from:
DSM-5 Critics Pump Up the Volume
MedPage Today
By John Gever
February 29, 2012
DSM-5 Leaders Stand Their GroundIn a conversation with MedPage Today, APA President John Oldham, MD, and DSM-5 task force chairman David Kupfer, MD, defended their handling of the revision and argued that many of the criticisms were off-base. For starters, Kupfer said, the proposed revisions were still open to change or abandonment. The DSM-5 will assume its near-final form in June or July, he said — meaning that the APA’s annual meeting in May would provide another forum to debate the changes. "[The proposals] are still open to revision," he said. "The door is still very much open." Oldham said he was satisfied with the process so far. "It’s an enormously long, and difficult, and challenging thing to do," he said. "We’re not going to get it perfect. I don’t think anybody could. I don’t think any previous edition could."Oldham and Kupfer also argued in favor of removing the bereavement exclusion from the depression criteria. Said Kupfer, "If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss." Oldham noted that extreme sadness can be triggered by any number of events – natural disasters, physical disability, job losses – yet the DSM-IV created an exclusion only for "bereavement."
He also pointed out that there are "ranges of heritable risk for major depression" – suggesting that depression may in some sense be normal, yet deserving treatment nonetheless. The DSM’s overarching purpose, Oldham said, is to enable "patients who need treatment [to] get it."
Kupfer conceded that field trials of the revised criteria, by design, were not testing whether the changes would increase or decrease the number of people receiving a particular diagnosis. As a result, the critics’ worries won’t be refuted or confirmed until after the revisions go into effect."We won’t get 100% consensus on all the proposals," Oldham said. "That would be totally unrealistic. But I personally think it’s been a thorough and careful process. We’re going to have disagreement. That’s going to happen."
In reading the the verbage from the DSM-5 Task Force, the APA, or KOLlege of KOLs in general, there are certain codings that need to be understood to make sense out of the peculiar things they say – usually with some passion. The quotes here have many examples of The Code:
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"If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss."Can anyone imagine that a person in that circumstance would be told something absurd like that in 2012? It’s a ludicrous assertion. So why would they be saying something like that? It has nothing to do with any clinical reality I can imagine. But it makes sense if you know The Code: Three examples here:
- intervention = medication
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The DSM-5 is not a Diagnostic Manual, it is a Treatment Manual
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the DSM-5 Task Force thinks that their book is so important that what they say in it will determine what doctors do, not function as a classificatory system to help them decide what to do – so again Diagnosis = Treatment [can you say Algorithm?]
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"patients who need treatment [to] get it."treatment = medication
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"‘ranges of heritable risk for major depression’ – suggesting that depression may in some sense be normal"Saying that grief is not a mental illness but a part of being human – in other words a psychological experience of living – can’t be right. All mental illness has something to do with the brain. Therefore, grieving people who get depressed must have a "heritable risk for major depression." So in The Code, all mental illness is biological.
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"The DSM’s overarching purpose, Oldham said, is to enable ‘patients who need treatment [to] get it.’"I don’t have any idea where that statement comes from. I thought it was to classify mental illness. Is there some shortage of people [doctors] treating mental illnesses [treating as in medicating]? That’s news to me. I thought it was the other way around. But in The Code, this makes perfect sense: Diagnosis = Treatment and treatment = medication because all mental illness is biological.
I wish I were just joking, making up satire, creating Straw Men, but I’m not. Try The Code out as you read what they say. We’ve got to catch psychosis early because Diagnosis = Treatment and treatment = medication because all mental illness is biological. Same for grief, Sleep disorders, psychosis, behavior disorders, etc. I find myself thinking that the DSM-5 Task force doesn’t need to be tweaked, but rather disbanded…
Said Kupfer, “If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss.†This is a classic nonsequitur. The grieving patient can get any kind of help the physician decides, on label or off label. This happens millions of times every day. Besides, the purpose of the DSM is not to promote treatment – it is to clarify diagnostic status.
