Posted on Tuesday 21 May 2013

In rural America, we do a lot of driving. The churches along the two lane roads have marquees that post quips like "Would you rather be Grumbly Hateful or Humbly Grateful" [I expect there are books and web sites filled with such things]. Yesterday’s gem was "When looking for faults, use a mirror, not a telescope." When I got home and read the article below, that marquee came immediately to mind:
DSM-5: Caught between Mental Illness Stigma and Anti-Psychiatry Prejudice
Scientific American: Mind
By Jeffrey A. Lieberman
American Psychiatric Association President
May 20, 2013

Like many psychiatrists, I have been amazed by the debates surrounding the DSM-5, the first major revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in nearly twenty years, which was just released. Never before has a thick medical text of diagnostic nomenclature been the subject of so much attention. Although I was heartened to see more and more people discussing the real-world issues and challenges — for patients, families, clinicians and caregivers – within mental health care, for which the book offers an up-to-the-minute diagnostic GPS, I was also alarmed at the harsh criticism of the field of psychiatry and the APA. Consequently, I believe that as you read and watch this increased coverage, it’s important to understand the difference between thoughtful, legitimate debate, and the inevitable outcry from a small group of critics – made louder by social media and support from dubious sources — who have relentlessly sought to undermine the credibility of psychiatric medicine and question the validity of mental illness.

DSM-5 has ignited a broad dialogue on mental illness and opened up a conversation about the state of psychiatry and mental healthcare in this country. Critiques have ranged in focus from the inclusion of specific disorders in DSM-5, to the concern over a lack of biological measures which define them. Some have even questioned the entire diagnostic system, urging us to look with an eye focused on the impact to patients. These are the kinds of debate that I hope will continue long after DSM-5’s shiny cover becomes worn and wrinkled. Such meaningful discourse only fuels our ability to produce a manual that best serves those touched by mental illness…

The "I have been amazed…" from Dr. Lieberman is his standard fare, either a literary device or the reflection of someone who is perplexed that others don’t think his thoughts. Just one example from last year’s pipeline summit about the drug companies pulling out of CNS drug development:
    “There are huge unmet clinical needs in mental disorders and addiction,” said Jeffrey Lieberman, M.D., incoming president-elect of APA and chair of psychiatry at Columbia University, who moderated the morning session. “There should be tremendous interest in this area, but there is not.”
Other than his feigned [or worse, genuine] amazement, he comports himself well in these opening remarks. He at least acknowledges that there are some things to complain about with the DSM-5. That’s better than Drs. Kupfer, Regier, and Scully have been able to muster over the recent years. He should’ve stopped there.
But there’s another type of critique that does not contribute to this goal. These are the groups who are actually proud to identify themselves as “anti-psychiatry.” These are real people who don’t want to improve mental healthcare, unlike the dozens of psychiatrists, psychologists, social workers and patient advocates who have labored for years to revise the DSM, rigorously and responsibly. Instead, they are against the diagnosis and treatment of mental illnesses — which improves, and in some cases saves, millions of lives every year — and “against” the very idea of psychiatry, and its practices of psychotherapy and psychopharmacology. They are, to my mind, misguided and misleading ideologues and self-promoters who are spreading scientific anarchy…
And then he’s off and running. I’ll leave what follows for your own reading. But here in his opening gambit before he even begins his rant, he goes all ad hominem by simplifying and attacking his designated enemies. There are indeed such people scattered among the critics that he’s about to lambast. But he appears to be oblivious to the fact that what makes that small group of "ideologues and self-promoters" he’s going after "misguided and misleading" is that they are doing exactly the same thing that he, Jeffrey Lieberman MD President of the American Psychiatric Association, is doing in this very piece he’s writing. They are depersonifying their targets, seeing them as filled with only evil destructive motives, and portraying themselves as the heroic others engaged in a holy quest for "truth, justice, and the American way." In the words of the roadside sign, "All telescope and no mirror."

I don’t like it when people use the word psychiatrist as an epithet either. It kind of hurts. It’s easier to shrug off when it’s an obvious attack, but harder when it’s closer to the mark. Like many of psychiatry’s critics, I don’t like being disrespectfully labeled and simplified any more than they do. I find myself on the wrong end of many labels at times: psychiatrist, psychoanalyst, southerner, white guy, man, liberal, democrat, etc. And I admit I can do it too – simplify critics and spit. It’s a human thing, that old Talion Law [an eye for an eye] that’s built into all of us. But Dr. Lieberman is in no position to use the valuable space afforded him in the Scientific American for such trivia. Here’s an off-the-cuff alternative:
    "While some of the criticism has come from small groups who would criticize anything we might do, that’s to be expected. More troubling is the criticism from our colleagues in psychiatry, other mental health specialties, and particularly patients. They worry about inappropriate labeling; about influences from industry and other conflicts of interest in recommending medication treatment, minimizing side effects and maximizing drug efficacy; about psychiatrists not spending enough time with patients to understand the context of their lives; about being overly enthusiastic about the exciting but distant frontiers of neuroscience; about over-diagnosing and over-medicating; and more." The traditional role of psychiatrists is listening, and I’ve heard those messages. In my coming year as President, I intend to lay the groundwork for seriously looking into each of these complaints and can assure you that they will be thoroughly and fairly studied. While many of those criticisms can be traced to outside forces, that’s no excuse for psychiatry to avoid taking a long genuine look in the mirror. And I intend for us to do just that."
Not bad for a first shot from an old guy…
    May 21, 2013 | 2:35 PM

    So Lieberman has a foil hat wardrobe, heh. Somewhat OT, have you seen the latest NEJM – the Case Record: “A Girl with Irritability, Hypersomnia, and Somatic Symptoms”? This case was presented (apparently with a “straight face”) by Dr. Sherry at Psychiatry Grand Rounds.

