my brief paranoid episode…

Posted on Thursday 5 December 2013

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?

You know what? I still want to know why that diagnosis is in the DSM-5 twice, after all the attention it received along the way. However, connecting Dr. Lieberman’s giving a talk about "Preventing Schizophrenia: An idea whose time has come" is off the table, in spite of my alarm bells ringing like it was the beginning of the Blitzkrieg. Looking into things, he’s been giving talks with that title as a visiting lecturer for well over a decade. If you want to hear the version that’s in line with his visit to Nevada, here’s one at Case Western Reserve last year – Prevention of Schizophrenia Through Early Intervention: Feasible of Fantasy? The first mention I found was in 1999:
[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.
His time-has-come/prevention-of-schizophrenia talks are scattered throughout the last decade. It’s his dog and pony show – the talk he takes on the road. Manyl have such talks. It’s much easier to give a talk to strangers than to colleagues. They haven’t seen your slides, heard your stories, learned to anticipate of your punch lines. This is Dr. Lieberman’s version and isn’t connected to this DSM-5 peculiariety.

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?

I don’t think my paranoid tendency came from senility or some hitherto unknown disease process. I acquired it during the time of the DSM-5 Task Force specifically because of the way they operated. They avoided glaring needs like the non-category of Major Depressive Disorder and focused on odd pet projects. They responded to criticism with ad hominem attacks, discounting arguments, or just ignoring it altogether. They took the idea of a closed shop to extremes, while publicly talking over the top of controversies that swirled around many of their decisions. If you were a psychiatrist like I am, you would have felt embarrassed by their comport most of the time. The levels of conflict of interest were disturbing. And the recent revelation that Dr. David Kupfer, the grand poo-pah, was part of a commercial enterprise that stood to gain from something he was advocating on the task force just piles more doubt on the whole enterprise [careful watching…]. So this strange business with the Attenuated Psychosis Syndrome seems like yet another behind-the-scenes agenda that needs to see the light of day. If that’s not the case, somebody needs to help us out with an explanation. We’re having a crisis of doubts out here…
    December 5, 2013 | 9:00 PM

    What!??? You mean the DSM is a concoction by an old boys’ network???

    December 5, 2013 | 9:28 PM

    The thing to keep in mind with dealing with an unprincipled entity is that the benefit of a doubt can quickly and easily become enabling if not colluding with skullduggery.

    December 5, 2013 | 9:30 PM

    Really, you can’t see the connection?! Since they have been bitching for what, 2 years there are no new advancements in meds to make some psychiatric illness more sexy and profitable, they just want to make more illness so they can use what little is left that is still profitable.

    As I wrote at an earlier post, if there is a god, there will be accountability when idiots start treating non psychotic teens/young adults with overmedicating antipsychotic regimens and then the discovery portion of lawsuits draws in the connections. After all, lawyers want to go after who has the most money, and after the pharmaceutical companies, who is more attractive, a lone psychiatrist, or, an organization that is grossing millions on the sale of this book?

    Lieberman is the poster child for what is so horribly wrong with the APA of late. It is the soulless, careless, and demeaning nature that is much of authority and leadership in America these days.

    So, I don’t think your writings are a brief paranoid episode, but a moment of brutal and frank candor documenting the incessant insults and destruction of our profession, brought to you by people that too many admire and follow!

    Linda T
    December 7, 2013 | 2:55 AM

    A little off topic perhaps, but he is more much needed “brutal and frank candor” and deep thought, from Iona Heath at the recent Preventing Overdiagnosis conference at Dartmouth.
    Video of her conference address is among others on this page
    Subsequent essay

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