharmacological. Private practitioners in psychiatry increasingly followed suit with more and more doing "medication management" for the clients of practitioners in other disciplines. And over the next twenty years the journals, practice, and focus of American psychiatrists followed  the more neoKraepelinian "biological aspects of mental illness" definition.

The DSM-III-R [1988] and DSM-IV [1994] revisions made changes in the Manual, but stayed with the Spitzer version [atheoretical, descriptive]. Meanwhile, academic and organized psychiatry continued along their biomedical neoKraepelinian path. The Decade of the Brain at the NIMH spanned the 1990s and there was a stream of new drugs – antidepressants and atypical antipsychotics. The Spitzer version was in the books and used by non-psychiatrists. The neoKraepelinian version was the stuff of clinical drug trials, the explosion of psychopharmacology, and psychiatry.

But in mainstream psychiatry, something subtle had happened. The distinction between the two versions was becoming anachronistic. It was no secret that the upper levels of psychiatry were almost universally biological. I don’t think in 2000 that most of us were aware of the extensive connections between academic and organized psychiatry with PHARMA, particularly the back room connections. In this next document written in 2002 in preparation for the next DSM Revision, there is no distinction. The descriptive approach is now called neoKraepelinian. The atheoretical aspect is nowhere seen. It looks to me as if they felt that they could finally stop equivocating and create the biologically based DSM they’d always wanted:

Need to Explore the Possibility of Fundamental Changes in the Neo-Kraepelinian Diagnostic Paradigm
in A Research Agenda for the DSM-V, 2002
edited by David Kupfer, Michael First, Darrel Regier
[full text on-line]

The DSM-III diagnostic system adopted a so-called neo-Kraepelinian approach to diagnosis. This approach avoided organizing a diagnostic system around hypothetical but unproven theories about etiology in favor of a descriptive approach, in which disorders were characterized in terms of symptoms that could be elicited by patient report, direct observation, and measurement. The major advantage of adopting a descriptive classification was its improved reliability over prior classification systems using nonoperationalized definitions of disorders based on unproved etiological assumptions. From the outset, however, it was recognized that the primary strength of a descriptive approach was its ability to improve communication among clinicians and researchers, not its established validity.

Dr. Spitzer’s compromise in 1980 was to settle for inter-rater reliability and let validity go [since we have no way to determine validity anyway, it was no loss]. They go on to say that the hope had been that the DSM-III groupings would lead to etiology, but since no biomarkers were yet defined, it hadn’t worked out. Notice that biomarkers and etiology are now connected. The atheoretical is gone for good. The problem at hand was that the expected biomarkers had not been found – as in not yet found. The conclusion was that the biological bases of mental illness were not revealed by the clinical categories of the DSM-III+, and by the way, the clinical disorders not only didn’t map to biological findings, but they didn’t map to the drug treatments either. As a matter of fact, they thought the DSM categories may even be hampering research in some way.
Disorders in DSM-III were identified in terms of syndromes, symptoms that are observed in clinical populations to covary together in individuals. It was presumed that, as in general medicine, the phenomenon of symptom covariation could be explained by a common underlying etiology. As described by Robins and Guze, the validity of these identified syndromes could be incrementally improved through increasingly precise clinical description, laboratory studies, delimitation of disorders, follow-up studies of outcome, and family studies. Once fully validated, these syndromes would form the basis for the identification of standard, etiologically homogeneous groups that would respond to specific treatments uniformly.

In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually led to DSM-III, the goal of val- idating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception…

Concerns have also been raised that researchers’ slavish adoption of DSM-IV definitions may have hindered research in the etiology of mental disorders. Few question the value of having a well-described, well-operationalized, and universally accepted diagnostic system to facilitate diagnostic comparisons across studies and to improve diagnostic reliability. However, reification of DSM-IV entities, to the point that they are considered to be equivalent to diseases, is more likely to obscure than to elucidate research findings.

Remember, this is a document from 2002 written by the APA psychiatrists charged with revising the DSM-IV. What they are saying is that the DSM-III, -IIIR, -IV paradigm didn’t pan out. The descriptive atheoretical system did not reveal any disease specific biological markers and so we should change the way we do diagnosis in order to find them. These biological illnesses have yet to reveal their secrets.
All these limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur. Therefore, another important goal of this volume is to transcend the limitations of the current DSM paradigm and to encourage a research agenda that goes beyond our current ways of thinking to attempt to integrate information from a wide variety of sources and technologies…

The atheoretical part of the system just quietly evaporated. This 2002 book is all about biology and neuroscience. The possibility that the biomarkers hadn’t been found because the Manual was faulty [eg absent Melancholia, etc] wasn’t considered. Even odder, there’s no mention of the possibility that many of the mental illnesses were not biological in the first place, ergo had no biomarkers hidden or otherwise. But that’s an obvious point. More cogent for the moment is that I couldn’t find where anyone considered that the major users of this diagnostic system by actual count are not psychiatrists, not people who would be involved with biological diseases or disorders. They are psychologists, social workers, counselors, etc. The content of this Research Agenda for the DSM-V was written from the perspective of biological psychiatrists frustrated that the confirmation of biomedical psychiatry had not been forthcoming, and it was being reevaluated to find a more biological-friendly system. The fact that this  tack was incompatible with the practices of the majority of mental health workers in America who use the DSM doesn’t seem to have been on the radar. In my way of thinking about this, the quiet compromise of the two paradigm versions, Spitzer vs neoKraepelinian, had been erased. So from 2004-2008, the DSM-5 Task Force held 13 planning conferences in conjunction with the NIMH, NIAAA, and NIDA before starting to work on the DSM itself, looking in to going biological. And then, starting in 2009, the NIMH introduced their RDoC:

Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders
by Thomas Insel, Bruce Cuthbert, Marjorie Garvey, Robert Heinssen, Daniel S. Pine, Kevin Quinn, Charles Sanislow, and Philip Wang.
American Journal of Psychiatry. 2010 167:748-751.
[full text online]

Current versions of the DSM and ICD have facilitated reliable clinical diagnosis and research. However, problems have increasingly been documented over the past several years, both in clinical and research arenas. Diagnostic categories based on clinical consensus fail to align with findings emerging from clinical neuroscience and genetics. The boundaries of these categories have not been predictive of treatment response. And, perhaps most important, these categories, based upon presenting signs and symptoms, may not capture fundamental underlying mechanisms of dysfunction. One consequence has been to slow the development of new treatments targeted to underlying pathophysiological mechanisms…

NIMH plans to maintain liaison with the American Psychiatric Association and the World Health Organization regarding mutual interests in psychiatric classification. As an initial step, representatives of the APA, WHO, and NIMH met in July 2009 to map out common ground. These organizations have also articulated the importance of adding molecular and neurobiological parameters to future diagnostic systems, but at our current state of knowledge this step seems more appropriate for research than for immediate clinical use. NIMH views RDoC as the beginning of a transformative effort that needs to succeed over the next decade and beyond to implement neuroscience-based psychiatric classification.…
Notice that the APA was there from the start of the RDoC, just like the NIMH has been there through the whole DSM-5 process. Notice that the opening argument is the same one made by the DSM-5 Task Force in 2002, and the one we’re reading in 2013 in these last couple of weeks. Finally, in 2011, the DSM-5 Task Force announced that they couldn’t bring off a biological DSM-5 after all, and they, themselves, discussed the NIMH RDoC:
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.
[full text online]

