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    NIMH Delivers A Kill Shot To DSM-5
    By Hank Campbell | May 3rd 2013 02:00 PM | 102 comments | Print | E-mail | Track Comments
    About Hank

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    A wise man once said Darwin had the greatest idea anyone ever had. Others may prefer Newton or Archimedes...

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    The National Institute of Mental Health (NIMH) is distancing itself from the the American Psychiatric Association and its upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

    While they acknowledge that the goal of DSM "is to provide a common language for describing psychopathology" they are no longer convinced that approach has value if we are going to solve 21st century cognitive science problems.  It is, paraphrasing the statement  of Thomas R. Insel, M.D., Director of the National Institute of Mental Health, more of a dictionary than a manual.  He uses the term "Bible" instead of 'manual' but I would have used 'glossary' rather than 'dictionary'.

    Insel pulls no punches in his statement on why they are not going to fund things based on DSM criteria any more.

    "The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure."

    This is a charge leveled at psychology as well, and the field in general, but psychiatry takes the biggest hits, because they are supposed to be the most evidence-based. Unlike psychology, psychiatrists have to be M.D.s first. Writing in The New Yorker, Gary Greenberg tries to tackle why cognitive science hasn't kept pace with medicine, much less the physical and life and earth sciences, writing rather nicely that "it’s not entirely clear that psychiatrists want a solution to the problem."

    Insel is more blunt. "DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever."

    Basically, he says DSM is stuck in the past.
    Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

    Patients with mental disorders deserve better.
    NIMH is leaving the past behind. In the past, Insel notes, they would reject a biomarker that did not match a DSM category. Now they instead want to collect how all data - genetic, imaging, physiologic and cognitive - cluster, and not just how symptoms do.  They call it the Research Domain Criteria (RDoC) project.

    "That is why NIMH will be re-orienting its research away from DSM categories.," he wrote, and that means funding applicants are going to have to adjust to the 21st century.

    The APA may be outraged, and certainly some DSM-5 defenders, but I predict people in cognitive science who want to really do science and get NIMH funding are relieved that they are not going to have to cater to a document everyone seems to know was always flawed.

    Read Insel's whole statement, Transforming Diagnosis, and have hope for the future.

    Comments

    Most mental health practitioners...actually a substantial majority....have absolutely nothing to do with NIMH. Having worked for nearly 20 years as a director of NIMH funded research projects at a major university...I can report that trying to disseminate findings that we developed through NIMH funded research to actual practitioners...where the rubber meets the road...is nearly impossible. The DSM has a long way to go before it's dead and buried, despite the new direction NIMH is taking.

    Hank
    Practitioners can do whatever they want, I suppose, but it was different for credibility when the largest mental health research funding agency on the planet supported the book.  Now that it does not, it looks bad.

    The rubber isn't meeting the road, which is why the NIMH is distancing itself. Success among practitioners is in placebo effect range.
    Hank
    Indeed. I am most impressed that someone whose only other review was a desk they put together took the time to wrote about this. Actually, it is a pretty good review. They disagreed with 2 things in a 300 page book with 90 topics that has 600 citations - but gave the book a 2 star because the 2 things they disagreed with were particular hot buttons. 

    But claiming I endorse evolutionary psychology or that we are "clueless, Steven Pinker-loving white guys" is pretty funny, and as wrong as imaginable. Since that 'endorsement' is why I got a 2-star rating, and virtually everyone on planet earth would laugh at the idea that I endorse evolutionary psychology, the review should be a 5.

    Because they agree with criticisms of the naturalistic fallacy, on Yucca mountain, on organic food, ethanol and GMOs, on anti-vaccine activists and inconsistent progressive support support for clean energy.

    They disagree that men are not misogynists by biological design. So do all scientists.

    I'll take it. Thanks for finding it.

    It is almost like 7th graders are running the NIMH. Apparently these so-called scientists have no idea that there are no biomarkers that reliably differentiate one mental disorder from another. There are no blood tests, scans, etc. that can differentiate the complexities and manifestations of these disorders. There are several reasons for this. One being that the science is not there at this time. Another is that mental disorders involve biological, psychological, and social aspects. In the reductionistic society we live in, "we" apparently even NIMH scientists want to find simple solutions for complex problems. There are none. By not funding these studies, the folks with mental disorders lose out. NIMH is doing what has been done for far too long with folks with mental illness...discriminating against them.

    The author of this article also seems to misunderstand what a psychologist does. Psychology is the "science of human behavior." They are as much scientistists as psychiatrists. The difference is that Psychologists do not use medication to treat those with mental illness, they use forms of psychotherapy, many of which have been proven as effective and in some cases more than medication. This so-called "science" website, needs to research matters better before commenting on them.

    Best,

    Gerhard Adam
    It seems that you're in agreement with the NIMH position.  Your comments basically indicate that psychology has no firm scientific grounding. 

    The point that seems to be perpetually missed in this kind of discussion is that there is nothing profoundly wrong with this, since it acknowledges the fundamental limits of our knowledge.  The problem with the DSM is that it attempts to offer classifications which are not scientifically grounded, thereby lending them an air of acceptance which they lack.

    If we don't know, then we don't know.  People can still work and investigate and try to pursue whatever avenues are necessary to try and afford treatment to those needing it.  However, false classifications and the pretense that these issues are settled doesn't help those needing it.

    Your claim that the NIMH scientists want simple solutions isn't accurate, since it is the DSM that attempts to create simple solutions.  Simply creating a definition doesn't create knowledge.

    In fact one of the primary criticisms I have about many scientific claims is that they are made without proper scientific verification.  Too many scientists are interested in advancing their careers rather than in advancing our knowledge.
    Mundus vult decipi
    Actually, psychology is based on science. Psychological assessments and treatments are based on empirical studies. It is a violation of the American Psychological Association ethical standards to treat patients with methods that are not empirically supported through research (unless the method is experimental and disclosed to the patient before treatment).

    It seems you are taking a very narrow view of what science is, assuming that if there is no biological basis for a illness or treatment then it is somehow not "science." That is simply incorrect. In many ways, psychologists employ more rigorous scientific criteria to diagnosis and treatment than psychiatrists. We make diagnoses based on a battery of empirically valid and reliable assessments, combined with clinical impressions, client history, etc. Whereas many psychiatrists rely primarily on clinical impression.

    Psychology is not a precise science, granted. But to say the approach is not scientific is incorrect. We deal with much more complex problems than medical doctors. Mental illness is not just biological in nature; it encompasses biological, psychological, and social elements. It is heavily dependent on the patient's subjective experience of his world as well.

    Its sad the NIMH has chosen to stop acknowledging the nature of mental illness.

    "... it encompasses biological, psychological, and social elements." Most every health condition has all those, and good doctors know to not neglect them, but that does not mean they do not order useful tests - the results of which may well consolidate all those influences.