    Berit Bryn-Jensen
    May 21, 2013 | 3:25 PM

    Intellectually corrupt – said dr Frances on the radio, on the DSM-5, and was right, to judge by the low level of discourse demonstrated by President- elect Jeffrey A. Lieberman.
    I am disgusted and delighted and a wee bit amazed that he comes on like a blabbering salesman on thin ice, not at all like a leading academic in mastery of his field. The radio interview and the Scientific American article revealed an already naked emperor-to-be of the APA, replete with the tactics of bullies. Sociopathic traits are said to be common in politics…

    May 21, 2013 | 3:45 PM

    I replied with the comment below. Many of us in Mad In America cannot see other people’s comments,

    Mr Lieberman,

    This is what Insel said,

    “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.”

    Now, prior to his April 29th blog, that was dismissed as “anti psychiatry”. Now it’s part of the official NIMH record. Your travesty/joint statement didn’t change that.

    It’s not prejudice that drives what you call “anti psychiatry”, but a desire for truth. Putting legitimate criticism to psychiatry on the same ground as AIDS denialism is an insult to intelligence. We have accurate biological tests to detect presence or absence of HIV infection. We know for a fact that except for a minority of so called “long term non-progressors”, every person infected with HIV ends up dying unless he/she is put on HAART. Psychiatry has nothing like that. Where is the biological test for schizophrenia? Nowhere. Diagnosis based on “behavior” is no different than labeling somebody a “heretic” based on the consensus of theologians. That is a fact.

    In a typical psychiatric trick, you are using semantics, ie a language that sounds scientific, to put forward fallacious arguments that do not stand any logical deduction. Psychiatry is a scam and DSM-5 has been the last straw. Apparently American shrinks got too greedy and thought they could get away with labeling 50% of Americans as “mentally ill”. It has backfired and it was about time.

    May 21, 2013 | 4:28 PM

    “Not bad for a first shot from an old guy…” Spot on target first shot Mickey. Like it.

    May 21, 2013 | 4:42 PM

    If the “traditional role” is listening, then the president-elect appears to have been abdicating his responsibility as a doctor; certainly as a leader.

    Look out, here comes the new APA.
    (Wait a minute, it looks just like the last bunch… )

    A new era?
    Yeah, right.


    May 21, 2013 | 5:39 PM

    Dr. Lieberman lives in the same alternative universe as Ron Pies. Maybe they’re roommates.

    May 21, 2013 | 5:42 PM

    perhaps suitemates [given the hoiti-toitiness of their styles]…

    May 21, 2013 | 5:57 PM

    Denial, Projection, and deflection, aren’t those immature defenses? read that today in Kaplan Sadock’s last edition of Synopsis of Psychiatry.

    Interesting that those who aspire and gain leadership positions often regress to the very behaviors that they are supposed to identify and try to treat.

    Not limited to the APA however…

    May 21, 2013 | 8:21 PM


    Good points.


    May 21, 2013 | 8:37 PM

    Dr. Nardo,

    Re: The word ‘psychiatrist’ as an epithet

    You said that this has caused hurt.
    And after trying to see it from your angle, I can see how it would.
    So I would like to apologize for the times I’ve done so on your blog.

    Thank you for providing this forum.


    Berit Bryn-Jensen
    May 22, 2013 | 6:26 AM

    Dr Nardo
    I had to check on the meaning of epithet. If I’ve used “psychiatrist” as an epithet, I must apologize too, as Duane has done, because I’m acutely aware of, I think, of huge variations, personally, professionally, intellectually, ethically and so on, within the profession. I would not be weary of recommending anyone to see you, but I do belive that you are not a typical run-of-the-mill psychiatrist, whom I see many reasons to avoid, based on experiences with several and personal horrorstories told in confidence by young people no longer among us.
    What struck me with dr Lieberman is how much he sounded like men I’ve met here, at the top of the professional association, yet unclear, defensive, fumbling, morally and intellectually unimpressive.
    A few years ago, after a meeting between members of NGOs and a then governing
    body of psychiatrists, one expatient said: I could feel sorry for them. Our little group nodded in silent agreement.
    If your off-the-cuff alternative had been the norm, the situation would have looked brighter, but I do not think men like you have what it takes to climb ladders to the top – I’ve seen no sign of the required lack of spine and emphathy called ruthlessness.

    May 22, 2013 | 8:49 AM

    Hardly surprising when you recall that Lieberman has been one of Nemeroff’s most vocal apologists.

    May 31, 2013 | 6:28 AM

    Dr. Lieberman living in alternate parallel universe along with Ron,good point..but better if they are not rommmates there

Sorry, the comment form is closed at this time.