{"id":36061,"date":"2013-05-05T00:20:16","date_gmt":"2013-05-05T04:20:16","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=36061"},"modified":"2013-05-05T00:29:21","modified_gmt":"2013-05-05T04:29:21","slug":"36061","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/05\/05\/36061\/","title":{"rendered":"a flair…"},"content":{"rendered":"
The DSM-5, the RDoC, the APA, the NIMH, the scandals, the PHARMA suits – it has all been going on so long that those of us following the widening gyre are all kind of fuzzy from thinking about it all. It’s nice to read something from a more editorial position rathe than front page perspective. In this case, Dr_Tad, a psychiatrist from Australia with a flair for the bigger picture. The title, Paradigms Lost<\/font><\/strong>, is already worth the price of admission. The title captures the journey of American Psychiatry as we seem to reform and deform repeatedly on our way to… Well, just on our way. Speaking of paradigms lost, I’ve snipped out Dr_Tad’s account of Dr. Patrick McGorry’s paradigm of Ultra·High·Risk [UHR] for psychosis patients in the service of space, but it’s an important piece of the paper, available on-line:<\/div>\n
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Paradigms lost: NIMH, McGorry & DSM-5’s failure<\/a>
Left Flank <\/font><\/strong>
by Dr_Tad
May 4, 2013<\/div>\n
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… Last week the National Institute of Mental Health — the peak US mental health research body — delivered a body blow to the authority of the DSM<\/em> by announcing that it was abandoning the manual<\/a> in favour of its own Research Domain Criteria [RDoC].<\/p>\n

This is a new phase of the controversy that has dogged the DSM-5<\/em> at every turn. Petitions opposing the project have garnered the signatures of thousands of clinicians. The revision process has been attacked for being kept behind closed doors, and for favouring the pet research areas of expert committee members. The corporate media — usually uncritical of mainstream psychiatry — has reported substantial criticisms of proposed changes. The taint of academic psychiatry’s incestuous relationship with Big Pharma has fed accusations of financial influence. And the psychiatrists who headed DSM-III<\/em> and DSM-IV<\/em> — Robert Spitzer and Allen Frances <\/a>— have attacked the DSM-5<\/em>.<\/p>\n

Even on the aims its creators set, the DSM-5<\/em> is a failure; an incoherent compromise and a mess. Significantly, its contents will reflect the impasse of the diagnostic paradigm that became hegemonic with the DSM-III<\/em> in 1980, following a “revolution” in diagnosis designed to save US psychiatry from its profound crisis in the 1970s. It will be a further sign of the failure to create a “scientific” basis for psychiatry through symptom-based diagnoses, as NIMH director Thomas Insel has argued on his blog<\/a>.<\/p>\n

But the authors of DSM-5<\/em> also wanted the kind of quantum leap Insel advocates. When they started work over a decade ago they saw their task as going beyond simply describing disorders in terms of the symptoms and behaviours [the DSM<\/em> is currently silent as to the “aetiology”, or cause, of almost all the disorders it defines]. Instead they would align diagnoses to the “underlying” genetics and neurobiology. Yet as they proceeded it became increasingly obvious that there was insufficient evidence for this shift. More importantly, the biomedical model was increasingly being challenged from a number of directions: A series of major scandals involving kickbacks from drug companies to psychiatric “thought leaders”, mounting public concern about the over-diagnosis and gross overmedication of adults and children, and the growing evidence that many top-selling psychiatric medications [especially anti-depressants] worked little or perhaps no better than placebo.<\/p>\n

It is no wonder that DSM-5<\/em> “innovations” like removing bereavement as an exclusion criterion for Major Depression<\/a> are widely opposed. It feeds into a suspicion that psychiatrists and drug companies are cynically expanding potential markets for the expensive services and products they are selling. The finished DSM-5<\/em> will have most of its original raison d’etre<\/em> missing, some of the rewriting [e.g. personality disorders] relegated to an appendix, and a pall of controversy, mistrust and confusion surrounding it. The APA has suffered financially in recent years from a stagnant membership base and growing regulation of its financial ties with industry. Sales of the manual [not cheap at US$199<\/a>] and its various guides to use<\/a> form a major part of the APA’s annual revenue and seems to have been a driver for getting a new edition out for sale. In the end politics<\/em> hobbled the DSM-5<\/em> because the “objective” scientific advances its developers saw as being just around the corner proved to be a mirage…<\/p>\n

While this is a setback for the DSM<\/em>, it is far from being a defeat for the dominant neurobiological model of mental health and illness. As blogger 1 Boring Old Man<\/a> points out, Insel is simply taking the established NIMH position to its logical conclusion by formally breaking with DSM-5<\/em>. And the last half-century is proof of how profoundly that model shapes psychiatric research and practice. No matter how lean the pickings they deliver, biologically based approaches remain powerful and those who question them tend to be sidelined. You can see this in Insel’s alternative program<\/a> for devising new diagnostic boundaries:<\/div>\n