{"id":31707,"date":"2013-01-05T16:31:10","date_gmt":"2013-01-05T21:31:10","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=31707"},"modified":"2013-01-05T17:02:44","modified_gmt":"2013-01-05T22:02:44","slug":"send-in-the-clowns","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/01\/05\/send-in-the-clowns\/","title":{"rendered":"send in the clowns&#8230;"},"content":{"rendered":"\n<ul>\n<div align=\"justify\"><sup><strong> Isn&#8217;t it rich, aren&#8217;t we a pair<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong> Me here at last on the ground &#8211; and you in mid-air<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong> Send in the clowns<\/strong><\/sup><\/div>\n<p>       <\/p>\n<div align=\"justify\"><sup><strong> Isn&#8217;t it bliss, don&#8217;t you approve<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>One who keeps tearing around &#8211; and one who can&#8217;t move<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong> But where are the clowns &#8211; send in the clowns<\/strong><\/sup><\/div>\n<p>       <\/p>\n<div align=\"justify\"><sup><strong>  Just when I stopped opening doors<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  Finally finding the one that I wanted &#8211; was yours<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  Making my entrance again with my usual flair<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  So sure of my lines &#8211; then nobody&#8217;s there<\/strong><\/sup><\/div>\n<p>       <\/p>\n<div align=\"justify\"><sup><strong>  Don&#8217;t you love a farce; my fault I fear<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  I thought that you&#8217;d want what I want &#8211; sorry my dear<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  But where are the clowns &#8211; there ought to be clowns<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  Maybe next year<\/strong><\/sup><\/div>\n<p>       <\/p>\n<div align=\"justify\"><sup><strong>  Isn&#8217;t it rich, isn&#8217;t it queer<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  Losing my timing this late in my career<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  But where are the clowns &#8211; send in the clowns<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong>  Don&#8217;t bother they&#8217;re here<\/strong><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">I hardly intend to imply that the authors of this article are clowns. They are some of our best and brightest. The song&#8217;s author explains:<\/div>\n<ul>\n<div align=\"justify\"><sup><strong>The &quot;clowns&quot; in the title do not refer to circus clowns. Instead,  they symbolize fools, as Sondheim explained in a 1990 interview. <em>&quot;I get a lot of letters over the years asking what the title means and  what the song&#8217;s about; I never thought it would be in any way esoteric.  I wanted to use theatrical imagery in the song, because she&#8217;s an actress,  but it&#8217;s not supposed to be a circus&#8230; <font color=\"#660033\">It&#8217;s a theater reference  meaning &#8216;if the show isn&#8217;t going well, let&#8217;s send in the clowns&#8217;; in  other words, &#8216;let&#8217;s do the jokes.&#8217; I always want to know, when I&#8217;m  writing a song, what the end is going to be, so &#8216;Send in the Clowns&#8217;  didn&#8217;t settle in until I got the notion, &#8216;Don&#8217;t bother, they&#8217;re here&#8217;,  which means that &#8216;We are the fools&#8217;.<\/font>&quot;<\/em><\/strong><\/sup><\/div>\n<div align=\"right\"><sup><strong><a href=\"http:\/\/en.wikipedia.org\/wiki\/Send_in_the_Clowns\" target=\"_blank\">Stephen Sondheim<\/a><\/strong><\/sup><\/div>\n<\/ul>\n<blockquote>\n<div align=\"center\"><a title=\"[full text on-line]\" target=\"_blank\" href=\"http:\/\/ajp.psychiatryonline.org\/article.aspx?articleID=1555604\">The Initial Field Trials of DSM-5: New Blooms  and Old Thorns<\/a><br \/>          <sup>by Robert Freedman, David A.  Lewis, Robert Michels, Daniel S. Pine, Susan K. Schultz, Carol A. Tamminga, Glen O. Gabbard, Susan Shur-Fen Gau, Daniel C. Javitt, Maria A. Oquendo, Patrick E. Shrout, Eduard Vieta, and Joel Yager <\/sup><br \/>          <strong><font color=\"#004400\">American Journal of  Psychiatry<\/font><\/strong> 2013 170:1-5.<\/div>\n<p align=\"justify\"><sup><strong>&ldquo;A rose is a rose is a rose&rdquo;. For psychiatric diagnosis, we  still interpret this line as Robins and Guze did for their Research Diagnostic  Criteria &mdash; that reliability is the first test of validity for diagnosis. To develop an evidence-based  psychiatry, the Robins and Guze strategy [i.e., empirically validated criteria  for the recognizable signs and symptoms of illness] was adopted by DSM-III and  DSM-IV. The initial reliability results from the DSM-5 Field Trials are now  reported in three articles in this issue. As for all previous DSM  editions, the methods used to assess reliability reflect current standards for  psychiatric investigation. Independent interviews by two  different clinicians trained in the diagnoses, each prompted by a computerized  checklist, assessment of agreement across different academic centers, and a  pre-established statistical plan are now employed for the first time in the DSM  Field Trials. As for most new endeavors, the end results are mixed, with both  positive and disappointing findings&#8230;<\/strong><\/sup><\/p>\n<div align=\"justify\"><sup><strong><font color=\"#660033\">The questionable reliability of major depressive  disorder, unchanged from DSM-IV, is obviously a problem. Major depressive  disorder has always been problematic because its criteria encompass a wide range  of illness, from gravely disabled melancholic patients to many individuals in  the general population who do not seek treatment. Although symptom severity on  the Hamilton Depression Rating Scale distinguishes those patients who respond  more specifically to pharmacotherapy, the DSM-IV criteria do not capture that  distinction.