{"id":20512,"date":"2012-03-01T20:29:40","date_gmt":"2012-03-02T01:29:40","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=20512"},"modified":"2012-03-01T20:35:46","modified_gmt":"2012-03-02T01:35:46","slug":"they","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/03\/01\/they\/","title":{"rendered":"<sup>brain circuitry, rather than chemical imbalance&#8230;<\/sup>"},"content":{"rendered":"\n<ul>\n<div align=\"center\"> <a href=\"http:\/\/www.psychiatrictimes.com\/blog\/frances\/content\/article\/10168\/2040708\" target=\"_blank\"><u><strong><font color=\"#200020\">My Third Letter to the APA Trustees<\/font><\/strong><\/u><\/a><br \/>       <strong><font color=\"#200020\">Psychiatric Times<\/font><\/strong><br \/>       By Allen Frances<br \/>       March 1, 2012<\/div>\n<p>      <\/p>\n<div align=\"justify\">This  letter was sent to the APA Trustees and to the DSM-5 Task Force on  February 12, 2012, under the title, &ldquo;<strong><font color=\"#200020\">Heads Up And Recommendations<\/font><\/strong>.&rdquo;<\/div>\n<hr width=\"75%\" size=\"1\" \/>\n<div align=\"justify\"><sup><em>DSM-5  press coverage has suddenly exploded&mdash;more than 100 stories from all  around the world were published in just the last three weeks (see title  and links below). The press is uniformly negative and extremely damaging  to DSM-5, to APA, and to the credibility of psychiatry.<\/p>\n<p>        The APA responses have been few,  unconvincing, and lacking in substance. Also troubling, 47 mental health  organizations have expressed their opposition to DSM-5 by endorsing a  petition requesting it to have a scientific review independent of APA.  And many users are planning to boycott DSM-5 altogether by substituting  ICD-10-CM (which will be freely available on the internet). <strong><font color=\"#200020\">It is fair  to say that DSM-5 has become an object of general public and  professional scorn.<\/font><\/strong><\/p>\n<p>        What would Mel Sabshin be doing in  this time of crisis? Of course, Mel never would have allowed APA to get  into this mess&mdash;but once in any crisis he was an expert in damage  control. Were he here today, Mel would certainly recommend that you  immediately cut the DSM-5 losses to prevent its inflicting further  damage on APA, on psychiatry, and most importantly on our patients. <\/p>\n<p>        Fortunately,  there is an easy and obvious solution. Before more harm is done, simply  reject the 5 most questionable DSM-5 proposals. This would mean: <br \/>     &nbsp;&nbsp;&nbsp;(1)  keeping the bereavement exclusion in DSM-5 (turning grief into  depression is by far the biggest object of public concern); <br \/>     &nbsp;&nbsp;&nbsp;(2) not  reducing further the threshold for already swollen ADD; dropping both  <br \/>     &nbsp;&nbsp;&nbsp;(3) &lsquo;attenuated psychotic&rsquo; and <br \/>     &nbsp;&nbsp;&nbsp;(4) &lsquo;disruptive mood dysregulation  disorder&rsquo; (because they both risk furthering the already excessive use  of off-label antipsychotics in kids and also lack sufficient research  support); and <br \/>     &nbsp;&nbsp;&nbsp;(5) not allowing the expansion of pedophilia to include  hebephilia (which would create a forensic nightmare).<\/p>\n<p>        The  many positive results of finally dropping these worst and most  dangerous of the DSM-5 suggestions would be immediate&mdash;the press quiets  down; mental health professionals find DSM-5 less unpalatable; the risk  is reduced of having the government investigate APA&rsquo;s exclusive control  of psychiatric diagnosis; the credibility of psychiatry is less  tarnished; patients receive fewer inappropriate medications (and I get  to drown my cursed blackberry in the ocean).<\/p>\n<p>        Other  serious DSM-5 problems would certainly remain&#8211;highly questionable DSM-5  proposals, distressingly imprecise writing, and forensic risks. But  these are less dangerous, less likely to completely discredit DSM-5, and  can be addressed and corrected in a less fevered atmosphere. In  contrast, the worst suggestions simply cannot be defended and need to be  rejected quickly before DSM-5 is ruined by them.<\/p>\n<p>        As the  responsible leaders of the APA, you cannot avoid your fiduciary  responsibility to regain control of the staff and to rein in a runaway  DSM-5 process. Continuing to do nothing means further loss of public and  professional faith, dramatically reduced DSM-5 sales, APA budget  shortfalls, declining membership, and potential loss of the DSM-5  franchise.