{"id":9102,"date":"2011-05-17T21:35:13","date_gmt":"2011-05-18T01:35:13","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=9102"},"modified":"2011-05-17T22:13:28","modified_gmt":"2011-05-18T02:13:28","slug":"dsm-iii-the-shift","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/05\/17\/dsm-iii-the-shift\/","title":{"rendered":"DSM-III: the shift&#8230;"},"content":{"rendered":"\n<ul>\n<div><strong><a target=\"_blank\" href=\"http:\/\/en.wikipedia.org\/wiki\/Paradigm_shift\"><u><font color=\"#200020\">Kuhnian paradigm shifts<\/font><\/u><\/a>:<\/strong> <\/div>\n<div align=\"justify\"><strong><sup>An epistemological paradigm shift was called a scientific revolution by epistemologist and historian of science Thomas Kuhn in his book <em><a href=\"http:\/\/en.wikipedia.org\/wiki\/The_Structure_of_Scientific_Revolutions\" title=\"The Structure of Scientific Revolutions\">The Structure of Scientific Revolutions<\/a><\/em>. A scientific revolution occurs, according to Kuhn, when scientists  encounter anomalies which cannot be explained by the universally  accepted paradigm  within which scientific progress has thereto been made. The paradigm,  in Kuhn&#8217;s view, is not simply the current theory, but the entire worldview  in which it exists, and all of the implications which come with it. It  is based on features of landscape of knowledge that scientists can  identify around them. There are anomalies for all paradigms, Kuhn  maintained, that are brushed away as acceptable levels of error, or  simply ignored and not dealt with&#8230; Rather, according to  Kuhn, anomalies have various levels of significance to the practitioners  of science at the time&#8230;<\/sup><\/strong><\/div>\n<p align=\"justify\"><strong><sup>When enough significant anomalies have accrued against a current paradigm, the scientific discipline is thrown into a state of <em>crisis,<\/em> according to Kuhn. During this crisis, new ideas, perhaps ones previously discarded, are tried. Eventually a <em>new<\/em>  paradigm is formed, which gains its own new followers, and an  intellectual &quot;battle&quot; takes place between the followers of the new  paradigm and the hold-outs of the old paradigm&#8230; Sometimes the convincing force is  just time itself and the human toll it takes, Kuhn said, using a quote  from Max Planck:  &quot;a new scientific truth does not triumph by convincing its opponents  and making them see the light, but rather because its opponents  eventually die, and a new generation grows up that is familiar with it.&quot; After a given discipline has changed from one paradigm to another, this is called, in Kuhn&#8217;s terminology, a <em>scientific revolution<\/em> or a <em>paradigm shift<\/em>. It is often this final conclusion, the result of the long process, that is meant when the term <em>paradigm shift<\/em>  is used colloquially: simply the change of worldview,  without reference to the specificities of Kuhn&#8217;s historical argument&#8230;<\/sup><\/strong><\/p>\n<div align=\"justify\"><strong><sup>A common misinterpretation of paradigms is the belief that the  discovery of paradigm shifts and the dynamic nature of science [with its  many opportunities for subjective judgments by scientists] is a case  for relativism:  the view that all kinds of belief systems are equal. Kuhn vehemently  denies this interpretation and states that when a scientific paradigm is  replaced by a new one, albeit through a complex social process, the new  one is <em>always better<\/em>, not just different. These claims of relativism are, however, tied to another claim that  Kuhn does at least somewhat endorse: that the language and theories of  different paradigms cannot be translated into one another or rationally  evaluated against one another &mdash; that they are <em>incommensurable<\/em>.<\/sup><\/strong><\/div>\n<\/ul>\n<div align=\"justify\">There is no argument that the change in Psychiatry marked by the 1980 DSM-III was a  dramatic paradigm shift &#8211; one that will likely be an example in some future text-book to illustrate the phenomenon. But unlike Einstein&#8217;s 1905 paper, <strong>On the Electrodynamics of Moving Bodies<\/strong>, Spitzer&#8217;s classification was hardly the final word and remains problematic even after extensive revision. The paradigm shift was actually in what it didn&#8217;t contain &#8211; psychoanalysis or any other references to the &quot;mind.&quot; That had something to do with the classification of the Major Affective Disorders, because it required removing Depressive Neurosis, the most common diagnosis in Psychiatry prior to the DSM-III. But it doesn&#8217;t explain why the DSM-III didn&#8217;t contain the wisdom of the day which made a distinction between Melancholia [endogenous, endogenomorphic, etc.] and other less severe Depressions, since we all think they are descriptively separable on clinical grounds [it&#8217;s even in the narrative of the DSM-III]. From this footnote&#8230;<\/div>\n<ul>\n<div align=\"justify\"><sup><strong>[Melancholia]  A term from the past, in this manual  used to  indicate a typically severe form of depression that is  particularly  responsive to somatic therapy. The clinical features that  characterize  this syndrome have been referred to as &quot;endogenous.&quot; Since  the term  &quot;endogenous&quot; implies, to many, the absence of precipitating  stress, a  characteristic not always associated with this syndrome, the  term  &quot;endogenous&quot; in not used in DSM-III.