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…

We realized from our Research Agenda conference series that we would not be able to accomplish by DSM-5′s deadline all of the things we set out to and, in fact, that portions of that agenda related to advances in neuroscience were already being addressed in other arenas. A logical extension of those discussions, as detailed in our Research Agenda  articles, is the Research Domain Criteria [RDoC] initiative recently launched by the National Institute of Mental Health [NIMH]. A commentary by Insel and colleagues  introduced readers to the working principles behind the RDoC, whose proposed reclassification of mental disorders for research purposes is predicated on a neuroscience-based framework that can contribute to a nosology in which disorders are grouped by underlying pathophysiological similarities rather than phenomenological observations…
So what do I make of this timeline? Well, first, there’s a piece that’s not yet on it – what happened in the gap between the Research Agenda of 2002 and the creation of the RDoC in 2009 – and it was a lot!:
  • 2002 was at the peak of the psychopharmacology era. The drugs were coming at a steady rate and business was booming. That year, Dr. Insel was a surprise pick to head the NIMH. It was a time of great enthusiasm, the dawn of a new millenium.
  • While it probably should’ve started in 1996 when the Chairman of Psychiatry at Georgia [Dr. Richard Borison] was convicted, the realization that there was corruption afoot in psychiatry came later. In the mid-2000s, problems with conflicts of interest, unreported PHARMA income, and ghost writing increasingly came to the fore culminating in a U.S. Senate Investigation with several psychiatry chairmen "stepping down" and others in high places censured.
  • Around the same time, the corruption in PHARMA reached the public eye. Allen Jones blew the whistle on TMAP, and elsewhere the civil suits began to pile up. In discovery, boxes of internal documents revealed the extensive connections between psychiatric authors a PHARMA, and the ubiquitous deceit in the publication of scientific data, along with a lot of shady drug promotion practices.
  • People like Dr. David Healy and others began to report unmmentioned adverse effects like suicidality. The "black box" warning was added to the antidepressants. The reports of adverse effects were joined by charges of inflated efficacy.
  • This was the era of large NIMH funded drug trials, and they were pretty disappointing. The new drugs hardly dazzled anyone.
  • In that period, we learned the term "pipeline" [drugs headed for approval], and then that there weren’t any more "me too" drugs on the way or anything to replace them
  • After a time of fretting over the "empty pipeline," the drug companies began to shut down their CNS drug development facilities – no candidates to work on.
  • This was a remarkably non-productive time in research. Lots of new technology and hype, but little in the way of results.
[just for starters]… And so the heyday of 2002 slid into a time with one piece of bad news after the other.

My own read on this narrative is cynical. First, I don’t accept that the American Psychiatric Association, Academic Psychiatry, the DSM-5 Task Force, and the Director’s office of the National Institute of Mental Health are separate entities. I see then as a consortium of people in high places who see the future of psychiatry and mental health as a function of new CNS drug development. That means that the entity we call PHARMA is part of the consortium, whether officially or unofficially – it’s a big part of the mix.

What I think happened is that the consensus around the turn of the century was that they could make the move to a solid biological psychiatry that took its place among the medical professions as a solid member.  The DSM-III had opened the door, and the DSM-5 was going to complete the process. But as time moved on and the bad news began to accumulate, things weren’t going as planned, their DSM-5 conferences were going nowhere [I read them so trust me on this point], and they had to do something. The vision of their Research Agenda was handed over to the NIMH who launched the RDoC. Once that was in place and launched, they made their announcement that they couldn’t bring it off. In the meantime, they’d ignored the real business of the revision they’d been assigned, so they got involved in a lot of add-ons [Attenuated Psychosis, Mixed Anxiety Depression, etc]. The original impetus [the future is psychopharmacology] showed in the loosened criteria for any number of diagnoses the dropped bereavement exclusion. It was a lackluster showing at best, because it wasn’t what they were really aiming for in the first place. Why did Insel jump in at the 11th hour? My guess is that it lets the DSM-5 Task Force off the hook, changing their failed attempt at a biological system into something else – a noble try, but the clinical syndromes are just not a good-enough basis for drug development or biological discovery.

I think that all these people really do believe that the only avenue to follow is psychopharmacology and new drug development. What I object to is all the behind the scenes wheeling and dealing, presented to us in carefully prepared sound bytes. I object that they haven’t listened to Dr. Robert Spitzer, Dr. Allen Frances, and the rest of us who are trying to tell them that their monocular vision is obscuring everything. The roar of criticism about the DSM-5 has all said the same thing, "You’re supposed to be revising our clinical diagnostic manual! And you’re doing something else!" Everything has been wrapped around new drug development. It’s not even about biology because they’ve ignored repeated calls to reinstate our best candidate – Melancholia. It’s just about drug development, finding new targets to entice PHARMA back into the game. They say that outright.

So I believe there is a real they composed of the groups above, with a fixed goal in mind to the exclusion of any other. They really liked the years leading up to 2002, and they just can’t let go of where they thought they were headed. In 5 days they‘re going to publish a book that will enshrine their folly…

and…

Press Release • May 13, 2013

DSM-5 and RDoC: Shared Interests

Thomas R. Insel, M.D., director, NIMH
Jeffrey A. Lieberman, M.D., president-elect, APA

NIMH and APA have a shared interest in ensuring that patients and health providers have the best available tools and information today to identify and treat mental health issues, while we continue to invest in improving and advancing mental disorder diagnostics for the future.

Today, the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), along with the International Classification of Diseases (ICD) represents the best information currently available for clinical diagnosis of mental disorders  Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5. As NIMH’s Research Domain Criteria (RDoC) project website states, “The diagnostic categories represented in the DSM-IV and the International Classification of Diseases-10 (ICD-10, containing virtually identical disorder codes) remain the contemporary consensus standard for how mental disorders are diagnosed and treated.”

Yet, what may be realistically feasible today for practitioners is no longer sufficient for researchers. Looking forward, laying the groundwork for a future diagnostic system that more directly reflects modern brain science will require openness to rethinking traditional categories. It is increasingly evident that mental illness will be best understood as disorders of brain structure and function that implicate specific domains of cognition, emotion, and behavior. This is the focus of the NIMH’s Research Domain Criteria (RDoC) project. RDoC is an attempt to create a new kind of taxonomy for mental disorders by bringing the power of modern research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness.

The evolution of diagnosis does not mean that mental disorders are any less real and serious than other illnesses. Indeed, the science of diagnosis has been evolving throughout medicine. For example, subtypes of cancers once defined by where they occurred in the body are now classified on the basis of their underlying genetic and molecular causes.