    What "useful test" accounts for the stress and difficulty of coping with a potentially life-threatening illness, cancer, etc? What "useful test" is available that "good doctors" can order to "consolidate all those influences" of psychological and social impact of their diagnosis or disease? Does an A1c, and ANA, a CBC, an MRI, a CT, a CMP, CRP, EKG?...do any of these tests quantify or "diagnose" the psychological and social difficulties of being diagnosed with cancer, or any other chronic illness? No sir, they do not. Because the thing is humans are more than just the sum of their parts...we're more than our blood counts, our A1c's, our organ's and structures visualized on MRI or CT. We have hopes, dreams, relationships, families, jobs, responsibilities, emotional needs, fears, and other elements to us that we can't quantify on some diagnostic lab. Good doctors take the time to talk to their patients, understand how they suffer beyond their physical symptoms and how their family history, childhood, environment and life situations affect them, assess their thinking/cognitive status, support them and their families, offer stress reduction/relaxation techniques, explore with their patients the root and meaning of their emotional and physical suffering, provide medications when these disturbances are severe and continue to rule out reversible medical components to their suffering, all while using caution when prescribing medications with known side effects. Guess what that is called: psychiatry. The problem is 1) psychiatry is being primarily practiced by general practicioners that have very minimal training and are ridiculously pressured by the system in terms of both time and productivity and 2) the continued stigmatization of those with mental illness/substance use disorders which has lead to countless people suffering to either be imprisoned or not have access to resources that will help them.

    Is DSM perfect? Absolutely not. Is it useful to identify syndromes based on behavioral observations and clinical history/exam in order to diagnose and treat people suffering with mental illness? Absolutely. Does more work need to be done to improve diagnosis and treatment of mental illness. Absolutely, and the work will never be complete...just as the same can be said for the majority of modern medicine. Few if any psychiatrists see the DSM as the end all be all/"bible" as it is often described in news clippings and media. It's one of many tools; an important one, but not the only one nor is it seen as without flaws. I think it's great that NIMH is engaging in this project, but it will be decades before we know if it will be of any more use than the current system.

    Lastly, psychiatry/psychology ISN'T like the rest of medicine...and that's ok. It's much more holistic and less reductionistic...and I think that is a good thing.

    Hank
    Lastly, psychiatry/psychology ISN'T like the rest of medicine...and that's ok. It's much more holistic and less reductionistic...and I think that is a good thing.
    The APA does not portray the DSM that way, it has encouraged people to call it a "Bible" and for insurance companies and the NIMH to use its categorizations in regards to how they spend money. So it can be holistic but that isn't science or even medicine and should not be funded like it is.
    Sure it is science AND medicine. How do you define science, Hank? How do you define medicine? Science is, from Webster's (pick your definition, all similar): "knowledge or a system of knowledge covering general truths or the operation of general laws especially as obtained and tested through scientific method." The scientific method being: develop a hypothesis, test it and obtain data, make conclusions/determine "laws", revise hypothesis, repeat. The DSM fits that bill...it's the outcome of the "scientific method" based upon the resources, technology and knowledge we have about the brain and behavior, taken in the context of social and psychological functioning. Medicine? "The science of diagnosing, treating, or preventing disease and other damage to the body or mind." Yep, does that as well. Maybe it doesn't fit YOUR definition of science or medicine. The DSM is devised from a bio-psycho-social model, not just bio. We don't have the know how or technology to reduce the brain, the mind, behavior down to discrete biologic elements...I doubt we ever will.

    It's "funded" the way it is because NO better alternatives for diagnosis of mental illness have been proposed, tested, and validated and psychiatric illness continues to exist and patients continue to seek relief/treatment...and while kind and compassionate, psychiatrists/psychologists/mental health therapists/etc need to get paid for their work. When a better system comes along, the DSM will go away...

    Of course the APA has a vested interest in it as it owns the rights and stands to profit on it. The APA also has an extremely vested interest in it being based on good science/the best we have as otherwise, like is being attempted now and in this article, it will be devalued and eventually it will go away, along with their profits from it. The APA having a vested interest in it doesn't make it "non science or non medicine". Who doesn't have a financial interest in science/research/medicine these days, Hank? Please don't say the NIMH and make me laugh.

    Do we even want to get into a debate about how overall research dollars and insurance company dollars are being spent on non-psychiatric/non-mental health areas and whether it's all based on good science or medicine?

    Hank
    The DSM fits that bill...it's the outcome of the "scientific method" based upon the resources, technology and knowledge we have about the brain and behavior, taken in the context of social and psychological functioning. Medicine? "The science of diagnosing, treating, or preventing disease and other damage to the body or mind." Yep, does that as well. Maybe it doesn't fit YOUR definition of science or medicine. T
    This is the problem. The DSM does not fit that bill in any way yet you dismiss it as 'not your definition' when anyone notes it. I didn't say it has no value and I didn't say therapy is easy, it just isn't science. Neither is engineering, neither is math, neither is anthropology or sociology or psychology. So what?  

    Anyway, you are arguing with the NIMH now, the largest mental health funding agency in the world, not me. They finally got the message that both scientists and people in cognitive science outside psychiatry were frustrated about and want to get the field out of the 1950s.
    What is your standard/definition for "science"? Or medicine? The DSM uses the best available science to categorize/identify diagnoses to be used in clinical (and research) settings...primarily clinical. It's born out of research and science. So call it what you want, but it comes from science. It's not the fault of the APA or DSM committees if the science is limited/behind others' expectations. Perhaps the NIMH, the "largest source of funding for mental health research", should get on advancing the science in order to improve DSM 5 (really they're indicting themselves with this critique)...and look, they're stating they're going to try! Good for them I say...competition is a good thing and hopefully something promising comes from this all. That's all that matters to me: give me more tools and means to help my patients!

    Gerhard Adam
    "Best available" or "limited" are not the criteria to be classifying anything.  In the absence of a predictive theory, this simply becomes a collection of anecdotes.

    The fact that this data needs to be collected is certainly desirable, and perhaps someday it may serve as a basis on which to build consensus for a scientific understanding.  However, simply assigning names to a variety of symptoms does not render understanding, nor does it promote diagnosis.

    Look, let's cut to the chase.  If you have a patient that requires treatment, then presumably with sufficient clinical experience you have a course of treatment you will pursue and adjust as conditions warrant.  You will not go to the DSM and see if something fits.  However, if you rely on the DSM to make a diagnosis, then there's a problem.
    Mundus vult decipi
    Oh, ok...how should we classify things NOW that people need addressed NOW if not on the best available evidence? Evidence that doesn't exist yet? The not-best-available evidence? Your logic is escaping me. Ignore the problems and suffering until we have "a predictive theory", whatever that means?

    Your example of strategy of treating patients (guessing you've never done so) is also, um, fuzzy at best. So "clinical experience" will guide your treatment plans...ok, so on what foundation did you develop and base that clinical experience? What framework are you using to diagnose, then treat the problem? Just randomly, based on gut, experience? Without RCTs using a defined framework developed from researching how these problems actually present across large populations? Hmm, not sure how that's an improvement.

    The DSM is a research/data driven diagnostic manual that provides as best as the evidence allows currently (yeah, so you realize every area of medicine revises, updates, adjusts diagnoses based on best available data, right?) a framework for diagnoses for which evidence based treatments have been developed. So if you're not using the DSM to help guide your diagnostic and thus treatment decisions now, you're in trouble and basically pissing in the wind.

    Again, it really isn't about DSM...it's about what is the best available evidence-based diagnostic tool for mental illness? Currently it is the DSM. If NIMH can use their dimensional approach as they described and come up with something better, more power to them...that'll be the next diagnostic "bible" then. My question is, since they're the largest funding source of mental health research why haven't they before now? Why now?

    There must be a foundation and framework from which to diagnose and base treatment, or it's just voodoo.

    Hank
    Actually, psychology is based on science.
    Okay, what is the theoretical basis of psychology then?  Honestly, most of the psychology that gets published is surveys of students and suspect lab studies that can't be replicated. That isn't science. It is social science, but that is also not science.
    logicman
    what is the theoretical basis of psychology
    Early psychology was mainly philosophical.  Modern psychology is - if properly conducted - an empirical science using the tools of medicine.

