don’t know what else to do…

Posted on Sunday 19 May 2013

I suppose that this kind of defensive opening Press Conference was to be expected. And they chose to defend criticisms of specific decisions made along the way. I’ve added just a few comments along the way, but they missed the overall point of the major criticisms of their [now released] DSM-5.
APA Leaders Defend New Diagnostic Guide
MedPage Today
By John Gever
May 18, 2013

The fifth edition of the "psychiatrist’s bible" was officially released here in all its 947-page glory, with its developers offering a spirited rebuttal to their critics. Known as DSM-5, the new version of the American Psychiatric Association’s [APA] Diagnostic and Statistical Manual of Mental Disorders was launched at a press briefing to kick off the organization’s annual meeting. Most of the changes from the previous edition had already been made public, at least in general outline.

At the briefing, DSM-5 Task Force chairman David Kupfer, MD, of the University of Pittsburgh, defended several of the most heavily criticized revisions from DSM-IV, as the last edition was called. Other top APA leaders, including current president Dilip Jeste, MD, of the University of California San Diego, and president-elect Jeffrey Lieberman, MD, of Columbia University in New York City, addressed another, more recent controversy over DSM-5, which was sparked by a blog post from National Institute of Mental Health [NIMH] Director Thomas Insel, MD. In his blog, Insel criticized the DSM classification system’s scientific validity, and his remarks were then reported in consumer media as suggesting DSM-5 is "out of touch with science," as a New York Times headline put it.

Kupfer identified several specific changes from DSM-IV in the new edition that had drawn the most heat from others in the mental health community and patient advocacy groups…
  • Autism Spectrum: …
  • Bereavement Exclusion in Major Depression: …
    APA fact sheet distributed at the briefing pointed to several features that "usually" distinguish depressive illness from normal grief in patients experiencing recent losses. They include continuous unrelieved negative mood and feelings of worthlessness and self-loathing. In normal grief, extreme sadness is typically intermittent and self-esteem is unaffected, the fact sheet said.

I just thought this was kind of funny. In the DSM-5, they distinguish grief and depression by duration of symptoms, yet in this handout, they differentiate them by specific findings [self loathing]. The funny part is that they are essentially quoting Freud’s 1917 Mourning and Melancholia without attribution.

  • Disruptive Mood Dysregulation Disorder (DMDD]: …
    The diagnosis "is intended, in part, to address issues about potential overdiagnosis and overtreatment of bipolar disorder," Kupfer said.

If they wanted to clarify Childhood Bipolar Disorder, they could’ve done that directly. Instead, the created another fictitious heterogeneous Disorder that can be overmedicated. What were they thinking, I wonder?

  • Mild Neurocognitive Disorder:
    In a critique of DSM-5 published on the eve of its launch, the head of DSM-IV’s development in the 1980s, Allen Frances, MD, of Duke University in Durham, N.C., singled out the new edition’s inclusion of mild neurocognitive disorder as another example of medicalizing normal function… "There has been concern that we may have added a disorder that may not be important enough to merit clinical attention," Kupfer said… "Clinicians have lacked a reliable diagnosis to assess such [impairments] and to understand what might be the most appropriate treatment or services," Kupfer said. Including mild neurocognitive disorders in DSM-5 "serves two essential needs," he said. One is that it provides "an opportunity for early detection," while another is that it "encourages the development of an effective treatment plan before deficits become more pronounced and progress to dementia."

Again, missing on purpose Dr. Frances’ point that this is a black hole for false positives created based on no data. It’s an example of their doing "pretend prevention" without their beloved "evidence base."

  • Insel’s Comments: …
    Apparently without meaning to, Insel set off a firestorm with an April 29 "director’s blog" post on the NIMH website, in which he lamented that the DSM – not just the new edition but its predecessors as well – is not grounded solidly in biology. Rather, he said, "the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.

If I may be candid, "without meaning to" my ass! Insel was grandstanding and it backfired. What’s worse. The DSM-5 Task Force agrees with Insel since their opening gambit in 2002. They were as disappointed with the DSM-5 they ultimately created as the rest of us, but they got over it as the deadlines approached.

