the road behind: paradigms that needed ending…

Posted on Thursday 14 February 2013

We shall drink no wine before its time…
Orson Wells

The DSM-III/DSM-IIIR/DSM-IV series had given the third party carriers, policy makers, and pharmaceutical industry what they wanted – an objective diagnostic system in psychiatry. In some ways, it was trivial because there’s so much more to a given person’s mental illness than signs and symptoms. In other ways, it was brilliant, because it was approximately accurate, somewhat reliable, and it smoothed the waters of constant bickering. It was abused by the industries that demanded it, but it did allow clinicians to communicate better. Meanwhile, mainstream psychiatry itself was publicly flowering in its new-found commitment to science and evidence-based medicine, while privately praying for rain. In its exuberance, the new pharmacology-based psychiatry had chronically promised more than it could deliver, and had come to a crossroads where it could either become right-sized or press ahead. As I mentioned in the last post [the road ahead…], with the DSM-V, the powers that be had either decided to take the plunge or didn’t even stop to think about what they were doing. Whichever the case, they were certainly warned:
A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences
Psychiatric Times
By Allen Frances, MD
June 26, 2009

…The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V…

So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality. Indeed, there has been only 1 paradigm shift in psychiatric diagnosis in the past 100 years—the DSM-III introduction in 1980 of operational criteria sets and the multiaxial system. With these methodological advances, DSM-III rescued psychiatric diagnosis from unreliability and the oblivion of irrelevancy. In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III and, at best, DSM-V could only hope to join them in making a modest contribution. Descriptive diagnosis is simply not equipped to carry us much further than it already has. The real paradigm shift will require an increase in our knowledge—not just a “rearrangement of the furniture” of the various descriptive possibilities.

Part of the exaggerated claim of a paradigm shift in DSM-V is based on the suggestion that it will be introducing dimensional ratings and that this will increase the precision of diagnosis. I am a big fan of dimensional diagnosis and wrote a paper promoting its use as early as 1982. Naturally, I had hoped to expand the role of dimensional diagnosis in DSM-IV but came to realize that busy clinicians do not have the time, training, or inclination to use dimensional ratings. Indeed, the dimensional components already built into the DSM system (ie, severity ratings of mild, moderate, and severe for every disorder and the Axis V Global Assessment of Functioning scale) are very often ignored. Including an ad hoc, untested, and complex dimensional system in an official nomenclature is premature and will likely lead to similar neglect and confusion…
In the four years since that warning, much of the contentious debate has centered on specific changes made in the DSM-5, as it came to be called. But I thought I’d go back to the beginning because some of what matters has gotten lost. There was no general outcry among clinicians about the DSM-IV in place since 1994. It was a code-book with its glitches, but it worked okay. The outcry was from the psychopharmacologists and neuroscientists who couldn’t map their findings and drugs onto the system. They blamed the system rather than considering that their science was not yet advanced enough for that kind of direct clinical application. Not their fault, but hardly a reason to be jury-rigging clinical medicine to fit their needs. If I had said as a psychoanalyst that the DSM-IV didn’t fit my understanding of patients, I’d have been run out of town on a rail, much like what happened when the 1968 DSM-II Task Force added some psychoanalytic theory to several of the categories [and have been vilified to the grave]. What Dr. Frances was warning them about was making that same mistake – that and overly complexifying a code-book with an elaborate dimensional system. The response less than a week later:
Setting the Record Straight: A Response to Frances Commentary on DSM-V
Psychiatric Times
By Alan F. Schatzberg, James H. Scully Jr, David J. Kupfer, Darrel A. Regier
July 1, 2009
    Dr Schatzberg is President of the American Psychiatric Association.
    Dr Scully is Medical Director, CEO, of the American Psychiatric Association.
    Dr Kupfer is Chair, DSM-V Task Force
    Dr Regier is Vice Chair, DSM-V Task Force
…The DSM-III categorical diagnoses with operational criteria were a major advance for our field, but they are now holding us back because the system has not kept up with current thinking. Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism.  Science has advanced, treatments have advanced, and clinical practice has advanced since Dr. Frances’ work on DSM-IV. The DSM will become irrelevant if it does not change to reflect these advances.
If the clinicians were complaining, they were doing it quietly. I hadn’t heard them. The researchers may have been complaining, but the NIMH had already begun setting up a system for them to research around on to their hearts content [RDoC]. Those responding to Dr. Frances were the big guns, and they not only ignored his warning, they attacked – a broadside ad hominem attack at that:
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.
Dr. Frances shook off the attack and carried on with his DSM-5 in Distress blog which mainly focused on some of the more outlandish new disorders and their expansion of old ones. In that year, 2009, Dr. Schatzberg, then APA president, was investigated for COI violations by the US Senate [Senator Grassley] and soon stepped down as Chairman of Psychiatry at Stanford. Dr. Scully has retired this year shortly after the DSM-5 was approved.