    Kenneth Wartenbe Spence (May 6, 1907 - January 12, 1967) laid down some ground rules for psychology as a science but is, today, almost forgotten.

    Psychology does have a woo factor, but it also has a wow factor, as in: "Wow! Look at that guy's brain activity when the nurse ... "



    image from
    An Overview of Research in Energy Psychology,
    David Feinstein
    (not peer-reviewed)
    Hank
    The wow may be coming back but a lot of woo needs to go away first. As I have noted a few times, it is young researchers who are getting the older frauds thrown out of the field. And that's good. Young people expected to do 21st century science and found out the discipline was overrun with surveys, poorly-conceived models and sometimes outright invention because no one expected or was able to do replication anyway.

    fMRI scans of today claiming to show cause and effect are almost as bad.  :)
    logicman
    I agree with you.

    fMRI scans of today claiming to show cause and effect are almost as bad.
    Yep!  I did say that the image source was not peer-reviewed.  ;-)
    Truly you jest, Hank or are you really that near sighted about the process of science? Is the scientific method, empiricism, and rational thinking really confined to the white lab coat and your subject area as you're attempting to argue rather unconvincingly? The question "Okay, what is the theoretical basis of psychology then?" is disappointingly revealing of how little of the empirical literature you've read on human behavior and learning, motivation, self-regulation, psychoneuroimmunology, etc. It appears you hold yourself in high regard for being scientifically minded - how about you do what is done in respectable peer-reviewed scientific journals and provide the reader with the data to verify your commentary and sweeping claims about most of psychology-based research that is published is from suspect labs and non-replicable findings... As they say in "science" in God we trust all others bring data.

    Hank
     The question "Okay, what is the theoretical basis of psychology then?" is disappointingly revealing of how little of the empirical literature you've read on human behavior and learning, motivation, self-regulation, psychoneuroimmunology, etc. 
    I have no issue with any of the empirical literature on behavior, as limited as it is.  But using that as your definition means everything is science. Sewing us science, cooking is science, playing chess is science.  Letting people dilute terms colloquially makes them useless - people use occupation, trade and profession interchangeably now, which means there is no reason for three different words and never would have been. Except they were not the same thing before people tried to puff themselves up by being a professional shoe salesman or whatever. Psychology is nice, it is one of my degrees, but it isn't science. Some day it will be, though.
    Now I get it... Science 2.0 and your posts are NOT really above advancing scientific/data-driven discussion of issues (but more about ad placement, promoting "Science Left Behind," and attempting to increase internet traffic to your site), as you don't answer the request posed to you. Rather you go further off message and bring into question even more your credibility and only attempt to buy it back by saying psychology is "one of my degrees." If indeed that's the case I venture to guess the U of Phoenix may be involved, because you're clearly out of touch with the scientific study of psychology (and it sounds like every other scientific discipline that isn't confined to physics/biology and a white lab coat). Stay on message and PROVIDE THE EVIDENCE for your claims or retract your unsupported claims (that's what scientists do).

    Bingo. Though (as I'm sure you aren't) don't expect a legitimate debate with Mr. Campbell actually supporting his sweeping statements with data. Not gonna happen. This is just another sensationalistic blog trying to stir the pot, drive traffic, sell ads and books.

    Hank
    It's your job to talk to crackpots. Not mine.
    well said. Anyone who knows how the DSM is formulated and still supports it is a dunce. Thats putting it nicely. In science something is or it is not. Consensus does not determine fact. It never has. It never will. So if anyone really thinks that what these "scientists" have done over the past 60 years is good science or science at all then I question whether that person even knows what a human being is, what health is, what therapy is, and ultimately what science is.

    I won't really contend with your point about psychology and/or cognitive science. There may be issues in these disciplines, but blanket statements that lump them together with psychiatry (e.g. Campbell's point above) really just obscures what the real issues are.

    On the other hand you're statement "these so-called scientists have no idea that there are no biomarkers that reliably differentiate one mental disorder from another" actually misses the point. The new NIMH project explicitly will not be trying to identify biomarkers for specific disorders. Instead they are looking to define some as yet undetermined set of biomarkers which extend across disorder categories and might allow the construction of very specific and well-defined "categories" dysfunction.

    I agree that this approach may not succeed, given the role of external factors in influencing how the brain and mind function (and I think Insel is pretty over-optimistic about how successful we're going to be)--but the entire point is to get the science there. It's also a great starting point to work on a better understanding of consistent relationships between biological, psychological and social factors and how they influence mental illness.

    Hank
    but the entire point is to get the science there. It's also a great starting point to work on a better understanding of consistent relationships between biological, psychological and social factors and how they influence mental illness.
    Sure, we know the status quo has gone nowhere. When I was an undergrad, DSM III was just out (they came out in rapid succession until then) but no progress has been made since then, it just became redefining disorders, which isn't really helping anyone.  But I applaud the NIMH effort, even if it fails (in science, as the saying goes, null results can be worthwhile too) which is why I ended with "and have hope for the future."
    there are biomarkers. they are difficult to use, and not 100% reliable.

    But maybe this is the push that psychiatry needs. Start studying biomarkers and
    clinical symptoms, along with response to therapy.

    Well said Dr S ! it is unbelievable what this article is claiming to be...what is the NIMH after all?
    and yes, we always knew that the DSM is a gentleman's agreement made into a "bible" !

    I don't think it is fair to compare Psychiatrists who medicate and Psychologists who perform psychotherapy. Drugs will have an effect almost immediately. That does not mean a person is healed, it just means it is masked or serotonin levels artificially altered. Psychotherapy will take longer as it often takes a lifetime to get into a mess, it is therefore going to take some time to untangle it.

    To the best of my knowledge, the best outcomes as described by international observers, as in Western Lapland, the Open Dialogue program, and in Trieste, Italy, with recovery through work, the social-cooperative model.

    Nothing in the DSM directs anybody to these models, or to Empowerment Initiaties, or to the Hearing Voices Networks, or other programs that are less authoritarian than most of the systems used in most of the world now.

    Hank
    You're saying DSM using consensus about symptoms is too scientific and NIMH says it is not science at all. That's a double-whammy. Basically, the only people accepting it seem to be the people writing it and a few others. But it's #17 on Amazon right now, so the public still believes it has something worth reading. But they also buy a whole lot of fad health books.
    The DSM is actually a treasure trove for dramatists and stand-up comics. Ron Coleman, whose books I love, sort of negotiated himself to recovery partly at Frog and Bucket, a comedy club in the UK somewhere. I, and many other proponents of the peer-empowerment movement, love it when he comes to Portland. The last time he came, I got to hear him speak and interact with us in the cozy library of Empowerment Initiatives, in the Linus Pauling House, on SE Hawthorne, named for a pioneer Portland carer of great compassion, compared to what what going on with his contemporaries.

    I believe there still is a Hawthorne Library on the campus of the Oregon Health Sciences University, on the other side of the river from EI, but on the same side as Will Hall, Hearing Voices Networks, and The Process Center.

    If you want to really stir something up, you can go to a NAMI-fest and mention Robert Whitaker. I had the honor of getting hissed while announcing a talk by Bob. It was kind of fun. At least I know I got listened to, and some of the more open-minded ended up coming to a Re-Thinking Psychiatry symposium, where they enjoyed the yummy bread from Happy Campers Gluten-Free.