Oldham noted that extreme sadness can be triggered by any number of events – natural disasters, physical disability, job losses – yet the DSM-IV created an exclusion only for “bereavement.” The default position would have to be that exclusions for other major life stresses are just as appropriate as the bereavement exclusion already is. Dr. Oldham displays no awareness of that default position.
Dr. Nardo is correct in saying the DSM is not a treatment manual. DSM-III and DSM-IV actually are silent on treatment issues. For that matter, DSM is not even a diagnostic manual. Its command of diagnostic process is weak. And it certainly has never been a scientific document. Since the days of Gerald Klerman as Administrator of ADAMHA leading up to DSM-III it has been clear DSM is mainly an administrative manual. It was not designed for actually making diagnoses. It is designed to ensure that the diagnoses made by clinicians conform to a minimum symptomatic data set for reimbursement purposes. All other claims are just hand waving and humbug.
As for Dr. Oldham’s words about an open and transparent process, I have to say that my communications over several years with the DSM-5 people disappeared into a black hole.
The authors of the DSM-5 are adapting the style and hidden agendas used by many ghostwriters of pharma-marketing sponsored clinical write ups and reviews.
Are these guys using ghostwriters? And is pharma driving all this?
I’m pondering that as we speak. Something is driving all this. That’s for sure.
from the Financial Times via biopharminsight 3/15/12
New autism diagnostic criteria may encourage symptomatic approach to drug use
http://www.ft.com/intl/cms/s/2/909caabe-6ed1-11e1-afb8-00144feab49a.html#axzz1pHGzfNpN
To make a diagnosis purely for the purpose of obtaining treatment, when the practitioner had no other basis for a good faith belief in the truth of the diagnosis is, put simply, fraud. And if public money is involved it is criminal fraud.
It would no morally different from diagnosing hypertension to justify prescription of aspirin when the patient needs aspirin as an analgesic for headache rather than as a blood thinner. Or vice versa.
The classic example of this is so-called Gender Identity Disorder which is diagnosed to justify somatic treatment but (in most cases) without a good faith belief that GID is truly a psychopathology (disease of the mind). If there is no good faith belief in mental illness in such a case then not only is diagnosis of GID dishonest, it is also unethical.
Seriously, why not create an alternative diagnostic manual? And, while at it, why not create an alternative professional psychiatric organization….the National Psychiatric Association or some such name? Too many people are too fed-up with the nonsense APA perpetuates and we (doctors and patients) can’t just wait and hope that one day they’ll come around and reform. I’m betting there would be big interest…
“….they should not be prevented from getting the appropriate care that they need….”
I agree this is a buzzword collection. I believe it deliberately appeals to “the base”: The so-called grassroots patient-advocacy organizations such as NAMI, many of which are Astro-turfed — funded by pharma — and do a great deal of the heavy lifting in lobbying governmental organizations to “reduce the stigma of mental illness” and “make appropriate care available to all who need it.”
For “appropriate care,” read “psychiatric medications.”
This is another example of how the APA is working for pharma and against the interest of clinicians, by aligning with organizations advocating universal access to “appropriate care.”
Pharmalot has a write up on the conflict of interest problems rampant in DSM5, and they cite a recent article on PLoS (link below):
A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001190
I asked a prescribing nurse to write a letter for extra test time and a quiet room for a math class (ADHD (head injury when I was 8)). She started writing a letter saying that I’m “psychotic”. I asked her what she was doing. She had years of records from a V.A. psychiatrist that said nothing about me being psychotic. She looked at me as if I were a small child who just didn’t get it, and said, “You have extreme fear, therefore you’re paranoid, therefore you’re psychotic. If you don’t believe me, look it up in the diagnostic manual.”
My extreme fear is from an experience I had in nuclear forces. It would have been psychotic not to feel extreme fear while witnessing a decapitating Soviet strike in real time with the policy of MAD. The shame of having been an instrument of total global annihilation is a bit heavy as well. She knew I had PTSD from that event, yet still preferred to label me as being “paranoid” even though she had never seen that fear.