All medical disciplines advance through research progress in characterizing diseases and disorders. DSM-5 and RDoC represent complementary, not competing, frameworks for this goal. DSM-5, which will be released May 18, reflects the scientific progress seen since the manual’s last edition was published in 1994. RDoC is a new, comprehensive effort to redefine the research agenda for mental illness. As research findings begin to emerge from the RDoC effort, these findings may be incorporated into future DSM revisions and clinical practice guidelines. But this is a long-term undertaking. It will take years to fulfill the promise that this research effort represents for transforming the diagnosis and treatment of mental disorders.

By continuing to work together, our two organizations are committed to improving outcomes for people with some of the most disabling disorders in all of medicine.

  1.  
    CannotSay2013
    May 14, 2013 | 10:42 PM
     

    Speaking of damage control, here is the real damage control,

    http://www.nimh.nih.gov/news/science-news/2013/dsm-5-and-rdoc-shared-interests.shtml

    It seems to me an attempt to square the circle that fails miserably. It is impossible to retract the following,

    ” The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. ”

    A vague appeal to “the evolution of diagnosis does not mean that mental disorders are any less real and serious than other illnesses. Indeed, the science of diagnosis has been evolving throughout medicine. For example, subtypes of cancers once defined by where they occurred in the body are now classified on the basis of their underlying genetic and molecular causes” will not cut it. The damage is already done, and there is no way back :D.

  2.  
    May 14, 2013 | 11:01 PM
     

    Reminds me of those old episodes of ‘To Tell the Truth’ -

    “Will the real psychiatry please stand up?”

    Duane

  3.  
    May 14, 2013 | 11:06 PM
     

    Only in this case, there is no real (reliable, valid) psychiatry.

    Duane

  4.  
    CannotSay2013
    May 14, 2013 | 11:11 PM
     

    Duane/Mickey, I am just wondering, speculating, whatever, but! Is it possible that Insel was threatened with termination to force him agreeing to this BS?

  5.  
    May 14, 2013 | 11:29 PM
     

    CannotSay2013

    Good thought!

  6.  
    CannotSay2013
    May 14, 2013 | 11:44 PM
     

    Mickey,

    I don’t think I have to work very hard to convince you, with all your experience working with all these that this is probably what happened :D. Here is the “problem” though,

    1- Insel said things that were agreed to by the chair of the DSM-5 Task force a few days later.

    2- The chair of the DSM-5 Task force probably panicked and in a rare moment of honesty was forced to agree to what Insel said.

    These things are now part of the public and official record. So although I am sure that during the last two weeks there have been many calls, threats, etc to do damage control, the above two points remain. This joint statement was carefully crafted with nonsensical language, but the fact remains that both Insel and the Chair of DSM-5 now have publicly agreed that DSM-5 lacks scientific validity. If I had the resources to do so, I would profit from this great opportunity to launch a legal challenge against the profession by carefully choosing some case that had been decided on the validity of the DSM alone.

  7.  
    May 15, 2013 | 12:43 AM
     

    The real legal challenge needs to address the long-standing tradition of the use of force – with drugs, ECT and “hospitalizations.”

    How can the use of this force be justified in light of the fact that there is no validity in diagnosis? How can the profession continue to violate civil (constitutional rights) in lieu of these admissions?

    If the 14th amendment applies to people accused of crime, surely the ‘due process’ clause should apply to someone in deep emotional stress, whose greatest “crime” is several days of insomnia…

    How can there possibly be two forms of civil law – one for the supposedly sane, the other for the severely “mentally ill”, when the terms “bipolar” and “schizophrenic” have no scientific meaning?

    This has always been about social control… based upon political science, not medical science.

    Duane

  8.  
    wiley
    May 15, 2013 | 1:59 AM
     

    When they started saying that one out four people suffer from “mental illness,” and oh we should make sure that everyone has pills for it, someone should have slammed on the brakes.

    At that rate, if the causes were only biological and hereditary, then in another generation or two, there would be no one unaffected enough to keep the factories running.

    A cursory look will tell anyone who has ever known insecurity and hasn’t forgotten what it felt like, that our culture is so demanding that it tells parents they can effectively parent their children by spending 15 minutes of quality time with their children a day. For a lot of parents that’s a net of under a dollar’s worth of time.

    Our society disdains all the things that are necessary for mental and social health that don’t produce profit, when it cuts into time that business want their employees to work for them.

  9.  
    May 15, 2013 | 4:19 AM
     

    Mickey, this is one of your best posts ever, and that is really saying something. I cannot thank you enough for your singularly valuable perspective on these issues. You have been a critical source for my preparation of a day-long workshop on DSM-5 which I am currently presenting in six Australian cities. My audiences come in expecting me to read lists of diagnostic criteria all day, and instead they get a healthy dose of critical analysis of the history, influences, and consequences of the modern DSM/biomedical era (in addition to DSM-5-specific changes). Audiences here are appalled at the biomedical functions served by the modern DSM, the extent of pharma influence on psychiatry, and the neo-Kraepelinian ideology of the DSM-5 task force and NIMH. Your “big picture” perspective has been immensely helpful in shaping my thinking on these issues, and I’m pleased to be spreading this perspective to others who appear quite appreciative of it. I should note that I cite you and your blog and recommend it to my audiences.

    I realize the news these days is abuzz with DSM-5/RDoC, but I’d like to make you aware of an article I authored that addresses big-picture issues associated with the biomedical model. It’s published in the most high-impact clinical psychology journal and I hope it will encourage additional recognition and dialogue of the broad issues that are a focus of your blog. The article is available here: http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/biomedical_model_commentary.pdf. Thanks Mickey, and keep up the great work!

    Best,

    Brett

  10.  
    May 15, 2013 | 7:09 AM
     

    “… a consortium of people in high places who see the future of psychiatry and mental health as a function of new CNS drug development.”
    Brain washed, indoctrinated, invested with power over vulnerable humans,richly rewarded for staying the course that upholds the phenomenal wealth and power of Big Pharma…They are in it together. Change hardly ever comes from the powers that are in position.
    Judging from the review-process of the ICD, the reigning powers are placed to take care of their vested interests. Havard’s Steven Hyman, formerly of NIMH, chairs a maledominated committee with present and former heads of World Psychiatric Association, Mario Maj, Norman Sartorious.. http://www.who.int.classifications/icd/Mental

    Thank you for another excellent post, and for the further enlightening links to more. Knowledge is power in our hands – together – clinicians and patients and families, open dialogues, robust listening and learning from the many voices of those whose lives are at stake, and those who honestly try to help.

  11.  
    May 15, 2013 | 8:02 AM
     

    Bret, Thanks. Nice article!…
    Berit, Can you check that link? It doesn’t work and it’s something I’d like to chase…

  12.  
    Berit Bryn-Jensen
    May 15, 2013 | 8:44 AM
     

    Sorry. I’m an old amateur, from Latin, to love etc…

    Try http://www.who.int/classifications/icd/en/

    The column to the right directs you to the steering committee, of which mr Hyman is chair, and the Topic Advisory Groups, with some very familiar names, too few women, as far as I can tell by the unfamiliar names. I hope this works…

  13.  
    Berit Bryn-Jensen
    May 15, 2013 | 8:46 AM
     

    It worked here… Best to you, with thanks, Berit

  14.  
    May 15, 2013 | 8:47 AM
     

    Thanks!