    Enlightened carers are into Temple Grandin's model in which one keeps a log and participates as a principal investigator in one's own journey.

    It would appear that what the NIMH is suggesting is, that with regard to applying science to its methods, psychiatry has more in common with chiropractors than it does doctors.

    Well except psychiatrists ARE doctors (ie went to medical school, passed all the same licensing boards), there are mountains of RCTs about the effectiveness of psychiatric meds, medical interventions, and psychotherapies and well, not so much from chiropractors. But let's not let reality get in the way of a snarky comparison...

    Hank
    Yes, but that is why it is a concern. If these were just psychologists or people who claim to heal with crystals, whatever, but the APA has been claiming to speak with authority and a giant research and insurance industry has played along - but it has only helped people in the placebo success range.

    So it's time to try something new. A glossary that finds new ways to create a larger market for psychiatrists is not it.
    Placebo levels? No. You're misinformed. There are many RPCTs of psychiatric medications and interventions that achieve outcomes much better than placebo. Know your facts before you make these over arching characterizations.

    A giant research industry has "played along"? Yeah, because their work has guided the formation of the DSM, now they don't like the results? If they had something better (NIMH, etc) it would be out there already and in use by now. It's not a glossary also, it's a diagnostic manual and will continue to be used that way until the evidence suggests there's something better. Mental illness is real and not going away just like heart disease and cancer (though much more complex)...and we need a framework by which to diagnose, treat and study them. DSM is the standard right now...doesn't mean it can't and won't be improved upon.

    And I'm glad there will be a competing faction looking to enhance the framework the DSM and APA established. That's always a good thing.

    Lastly, lumping psychologist with "people that heal with crystals" is insulting to psychologists and far from a fair characterization...and I'm a psychiatrist ;-). Psychologists have an abundance of evidence based therapies that work better than your snarky "placebo success range". But you've already established a position and will mold the evidence to fit your "truth". Not very scientific, Hank.

    Gerhard Adam
    There are many RPCTs of psychiatric medications and interventions that achieve outcomes much better than placebo.
    Yet, this is precisely one of the major problems.  There is no measurements or data describing what constitutes a placebo, there are no standards, there isn't even sufficient understanding of what the placebo effect is. 

    The fact is that many of these pharmaceutical studies also contain a heavy dose of confirmation bias.  All one has to do is ask what the standard constitution is of a placebo.
    Mundus vult decipi
    You know pharmaceutical companies aren't the only ones researching these medications right? You know all medications are studied via placebo control trials, right? This isn't unique to psychiatry.

    A placebo is an inert pill with no medication...it's used to test a medication to rule out that the response is solely from the act of taking a pill and thinking it will help you. The placebo effect is the response to the inert pill thinking it is a medication designed to help you.

    Gerhard Adam
    But medical professor Beatrice Golomb, of the University of California at San Diego, worries that placebos may sometimes do more than we think.

    Golomb:
    We don't know how often placebo composition has affected the outcome of trials, because we have no idea what's been in the placebo most of the time.

    She and her colleagues found that the vast majority of studies don't say what's in their placebos. The few that do reveal potential conflicts. For example, an old cholesterol drug study used olive oil and corn oil as placebos—oils that were later found to improve cholesterol levels themselves. Standardizing placebos is a tricky idea, but Golomb says more disclosure would at least help researchers figure out which placebos work best—or rather, least—in different situations.
    http://sciencenetlinks.com/science-news/science-updates/placebo-standards/
    Mundus vult decipi
    You might check the DSM to see how it diagnoses thin skinned people who suffer under the delusion
    that the letters M and D somehow inoculate them against self serving pomposity.

    Or anonymous article commenters that drop snarky comments and offer nothing to the discussion.

    I have a copy of DSM-IV. I have read several articles on the new DSM-V, APA, NIMH. I have read Cleckley, Hare, and Boddy. Apparently, none of the current commentary addresses psychopathy, which was removed from previous editions of DSM.

    Karl Marx was a psychopath. Lenin and Stalin were psychopaths. Mao, PolPot, the Kims were psychopaths. The Ayatollahs and Saddam Hussein are/were psychopaths. Charles Manson, John Wayne Gacy, Ted Bundy "Chainsaw" Al Dunlap, Bernie Ebbers, and Jeff Skilling, psychopaths all.. Dr. Clive Boddy makes an intriguing argument that the multi-trillion dollar 2008 financial meltdown was driven by financial and political psychopaths. Most of our biggest social and economic problems in the last century were driven by psychopaths. And we spend all our time quibbling over the virtues and failures of DSM-V. We certainly need to establish a sense of priorities here.

    Congratulations, you have just rendered psychopathy meaningless.

    Antisocial personality disorder encompasses psychopaths. So your argument has no basis.

    Psychopathy was first noted by Dr. Philippe Pinel over 200 years ago, who described it as "insanity without delirium." Dr. Hervey Cleckley provided the first clinical description of psychopathy in his book, "The Mask of Insanity" in 1941. Dr. Cleckley described psychopathy in terms of anti-social and narcissistic behaviors, and noted that psychopathy was often accompanied by various co-morbidities.

    As a young man, Dr. Robert Hare worked with Dr. Cleckley. Dr. Hare is now the most widely recognized authority on psychopathy, and produced the premier tool for measuring psychopathy, the Psychopathy Check List - Revised (PCL-R). The PCL-R consists of twenty-one items in three classifications, anti-social, narcissistic, and "traits not correlated."

    Out of Dr. Cleckley's and Dr. Hare's original work, there have many personalized adaptations, some quite bizarre. Dr. Nassir Ghaemi denies that psychopathy and narcissism exist, and describe such behaviors as bi-polar. According to Dr. Ghaemi, Roosevelt, Churchill, and Hitler were bi-polar. Dr. Kevin Dutton has interviewed many psychopaths, has allowed the psychopaths to play him, and then finds that psychopaths have a certain virtue and wisdom. So I suppose that it is not surprising that there are so many interpretations of a subject that is very complex.

    I find your idea of psychopathy being a sub-set of anti-social behavior quite novel. Did you invent this yourself, or do you have a citation for us?

    yay!!!!!!! i'm glad the NIMH did it's job!!!!!!!!!!! please sign this if you're against the changes in the DSM 5: http://www.change.org/petitions/dsm-5-committee-dont-reduce-the-criteria-for-an-autism-spectrum-condition-in-the-dsm-5\

    Those silly rats of NIMH - who do think they are applying standards?

    Well, there is no blood test to conclusively prove that any mental illness exists, so it appears that the NIMH director, Dr. Insel, is correct when he states that the weakness of DSM 5 is that it lacks validity.

    How do neurologists diagnose migraines, Parkinson's, Alzheimer's, ALS? History and physical exam. Do they cease to exist then since there aren't yet well established, valid, clinically useful biomarkers to diagnose them? Are they fabricated entities? Is the suffering of these patients "all in their head"? There are numerous examples in "medicine" that do not have valid or well established biomarkers, but they still exist and people still suffer from them and need treatments. We rely on good ole fashioned detailed histories and physical exams in these cases, not unsimilar to how we diagnose psychiatric disorders. Biomarkers will be helpful in the future for psychiatry and hopefully will allow us to better specify and stratify mental illness, but given that psychiatric disorders have not only biologic/genetic components but also social and psychological components (hence the use of bio-psycho-social model), there aren't going to be magic bullet tests or "magic pill" treatments that pinpoint them or cure them. If that's the goal, then we're all missing the point. These are complex issues, with complex and multi-faceted etiologies defined in the context of behavioral dysfunction. The brain (and thus mind) is incredibly complex, more so than any other organ system by an exponential degree. Until we have the solid science and understanding of the brain (by the way, we already have a number of imaging findings and biomarkers in the research/in progress) to conclusively use biomarkers to guide diagnosis, we must do the best we can with the information we have attained scientifically about behavioral disorders/mental illness. Our patients are still suffering and seeking us for help...unlike the NIMH, we clinicians don't have the luxury of waiting until our diagnostic system is perfected.