Both of the two main topics from Dr. Frances’ initial criticism above – the paradigm shift to a biological basis for the DSM-5 and their complex dimensional system – were totally abandoned along the way [for the reasons he foretold]. In addition, also along the way, the APA DSM-5 Task Force has managed to alienate almost every one of the non-medical mental health professions by looking at mental illness through the monocular lens of a subset of psychiatrist neuroscientists.

While I obviously agree with Dr. Frances’ perspective and did when he first started talking about it in 2009, the thing about the road behind that bothers me is not just their inappropriate insertion of the biological agenda into the DSM-5 revision, it’s what they didn’t do. As I’ve gone through the Clinical Trial literature over the last twenty-five years, it’s abundantly clear that the imprecision of the DSM-III+ has made a mess of the drug trials that underlie our psychopharmacology literature, particularly in depression. In practice, the majority of antidepressant prescriptions are written  based simply on a patient’s report, "I’m depressed," not on a careful evaluation. Worse, even in situations where a patient is thoroughly examined, the existing category of Major Depressive Disorder is so broad and overly-inclusive that the best cohort possible is still unacceptably heterogeneous.

In adults, it includes Melancholic Depression, the depressive affect of people with personality disorders, situational depressions, the culturally deprived, the traumatized, etc. etc. In kids, it’s worse. I’ve never personally seen a depressed adolescent that didn’t have an apparent reason to be depressed – and it’s usually a reason that needed to be addressed. We all know that Major Depressive Disorder was a political creation [as historian Ed Shorter puts it], and yet nobody took it on as an area in need of the intense study it deserves. I sure don’t blame just psychiatry for the depression problem, though we certainly have played our role. Both the third party carriers [insurance] and the pharmaceutical industry have a major part in the depression game – both driven by money, not mental health. But it’s ours to fix, and I don’t even think the DSM-5 Task Force looked at it. They kvetch about the problem of not being able to map their drugs or their neuroscience findings on clinical diagnoses, but matching anything with that category is like matching long words with a bowl of soggy alphabet soup. That’s the loudest example, but there are many others.

With all the talk about the misguided things the DSM-5 did try to do, there are two central things it didn’t do. It didn’t revise the categories that begged for revision like Major Depressive Disorder. And it didn’t set an over-riding agenda to address the widespread problem of industry driven interference and rampant over-use of medication. If anything, it promoted them under the guise of early intervention. The DSM-5 could have been a vehicle for change that focused attention on some paradigms that needed ending – conflicting interests and tolerance of scientific corruption…
  1.  
    February 14, 2013 | 9:34 PM
     

    Don’t forget the journals. Found this today:

    ... Ioan­ni­dis describes a night­mare sce­nario, “Planet F345, Androm­eda Galaxy, Year 3045268? in which the entire process of sci­ence is dis­torted by numer­ous per­verse incen­tives placed on researchers by dic­ta­to­r­ial jour­nal pub­lish­ers and finan­cial offi­cers “recruited after suc­cess­ful careers as real estate agents, man­agers in super­mar­ket chains, or employ­ees in other cor­po­rate struc­tures where they have proven that they can cut cost and make more money”.

    From a distance, it’s sort of funny.

  2.  
    February 14, 2013 | 10:29 PM
     

    What are the primary defenses of cluster B subtypes in Axis 2 disorders? In order of what the APA seems to be practicing before, during, and well likely after DSM 5 is on the shelves: Denial, rationalization, projection, and minimization. Makes you wonder what are the requirements to be in leadership for organizations like the APA.

  3.  
    Bernard Carroll
    February 14, 2013 | 11:11 PM
     

    Sometimes you just have to acknowledge that the people on the other side of a discussion are both stupid and malevolent. That’s how Alan Schatzberg, James Scully, David Kupfer, and Darrel Regier come across in their vicious ad hominem attack on Dr. Frances and Dr. Spitzer. They have had over three years to reconsider and apologize for this self defeating blunder. Don’t hold your breath, anybody.

  4.  
    February 15, 2013 | 12:08 AM
     

    It was a vicious comment. It set a tone that any criticisms were going to be met with either silence or some contemptuous retaliation. They did it again in March 2012 in Time Magazine using an APA hired PR man, “Frances is a ‘dangerous’ man trying to undermine an earnest academic endeavor.” [see dangerous men…]…

  5.  
    Speck
    February 15, 2013 | 1:38 AM
     

    It seems quite likely the APA has turned itself into a sort of business, to sell the DSM and promote pharmaceuticals for profit.

    I recall the APA even filed a SLAPP suit to silence a blogger of the DSM5 revisions [1].

    Lots of unpleasant things happened with the DSM5. There were Task Force members who resigned from the Board and went on various published journals to accuse the DSM-5 board of ‘Ignoring science” and increasing prescriptions [2]. The APA actually spent $25 million and put themselves $350,000 into a financial hole [3].

    Marketing the DSM and promoting pharmaceuticals to gain funding from sponsors is the only way out of that hole.

    A few months ago, I used the wayback machine (archive.org) to determine membership decline at the APA between 2001 and 2013.

    The results were that membership declined from 40,500 in 2001 to 33,000 in 2013. The most significant changes were recent.

