{"id":15665,"date":"2011-11-02T15:00:29","date_gmt":"2011-11-02T19:00:29","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=15665"},"modified":"2011-11-02T16:22:21","modified_gmt":"2011-11-02T20:22:21","slug":"listening","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/11\/02\/listening\/","title":{"rendered":"listening…"},"content":{"rendered":"
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DSM 5 Against Everyone Else<\/font><\/strong><\/u><\/a>
Its Research Types Just Don’t Understand The Clinical World<\/font><\/strong>
DSM5 in Distress: Psychology Today<\/font><\/strong>
by Allen J. Frances, M.D.
November 1, 2011<\/div>\n

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Strikingly, there seems to be virtually no support for DSM 5 outside the very narrow circle of the several hundred experts who have created it and the leadership of the American Psychiatric Association [APA] which stands to reap large profits from its publication. There is no group and precious few individuals outside of APA who have anything good to say about DSM 5. And even within the DSM 5 work groups and the APA governance structures, there is widespread discontent with the process and considerable disagreement about the product…<\/p>\n

There is obviously a huge, growing, and so far totally unbridgeable gulf between the researchers who have prepared DSM 5 and the clinicians who will have to use it. The experts, if they see patients at all, tend to do so only in the ivory tower of university research clinics. Clinicians have to apply the DSM under more difficult real life circumstances and often have a much clearer understanding of how it can be misused – with loose diagnosis often leading to excessive use of medication…<\/p>\n

The experts are well intentioned and are making very bad decisions for the purest of reasons. Their conflict of interest is purely intellectual, not financial.<\/font><\/strong> Experts overvalue their pet diagnoses and their own research – and greatly underappreciate how an idea that works well in their own research setting may be disastrously misunderstood and misused in clinical practice…<\/p>\n

If DSM 5 remains at war with its users, it won’t be used. Why buy an expensive book if it is likely to be more harmful than helpful when the official ICD-10-CM codes will be freely available on the internet. DSM 5′ s stubborn refusal to abandon risky suggestions is a foolish gamble not only for clinicians and patients, but also with its own future.<\/sup><\/div>\n<\/blockquote>\n

As Dr. Frances continues to wield his well placed hammer, he repeatedly throws in things like, "The experts are well intentioned and are making very bad decisions for the purest of reasons. Their conflict of interest is purely intellectual, not financial<\/font><\/strong>." I expect that he’s trying to neutralize the idea in the minds of many that psychiatrists are simply crooks in league with the pharmaceutical industry. That’s an uphill climb, because we’ve had more than our share of people who fit the bill, and an even larger number who may not be crooks, but who have been way too close to industry [and well paid for their time]. It is unlikely that his simple declaration will change that perception. So I’m not sure that purity<\/font><\/strong><\/em> would be my main metaphor for describing the motives of the neo-framers – "the purest of reasons"<\/font><\/strong> or "purely intellectual"<\/font><\/strong>]. <\/div>\n

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And another thing, the first paragraph of this article [in Psychology<\/u> Today<\/font><\/strong>] reads:<\/div>\n
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So far, opposition to DSM 5 has been expressed by the following organizations: British Psychological<\/font><\/strong> Society; American Counseling<\/font><\/strong> Association; Society for Humanistic Psychology<\/font><\/strong> [APA Division 32]; Society for Community Research<\/font><\/strong> and Action: Division of Community Psychology<\/font><\/strong> [APA Division 27]; Society for Group Psychology & Psychotherapy<\/span><\/font><\/strong>[ APA Division 49]; Developmental Psychology<\/font><\/strong> [APA Division 7]; UK Council for Psychotherapy<\/font><\/strong>; Association for Women in Psychology<\/font><\/strong>; Constructivist Psychology<\/font><\/strong> Network; Society for Descriptive Psychology<\/font><\/strong>; and the Society of Indian Psychologists<\/font><\/strong>.<\/sup><\/div>\n<\/blockquote>\n
There’s something of a monotony about these groups who are up in arms about the DSM-5 [and probably its predecessors if the truth were spoken] – the word Psychology<\/font><\/strong> [and its near synonyms]. In a later paragraph, Frances adds:<\/div>\n
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The users are more than 500,000 thousand mental heath clinicians [and probably, on an occasional basis, about an equal number of primary care physicians]. Of the mental health workers, about 202,000 are social workers; 120,000 are mental health counselors; 93,000 are psychologists; 75,000 are psychiatric nurses; 55,000 are marriage<\/span> & family therapists; 38,000 are psychiatrists; and an unknown additional number are occupational therapists, educators, experts in forensics, researchers etc.<\/sup><\/div>\n<\/blockquote>\n
And from the leadership of his opposition:<\/div>\n
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Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5<\/font><\/strong>
by David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.<\/sup>
American Journal of Psychiatry<\/font><\/strong> 2011 168:672-674.<\/div>\n