    Gerhard Adam
    Yes, but couldn't one correspondingly argue that this has nothing to do with the DSM?  After all, is it really necessary to go after an extensive series of classifications if the requirements for treatment already exist?
    But the new DSM is about to come out and -- as one of it's chief critics, Allen Frances, says -- the boundaries of what's considered normal are getting narrower and narrower. This is what happens when you allow taxonomists -- people who love to categorize people -- to take over the world.
    http://www.huffingtonpost.com/jon-ronson/psychopath-test-ted-talk_b_2973423.html?utm_hp_ref=science&ir=Science
    Let's bear in mind that Allen Frances was the chair of the DSM-IV Task Force.  The point isn't to trivialize these disorders, but rather to draw attention to the fact that we are defining, redefining, and offering classifications for conditions that we barely know anything about. 

    However, regardless of the difficulties in recognizing and treatment, the DSM does not provide any answers.  It simply provides another administrative vehicle which contributes nothing to the science and lends an air of credibility for conditions that, at best, are scientifically ill-defined.

    Forgive my cynicism, but let's cut to the chase.  The DSM provides little value in terms of science or treatment.  In my view it exists solely for financial reasons [i.e. specifically insurance].  Am I wrong?
    Mundus vult decipi
    Unfortunately, the medical system (ok, insurance/third party payers/Medicaid/Medicare) DEMANDS that everything is neatly codable in order to be able to bill for services. Going down that road would take us into an entirely different conversation about the "brokenness" of the entire medical system. The DSM was never intended to be the insurance company guidebook for determining what will be covered psychiatric entities nor was it intended to be a target for drug companies to manipulate to turn massive profits. It was intended to define (and therefore allow clinicians to diagnose) psychopathology using the best available data and research we have at a given time to understand dysfunctional behavioral and emotional syndromes/patterns/disorders as they're seen in patients. If we don't have a system for organizing how we diagnose these things, how can we get to or establish treatments that can relieve them? The DSM sought to do that rather than the haphazard way of diagnosis and treatment that existed prior. It is useful for research/science and treatment as a framework from which to start. It's not and shouldn't bve perceived by non-psychiatrists as the "end all" or "Bible". That's why there are revisions and updates. The science is ever growing, as it is in all areas of medicine.

    Gerhard Adam
    I understand what you're saying and recognize the difficulties of the clinical situation.  However, over the years of the DSM, what has improved?  What has it done to help advance the better articulation of these conditions?  The primary criticism that I hear is that it narrows the definition of "normal" to the point of where it becomes increasingly absurd to anyone looking at the process.

    How do you respond to that?
    Mundus vult decipi
    That's not accurate at all in my opinion. First off, how do we define "normal"? DSM defines psychopathology as representing marked dysfunction in social, occupational, and emotional domains in the context of prevailing societal norms. DSM doesn't attempt to rigidly define "normal". Normal, in terms of behavior and thought, is defined by society and societal norms...which are ever changing. Having not seen the final print of DSM 5 yet (thus going off DSM 4), a required element (diagnostic criteria) for all disorders is it must cause significant dysfunction (social, occupational), cannot be due to the direct effects of a medical condition or due to intoxication/withdrawal of a substance and then nearly all diagnoses have extensive time frames, requirement of multiple clusters of symptoms in order to diagnose. If pathologizing a pattern of 6 months or more of auditory or visual hallucinations, delusions, disorganization of thought/speech and cognitive deficits, withdrawal from social interaction, flattening of affect or marked alterations of sleep, concentration, motivation, energy, mood, psychomotor slowing, marked decrease interest in engaging in pleasurable activities, and suicidal thinking for 2 weeks or more that interferes with one's ability to function, etc, etc (pick your DSM diagnosis, read all the criteria and tell me if you believe it is "normal" or not) is narrowing the definition of "normal" then ok, maybe you have a point. Keeping in mind a requirement of diagnosis of any disorder in DSM is it causes marked dysfunction. I often wonder if critics have actually read it in its entirety or do they just cherry pick pieces to fit their slant, because often they are short on the very important details.

    What has improved since DSM? Well, it has provided a framework from which mountains of research about the brain, behavior and psychopathology have grown. It's helped the development of a multitude of medications, evidence based therapies (CBT, DBT, ACT, etc), allowed for mental health parity laws, more resources for the mentally ill/funding, the movement away from institutionalization and toward community based treatment (good and bad) and has helped (though certainly not completely) remove the stigma of these syndromes/clusters of symptoms and identify them to allow more people to seek treatment to better their lives and not have to suffer in silence.

    If there has been a "narrowing of normalcy" it has been done by society as a whole and/or those using the DSM (mostly general practitioners by the way), not by the DSM as intended.

    Now I fully reserve to retract any and all comments once we finally see what is in print in DSM 5 ;-)

    Gerhard Adam
    Let's remember the criticism I mentioned was leveled by the Chair of the DSM-IV Task Force. 

    So, what is the basis for defining dysfunction?  What is the criteria?  After all, if you can't define normal, then how you there be an assessment that something isn't normal [i.e. dysfunctional]?

    Without a specific scientific definition of what constitutes normal, then everything simply becomes subject to taxonomy, and it is a meaningless collection of rationalized results which have little meaning.

    After all, we can reasonably claim that experiencing hallucinations [visual or auditory] in the absence of drugs/intoxication or sleep deprivation is not normal.  This is not an expected behavior or response so we can examine such conditions as being abnormal.  Of course, if they impair the individual then clearly they are dysfunctional.

    However, if someone is experiencing grieving because of the death of a loved one, we already know that there are numerous variations on such a situation, exacerbated by many other emotional elements [i.e. guilt, etc.].  So, what is a normal response?  It may certainly be dysfunctional in the sense that perhaps they can't work or concentrate, but is it a condition that warrants treatment?  In other words, are we treating people to feel better, or simply so that they can go back to work?

    It's time that society take a serious look at the expectations it has of people and not simply presume that because people may have varying psychological responses to different situations, we can't simply drug or induce them to behave in expected ways simply because it's convenient.



    Mundus vult decipi
    Your last paragraph in no way resembles psychiatric practice. More your skewed, media distorted view of psychiatry projected on to it. We don't "drug or induce them to behave in expected ways simply because it is convenient". How very Big Brother...