    2010/Dec 7 38,000
    2011/Nov 13 36,000
    2012/Nov 19 36,000
    2013/Jan24 33,000

    2001-2002 represents the largest drop in membership, of -3.5k to ~37,000.
    2007-2008 represents the largest gain in membership, of +3k to ~38,000.
    2012-2013 represents the 2nd largest drop in membership, of -3k to 33,000

    What is interesting is that the decline in the number of Psychiatrist physicians is almost twice the decline in APA membership. That numbers really add up.

    Using the 35k remaining psychiatrists in the USA figure (2012), the decline of psychiatrist physicians is > 22% from 2003-2013 (45k to 35k), and an 11% decline in APA membership between 2003-2013.

    Unless membership by the APA has been increasing worldwide, the APA must have 10% retired or non-psychiatrist members.

    In any case, i wonder if psychiatry would benefit from getting rid of the APA altogether. I’m unsure if that would mean suicide for the field, or if it is an option psychiatry may want to consider. The profession has definitely been hijacked, and the APA has become an abomination.

    It’s possible the APA will kill the field itself by worsening the progressive decline in recruitment.

    [1] http://www.reportingonhealth.org/blogs/2012/02/29/slap-american-psychiatric-association-targets-one-dsm5-critic-ignores-others
    [2] http://www.psychologytoday.com/blog/dsm5-in-distress/201207/two-who-resigned-dsm-5-explain-why
    [3] http://www.psychologytoday.com/blog/dsm5-in-distress/201205/dsm-5-costs-25-million-putting-apa-in-financial-hole/

  6.  
    February 15, 2013 | 2:41 AM
     

    I thought these guys were supposed to be doctors!

    They spend all their time classifying symptoms (and collections of symptoms), so they can justify their existence as a medical specialty.

    If they spent a *fraction* of that (wasted) time learning about how to assess and treat the *underlying* causes of these symptoms, they could help people heal. –

    http://psychoticdisorders.wordpress.com/bmj-best-practice-assessment-of-psychosis/

    In the event the symptoms are caused by emotional distress, they are best treated by counselors, psychotherapists on the professioal-side, and peers, survivor groups on the non-professional side.

    Doctors should be treating underlying *physiological* conditions.

    … Is there a shrink anywhwere un this country who uses a stethoscope?

    “Doctors”… Give me a break!

    Duane

  7.  
    February 15, 2013 | 2:56 AM
     

    Psychiatrists need to begin to look beyond the brain for these root causes, particularly the thyroid, intestines, etc…

    We *already have* doctors who are skilled at treating brain disorders.
    They’re called *neurologists*!

    Duane

  8.  
    February 15, 2013 | 1:08 PM
     

    For the record, the recently launched new APA webpages has this new figure of 33,000 membership on this page:

    http://www.psychiatry.org/about-apa–psychiatry

    “The American Psychiatric Association, founded in 1844, is the world’s largest psychiatric organization. It is a medical specialty society representing more than 33,000 psychiatric physicians from the United States and around the world…”

    There are financial charts on Page 25 of this document:

    http://www.nxtbook.com/nxtbooks/apa2/annualreport2011/#/24

    The “APA Assembly Notes Spring 2012” are available, here:

    http://alabamapsych.org/wp-content/uploads/2012/02/apa_assembly_notes_may_2012.pdf

    Powerpoint slides, here, of finances:

    “APA Treasurer’s Report May 2012” [.ppt compatible PowerPoint reader required]

    https://docs.google.com/file/d/0BzWdENl1wkVSYk5aXzRZelFYUjA/edit?pli=1

  9.  
    February 15, 2013 | 2:22 PM
     

    Speck writes:

    “I recall the APA even filed a SLAPP suit to silence a blogger of the DSM5 revisions [1].”

    Still blogging, Speck, though under another domain.

    This week on Psychiatric Times:

    http://www.psychiatrictimes.com/blog/frances/content/article/10168/2128069

    “Mislabeling Medical Illness As Mental Disorder” Allen Frances, MD, with Suzy Chapman

    The “Somatic Symptom Disorder” issue was reported on, this week, by Keith Ablow,, MD, for Fox News Health:

    http://www.foxnews.com/health/2013/02/14/does-somatic-symptom-disorder-really-exist/

    “Does somatic symptom disorder really exist?”

    Christopher Lane, on the SSD issue, at Side Effects, on Psycholgy Today:

    http://www.psychologytoday.com/blog/side-effects/201302/dsm-5-has-gone-press-containing-major-scientific-gaffe

    “DSM-5 Has Gone to Press Containing a Major Scientific Gaffe”

    David J Kupfer, MD, DSM-5 Task Force Chair, defended the new SSD Dx, at Huff Po, on February 8:

    http://www.huffingtonpost.com/david-j-kupfer-md/dsm-5_b_2648990.html

    “Somatic Symptoms Criteria in DSM-5 Improve Diagnosis, Care”

  10.  
    Speck
    February 16, 2013 | 1:09 AM
     

    @Suzy Chapman
    Thank you for the additional references,
    Glad to see you would not be silenced. Looks like you really put the screws to them.

Sorry, the comment form is closed at this time.