<\/p>\n<p>        Time is running out and things are fast approaching a point of no return.<\/p>\n<p>        All  of this was absolutely predictable and completely preventable 3 years  ago. The longer you wait, the harder it will be to produce an acceptable  DSM-5. Unless you act soon to make DSM-5 safe, the press, public, and  professional reactions will undoubtedly just keep getting worse; there  will be less time for correction, necessitating yet another DSM-5  publication delay; and <strong><font color=\"#200020\">the risks mount that the DSM&rsquo;s will no longer be  considered the standard for psychiatric diagnosis.<\/font><\/strong> You are reaching the  point of &ldquo;now or never.&rdquo;<\/em><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">I know little of the DSM-5 franchise, the APA&#8217;s budget or its membership, and have little energy for the specifics of the DSM-5&#8217;s current obvious bloopers. But I do feel something of a passion about this particular revision effort that I haven&#8217;t felt for the ones that came before. I had no use much for the DSM-II [yes I was alive then]. I don&#8217;t mean that negatively, what I mean is I didn&#8217;t use it. The traditional psychiatric Diseases [Schizophrenia, Manic Depressive Illness, Melancholia, Alzheimer&#8217;s Disease, etc.] can be listed on the back of an envelope. The remaining classification of people and their ills hasn&#8217;t been like that for me &#8211; discrete diseases. It is much more like a matrix with way too many dimensions to describe, and I&#8217;ll not try here. So the DSM-III when it showed up wasn&#8217;t my cup of tea and I largely ignored it except to show others that I could read. I only thought about it when I talked with colleagues or filled out forms &#8211; not when I was seeing patients.  <\/div>\n<p align=\"justify\">I&#8217;ve changed my mind about that. I now think the idea behind the DSM-III was sound. I recant. The DSM-III was a crude outing, but the idea of consensually validated descriptive diagnoses and uniform coding was useful. I think what they did with depression was inexcusable and destructive &#8211; but that was a localized problem. The later iterations didn&#8217;t do much for me, pro or con. I don&#8217;t think they made much difference from the prospective of a single practitioner with a particular patient base. Little changed, and the depression mistakes just continued untouched by more rational hands. But this DSM-5 Version does upset me. I&#8217;m not close enough to know about all the administrative snafus, missed deadlines, and secrecy &#8211; although when Dr. Frances called them to our attention, they&#8217;re as plain as the nose on your face.<\/p>\n<p align=\"justify\">It was late Summer and Fall before I figured out why I cringed whenever the DSM-5 Revision came up. It was reading things like this:<\/p>\n<blockquote>\n<div align=\"center\"><u><strong><font color=\"#003322\">Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5<\/font><\/strong><\/u><br \/>           <sup>by David J. Kupfer, M.D. and  Darrel A. Regier, M.D., M.P.H.<\/sup><br \/>           <strong><font color=\"#003322\">American Journal of Psychiatry<\/font><\/strong> 168:672-674, 2011.<\/div>\n<p align=\"justify\"><sup>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><sup> In <strong><em><u>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&#8230;<\/sup><\/p>\n<div align=\"justify\"><sup>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&#8217;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 &quot;not otherwise  specified&quot; category have continued&#8230;<\/sup><\/div>\n<\/blockquote>\n<blockquote>\n<div align=\"center\"><a target=\"_blank\" href=\"http:\/\/www.nimh.nih.gov\/research-funding\/rdoc\/nimh-research-domain-criteria-rdoc.shtml\"><u><strong><font color=\"#000099\">Research Domain Criteria (RDoC)<\/font><\/strong><\/u><\/a><br \/>             <strong><font color=\"#000099\">National Institute of Mental Health<\/font><\/strong><br \/>             June 2, 2011<\/div>\n<p>            <\/p>\n<div align=\"justify\"><sup>Over  the past several decades, an increasingly comprehensive body of   research in genetics, neuroscience, and behavioral science has   transformed our understanding of how the brain produces adaptive   behavior, and the ways in which normal functioning becomes disrupted in   various forms of mental disorders. In order to speed the translation of   this new knowledge to clinical issues, the NIMH included in its new   strategic plan Strategy 1.4: &ldquo;Develop, for research purposes, new ways   of classifying mental disorders based on dimensions of observable   behavior and neurobiological measures.