{"id":16824,"date":"2011-12-03T22:21:35","date_gmt":"2011-12-04T03:21:35","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=16824"},"modified":"2011-12-03T22:21:35","modified_gmt":"2011-12-04T03:21:35","slug":"the-grand-prize","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/12\/03\/the-grand-prize\/","title":{"rendered":"the grand prize&#8230;"},"content":{"rendered":"\n<div>Since Dr. Allen Frances seems to have taken a well-deserve holiday, I thought I&#8217;d revive one of his older posts:<\/div>\n<blockquote><p>    <\/p>\n<div align=\"center\"><a href=\"http:\/\/www.psychologytoday.com\/blog\/dsm5-in-distress\/201111\/dsm-5-living-document-or-dead-arrival\" target=\"_blank\"><u><strong><font color=\"#200020\">DSM 5 &#8211; &#8216;Living Document&#8217; or &#8216;Dead on Arrival&#8217;<\/font><\/strong><\/u><\/a><br \/>      <sup>untested &#8216;scientific hypotheses&#8217; must be dropped<\/sup><br \/>       <strong><font color=\"#0066ff\">Psychology Today<\/font><\/strong><br \/>    by Allen J. Frances, M.D.<br \/>      November 11, 2011<\/div>\n<p>    <\/p>\n<div align=\"justify\"><sup>News  flash From Medscape Medical News &#8211; &#8216;APA Answers DSM-5 Critics,&#8217; a  defense of DSM 5 offered by Darrel A. Regier, MD, vice-chair of the  DSM-5 Task Force. Wonderful news that APA is attempting to address the  fact that DSM 5 alarms many of its potential users- it is long past time  for an open dialog. Unfortunately, however,  Dr Regier dodges the  concerns that must be addressed if DSM 5 is to become a safe and  credible document. Five simple questions were previously posed to APA  with a request for five straight answers:<\/sup><\/div>\n<ul> <sup><\/p>\n<div align=\"justify\">[1] Why is APA not willing to have an independent scientific review of questionable DSM 5 proposals- especially since its own internal and confidential review process has been so badly discredited?<\/div>\n<div align=\"justify\">[2] Since the DSM 5 suggestions will all broaden the definition of mental disorder, why should we not worry about diagnostic inflation and the massive mislabeling of normal people as mentally ill?<\/div>\n<div align=\"justify\">[3] Won&#8217;t this diagnostic inflation exacerbate the already rampant over prescription of psychotropic medications [especially by primary care doctors, especially <span class=\"pt-basics-link\">antipsychotics<\/span>, especially to kids]?<\/div>\n<div align=\"justify\">[4] Why should we not worry about the unintended forensic complications of a sloppily written DSM 5 containing suggestions that are obvious targets for forensic misuse?<\/div>\n<div align=\"justify\">[6] Won&#8217;t the many small, needless, and arbitrary changes in DSM 5  complicate future research efforts and make impossible the  interpretation of data collected before vs after DSM 5?<\/div>\n<p> <\/sup><\/ul>\n<div><sup>None of the five questions gets anything approaching a real answer. Instead Dr Regier tells us that:<\/sup><\/div>\n<ul><sup> <\/p>\n<div>[1] &quot;<em>We hear your concerns and are aware of those from others in the mental  health field, and take them under serious consideration in our  deliberations<\/em>&quot;. But if APA really heard our concerns, there would  be an immediate independent scientific review to allay them. What  possible excuse is there for not taking the one obvious step that will  make DSM 5 credible?<\/div>\n<div align=\"justify\">[2] Dr Regier assures us not to worry about  the radical DSM 5 suggestions, promising &quot;<em>a rigorous test-retest design  to assess the reliability and clinical utility of proposed criteria &#8230;  in 11 academic field trial centers.&quot; &quot;The full range of disorders will  be assessed in this field trial and the findings will contribute to the  final decisions about the diagnoses.<\/em>&quot; But, simply stated, the field trials are completely useless for DSM 5 decision making.  They failed to ask and therefore cannot begin to answer the only really  important question- what will be the effect of DSM 5 on the rates of  mental disorder? Will DSM 5 mislabel as mentally ill millions of people  who  have problems that are just part of the human condition. And  experience teaches us that results generated in academic centers often  have nothing at all to do with how DSM is actually used (and often  misused) in the real world.&nbsp; <\/p>\n<div align=\"justify\">[3] Dr. Regier goes on to admit the  obvious- that the new DSM 5 proposals are not based on anything  resembling adequate research: &quot;<em>However, a lot of this has not been  tested as well as we would like.&quot; &quot;Some of these fixes are not as well  studied as others and we recognize that. But we can&#8217;t move forward  without some of these put into practice. So we think this is a much more  testable set of scientific hypotheses.&quot; &quot;And that&#8217;s what the DSM is &#8211; a  set of scientific hypotheses that are intended to be tested and  disproved if the evidence isn&#8217;t found to support them.