{"id":35351,"date":"2013-04-16T09:27:19","date_gmt":"2013-04-16T13:27:19","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=35351"},"modified":"2013-04-16T09:39:24","modified_gmt":"2013-04-16T13:39:24","slug":"in-great-flux","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/04\/16\/in-great-flux\/","title":{"rendered":"in great flux…"},"content":{"rendered":"
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Letter to a Foreign Psychiatrist <\/a>
Psychiatric Times<\/font><\/strong>
By Seyyed Nassir Ghaemi
April 11, 2013<\/div>\n

I write to you as an American who was once not an American. Of course, all Americans, at one time, were not Americans, but there is still a prototype: the Christian American of European descent. I’m not in that majority, so I write to you as something of an American, but also as a non-American. You ask me what I would advise a young psychiatrist beginning a career in another country? I would first bring to your attention what you already know: the world has one great power—America. This country is not just a military power; it is a cultural force. In psychiatry, it has taken over almost every country at least as effectively as its political forces vanquished Soviet communism. All psychiatry, anywhere in the world, is American psychiatry. This is both bad and good.<\/strong><\/sup><\/p>\n

First the bad. DSM is a primary source of American domination of world psychiatry. It may not have been meant to be so: it is, after all, the diagnostic system for the American Psychiatric Association. But, as the Soviet Union fell, DSM rose: America’s political triumph translated on all levels, including medicine and psychiatry. The changes of DSM-III in 1980 had become worldwide in their influence by the post–Cold War years of the 1990s…<\/strong><\/sup><\/div>\n<\/blockquote>\n
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Honest American psychiatrists know and admit that DSM, by simplifying psychopathology and diagnosis to a bare minimum of criteria, has ruined a generation of clinicians who haven’t heard of anything not included in the manual and whose knowledge of the manual itself is limited to baldly described criteria.<\/font> A few years ago, Nancy Andreasen, a force in DSM-III, admitted that phenomenology … had literally been killed by DSM-III. This is like a cardiologist who can no longer discern heart sounds, or a neurologist unable to use a reflex hammer.<\/strong><\/sup><\/div>\n<\/blockquote>\n
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Psychiatry is simple, so simple: like being a Volkswagen mechanic, a New York clinician infamously stating the painful truth. This false sense of simplicity hides a complex truth: We have lost the ability to accurately recognize our patients’ signs and symptoms; hence, we routinely misdiagnose, then we mistreat. And throughout the process, we have little clue that we might be wrong. And most of the blame has to do with DSM-III onward: simplistic criteria that are often wrong<\/font>, partly because they are explicitly non–research-based; and when they might be right, DSM’s baleful influence of being a teaching tool, replacing careful phenomenology, has dumbed down the clinical capacities of my generation. So, my first suggestion: live beyond DSM. See it as a tool, a fallible tool, a mostly [but not completely] false tool. Look for the few places where it is based on solid research, and build on those parts. But put it aside as a central approach to clinical treatment: there it fails…<\/strong><\/sup><\/div>\n
hat tip to Jamzo… <\/strong><\/sup><\/div>\n<\/blockquote>\n
Maybe it takes "an American who was once not an American<\/em>" like Dr. Ghaemi to step out of the traffic and say the obvious – the diagnostic systems we’ve called the DSM-III, DSM-IIIR, DSM-IV, and soon DSM-5 are administrative code books. The disorders are not particularly useful for diagnosis or treatment, inappropriate for use in clinical trials of medications [as we’ve repeatedly proven], and the manuals have been neither textbooks of psychiatry nor treatises on mental illness. So if they’re just administrative code books, how did they get to be elevated to such heights in the last third of a century?<\/div>\n

While Dr. Ghaemi is focusing on how these code books "dumbed down" psychiatric diagnosis, there were other dramatic changes as a result of the 1980 DSM-III. American psychiatry seemed to sever its ties with its own past [I can’t think of a better way to say that]. The disconnection with its psychoanalytic past and the American psychoanalysts was by design, but it went much further than that. People like Adolf Meyer or Harry Stack Sullivan who were not analysts were also discarded. The generation of psychiatrists from the years before were gradually marginalized and forgotten. It was as if someone had rebooted the specialty, it was born again, and one rarely finds anything much from before 1980 mentioned in the contemporary psychiatric literature.<\/p>\n

The DSM-III Revision came in a time of widespread disillusionment from within and without psychiatry. It solved the problems of the day by objectifying the diagnostic criteria hinging on inter-rater reliability as its standard of objectivity. It was followed by an era where evidence-based medicine and its randomized clinical trial became the standard – both were attempts to locate and certify a long-sought objectivity. k<\/font><\/strong><\/em> [reliability] and p<\/font><\/strong><\/em> [probability] replaced opinion and intuition as our gold standards. As Ghaemi points out, the downside of the DSM-III was oversimplification and inaccuracy. The downside of the clinical trial was that it became an open conduit for corruption.<\/p>\n

It’s hard to think about the why of these things without blaming the obvious targets – and there are more than enough candidates in every direction. Dr. Ghaemi’s advice to someone coming into this ball of confusion is more measured. Don’t let the pseudo-objectivity and simplicity of the DSMs get in your way in learning about and caring for the mentally ill. I would give the same advice about evaluating the ubiquitous clinical trials. Finding objectivity in the subjective world of mental illness remains a work in progress, currently in great flux…<\/div>\n","protected":false},"excerpt":{"rendered":"

Letter to a Foreign Psychiatrist Psychiatric Times By Seyyed Nassir Ghaemi April 11, 2013 I write to you as an American who was once not an American. Of course, all Americans, at one time, were not Americans, but there is still a prototype: the Christian American of European descent. I’m not in that majority, so […]<\/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-35351","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/35351","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=35351"}],"version-history":[{"count":55,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/35351\/revisions"}],"predecessor-version":[{"id":35421,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/35351\/revisions\/35421"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=35351"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=35351"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=35351"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}