In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders,we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder.<\/sup> In A Research Agenda for DSM-V<\/u><\/em><\/strong>, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…<\/sup><\/p>\n

The seminal article by Robins and Guze on diagnostic validity, which proposed a classification of psychiatric illnesses based not on psychodynamic, a priori hypotheses but rather on external, empirical indicators, built a direct pathway to DSM-III. Their proposed classification steps included identifying core clinical features, conducting differential diagnosis to separate the condition from similar disorders, gathering laboratory data, assessing temporal stability of the diagnosis, and determining familial aggregation of the disorder. The resultant explicit criteria featured in DSM-III and subsequent editions have significantly improved our understanding of psychiatric disorders, but they did not come without a price. While diagnostic reliability has thrived, large-scale epidemiological studies have underscored the inefficiency of DSM’s criteria in accurately differentiating diagnostic syndromes, especially in community samples. With reification of the criteria through revised editions of DSM-III-R and DSM-IV, proliferation of diagnostic comorbidities and overreliance on the "not otherwise specified" category have continued…<\/sup><\/div>\n<\/blockquote><\/div>\n
While I don’t personally agree with "Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder<\/font><\/strong>" and think they’re closer to the mark with, "… we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred<\/font><\/strong>," that’s not my direction in this particular post. Kupfer and Regier go on to say, "The seminal article by Robins and Guze on diagnostic validity, which proposed a classification of psychiatric illnesses based not on psychodynamic, a priori hypotheses but rather on external, empirical indicators, built a direct pathway to DSM-III<\/font><\/strong>" comes closer to the part I want to talk about. Anyone alive during those days knows that the DSM-III essentially ended the influence of the psychoanalysts in the medical specialty of psychiatry. In fact, ending that influence was an active overt and covert goal of the revision. The result was essentially to expel psychoanalysis from psychiatry altogether, and it was successful. As I am both a psychiatrist and a psychoanalyst, anything I might say about that would be suspect – a conflict of interest. And if we’ve learned anything in these last few decades, just declaring a conflict of interest doesn’t make it go away. Even I would be suspicious of what I had to say. But I can say some things  that I do trust about the consequences of that revision. <\/div>\n

I agree with the idea of "a classification of psychiatric illnesses based not on psychodynamic, a priori hypotheses<\/font><\/strong>." Unfortunately, in the DSM-III, they didn’t just throw out psychoanalytic theories, they threw out a psychodynamic thread in psychiatry that belonged to psychiatry itself, not psychoanalysis. It was a rich tradition that the analysts certainly influenced, but so did Adolf Meyer, Harry Stack Sullivan and countless others who taught us how to talk with and listen to our patients [no apologies for the influence of the analysts intended]. So, the framers of the DSM-III threw out psychodynamic psychiatry too – the baby with the bathwater. In fact, they essentially threw out "the mind" altogether. That was a huge mistake – probably an irredeemable mistake. And they said they created "<\/span>a classification of psychiatric illnesses based not on psychodynamic, a priori hypotheses but rather on external, empirical indicators<\/font><\/strong>," but that’s not true either. They created a classification based on another "<\/span>a priori hypotheses<\/font><\/strong>," that all mental illness is biologic. It would’ve been okay for them to say all mental illness that psychiatrists are going to treat<\/em> is biological. Or it would’ve been fine for them to say that our classification was only going to include known or suspected biological conditions [it would’ve been a very small book]. They said neither. They tried to hold on to the whole ball of wax. So they talked "<\/span>external, empirical indicators<\/font><\/strong>" but lived biology, and they preached evidence-based medicine but practiced expert opinion [or at least the opinion of declared experts<\/em>].<\/p>\n

Using Dr. Frances’ numbers:<\/div>\n