  15.  
    May 15, 2013 | 9:42 AM
     

    Typo -’ in light of’ (not ‘in lieu of’)

    Thank you for this post.

    Duane

  16.  
    May 15, 2013 | 4:08 PM
     

    Have you ever thought about including a little bit more than just your
    articles? I mean, what you say is valuable and everything.
    However imagine if you added some great graphics or video clips to
    give your posts more, “pop”! Your content is excellent but with pics and videos, this
    blog could certainly be one of the very best in its niche.
    Wonderful blog!

  17.  
    Edward Shorter
    May 15, 2013 | 5:26 PM
     

    Dr Nardo’s summary of the recent history of DSM is brilliant, and deserves wider circulation. I just want to make a couple of minor points that amend his narrative:

    1. It is a false dichotomy to contrast Spitzer vs the Neokraepelinians. The essential element of Kraepelin’s system — that DSM-III incorporated — was the firewall between mood disorders and psychosis. This is the spinal column of DSM-III. ( By contrast, Kraepelin saw “manic-depressive illness” as a unitary entity, and this the disease designers of DSM-III wrecked completely.)

    2. Spitzer made a pretense of being “atheoretical” only to get the document through the APA leadership, which was populated by glowering psychoanalysts. Spitzer’s real theoretical ambition was to destroy psychoanalysis within psychiatry, and he called the document “atheoretical” only so the analysts wouldn’t kill his precious baby in the cradle.

    3. Spitzer himself didn’t care that much about causation, but many of the people from the New York State Psychiatric Institute who surrounded him were big biological thinkers, and huge on psychopharmacology (unlike the Wash U gang). So, to call Spitzer “atheoretical” in contrast to the biological Neokraepelinians is a bit summary.

    4. The “Feighner criteria” were indeed a crucial stage, and Spitzer was intimately involved in RDC (1978) but the final product, DSM-III, deviated vastly from the Feighner criteria, because DSM-III was basically a political document, while the Wash U residents who produced Feighner were interested in clinical science.

    5. It’s simply not correct that there are “no biological markers in psychiatry.” The dexamethasone suppression test (DST), serum cortisol, and various sleep changes have been well validated as markers for melancholic depression. (See the book I wrote with Max Fink, Endocrine Psychiatry, Oxford)

    6. Dr Nardo, at the end, rails somewhat against psychopharmacology, and curses nosology for being martyred to the cross of medicinal chemistry. This requires a more nuanced view. Industry’s impact on clinical psychiatry has been nefarious, twisting diagnosis out of shape. But drug development is important, and we really haven’t had any new drugs in the last three decades (clozapine was patented in 1963). We need diagnoses that correspond to actual disease entities in nature, to open the faucets of drug development once more. We don’t have them now.

    Sorry to go on so long.

    Edward Shorter

  18.  
    May 15, 2013 | 5:51 PM
     

    Edward Shorter,

    Regarding this comment:

    “We need diagnoses that correspond to actual disease entities in nature, to open the faucets of drug development once more. We don’t have them now.”

    Response:

    Are you kidding me?
    Who’s going to pay for it?
    The drugmakers want out.
    They know failure when they experience it.

    The taxpayer?
    Really?
    Good luck with that.

    Long-term treatment outcomes for psychiatric drugs> -

    http://www.madinamerica.com/source-documents/

    And we need more of them?!

    Duane

  19.  
    wiley
    May 15, 2013 | 6:43 PM
     

    Well, if you feel like you’ve chewed your way to the bottom of this, then I would like to request some consideration for posts on replicated research on the link between “mental illness” and trauma/abuse; and on the relationship between “mental illness” and medical disorders.

    Really, if psychiatrists want to be all medical, then they should be required to rule out physical causes like iron or b-12 deficiencies, thyroid, inadequate sleep, drug and/or alcohol abuse, and medications such as the contraceptive pills that can have a negative impact on mood. They should also be required to take note of abuse that it going on a person’s life when they see them, and should consider the abuse THE problem.

    So much useful information is behind pay walls— a good summary of a good study (especially if it has been replicated), would be quite the gift. There is information out there that is valid, useful, and unsung because of the dominance of the biological model and its woo.

  20.  
    CannotSay2013
    May 15, 2013 | 9:24 PM
     

    Edward Shorter,

    Only want to say that if what you say in 5. is true, you should run and tell both Tom Insel and the chair of the DSM-5 task force because they are not BOTH on record that there are no reliable bio markers in psychiatry (that much was agreed by both, and even this travesty of press release does not deny that).

    I understand that you are a historian and that science is not your forte, but, anecdotal evidence is not the same as empirical evidence of the kind that has been used to establish HIV as the cause of AIDS for instance.

  21.  
    CannotSay2013
    May 15, 2013 | 9:27 PM
     

    “because they are not BOTH on record that there are no reliable bio markers in psychiatry”

    I meant, of course,

    “because they are NOW BOTH on record that there are no reliable bio markers in psychiatry”

  22.  
    a-non
    May 15, 2013 | 9:31 PM
     
  23.  
    May 16, 2013 | 1:54 AM
     

    CannotSay,

    We’re on the same page.
    And, I don’t think we’re alone.
    In fact, I think our numbers are growing, every day.

    Duane

  24.  
    Bernard Carroll
    May 16, 2013 | 5:49 AM
     

    Insel and Kupfer have declared that DSM-5 diagnoses lack validity. They do the field of psychiatry a great disservice by promoting this position, and by using it as the justification for RDoC. They also display a weak grasp of the place of laboratory data in refining diagnoses. In response, many of the comments in this discussion thread repeat the error of harping on laboratory tests before we accept the reality of psychiatric diseases. There are some key issues to understand. I reviewed those issues a few days ago on Gary Greenberg’s blog, and they are worth repeating.
    http://www.garygreenbergonline.com/w/?p=330#comments

    We need to be clear that the existence of disease is not predicated on having a biological test. It’s nice when we do have one, but there are many areas in medicine where there is no conclusive diagnostic test. Think migraine. Think multiple sclerosis. Think chronic pain. Indeed, clinical science correctly recognized many diseases long before lab tests came along for confirmatory diagnostic application. Think Parkinson’s disease, Huntington’s disease, epilepsy… it’s a long list.

    We need to be clear that laboratory tests are not the automatic gold standard of evidence for validity that Insel and Kupfer imply. Indeed, in many areas diagnostic tests cause mischief. That’s what the whole debate around indiscriminate diagnostic screening is about. Laboratory measures are the servants of clinical science, not the other way around. The reason for this emphasis is that the great majority of laboratory tests are probabilistic rather than pathognomonic – which means that clinical judgment enters into their interpretation. A critical aspect of that process involves awareness of the prior probabilities of salient differential diagnoses for a given patient. This is standard Bayesian information theory and it applies throughout medicine.

    We need to be clear that clinical medicine is a pragmatic field that operates always under uncertainty. Diagnoses are probability statements and treatments are N = 1 experiments. I agree that the DSMs fail to convey these aspects of psychiatry. If you want diagnostic certainty, then don’t allow your surgeon to perform exploratory laparotomy next time you arrive in the ER with an acute abdomen but the CT scan and the blood tests are inconclusive. If you want diagnostic certainty, then by all means refuse your physician’s prescription of corticosteroids for your arthritis that is probably, but not conclusively, systemic lupus erythematosus or SLE based on the preponderance of the laboratory evidence.