<\/em>&quot; There  could not possibly be any more eloquent testimony to exactly where DSM 5  has gone badly and dangerously off the tracks. DSM 5 most definitely  should not harbor the ambition of providing a set of &#8216;scientific  hypotheses&#8217; created by and for researchers to encourage further testing  of their pet ideas. DSM 5 is not at all meant to be a program setting  forth &#8216;scientific hypotheses&#8217; to guide future research. Instead, DSM 5  is a guide to current clinical practice that will have a crucial impact  on the lives of the people misdiagnosed- they will often be hurt,  sometimes badly hurt, by receiving unnecessary medicine and unnecessary  stigma. Recent experience proves that children will be particularly  vulnerable to the mislabeling that will follow this exercise in DSM 5  &#8216;hypotheses testing.&#8217; To say nothing of the misallocation of resources  away from the truly ill (who desperately need them) and toward the  worried well (who often will be more harmed than helped). There is no  conceivable excuse for conducting what amounts to an uncontrolled public  health experiment just so the DSM 5 researchers can further the testing  of their pet ideas. <\/p>\n<div align=\"justify\">[4] Dr Regier is fond of calling DSM 5 a  &quot;<em>living document that can be revised regularly.<\/em>&quot; &quot;<em>We&#8217;re thinking of  having a DSM-5.1, DSM-5.2, etc<\/em>&quot;. The implication of this &#8216;living  document&#8217; concept is chillingly out of touch with the perils of clinical  reality. Although he doesn&#8217;t come right out and say it, Dr Regier seems  to be reassuring us with something like &#8211; Don&#8217;t you worry if our  untested hypotheses get it wrong now, we can always fix it up later.  This blithely ignores the needless and sometimes dangerous medication  side effects and stigma to be endured by those who are mislabeled by the  premature and untested DSM 5 &#8216;scientific hypotheses&#8217;. The makers of DSM  5 have forgotten the most important injunction in medicine &#8211; the  Hippocratic First Do No Harm. What needs to be done?  In the short  term, APA has only two choices- submit DSM 5 to external review or drop  the most dangerous suggestions. Otherwise DSM 5 risks not being trusted  and not being used by mental health clinicians. <\/div>\n<\/div>\n<\/div>\n<p><\/sup><\/ul>\n<div align=\"justify\"><sup>For the future,  the lesson couldn&#8217;t be  clearer- never again allow researchers the  freedom to turn DSM into a plaything for their pet &#8216;scientific  hypotheses&#8217;. The DSM&#8217;s are not meant to be a casually undertaken  experiment. They have become far too important an influence on clinical  practice and public health policy. DSM 5&#8217;s radical ambitions have  failed- it attempted to fly too high and now must come back to earth.If  you agree we me that the APA defense of DSM 5 is much more troubling  than reassuring, consider signing the petition requesting reform at:  <u><font color=\"#200020\"><strong><a title=\"http:\/\/www.ipetitions.com\/petition\/dsm5\/\" href=\"http:\/\/www.ipetitions.com\/petition\/dsm5\/\" target=\"_blank\">http:\/\/www.ipetitions.com\/petition\/dsm5\/<\/a><\/strong><\/font><\/u><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">This is the part I wanted to talk about, both what Dr. Regier said and Frances&#8217; response:<\/div>\n<ul>\n<div align=\"justify\">Dr. Regier goes on to admit the  obvious- that the new DSM 5 proposals  are not based on anything  resembling adequate research: <strong><font color=\"#200020\">&quot;<em>However, a  lot of this has not been  tested as well as we would like.&quot; &quot;Some of  these fixes are not as well  studied as others and we recognize that.  But we can&#8217;t move forward  without some of these put into practice. So  we think this is a much more  testable set of scientific hypotheses.&quot;  &quot;<\/em><\/font><em><font color=\"#990000\">And that&#8217;s what the DSM is &#8211; a  set of scientific hypotheses that are  intended to be tested and  disproved if the evidence isn&#8217;t found to  support them.<\/font><\/em><\/strong><strong><font color=\"#200020\">&quot;<\/font><\/strong> <strong><font color=\"#0000ff\">There  could not possibly be any more eloquent  testimony to exactly where DSM 5  has gone badly and dangerously off the  tracks. DSM 5 most definitely  should not harbor the ambition of  providing a set of &#8216;scientific  hypotheses&#8217; created by and for  researchers to encourage further testing  of their pet ideas.<\/font><\/strong> DSM 5 is  not at all meant to be a program setting  forth &#8216;scientific hypotheses&#8217;  to guide future research. Instead, DSM 5  is a guide to current clinical  practice that will have a crucial impact  on the lives of the people  misdiagnosed- they will often be hurt,  sometimes badly hurt, by  receiving unnecessary medicine and unnecessary  stigma&hellip;<\/div>\n<\/ul>\n<div align=\"justify\">It&#8217;s hard for me to believe that Dr. Regier even said that part in red. For Dr. Regier to even write it means that he must actually believe it, and I suspect that many others on the Task Force feel the same way. It&#8217;s grounds to dissolve the DSM-5 Task Force altogether. It belies a deep misunderstanding of what the field of medicine actually is, and what the word &quot;research&quot; actually means. As Dr. Frances points out, it flies in the face of a now integral tenet of medicine &#8211; <strong><font color=\"#200020\">informed consent <\/font><\/strong>&#8211; a corollary of p<span class=\"st\">rimum non nocere [<em>first, do no harm<\/em>].