    Gerhard Adam
    We don't "drug or induce them to behave in expected ways simply because it is convenient". How very Big Brother...
    ... and yet this precisely the concern, that psychiatry has been plagued with fad treatments that have done more harm than good.  Similarly by extending many of the criteria in DSM-V there is increased concern that there is too much emphasis on drugs without sufficient evidence regarding efficacy. 
    The simple truth is that descriptive psychiatric diagnosis does not need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders.
    http://beforeyoutakethatpill.com/2009/6/Frances_DSM-5.pdf
    A radical change could only be justified if there were a fundamental leap in the understanding of what causes mental disorders, he says, and though advances in neuro-science and brain imaging show promise, that leap has yet to occur. Too many changes to the DSM will only lead to many people being mistakenly labelled as mentally ill and put on medications without good reason. In his email, Frances says the “ambition to be innovative, when no substantial innovation is possible, will likely lead to arbitrary changes that will often do more harm than good.”
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2802599/
    However, one of the primary problems is unaddressed in this discussion.
    Second, primary care medical practitioners have increasingly taken on the identification and initial treatment of patients with mental disorders.  This laudable development promises to bring treatment to many patients whose conditions have been undiagnosed and untreated. However, the need to operationalize the diagnostic process in nonpsychiatric settings has posed important challenges to practitioners.

    Third, criteria listed in the DSMs have been uncritically used by legal professionals and health care administrators as representing lapidary, received wisdom about the nature of mental disorders. This high-impact but uncritical use fails to recognize the variability in the level of empirical support for the reliability and validity of different diagnoses. If the text or criteria included a more explicit rating of empirical support for the different diagnoses, users unfamiliar with the field might be less likely to assume that criteria for all listed disorders are equally well established. Another factor underlying potential misinterpretation of DSM is the degree to which many, if not most, conditions and symptoms represent a somewhat arbitrarily defined pathological excess of normal behaviors and cognitive processes. This problem has led to criticisms that the system pathologizes ordinary experiences of the human condition, such as normal bereavement or the rebelliousness of adolescents. If the diagnostic system included criteria or decision rules that explicitly acknowledged the continuum nature of symptoms and disorders, this would place the pathological nature of more extreme symptomatic behavior into context. In particular, it may be helpful to find ways to denote a distinction between mild or borderline cases and clear-cut or severe cases.
    https://www.contextualpsychology.org/system/files/Kupfer,2002.pdf#page=25
    In the end, the point is that the DSM-V exerts an influence well beyond it's actual scientific merits. 

    The irony, of course, is that in any other circumstance the idea that someone can prescribe treatment and medication without a firm scientific basis for it, they would be called out as quacks.  Yet, here we find that not only do we have such advocacy, it is publicly available and used well beyond the narrow scope of its applicability.  As a result, it is attempting to impart a level of credibility which is scientifically unsubstantiated.
    Mundus vult decipi
    logicman
    psychiatry has been plagued with fad treatments that have done more harm than good.  Similarly by extending many of the criteria in DSM-V there is increased concern that there is too much emphasis on drugs without sufficient evidence regarding efficacy.

    Agreed!  But my medical evidence is based on my personal experience as a patient victim, hence it is both anecdotal and scientifically suspect.  ;-)
    I have addressed the fact that general practitioners are the largest (by far) prescribers of psychiatric meds...that is a big problem (and the reason why psychotropics are over prescribed). Throw in nurse practitioners and clinical nurse specialists and yikes! None of that is the fault of the DSM or psychiatry...it is a fault of the medical system. People that are very poorly trained in understanding psychiatric illness/treatments or how the DSM should be best used are the primary prescribers of psych meds. I can't tell you the disasters I've had to clean up from primary care doctors, most of which are trying to do the best they can. Problem is access to well trained psychiatrists (or hell, even psychologists) is pitiful. There aren't enough and psychiatric treatment is very poorly funded and their patients aren't given the access or resources to get good care, so they end up over medicated from someone who saw them for 5-15 minutes and had a couple lectures on DSM/psychotropics. Major, major issue.

    Psychiatric medications and treatments (by the way we are extensively trained in therapy as well, we don't just prescribe) like ALL medications, only work if used correctly, monitored appropriately and in the context of a comprehensive treatment plan. The problem is they often (for reasons I've described above) aren't. But it's just easier to vilify psychiatry...

    You all realize hardly ANY medications CURE any disease, right?

    Gerhard Adam
    None of that is the fault of the DSM or psychiatry...it is a fault of the medical system.
    Actually it is.  Someone can't simply hang out a shingle and begin practicing medicine because they have a PDR and the Merck Medical Manual.  Yet, this is precisely what the DSM-V fosters.  It creates the aura of authority which renders anyone with access the presumption of credibility.
    Mundus vult decipi
    What? No, that's not true at all. You have to go to medical school, graduate, pass boards, go to residency, become board certified to practice any kind of medicine, including psychiatry. To be a psychiatrist, after you graduate residency you train for 4 years in psychiatry.

    To be a psychologist you have to get a PhD is psychology (4-5 years post graduate minimum). And they can't prescribe meds. Mental health therapists are Master's trained and only function under the supervision of psychologists or psychiatrists.

    Not being adequately trained and trying to treat patients and MISusing the DSM has nothing to do with the DSM itself or psychiatry. Just like getting a Netters and doing surgery has nothing to do with the field of surgery or surgical standards of care. Good lord...

    Having a DSM doesn't give you authority to treat pts. Where in the world do you get your information?

    Gerhard Adam
    Then what is the basis for your claim that general practitioners are the primary problem in over-prescribing?  I certainly didn't mean any lay person, but then again, a medical doctor with no training is psychiatry is hardly any different.
    Mundus vult decipi
    I see what you're saying. But again, it's not the DSMs fault you aren't using it properly nor are you prescribing psychotropics properly. How does that make sense? A tool is only useful and valuable if used correctly by those skilled to use it. There's no intrinsic authority given to it. Also, you don't throw away a tool that is useful in the right situation/with the right operator just because some use it incorrectly. That wouldn't make sense.

    I can start practicing as an internist technically, but that'd be beyond my scope of practice and I'd likely be committing malpractice. Many general practitioners are committing malpractice in their use of psychotropics...not all, but many. I can only speak for my area, but psychiatrists are trying to educate them on how and how not to use psychotropic meds. We're vastly outnumbered. Society is allowing this to happen...

    Gerhard Adam
    Society is allowing this to happen...
    Yes, but equally there is clearly a sufficiently large population of professionals that don't view their lack of skill as an impediment to prescribe drugs nor make diagnosis.

    I found your comment about trying to "educate them on how and how not to use psychotropic meds" to be fascinating.  After all, you're basically stating that individuals that have gone to medical school, been licensed, and basically educated in all the intricacies of human health, should somehow presume that this is an area in which they can operate in ignorance.

    I understand and appreciate your points about society, the general public, economics, business, etc.  Yet, I can't help but marvel at how individuals that are perpetually warning about the rising costs due to litigation and malpractice costs/insurance should be so cavalier about prescribing medications that they are clearly unqualified to provide.

    How does one reconcile such behavior with the individuals that are supposed to be the most highly educated regarding human health and medicine?
    Mundus vult decipi
    It just illustrates that medicine has become too complex for family docs to "do it all" and do it well (obviously I'm generalizing here, there are probably a good number that know their limitations and appropriately refer out when needed etc). Also it illustrates the massive flaws in the system as a whole and issues with access to care/specialists, etc. Unfortunately more and more docs are being squeezed and intensely pressured to do more with less. Billings favor pushing pills and doing procedures and not spending time with patients and thus so do hospital business managers and administrators (who are not doctors). And there are certainly greedy doctors that are bilking the system for profit to (just like there are shady characters in all industries and walks of life). It's incredibly discouraging to most of us that came into medicine to care for and help heal our patients. We (the younger generations of doctors) have to continue to strive for better for our patients and profession.