    Clinical science operates through a process of convergent validation. That is how disease constructs take form, through iterative attention to signs, symptoms, course of illness, response to treatments, family history, and laboratory data. This is an area where DSM-III and DSM-IV failed us by limiting their focus to signs and symptoms. Had the framers of DSM-III understood the original Washington University position, they would have incorporated course of illness, response to treatments, family history, and laboratory data into the manual. Instead, Spitzer rejected these potential validators, saying they might introduce circular logic, and that misstep has been carried forward. However, a positive family carries great diagnostic weight in Huntington’s disease; likewise neurologists routinely use response to l-DOPA as a diagnostic test of Parkinson’s disease (to distinguish it from look-alike disorders). To give just a few examples, one can only wish that NIMH and the APA had committed resources over the past 30 years to clarifying how a positive family history can reduce diagnostic uncertainty in mood disorders, or how response to lorazepam can confirm the diagnosis of catatonia, or how a history of recurrent depressive episodes with full remission affects the differential diagnostic probabilities in a patient presenting with psychotic and depressive features.

    This process of convergent validation has given us an A-list of psychiatric diagnoses that are candidate brain diseases. Here is the list: psychosis, mania, melancholia, vascular depression, crippling anxiety, panic disorder, dementia, autism, obsessive-compulsive disorder, delirium, catatonia, and more. Then there is a B-list of disabling personality variants, addictions, and reactive conditions like posttraumatic stress disorder, where we think predisposition and experience interact to cause problems.

    The fact that we have not nailed the pathophysiology of these conditions does not invalidate the diagnoses, however. We knew about Huntington’s disease and correctly diagnosed it for 110 years before its genetic basis was discovered, and that knowledge, gained 30 years ago, still has not yielded targeted new treatments. If you want the objective validity that Insel and Kupfer naively aspire to, then by all means tell the magistrate at your next commitment hearing that you were serious when you commandeered an airliner, prevented the scheduled passengers from boarding it, declared yourself the owner of the airline, announced that you were going to fly your entire extended family to London to meet with Margaret Thatcher, and that the psychiatrist who said you suffer from mania must be wrong because he hasn’t shown the court a laboratory diagnostic test for mania.

    There is no problem with the clinical validity of most psychiatric diagnoses. Sadly, it seems the APA and NIMH have joined forces to declare that there is.

  25.  
    Berit Bryn-Jensen
    May 16, 2013 | 7:19 AM
     

    Pondering the mysteries of what we usually call serious mental illness, having seen fellow men in anguish, in states of hyperarousal, numbness or lashing out in words and deeds against mortal dangers I did not see, I’m not denying that states of intense suffering are real, dramatic and very challenging. But I think it would be far less stigmatizing and lifethreatening to the sufferers themselves, if the practice of psychiatry was not based on unproven assumptions of the persons’ biology, but had instead adopted/remained questioning, openminded to the wide variety of possibilities as to etiology. But that would not have founded any globalized, wealthproducing schools and businesses of academic knowledge, teaching, researchindustries, drugs and device-manufacturing, professional and political power. If humility, about possible oceans of ignorance, carried along more or less unconciously, was the attitude most common in medicine and psychiatry, then listening to the designated patient, and to those who will and can help, would long since have been standard practice, and foul, degrading, coercive treatments things of a dark past. It’s not. Ambitious competition, rivalry, jealousy, greed and Big Egoes are rampant – in medicine and in psychiatry. Open dialogues are not the norm.

  26.  
    Annonymous
    May 16, 2013 | 7:25 AM
     

    1bom, I hope you consider highlighting this comment from Dr. Carroll in a full post.
    Dr. Carroll, I hope you consider posting this comment as a full post on Health Care Renewal. It is a superb comment and deserves a careful reading by a wide audience.

  27.  
    Jane
    May 16, 2013 | 10:23 AM
     

    Dr. Carroll: Laboratory and/or radiographic tests may fail to detect early or mild SLE, MS, etc., but Thomas Szasz’s definition that a disease will always reveal itself at autopsy (on a macroscopic or microscopic level) holds for even these illnesses. Szasz’s definition is particularly true for degenerative brain diseases (Huntingdon’s, Parkinson’s).

  28.  
    Bernard Carroll
    May 16, 2013 | 11:59 AM
     

    Jane, I think you overstate the certainty even of autopsy diagnoses. The most striking recent refutation of Thomas Szasz’s claim concerns Alzheimer disease, where amyloid plaque depositions are not by themselves sufficient to correlate with the clinical picture. The so-called Nuns’ Study identified cases with extensive deposits but no clinically apparent cognitive impairment, whereas other cases with lower plaque burden, in the range that occurs in non-Alzheimer cases, did manifest cognitive impairment if there was comorbidity in the form of cerebral vascular disease. As another instance, not even Dr. Szasz would succeed in making an autopsy diagnosis of migraine.

  29.  
    Jane
    May 16, 2013 | 1:11 PM
     

    Dr. Carroll: I’m not a physician (tho, I’ve been married to one for 30+years) but I’ve never understood or been told that migraines were a “disease” or an “illness”. I’ve always been under the impression that migraines were a self-limiting “condition”. Right now, I’ve got a rip-roaring case of poison ivy (yes, it’s rather early in the season for this) but I think we would both agree that I have a self-limiting “condition” (even though a skin biopsy would certainly show some histological manifiestations of my allergeric response). I’m aware that microscopic and macroscopic changes do not correlate (1:1?) with clinical presentations – individuals can and do compensate for or mask (to varying degrees) loss of function – particularly in the intellectual/social sphere.

  30.  
    Bernard Carroll
    May 16, 2013 | 1:21 PM
     

    Jane, migraine is a disease. You are correct to say it is usually self limiting. On the other hand, if you vomit enough during a migraine attack you can suffer serious consequences and you could die. Herein lies one of the weaknesses of DSM – the lack of attention to clinical staging.

  31.  
    May 16, 2013 | 3:21 PM
     

    Dr. Carroll, the field needs checks and balances against mental “diseases” being diagnosed that are actually projections by the clinician.

  32.  
    CannotSay2013
    May 16, 2013 | 3:32 PM
     
  33.  
    CannotSay2013
    May 16, 2013 | 3:40 PM
     

    Bernard Carroll,

    “We need to be clear that the existence of disease is not predicated on having a biological test.”

    Actually we need to be clear that NEEDS to be case, especially when we talk about the “mind being diseased” :D. We have to base those assessments on objective, quantitative data. The most obvious example is of course homosexuality.

    - Psychiatry’s invented diseases ARE NOT genetic diseases such as Down Syndrome is.

    - People’s behavior is a combination of their genes (“predisposition” of their biology if you will), their environment and I would add (from a Christian perspective), their soul/free will.

    If we agree on this, then we should all agree that all coercive psychiatry should be abolished. Why do we punish DSM-5 behaviors but not others like homosexuality that have exactly the same origin (the same type of studies with self described homosexuals have been performed on identical twins with similar results as those who performed on so called “schizophrenic”).