<\/strong><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">&#8230; one might think they were afraid that they would be letting a little psychodynamic thinking leak in. There&#8217;s another non-explanation explanation:<\/div>\n<ul>\n<div align=\"justify\"><strong><sup> For example, there has been a continuing&nbsp;  controversy as to whether or not severe depressive disorder and mild  depressive disorder differ from each other qualitatively [discontinuity  between diagnostic entities] or quantitatively [a difference on a  severity continuum]. The inclusion of Major Depression With and Without  Melancholia as separate categories in DSM-III is justified by the  clinical usefulness of the distinction. This does not imply a resolution  of the controversy as to whether or not these conditions are in fact  quantitatively or qualitatively different.&quot;<\/sup><\/strong><\/div>\n<\/ul>\n<div align=\"justify\">Throughout three revisions, Major Depression remains very close to where it started thirty years ago even though the psychoanalysis issue seems long past.<\/div>\n<p align=\"justify\">It matters for two reasons. First, they shot a number of biological researchers in the foot by essentially relegating the object of their research to a fifth digit add-on diagnosis. And second, they opened the door for drug companies to radically expand their markets for any drug they could get approved as an anti-depressant &#8211; leading to a lot of really questionable clinical trials and unethical, misleading marketing. This was an active decision over <strong><u><a href=\"http:\/\/1boringoldman.com\/images\/dsmiii-2.gif\" target=\"_blank\">objections<\/a><\/u><\/strong> from people one might have thought were in the framer&#8217;s camp.<\/p>\n<p align=\"justify\">And, as I [and many before me] have mentioned, they expanded, complexified, and revised Mania diagnoses into the multiple flavors of Bipolar Disorder without reasons that have any scientific rhyme &#8211; a change that continues to confound to the present. After the DSM-III came, we went through &quot;chemical imbalance&quot; and &quot;Bipolar&quot; epidemics making it hard not to be suspicious that this was another drug promo decision. If it was on solid evidence-based grounds, that evidence hasn&#8217;t been widely disseminated.<\/p>\n<p align=\"justify\">As I mentioned in my last post, the &quot;shifted to&quot; paradigm relies on biology, not in the abstract but in reality &#8211; biological underpinnings to mental illnesses and biological treatments. The former are elusive and the latter&#8230; well, they haven&#8217;t worked out so well as was hoped, in spite of topping the charts in sales [being widely prescribed by non-psychiatrists].&nbsp; And the new paradigm requires that the leading edge be always moving forward, because anything that can be turned into a simple &quot;algorithm&quot; can [and will] be done by primary care physicians.<\/p>\n<p align=\"justify\">So maybe the framers of the DSM-III had no intention of ushering in an era of increasingly corrupt and\/or trivial science, but they facilitated that development by restricting the psychiatric paradigm to biology and counting on a steady stream of scientific discoveries to carry the day. And maybe they enabled the development of the whole Clinical Research Industry that specializes in finding its &quot;evidence&quot; in large studies with small differences [resulting in small efficacy in the pill bottle]. And maybe they pushed psychiatrists into an alliance with the pharmaceutical industry because that&#8217;s where the necessary biological treatments usually originate. And perhaps the proliferation of flim-flam men in high places [KOLs] in psychiatry has something to do with needing people with the charisma to &quot;keep the dream alive.&quot; And worst of all, maybe the emphasis on keeping the new treatments flowing and the high premium on &quot;translational science&quot; [speeding up the movement from bench to the drugstore] has been at the expense of encouraging and developing careful and creative researchers who would best be left alone to move in their own directions at their own pace.<\/p>\n<div align=\"justify\">It&#8217;s obviously time for another shift in psychiatry. But this time, it&#8217;s not some change in scientific paradigm or ideology. It&#8217;s time for a renewed focus on the people who seek our help and their individual illnesses, along with a commitment to the time honored ethical stance of medicine which too many of us have abandoned. That includes a clean and amicable&nbsp; break with the pharmaceutical and device industry. The marriage was doomed from the start. It was more like incest &#8211; taboo for good reason&#8230; <\/div>\n","protected":false},"excerpt":{"rendered":"<p>Kuhnian paradigm shifts: An epistemological paradigm shift was called a scientific revolution by epistemologist and historian of science Thomas Kuhn in his book The Structure of Scientific Revolutions. A scientific revolution occurs, according to Kuhn, when scientists encounter anomalies which cannot be explained by the universally accepted paradigm within which scientific progress has thereto been [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","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-9102","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/9102","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=9102"}],"version-history":[{"count":24,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/9102\/revisions"}],"predecessor-version":[{"id":9131,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/9102\/revisions\/9131"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=9102"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=9102"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=9102"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}