    Also, I don't believe the intention is to be "cavalier". I think doctors see their patients suffering and they want to help them the best they know how. When they go to refer out, often there just aren't enough psychiatrist available to see their patients (there's a significant shortage nationwide, primary care docs too). So they try to use what they know and attempt to treat them themselves, not even knowing really how little they really know about treating the truly mentally ill. I think they mean well mostly, but so often get in over their heads and sometimes make things even worse. It's a resource problem...a systems problem. Family docs shouldn't have to be substituting for highly trained psychiatrists, but they are. Some of this is the fault of psychiatry (being historically too separate from other areas of medicine, too isolated) and a lot of it is due to the poor support and funding for psychiatric care (which as you can imagine is not a money maker for hospitals because it actually requires spending a lot of time with patients and few if any procedures to bill).

    Medicine has become about the bottom line and it's ruining it. Sadly, the same can be said for academic research, drug development and many other things.

    Gerhard Adam
    While we disagree on some details, and even use different words to describe what's occurring, I think we have reached a kind of middle ground where we can see what's wrong and what's broken.

    I think you've done an admirable job of making your points, but unfortunately we have reached a place where it's beyond either of us to address a solution.
    Mundus vult decipi
    Thanks for the thoughtful discussion and for your fair and reasonable consideration of differing viewpoints. It's been engaging. In many ways I think we aren't that divergent in our opinions. I think this kind of real, thoughtful, honest discussion needs to happen more.

    As I'm just really getting started in this profession, I hope to work to seek better methods, treatments, diagnostic approaches for my patients as well as continuing to be an advocate to ensure they're getting the care and consideration they deserve. I may not succeed ultimately to change the system, but I'm going to do everything I can to try.

    Take care.

    John Hasenkam
    Sure, I'm currently sharing a house with someone so dosed up on olanzapine he sleeps 12-14 hours per day and then spends his waking hours watching reality TV. The script is amazing: 4 repeats, take as required. WTF! He has depression\anxiety(yeah, even sorting those two out is terribly difficult so spare me the diagnostic accuracy jazz) yet the data does not support the use of Olanzapine for anxiety and a recent meta-analysis concluded that it is of little value in depression especially given the side effect profile. 
    Two weeks ago I met a chap who has been on antidepressants for over a decade. I had previously advised a mate of his that he should get off that drug. He did, went cold turkey which was not good. Love the term - SSRI discontinuation syndrome - shouldn't that be serotonin withdrawal syndrome? Effexor, oh golly does that give some people the horrors ... . The chap noticed no difference at all in stopping the antidepressant, probably become resistant to it years ago yet he just kept trotting up to the GP who kept plying him the drug. 

    Given that prescription opoid related deaths now outnumber cocaine and heroin deaths in the USA, given the alarming number of children being prescribed antipsychotics and antidepressants in the USA, the utter hypocrisy of prescribing these drugs while rightly condemning the use of illicit drugs in pre adults because "we don't know what the developmental outcomes will be because of that", it is somewhat precious for psychiatrists to argue that there are no serious problems in psychiatric diagnosis. 

    WTF is wrong in the USA that so many people are on psychiatric drugs? Serious question. 

    I know there are psychiatrists desperately trying to do the right thing, I know the anti-psychiatry crowd is nuts, but I also know that psychiatrists need to be more upfront about the challenges the face and stop pretending they have the diagnosis game sorted out. The famous experiments of Szazs and Rosenhan put paid to that and even recently there was a documentary where 3 psychiatrists spent a week with a group of people, tests were done etc and guess what, they couldn't get the diagnosis, not even after a week of exposure to these individuals. How long does the average psychiatrist spend with a patient before diagnosis? Do they even check thyroid function these days?  

    The DSM isn't the only game in town. There is the ICD. I don't hold out much hope for the NIMH objective, too early and we're too ignorant. 

    Biomarkers: that could become possible, there is certainly improvements in our understanding. For eg. Depression: look for glucocorticoid resistance, elevated il1, tnfa, il6, 12, maybe 23, reduced BDNF(v. common), and possibly heightened Ach turnover. It won't be a single biomarker. 









    WTF is wrong in the USA that so many people are on psychiatric drugs? Serious question.

    Exactly. And more, can you name a single cure from a psychiatric drug? A drug suppresses symptoms, but does not handle the underlying situation. What is the point?

    Your anecdotal stories don't reflect common psychiatric practice. And uh, yes we check TSHs...comical.

    Your point about people on opioids (psychiatrists aren't prescribing them, we're treating the train wrecks that surgery, medicine, general practitioners create) is a good one. The over arching problem is a SOCIETAL one: "give me a pull to fix all my problems" and a medical system set up to favor that approach. Psychiatrists aren't the problem there, primary care docs and a system designed to overwhelm them and NOT fund adequate good psychiatric care are how so many end up on psych meds. That and the ridiculous influence allowed by drug companies to direct market to consumers and these overwhelmed general practitioners. Again, that's not the APA, psychiatry's or the DSMs fault.

    And lastly ALL psychiatrists (as I've done repeatedly here) acknowledge the limitations of our knowledge, the DSM, etc and the need to continue to gain for scientific knowledge about the brain and human behavior/psychopathology. There's no grand cover up or conspiracy, it's all out there. We know a lot, but there is a lot more to be discovered. As there is in EVERY medical specialty.

    Gerhard Adam
    It seems like your arguments are make it clear that you are certainly trying to do the best you can within a system that isn't very supportive.  Yet, I would have to question what the role of the professional organisms and literate are then.

    Why aren't there more strident criticisms of medical practitioners that engage in prescribing drugs for which they have no expertise or experience?  Why is the DSM-V made available for practitioners that lack experience or expertise?  Why aren't there more vocal steps taken to argue against the pharmaceutical advertising machinery?

    It seems that this is precisely the purpose of professional organizations rather than just individuals. 
    The over arching problem is a SOCIETAL one: "give me a pull to fix all my problems" and a medical system set up to favor that approach.
    Yes, and in this regard I have little faith in medical doctors either.  A professional that allows themselves to be bullied is not behaving professionally.  When doctors prescribe antibiotics for a condition that doesn't warrant it because a patient demands it, they are being unethical and unprofessional.  So, it is with all the issues you've raised.  As much as we can point the finger at the simplistic solutions of the public, the reality is that this is precisely why professionals are supposed to be licensed.  If they are simply indulgent, then they are the enablers that allow such a system to exist in the first place.

    It is unreasonable to expect the public, or society at large, to reign in the individuals that are supposed to represent the professional face of their discipline.  The present situation exists precisely because too many professionals are unscrupulous.  Every one of them, from general practitioners to psychiatrists collect a fee for their services and presumably their expertise.  If that is lacking, then the onus is on them to clean house. 
    Mundus vult decipi
    Hank
    I think his comments, once he got out of the 'you are all against us' zone, are pretty reasonable - but they highlight the issue. He can't name a protocol that works so how will the public have confidence? Why have taxpayers or insurance companies limit funding to a manual that is clearly not helping anyone? If, as anticipated, 80% of America will have a disorder under DSM-5, we have a real problem in the goal of the document. If a clinical pharmacology book gets released, hypochondriacs may find new stuff to worry about but doctors are not rushing to find each new disorder. Now, once a decade the cognitive science community comes up with a new epidemic in kids.