    What makes behavior described as “schizophrenic” pathological but, in this day and age, “homosexuality” non pathological? We cannot base that on what a group of self appointed “mind guardians” think.

    We already have the criminal justice system to deal with those who misbehave in ways agreed upon by society via the democratic process. Note that I say ALL, not “all except case a, b, c, d, etc”. ALL.

    This is perfectly consistent with dealing appropriately with disabilities due to “real” diseases such as Down Syndrome, Alzheimer’s, etc.

    Psychiatry is not a scientific endeavor, is a pseudo scientific scam that is used for the purposes of social control by governments worldwide with the coordination of psychiatrists and Big Pharma companies are are too willing to comply with the scam while they enrich themselves in the process.

  34.  
    May 16, 2013 | 6:41 PM
     

    We need to be clear for these reasons:

    1) The loss that comes with the diagnosis of a severe mental illness – lcivil rights from the states; fallout with private health and life insurance; several other areas

    2) The use of coercise treatment(s) – obviously, without fully-informed consent or non-drug or ECT options, often involving incarceration without due process

    That’s why we need some clarity.

    Duane

  35.  
    May 16, 2013 | 6:42 PM
     

    Until psychiatry can come up with something solid, this all needs to stop.
    Really.

    Duane

  36.  
    Nick Stuart
    May 16, 2013 | 7:02 PM
     

    Bernard Carroll, you say
    ‘This process of convergent validation has given us an A-list of psychiatric diagnoses that are candidate brain diseases. Here is the list: psychosis, mania, melancholia, vascular depression, crippling anxiety, panic disorder, dementia, autism, obsessive-compulsive disorder, delirium, catatonia, and more.’

    Yes they may be ‘candidate’ but until science shows otherwise this is just a hypothesis. Richard Bentall would dispute that psychosis and mania are brain disorders. I personally suffered in my youth with crippling anxiety and panic attacks. Once I understood that my fears were caused by certain situations and why that panic emerged then I was ‘cured’ I see many others who have experienced this. Did I cure my brain disease like I could cure a tumour? No of course not.

    Your statement lacks scientific credibility. Maybe you could show the actual evidence. Thanks.

  37.  
    tom2
    May 16, 2013 | 8:11 PM
     

    Dr. Carroll and Mr. Shorter, thank you both for your clear-sighted commentary.

    I am currently volunteering in an ER and I am consistently overwhelmed by the number of patients with full-blown psychosis. It’s a sight to behold. One encounter with such a patient-especially when the toxicology screen comes back completely negative-is utterly bewildering. Unfortunately the police almost always haul the patients in, usually for disorderly conduct (defecation/ urination in public, laying down in the middle of an intersection, screaming at random children…). What the hell becomes of these people after they leave the hospital? There are no state institutions for them, and expecting them “to freely integrate back into society” is brutally naive.

    Seriously folks, if you think psychiatry is utter bullshit, just some clever way of controlling people with valuable and edifying differences, then spend some time in an ER or psychiatric hospital. The clinical reality will shock you. What will also shock you is how much better some of these patients get with proper treatment (MEDICATION).

    It’s one thing to criticize the DSM process and the overweening ambitions of certain neuroscientists, but really, a cold dose of clinical reality would do many of you anti-psychiatry zealots some good.

  38.  
    Berit Bryn-Jensen
    May 16, 2013 | 8:14 PM
     

    An editorial in BMJ is pointing in the same direction as several of the commenteres on this blog:
    http://www.bmj/content/346/bmj.f4614 Let the patient revolution begin

    Some hundred years ago the acquired experience of lay people, often women, was sidelined and ousted by university trained males, doctors of medicine, who got themselves monopoly by way of royal privilege to practice medical interventions. According to several historians of medicine, Roy Porter outstanding among them, the results were shortened lifespans among the affluent who could afford these services, … The doctors should have noticed that this is the situation in modern psychiatry, with dangerous drugs and ECT, as documented when available statistics are publicized as Robert Whitaker did in Mad in America and Anatomy of an Epidemic, as health authorities in several countries are putting their numbers together and getting the same dismal picture of disability, early death, disaffected citizens, growing distrust.
    Psychic health and dis-ease are too important and too complex to be left to professional, vested interests to define and decide and research as inside jobs. It has to be broad, cooperative ventures free of traditional power dominance.

  39.  
    May 16, 2013 | 8:33 PM
     

    tom2,

    Don’t assume some of us haven’t seen the things you describe, or that we haven’t met people who have experienced the same.

    There are better ways.

    Duane

  40.  
    CannotSay2013
    May 16, 2013 | 8:45 PM
     

    tom2 ,

    The problem is that after having the NIMH director and the Chair of the DSM-5 task force both agreeing that DSM diagnosis lack scientific validity (even the travesty joint statement doesn’t dispute that), it is very hard to discount these concerns as “anti psychiatry zealotry”. Even The Economist is echoing these issues

    http://www.economist.com/news/leaders/21578050-single-book-has-come-dominate-psychiatry-dangerous-shrink-wrapping

    That the “zealot shrinks” need to understand is that we are now in a new regime. Repeating old mantras to disqualify us will not work anymore.

  41.  
    Berit Bryn-Jensen
    May 16, 2013 | 8:53 PM
     

    http://www.bmj.com
    of May 14th, 2013 is a better link to the editorial.

    tom2: Heavily drugged/ intoxicated people in an American ER can hardly be anything but the most simplistic argument for more drugging, but legally, since it’s in a hospital. There are better options than a stoneage-like approach with pharmaceutical drugs effective like clubs. It can be done in another social and cultural setting than your US emergency room.

  42.  
    tom2
    May 16, 2013 | 11:12 PM
     

    Berit, my point was that these people are not intoxicated or drugged; that is, their tox screens come back NEGATIVE. I remember one of the first patients I saw in the fits of psychosis, and I was thinking, “oh, she’s seriously strung out on meth.” Nope. Wrong. No meth. No coke. No alcohol. No PCP. Nothing.

  43.  
    May 16, 2013 | 11:38 PM
     

    tom2,

    There are *numerous* reasons for psychosis. The problem is that ER docs (and especially psychiatrists) do not conduct a proper and thorough assessment. From the British Medical Journal -

    http://psychoticdisorders.wordpress.com/bmj-best-practice-assessment-of-psychosis/

    Duane

  44.  
    Berit Bryn-Jensen
    May 17, 2013 | 5:25 AM
     

    tom 2,

    If you would reconsider, maybe you could see the inherent, mixed messages in your comments. Mental patients as emergencies delivered/dumped into ERs by the police are the far end of systematically missed opportunities, caused by any of the multiple triggers present in deeply unjust, traumatogenic societies, of which the USA is, sadly, a prime example, demonstrating at times the best care money can buy, but more often the very worst – for rising numbers of marginalized citizens.

  45.  
    Annonymous
    May 17, 2013 | 10:11 AM
     

    It seems an oversimplification to imply that “proper” long-term treatment for all people presenting with psychosis to an emergency room, and showing no laboratory evidence of acute drug ingestion, is “MEDICATION.”