<br \/>  <\/span><\/div>\n<p align=\"justify\">Unfortunately, it&#8217;s not something limited to the mind of Dr. Regier, but rather a macabre version of a widely held way of thinking. In the early 1980s when I was first exposed to this breed of psychiatrist, I recall spending a lot of time feeling confused. I had left a research oriented career in Immunology before coming into psychiatry, and I thought that I understood the place of research in medicine. I&#8217;d done it for a few years myself &#8211; in tandem with clinical medicine. I was an Internal Medicine Resident for half the day and on call at night. And my other half time was in a research lab. Occasionally, I&#8217;d run across an intersenting clinical case that we studied with the extensive technology availabe, but for the most part, there was a firewall between the two parts of my life &#8211; doctor, researcher. Beside the laboratory studies, we had a clinical project and the subjects were recruited, transferred to a research ward, and heavily informed about what we were doing.<\/p>\n<p align=\"justify\">In psychiatry, the new breed talked mostly about research, even on clinical rounds. Grand rounds became almost exclusively about new drugs or new thoughts about old drugs. At the time, I was teaching the 2nd year medical student&#8217;s course, and when I had the new people as guests, they talked about the future &#8211; not behavioral science. I stopped inviting them because the students were confused by what they said. It was as if psychiatry hadn&#8217;t existed before, and everything was new, future-oriented. The only place I felt comfortable was my office seeing patients, so I left and did just that until I retired. I taught a lot, but what I taught were things I knew about, not what I or someone else might know at some later date. I shied away from psychiatry as-a-whole and stuck to psychotherapy because I really didn&#8217;t get what was going on in the rest of psychiatry. I now think I was confused because it was confusing, but back then, I felt sort of inadequate. I couldn&#8217;t separate out what was known from what was speculation. I&#8217;m bitter about that, because I lost something that I valued &#8211; a kind of mastery of clinical psychiatry that had been important to me.<\/p>\n<p align=\"justify\">So what I now think is that the blurring of a clear boundary between research and clinical medicine, between what&#8217;s known and what&#8217;s not yet known was a gargantuan mistake. When I went to a psychiatric meeting and attended a talk, I didn&#8217;t feel like I was listening to seasoned clinicians who were speaking from experience &#8211; the kind of people I&#8217;d become accustomed to listening to and learning from. It was more like the brown-bag seminars of research fellows from my fellowship where we talked about hyotheses yet to be confirmed. Clinical doctors find such things interesting, but what we really want to know is how to approach the patients we will see tomorrow.<\/p>\n<p align=\"justify\">So Dr. Regier&#8217;s notion, <strong><font color=\"#200020\"><em>&quot;<font color=\"#990000\">&#8230;<\/font><\/em><\/font><em><font color=\"#990000\">  that&#8217;s what the DSM is &#8211; a  set of scientific hypotheses that are   intended to be tested and  disproved if the evidence isn&#8217;t found to   support them<\/font><\/em><\/strong>&quot; feels like an extrapolation of that blurring of boundaries between research and clinical medicine that I saw twenty-five years ago carried to a sick extreme. He must have no idea how far out in left field his statement really is. If he did, he wouldn&#8217;t say it. It explains why they would consider Attenuated Psychosis Syndrome or Disruptive Mood Dysregulation Disorder and not understand why we might object. Frankly, I think the same can be said of the current versions of Major Depressive Disorder on some of the extensions of the Bipolar Disorder diagnoses.<\/p>\n<div align=\"justify\">I agree with what Dr. Frances says in this post, but the piece I&#8217;ve highlighted takes the grand prize. Without an independent review, the DSM-5 simply shouldn&#8217;t be adopted &#8211; no matter what they do internally.<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Since Dr. Allen Frances seems to have taken a well-deserve holiday, I thought I&#8217;d revive one of his older posts: DSM 5 &#8211; &#8216;Living Document&#8217; or &#8216;Dead on Arrival&#8217; untested &#8216;scientific hypotheses&#8217; must be dropped Psychology Today by Allen J. Frances, M.D. November 11, 2011 News flash From Medscape Medical News &#8211; &#8216;APA Answers DSM-5 [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-16824","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/16824","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=16824"}],"version-history":[{"count":4,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/16824\/revisions"}],"predecessor-version":[{"id":16828,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/16824\/revisions\/16828"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=16824"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=16824"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=16824"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}