<\/font> A second problem not resolved  by the DSM-IV criteria is the common co-occurrence of anxiety, which markedly  diminishes the effects of antidepressant treatment. The DSM-5 work group decided  not to change the criteria for major depressive disorder from DSM-IV and instead  created other diagnoses for the mixture between anxiety and depression. However,  these efforts did not improve the poor reliability of DSM-IV depression; &ldquo;mixed  anxiety and depression&rdquo; has a kappa of 0&#8230;<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">While I appreciate their acknowledging the point that the Major Depressive Disorder diagnosis &quot;<em><strong><font color=\"#660033\">encompass[es] a wide range  of illness<\/font><\/strong><\/em>,&quot; they go on to talk as if it&#8217;s a continuum [which it isn&#8217;t] based on severity [which isn&#8217;t true enough to count on] and imply that response to pharmacotherapy is the point of diagnosis [is it?]. But I digress [as a johnny one-note tends to do]. &quot;<strong><em>As for most new endeavors, the end results are mixed, with both  positive and disappointing findings<\/em><\/strong>.&quot; Sorry, but it doesn&#8217;t look so new to me &#8211; it&#8217;s over thirty years old. If they&#8217;re implying that the DSM-5 Task Force used a better method than the DSM-III and DSM-IV, they&#8217;re invalidating the past, not explaining the present [send that part back for a rewrite]: <\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong>&ldquo;A rose is a rose is a rose is a rose&rdquo; had deeper  meaning for Gertrude Stein, to do not only with the classification of the flower  but also with its enduring essence. Understanding the natural  course of a disorder, its response to treatment, and its impact on the life of  the individual are the reasons that we strive to make reliable diagnoses, but a  single diagnostic interview, regardless of how reliable, does not capture the  essence of what is happening to a patient. If there are lessons for clinicians  and patients and families reading these field trials, perhaps the most important  one is that accurate diagnosis must be part of the ongoing clinical dialogue  with the patient.<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">Couldn&#8217;t have said it better. Note to self: Send that quote to the people who answer the phones at the Managed Care centers so they&#8217;ll start saying, &quot;<em>Doctor, are you sure you&#8217;ve thoroughly evaluated your patient? How about seeing them a few more times to be sure you&#8217;ve made a precise diagnosis.<\/em>&quot; <\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong>The improvement of diagnosis is also ongoing. Future  tests need to consider clinical utility in actual treatment situations and the  reliability and practicality of applying the new criteria outside academic  medical centers. Solo practitioners and mental health clinics may not have  resources for the level of training that the field trials required. The patients  were required to speak and read English, although some were bilingual.  Reliability may not be the same for patients who have lower levels of education  or for whom English is not their most fluent language. The findings of these  field trials will be used to make further improvements, and hence the final  criteria may change and require further testing after DSM-5 publication. Like  its predecessors, DSM-5 does not accomplish all that it intended, but it marks  continued progress for many patients for whom the benefits of diagnoses and  treatment were previously unrealized.<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">The only reason this post is here is for this latter paragraph. It&#8217;s just more future-think. The Task Force talks of a living document to be added to, updated. The expert clowns were sent in to lighten up the discussion and talk about how the Field Trials will lead to yet some other future improvement. But they&#8217;re not mentioning that there were two Field Trials planned, but only one got done. And they&#8217;re talking about future improvements before the pages even have ink on them. This editorial reads like Sondheim&#8217;s line, &quot;<em>Maybe next year.<\/em>&quot; And I&#8217;d add to &quot;<em>Don&#8217;t bother they&#8217;re here<\/em>&quot; that they can&#8217;t count on fools in the audience forever. This editorial is an apology, perhaps a Eulogy&#8230; <\/div>\n<p align=\"center\"><iframe loading=\"lazy\" width=\"500\" height=\"281\" src=\"http:\/\/www.youtube.com\/embed\/5os4NFeKFFs?feature=player_detailpage\" frameborder=\"0\" allowfullscreen><\/iframe><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Isn&#8217;t it rich, aren&#8217;t we a pair Me here at last on the ground &#8211; and you in mid-air Send in the clowns Isn&#8217;t it bliss, don&#8217;t you approve One who keeps tearing around &#8211; and one who can&#8217;t move But where are the clowns &#8211; send in the clowns Just when I stopped opening [&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_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-31707","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/31707","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=31707"}],"version-history":[{"count":18,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/31707\/revisions"}],"predecessor-version":[{"id":31725,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/31707\/revisions\/31725"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=31707"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=31707"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=31707"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}