1 Boring Old Man

I’ve been trying to find a way to see the double entry of the Attenuated Psychosis Syndrome [outright skullduggery…] as some kind of publication error [a corrigendum as they like to call it]. But I can’t make that work. The two different definitions are indexed in the back of the book and appear to be presented in context in both places. And it’s not a hold-over from the DSM-IV. I don’t particularly want to be one of those people who jumps on every little molehill and blows it into a mountain, but this one seems plenty suspect. It looks like the product of two minds, acting independently. So it’s not as though I wasn’t already suspicious when someone pointed me to this announcement. It just to threw gasoline on the fire:

I’m afraid not to be an alarmist at this point. Too many of us didn’t pay close attention for far too long, and the results were disastrous. Medicine is meant to be self policing. I always liked that. But with the intrusion of the forces of the insurance, hospital, and pharmaceutical industries into matters medical, that process has eroded. We rarely hold up the standard that there should not be even the appearance of a conflict of interest. And when I run across something like this double entry diagnosis, I find it impossible not to say, "Uh oh. What’s up?" And though I wish I could stop with the "forces of industry," I’m afraid I have to include members of the profession in that suspicion – even people who aren’t morally challenged by nature. Sometimes, the zealots can be as dangerous as the devious. Did APA President Liebermen have something to do with that extra Attenuated Psychosis Syndrome in the DSM-5, the one with a code number that could lead to reimbursement? or a drug approval?

[July 20, 1999] Forty years ago, scientists found the first modern drug to treat schizophrenia. Now they may be getting close to the next big step: preventing it. New studies hint at ways to pick out people on their way to developing the disorder, and scientists are testing whether they can be helped. It’s all very preliminary; but the federal government announced in April that it will pay for more studies, a big boost to the young field. And researchers are planning conferences to examine this bold notion of preventing schizophrenia. "Its time has come," says psychiatrist Jeffrey Lieberman of the University of North Carolina at Chapel Hill.

There was a time when I would have passed right over that announcement. I’m literate in the area of preventive strategies in Schizophrenia. I know it as an intriguing topic, something to follow along hoping someone will refine a way of defining a pre-psychotic diathesis that’s reproducible, that will allow us to think in earnest about etiology and prevention. I know that a lot of promising fits and starts haven’t panned out, but it’s still worth pursuing. I know that my attention in more recent times is drawn to look for it being engaged by those pushing medication sales. But I wouldn’t go off with suspicions like those that came to mind after reading Dr. Frances’ post then seeing that blurb on Dr. Liebermen’s talk. That’s something new, something acquired – at least for me. It’s a new kind of paranoia that’s unfamiliar, uncomfortable, and unwanted. It feels like the kind of hyper·vigilance patients with PTSD describe – nagging on the side of the mind until it has been thoroughly run down. It’s not the benign skepticism of a psychotherapist listening with a third ear for those lapses and wrinkles that signal unconscious forces at work in the background. It’s more jarring, like being played by a con man – discordant and distancing. It takes up a lot of space -and it detracts from the kind of things I’d rather be thinking about.

But having worked through my brief paranoid episode, that diagnosis repetition  still nags at me. Throughout the DSM-5 Task Force’s deliberations, the Attenuated Psychosis Syndrome was on the menu for a place of its own. And when it became shrouded in controversy, the issue was always whether it would become a diagnosis proper in Section II, or be relegated to the also-rans limbo of Section III. Having it subsumed under Schizophrenia-Anything was really never on the table. So it’s hard to even imagine that it was mistakenly left in, since there’s no reason for it to be there in the first place. And it does have potential consequences as a billable diagnostic code, so it needs to be exposed at the least and ultimately changed. More interesting and perhaps more importantly, How did it get there?