    It also seems an oversimplification to imply that all instances of people who present with psychosis causing serious functional impairment is “caused by any of the multiple triggers present in deeply unjust, traumatogenic societies.”

    What about very young children with autism?

  46.  
    Berit Bryn-Jensen
    May 17, 2013 | 12:49 PM
     

    Annonymous
    Accepting that life is fraught with uncertainty is difficult. It’s very human to expect answers, whether from whichdoctors or our more modern experts. But I would question diagnosis of “very young children” with anything that did not come with biological markers, whether autism, bipolar or anything else of greater benefit to others than to the children. Our brains are in development for a longer time and are more wonderfully complex than imagined a few years ago, so rushing to conclusions about very young children seems illadvised to this grandmother, when time, patience, guidance, nourishing food and milieu is what all children need, and some have additional, special needs. If basics are lacking, the prudent approach would be to attend to the basics, I think, before labelling “very young children”

  47.  
    tom2
    May 17, 2013 | 1:15 PM
     

    Let me be clear, I am not advocating for a complete defense of every aspect of psychopharmacological psychiatry-I am just a premed student with the shakiest knowledge of basic science. However, I semi-consistently see patients who are severely disturbed, patients who respond not a scintilla to verbal suggestion, patients who, owing to their outrageous behavior, alienate themselves from their families and their communities, and finally, I see these same patients stabilize exceptionally well with medication, albeit after several days of treatment.

  48.  
    Annonymous
    May 17, 2013 | 1:31 PM
     

    The point about labeling is a fair one. Overall I would agree with that, especially in regards young children. And, would agree that society has a nasty tendency to be drawn to labeling children instead of taking on the more daunting task of addressing societal issues. Psychiatry is prone to being used by society for purposes that do not necessarily serve those being “cared” for. An interesting take on this can be found here:

    http://thelastpsychiatrist.com/2013/05/dove.html
    “The ad’s association to therapy here was probably not planned but it was inevitable, just as Mantegna selecting a psychiatrist and not an engineer or a cook or a stripper as the mark in House Of Games was inevitable. It is the only system of rules based on self-deception, it encourages the illusion of “self” separate from behavior. And as long as psychiatry uncritically elevates identity over behavior, it makes it– not the patients, it– an easy mark for con men with their own agenda: SSI, the justice system, gun control, schools, whatever. “It’s called a confidence game. Why, because you give me your confidence? No: because I give you mine.” Take a minute, think it through.”

    I do think, however, that Dr. Carroll is making a very important point about “biological markers” that is not adequately being taken into consideration. If you look at the rest of medicine (or at medicine for those who prefer to think of psychiatry as separate) a lot of potential overlabeling and overtreatment is being driven by overinvestment in biological markers.

    Psychiatric practice is truly of less “value” and lacks “scientific validity” because it is not based on “biological markers.” Or, psychiatric practice will truly be of “value” and will truly have “scientific validity” once it has “biological marker.” They seem like two faces of the same coin.

    Our brains are in development for a longer time and are more wonderfully complex than imagined a few years ago, so rushing to conclusions about very young children seems illadvised to this grandmother, when time, patience, guidance, nourishing food and milieu is what all children need, and some have additional, special needs. If basics are lacking, the prudent approach would be to attend to the basics, I think, before labelling “very young children”

    While I think there is more to discuss about how that all plays out in the world, I think it would be foolish to argue with the spirit of what you put very well.

    The underlying judgment (on the part of the physician, on the part of the patient, on the part of legislators, on the part of teachers, …etc) is critical. That will still be the case when we have more “biological markers.” The way we “label” a child, and the assumptions we make about what that “label” tells us we should so to them, should give us just as much pause whether or not there are blood or radiology findings we think are suggestive.

    That hyperenthusiasm for biological markers is shared by the current leadership in psychiatry should perhaps give pause to those who are not enamored by psychiatry as it currently stands.

    If the day comes when primary care doctors run mass blood screening and start putting large numbers of people on prophylactic psychiatric medications (basically the using a statin to treat a biomarker model that is more the “medical” model), no psychiatrists or psychiatry required, I am not sure that we will necessarily achieved a model of care with great value or validity.

  49.  
    Berit Bryn-Jensen
    May 17, 2013 | 2:21 PM
     

    I appriciate your comments, tom2 and Annonymous. I certainly agree that there is “more to discuss” and it seems to me that open dialogues brings greater mutual understanding. And I’d be surprised and sceptic, if the day ever comes, and I’m still around, that the NIMH announces that the schizophrenia gene(s) is discovered and biological markers for every disease on the books. Yes. Dr Carroll is making an important point about the overinvestment in biological markers. Potentially lethal overinvestment, according to recent history.

  50.  
    wiley
    May 17, 2013 | 3:16 PM
     

    Tom2, are you familiar with the concept of “secondary psychosis“? It seems that psychiatry sees “comorbid mental illness” where scientists see physical causes of psychosis, depression and other states that have been the purview of the DSM.

    Secondary psychoses: an update
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3619167/

    DSM-5 And Somatic Symptom Disorder – Dire Consequences For Rare Disorders

    http://socialjusticesisters.wordpress.com/2013/02/12/dsm-5-and-somatic-symptom-disorder-dire-consequence-for-rare-disorders/

    Evolutionary Biology and Anthropology Suggest Biome Reconstitution as a Necessary Approach toward Dealing with Immune Disorders
    http://emph.oxfordjournals.org/content/early/2013/04/18/emph.eot008.abstract

  51.  
    wiley
    May 17, 2013 | 3:40 PM
     

    Evolutionary Biology and Anthropology Suggest Biome Reconstitution as a Necessary Approach toward Dealing with Immune Disorders
    http://emph.oxfordjournals.org/content/early/2013/04/18/emph.eot008.abstract

    Sleight of Hand, Sleight of Mind: Illusions, Delusions and the Immune System
    http://blogs.scientificamerican.com/scicurious-brain/2013/01/30/scicurious-guest-writer-sleight-of-hand-sleight-of-mind-illusions-delusions-and-the-immune-system/

    Psychopathology in Multiple Sclerosis
    Diagnosis, Prevalence and Treatment
    Brief psychotic episodes – mainly comprising religious or persecutory delusions and hallucinations – may occur as manifestation as well as a remission-followed onset relapse in MS. Psychosis in MS distinctly differs from schizophrenia as it has a later age at onset, quicker resolution, fewer relapses, better response to treatment and a better prognosis… It may be related to a predominance of lesions in the temporal lobes and with larger lesions in general. MS patients with psychosis had a higher total lesion score and significantly differed from patients with MS alone in bilateral plaques involving the temporal horns. In all cases, neurological symptoms preceded the onset of psychosis.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002616/

    Patterns of misdiagnosis of multiple sclerosis.
    The patients had been referred to 2.2 +/- 1.3 specialists before seeing a neurologist, and learned about their disease 3.5 years after the onset of symptoms. Twenty-nine patients (58%) were initially given 41 wrong diagnoses. While the majority of women were misdiagnosed mentally, orthopedic work-up was offered to the men. Misdiagnosis of MS occurred most often in patients who presented with non-specific sensory symptoms that did not conform to a specific neurologic syndrome. The patients emphasized the fact that not knowing worsened their anxiety, whereas receiving the diagnosis enabled them to begin coping with their disease.
    http://www.ncbi.nlm.nih.gov/pubmed/12901244