    At the press briefing here, APA officials reiterated that there is, in fact, no disagreement with Insel. "We support what he’s trying to do," said John Scully, MD, the APA’s chief executive officer. "We want him to get biomarkers for us." Added Lieberman, "He [Insel] was trying to exhort the biomedical research community to try to break new ground that will lead to more dynamic and fundamental changes in psychiatric diagnosis." Yet, Kupfer suggested, the flaws in DSM-IV for daily clinical practice needed to be addressed in the short term, and an extension of the symptom-based approach remained the only alternative. "While we don’t yet have the biomarkers that we are hoping are on the edge of discovery, patients can’t keep waiting, and we can’t keep waiting," he said.

The DSM-5 Task Force spent years and untold amounts of money chasing the same dream Insel has to no avail. What they didn’t do was revise the DSM-IV which was in need of attention by all accounts [including that of Dr. Frances who directed that revision], and was their assigned task. They ignored the fact that the most common diagnostic category, Major Depressive Disorder, has been hopelessly flawed from day one [1980] and should have been an abiding concern along with several other major categories. Instead, they piddled around trying to add some things that were immaterial and actually detracted. They were so taken with their expertise and ideologies that they failed to notice that the train was off the track and too deaf to hear people desperately trying to help them do their job.

  • Other Criticisms …

This Press Conference is an exemplar of what they’ve done for the whole time – try to explain themselves to people who know better, banking on an authority they think they have… but don’t. I wonder if they actually miss the point as badly as it appears, or if they just don’t know what else to do…
    May 19, 2013 | 12:05 PM

    Irregardless of the setting, political issues in an organization, be it our federal government or the APA as front and center examples, leadership has been whittled away to just personal gain, the needs of the group or society are not of concern.

    This is why I rail these days about narcissism and antisocial qualities in people of positions of power. They are becoming dangerous, not just a nuisance or irritation. And as long as the general public, or average member of the group, either lie silent or just rationalize the status quo, things get worse.

    You would thing a media outlet like the internet could energize and empower. But, all it does is amuse and distract. Oh well, nice post about the issue.

    By the way, as I did at my site and now do here personally to you Mickey, my sincere apology about the Nuremberg comment at a prior post. See the mistake, but ask you to consider reviewing my post about it today.

    If linking the post is a mistake, then delete the comment here, or just edit the comment above the link to this post.

    Happy Sunday!

    May 19, 2013 | 1:39 PM

    That’s one of my prime concerns, as well, Joel. Sociopathy may kill us all. We need to learn how to identify it and prevent those who are it, or who are so informed by it that they might as well be it, and keep them out of positions in which their pathological perspectives and behaviors can have an impact on large populations and wide swathes of the earth.

    Psychiatry and psychology (sorry about the personification, Mickey) could be doing the human race this service, but are too busy patching up victims and doing what they can to make victims either more pleasing to the sociopaths or more like them.

    May 19, 2013 | 1:58 PM

    Exercising authority it doesn’t have.

    It sounds like the profession’s leadership is doing what its rank-and-file does every day. It seems to be of the culture.


    May 19, 2013 | 2:00 PM

    typo – part of the culture


    May 19, 2013 | 2:32 PM

    “Psychiatry and psychology (sorry about the personification, Mickey) could be doing the human race this service, but are too busy patching up victims and doing what they can to make victims either more pleasing to the sociopaths or more like them.”

    Amen to that!

    By the way, had a typo in my first comment, so let me fix it:

    “You would THINK a media outlet…”

    May 19, 2013 | 3:22 PM

    People, join, there is a lot great action going on here

    May 19, 2013 | 7:26 PM

    Nice catch regarding the basic plagiarizing of Freud’s Mourning and Melancholia. It is indeed quite funny– and pathetic. Our modern neuroscientific DSM-5 know it alls just can’t improve on Freud’s insights into melancholia!!!

    May 20, 2013 | 2:10 PM

    “”But the science did not arrive in time. “It would be great if we had been able to have a paradigmatic shift” by basing the diagnosis of mental illness on biology, as the APA hoped to when it began the DSM-5 process”, said Dr Jeffrey Lieberman, chairman of psychiatry at Columbia University and president-elect of the APA.

    But the science did not arrive in time. “The DSM can only reflect the research we have,” said Lieberman.

    “The latest revision began in 1999 with high hopes for putting mental illness on a scientific footing, using neuroscience in particular to tell the difference between, say, normal sadness and major depression.””

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