&rdquo; The implementation of this  strategy has been named the Research Domain Criteria Project [RDoC]&#8230;<\/sup><\/div>\n<\/blockquote>\n<blockquote>\n<div align=\"center\"><a href=\"http:\/\/www.bmj.com\/content\/343\/bmj.d5581.extract?ct\" target=\"_blank\"><u><strong><font color=\"#0066ff\">Brain circuitry model for mental illness will transform management, NIH mental health director says<\/font><\/strong><\/u><\/a><br \/>    <strong><font color=\"#0066ff\">British Medical Journal<\/font><\/strong><br \/>    by Caroline White<br \/>    1 September 2011<\/div>\n<p align=\"justify\"><sup>The  field of mental health is on the cusp of a revolution, which is set to  transform the diagnosis and treatment of mental illness and reverse the  lack of major progress made in curbing associated ill health and death  over the past 100 years, the director of the US National Institute of  Mental Health, has claimed. &ldquo;We are at an extraordinary moment when the  entire scientific foundation for mental health is shifting, with the  20th century discipline of psychiatry becoming the 21st century  discipline of clinical neuroscience,&rdquo; Thomas Insel said before a meeting  on the challenges facing mental health research at the Royal Society in  London on 31 August&#8230;<\/sup><\/p>\n<div align=\"justify\"><sup>The seismic  shift had been driven by what he described as three &ldquo;revolutionary  changes&rdquo; in thinking, the first of which was that mental illness was  increasingly being recognised as a disorder of brain circuitry, rather  than as a chemical imbalance, thanks to neuroimaging techniques and the  discovery of some key biomarkers. Secondly, mental ill health was now  recognised as a developmental disorder for which early intervention was  vital, said Professor Insel, highlighting US research showing that 50%  of study participants had reported the onset of mental health problems  by the age of 14, and 75% by the age of 24. &ldquo;We are still stuck with  getting to the problem very late. The future will be about understanding  the trajectory of illness so that we can identify the first signs  before it develops into psychosis,&rdquo; he said&#8230;<\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">I&#8217;m a doctor that sees patients who show up because they <em>hurt in their mentals<\/em>. Most of them don&#8217;t have <em>disorders of brain circuitry<\/em>, I&#8217;m sure of that. Most of them will never be diagnosed with <em>genetics, neuroimaging,  cognitive science, and pathophysiology<\/em>. I&#8217;m sure of that too. There are such patients, and I keep up so I won&#8217;t miss them when they come along, but they&#8217;re not the main stream of the patients that come for help. And I really enjoy reading about neuroscience, and hope that if they keep at it they&#8217;ll find some ways to use it effectively in some cohort of patients to help them get better. But right now, I&#8217;d kind of like the people who are constructing the DSM-5 to give us a classification we can use <em>now<\/em>, for patients we see <em>now<\/em>, with the conditions we treat <em>now<\/em>. This summer, I finally got it that this DSM-5 crew isn&#8217;t thinking about me or the patients I see. If I feel that way, one can only imagine how the vast majority of non-psychiatrist mental health professionals who are actually seeing and treating patients must feel. As a matter of fact, it was Dr. Frances&#8217; efforts that brought a lot of them out of the woodwork to sign that petition at the upper left of this blog page, and their numbers are rising. How do the fantasies of clinical neuroscience types like Kupfer or Insel come across to them? They are like me. They use the DSM-whichever as a diagnostic manual too [at least they used to use it].