    Sleight of Hand, Sleight of Mind: Illusions, Delusions and the Immune System
    http://blogs.scientificamerican.com/scicurious-brain/2013/01/30/scicurious-guest-writer-sleight-of-hand-sleight-of-mind-illusions-delusions-and-the-immune-system/

    Psychopathology in Multiple Sclerosis Diagnosis, Prevalence and Treatment

    Brief psychotic episodes – mainly comprising religious or persecutory delusions and hallucinations – may occur as manifestation as well as a remission-followed onset relapse in MS. Psychosis in MS distinctly differs from schizophrenia as it has a later age at onset, quicker resolution, fewer relapses, better response to treatment and a better prognosis… It may be related to a predominance of lesions in the temporal lobes and with larger lesions in general. MS patients with psychosis had a higher total lesion score and significantly differed from patients with MS alone in bilateral plaques involving the temporal horns. In all cases, neurological symptoms preceded the onset of psychosis.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002616/

    Patterns of misdiagnosis of multiple sclerosis.
    The patients had been referred to 2.2 +/- 1.3 specialists before seeing a neurologist, and learned about their disease 3.5 years after the onset of symptoms. Twenty-nine patients (58%) were initially given 41 wrong diagnoses. While the majority of women were misdiagnosed mentally, orthopedic work-up was offered to the men. Misdiagnosis of MS occurred most often in patients who presented with non-specific sensory symptoms that did not conform to a specific neurologic syndrome. The patients emphasized the fact that not knowing worsened their anxiety, whereas receiving the diagnosis enabled them to begin coping with their disease.
    http://www.ncbi.nlm.nih.gov/pubmed/12901244

    My first and only psychotic episode occurred one month shy of my 51st birthday. At the time, I was in my first MS remission, I was taking drugs that could cause psychosis (baclofen, morphine, and copaxone), I was suffering the worst PTSD ever, and what was by far the worst extended period of sleep deprivation ever. I’ve been a decidedly dedicated sleeper since I was 21. Hypervigilance and pain had been keeping me awake and waking me up after one or two hours of sleep.. I was also drinking. (It took me four months to realize that on the anniversary of my trauma I went out and bought liquor. I don’t normally drink.

    I have lesions in my brain. For some reason, with this dream of finding biological causes of “mental illness,” the tendency of the psychiatric profession has been to call what they see as DSM classifications as being “comorbid.”

    My psychotic episode fits the description of secondary psychosis in MS perfectly. But, because I had a hypomanic episode on an antidepressant I’m supposed to understand that any psychic disturbance is “bipolar disorder” and my PTSD diagnosis seems to have stopped existing about the time that Type II Bipolar was “discovered” through drug interaction.

    Sleep deprivation is known to lead to psychosis. Isolation— people in SuperMax prisons who are not SuperCriminals go mad from the isolation and sensory deprivation. Autoimmune disorders with schizophrenic like episodes have been known and successfully treated with blood transfusions or immunoglobulin since 1934, yet all psychiatry (sorry about the personification, Mickey) seems to perceive is their classifications that they yearn to discover biological causes for, even as a direct biological cause is right in front of them.

    Also, my own psychotic episode— and I have no doubt that this true for many— was a perfect storm of stressors that were intense, very real, threatening, and overwhelming. My best friend, who depended on medication to life was having his life threatened by a bureaucracy that was considering cutting him off.

    It seems to me that the best approach to first episode psychosis would be open-mindedness; and the goal should be soothing and helping the patient process what just happened to them, rather than slapping a label on them, prescribing powerful brain-damaging medication, and telling the patient that they’ll always be mentally ill.

  52.  
    tom2
    May 17, 2013 | 7:06 PM
     

    Wiley, thank you for sharing your story. I hope that your situation is now better.

  53.  
    wiley
    May 17, 2013 | 8:14 PM
     

    It’s great, tom. I feel inner peace now, like it, and as much of a stranger as it’s been all my life, it feels like home.

  54.  
    Richard Noll
    May 18, 2013 | 3:53 AM
     

    I’ve been on the road for a week and am just now catching up on all the excitement. So as the 50-umpth response to Mickey’s superb blog post, I risk being overlooked, but here goes:

    Barney Carroll’s “A-list” and “B-list” for mental disorders is a point that seems to get lost at all levels of these sorts of debates in psychiatry. Because I had extensive inpatient experience, including 4 years on the wards of a state hospital, my deep concerns have always focused on the A-list conditions, particularly schizophrenia and manic-depression. It has always seemd to me that these A-list conditions should be the primary focus of biomedical research in psychiatry, including the possiblity of developing new pharmacological agents that do more that target neurotransmitter systems only after we take novel approaches to understanding these disease processes from a systemic or “whole body” perspective. The brain is affected, but for many of the A-list conditions it might be the final stage of a cascade of physiological processes of which genes (which may account for only 2% of the variance) are only sparks that may or may not ignite a smouldering process through several systems (immunological, endocrine, the microbiome) and, with the help of “environmental” factors, result in a blazing “fever.” To do this requires new approaches and new basic foundational research in biology — not just psychopathology. This approach has not been given its proper respect in US psychiatric research, although European researchers (especially in Germany) are more accepting of it. Etiologies may never be fully understood (as they are not for most medical diseases), but I would settle for a fuller articulation of pathophysiologies as not only new understandings but also as points of entry for therapies of all kinds, pharmacologic and psychological.

    Hence, I already see the limitations of the RDoC approach as it currently exists in the published summaries of the various workshops on each of the domains. Whatever the end result of RDoC may be one day, it can only lead to a narow focus that justifies the need for more drugs that target brain neurotransmitter systems to the exclusion of other physiologies of the human body. Again, just the opinion who has no dog in this fight.

    I think we do indeed have enough clinical validation for the A-list/B-list distinction and should bear these discinctions in mind with respect to resources for resesearch and for treatment options. Again, this is just one opinion from a state hospital veteran who learned to loathe the biological disease processes that wrecked the lives of so many young people (mostly men) that I spent my days with and who were told by my colleagues that either their mothers were to blame or that they had a “chemical imbalance” in the brain that their multiple drugs put back in balance.

    By the way, a question for Drs. Carroll and Shorter: I’ve noticed an increasing tendency in the literature to use the word “psychosis” in place of “schizophrenia,” though the new usage does not seem to solve the problem of the latter’s massive heterogeneity and risks blurring the symptom/syndrome distinction. Any information as to when and who started this linguistic shift, and why it is occurring, would be appreciated. I am hoping it is not totally derived from Pharma, i.e., antipsychotic drugs treat psychosis.

  55.  
    May 20, 2013 | 1:43 AM
     

    tom2,

    You sound like a good gut and I apologize if my comments came across as personal. It certainly was not my intent.

    Duane

  56.  
    May 20, 2013 | 1:19 PM
     

    typo – good guy

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