<\/div>\n<p align=\"justify\">And the DSM-5 Task Force seems to have the idea that treatment is part of their charge. They want to eliminate &quot;grief&quot; as an exclusion because they want to remind me to treat patients if they get real sick &#8211; as if I wouldn&#8217;t know to do that. They want me to call weird people Attenuated Psychosis Syndrome because up to 30% of them might develop Schizophrenia. I know that, but I don&#8217;t want to pathologize the 70% that don&#8217;t. Might-be-gonna-be-something isn&#8217;t early detection, it&#8217;s labeling. They want me to call out-of-control kids disruptive mood dysregulation  disorder as if they all have the same thing. I don&#8217;t think they do, but I don&#8217;t know. They don&#8217;t either. Two years ago, they wanted me to pretend the same kids were Bipolar and treat them with antipsychotics. Now they&#8217;re going to have DMDD to justify antipsychotics. I don&#8217;t question that <em>some few<\/em> of these kids are legitimately put on antipsychotics for behavior control, but I want that to be because there are no other options and I want the people using big medicines in this way to know what they&#8217;re doing and why, not hiding behind some faux diagnosis.<\/p>\n<p align=\"justify\">So I don&#8217;t like the science fiction neuroscience bent to the DSM-5, and I don&#8217;t like them directing treatment, <strong><font color=\"#200020\">and by the way, I don&#8217;t like them<\/font><\/strong>. <strong><font color=\"#200020\">They<\/font><\/strong> act as if their little corner of the world is the whole arena. <strong><font color=\"#200020\">They<\/font><\/strong><em> <\/em>don&#8217;t make room for people like me who believe that the lives and minds of our patients are a big deal. And <strong><font color=\"#200020\">they<\/font><\/strong> make no room for the majority of our patients or our colleagues in other disciplines. I don&#8217;t like the way <strong><font color=\"#200020\">they<\/font><\/strong>&#8216;ve responded to Dr. Frances, or Suzy Chapman, or anyone outside the clique. I know that some pretty known people have tried to get <strong><font color=\"#200020\">them<\/font><\/strong> to think about the inadequate way <strong><font color=\"#200020\">they<\/font><\/strong>&#8216;ve dealt with depression, and have been ignored. I don&#8217;t like that a majority of <strong><font color=\"#200020\">them<\/font><\/strong> have been involved with industry and drug companies in inappropriate financial ways. It&#8217;s not just Allen Frances being ignored. He&#8217;s a proxy for the majority of mental health practitioners, the majority of our patients, and people like me &#8211; the psychiatrist who sees patients. That ought to be <strong><font color=\"#200020\">their<\/font><\/strong> constituency, not <strong><font color=\"#200020\">their<\/font><\/strong> neuroscience obsessed, future-think pals.<\/p>\n<div align=\"justify\">Our forefathers thought there were too many psychoanalysts in the upper halls of psychiatry &#8211; too much influence. Well, they were probably right. But they&#8217;ve been replaced by something much worse &#8211; a class of arrogant and controlling neuroscience insiders who have lost touch with the point of their being there in the first place. Dr. Frances ends with the phrase, &quot;<em>now or never<\/em>.&quot; I expect <strong><font color=\"#200020\">they<\/font><\/strong> don&#8217;t even know what he&#8217;s talking about [that will mean &quot;<em>never<\/em>&quot;]&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>My Third Letter to the APA Trustees Psychiatric Times By Allen Frances March 1, 2012 This letter was sent to the APA Trustees and to the DSM-5 Task Force on February 12, 2012, under the title, &ldquo;Heads Up And Recommendations.&rdquo; DSM-5 press coverage has suddenly exploded&mdash;more than 100 stories from all around the world were [&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-20512","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/20512","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=20512"}],"version-history":[{"count":21,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/20512\/revisions"}],"predecessor-version":[{"id":20533,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/20512\/revisions\/20533"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=20512"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=20512"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=20512"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}