    I think everyone wants there to be more science in brain science. I can't agree with his circling the wagons around psychology, since he wouldn't if he knew how unscientific it is, but it's not unreasonable for him to think psychologists have the same evidence-based foundation that psychiatrists do. It's pretty common to assume everyone uses the same effort and if I criticized anesthesiologists, some anesthesiologists would object, even though that field has more withdrawn/retracted papers than any other. It wouldn't change the facts.
    Oh proponent of good science...where on the world are you getting your data that 80% of America has a disorder via DSM 5? Please include a scientific source or your just another huge hypocrite. Pretty reasonable? Yeah that's because I know what I'm talking about and walk the walk. You see I actually do this for a living and see these people suffering and needing help everyday...and I help them.

    ECT works very well for severe depression.
    Stimulants work for those who actually have ADHD (the vast majority, diagnosed most often by their pediatrician or family doctor do not actually meet criteria).
    Antidepressants (SSRIs, SNRIs, even TCAs) have response rates of 66% for moderate to severe depression. Closer to 75% combined with CBT. SSRIs, SNRIs are also effective for PTSD.
    CBT works for mild-moderate depression, OCD, generalized anxiety.
    Lithium and Depakote work for actual Bipolar I disorder.
    Antipsychotics work for those that actually have schizophrenia.
    Behavioral therapy works for enuresis, ODD,etc.
    DBT, schema therapy work for people that actually have borderline personality disorder.
    I could go on but this is becoming a huge waste of time for me. I see what this really is.

    Before the DSM people were "imbeciles, hysterics, fools, freaks" and left to suffer in institutions, prisons, or in silence. Now they have a way to identify/name their suffering and get care/treatment for it. Many, many people have been helped...you really are out of your element on this. I hear much more opinion, emotion, bias, stereotyping, and ignorance than the analysis of a scientific mind that truly wants answers or a better solution.

    Can I please ask what you mean by 'works for', or 'effective for'? Does this just mean they act 'normal', or pacified? Do the stimulants or antidepressants handle the situation after the person takes them for 6 months, so they are no longer needed afterwards?

    Do you see what I am asking? Alcohol similarly 'works' for the loss of a loved one - until you become sober.

    Please amplify.

    Meaning reduce or alleviate symptoms and restore or improve function. The lengths of time they're effective, the length of time required to take to be effective, etc vary upon the med/intervention/therapy and vary with the individual as well (depending on the kinetics/metabolism/weight/genetics). Sorry but I'm not going to take the time to explAin psychopharmacology to you via a comments section.

    Read the STAR*D trial, CATIE trial, TADS trial, MTA trial, etc etc. And pick up a Stahl's Essentials of psychopharmacology and a Kaplan and Saddock. Happy reading.

    Just answer this:

    Give me a rough average percentage of individuals 'treated' that no-longer have those original symptoms, one year after they stopped drugging themselves, regardless of how long they were 'treated'.

    Thanks.

    I don't completely disagree with your comments, however it's more complex than "professionals being unscrupulous". Medicine is now run like a big business (generally, always exceptions)...and there are productivity pressures, "performance"/customer service driven pressures, cost effectiveness pressures, more patients/less time to spend with them, an extremely LITIGINOUS society, an entitled society, the "fix all my problems with a pill/i dont want to nake tough changes" society, the massive debt and time investments for training/education, exorbitant malpractice insurance, diminished public and media respect for doctors, paying the price for past greedy doctors, and the fact that most doctors are now employees of massive hospital systems/corporations. The power players are administrators (almost all aren't doctors), massive hospital systems, insurance companies and the government. Not doctors, nurses and the people who make it all go...

    It's no wonder medicine is broken. But hey, welcome to America in 2013. It's a stacked deck for the top few while the rest of us toil away or suffer.

    And none of this is unique to medicine. These are SOCIETALLY driven problems. And they exist everywhere. We all need to take a long look in the mirror.

    Gerhard Adam
    Well, I think we can all agree that lawyers are a group that deserve to be kicked around to an extent.  I can also understand the issue of medicine being run as "big business".

    I don't think we disagree that the system is broken.  However, I won't digress into an alternate discussion, but I would change your comment that this is a "societally driven problem" and argue that it is an economically driven problem.

    As we are discovering, our economic system continues to create and reward the wrong incentives and produces a spiraling behavior that moves in the opposite direction of where we desire to go.  Don't get me wrong, I'm not advocating for some other tedious "ism" that also doesn't work.  Instead, I would argue that we need stop clinging to economic systems that worked in small city-states or tribes and begin to consider what is necessary to handle a world-wide series of interactions.

    Anyway ... I digress
    Mundus vult decipi
    I can't disagree my friend.

    Gerhard Adam
    Ahhh ... consensus :)
    Mundus vult decipi
    logicman
    Well, I think we can all agree that lawyers are a group that deserve to be kicked around to an extent.

    I strongly disagree.  Can you demonstrate a real need for the qualifier 'to an extent' ?  ;-)
    John Hasenkam
    And lastly ALL psychiatrists (as I've done repeatedly here) acknowledge the limitations of our knowledge, the DSM, etc and the need to continue to gain for scientific knowledge about the brain and human behavior/psychopathology.

    But that just standard in so many sciences Doc. I have seen psychiatrists point to fMRIs and say to the journalist: see , this means that. Well the truth is we're not sure what it all means. A couple of recent meta-analyses suggest there are a great many problems with neuro-imaging. There is too much show pony behavior in psychiatry and psychology. A recent Cochrane Review concluded that most people on anti-depressants aren't benefiting from them, but Big Pharma is. I recently read Dr. Healy's The History of Psychopharmacology and that is a very concerning text because it powerfully illustrates how the industrial psychiatric complex has become too dominant in psychiatry and this is true of medicine generally. While I am not an unalloyed fan of alternative approaches to mental illness I do see merit in a more exploratory attitude to treating mental illness but over recent decades the focus has shifted more towards drug use and this in spite of the evidence showing that psychotherapy and drugs are the best combination. That is true for depression and there is also evidence to suggest it is beneficial in psychosis but I remain doubtful about that. Psychosis is mysterious and the efficacy of antipsychotics is even more mysterious. 


    The drugs work, sometimes, I don't deny that, but I have to challenge the use of so many powerful drugs in children. We have no idea about the long term implications of this. The USA in particular needs to take a long hard look at its drugging of children by psychiatrists. The increasing off label use is worse than being non-scientific it is closer to guessing than science. 


    You are correct, this is a societal issue and as psychiatrists are on the front line they should be leading the way but it seems they are retreating behind neurobabble. As a profession psychiatrists are well paid by Big Pharma and studies have shown the receipt of payments and "gifts" does affect prescribing habits. I am somewhat amazed that psychiatrists should accept gifts because of all the medical professions they should know that this will influence their judgment. So it seems to me that psychiatry has given up the fight, takes the money and runs, and then turns around and blames Big Pharma. Big Pharma does not write the scripts, the buck, figuratively and literally, stops in the psychiatrist's office. 


     




    Scientologists have been saying these statements for years. Maybe they were right after all.

    Oh boy. Yes, let's evoke Scientology: a massive pyramid scheme/cult being run like the mafia created by a science fiction writer who based his theories (though poor grasp of them) on psychoanalytic theory from....psychiatry! Then mixed it with nonsensical science fiction and called it a religion to gain tax and governmental protections, and intentionally recruited (foolish) celebrities to sell it to the world. Good call.

    logicman
    Oh boy. Yes, let's evoke Scientology: a massive pyramid scheme/cult being run like the mafia created by a science fiction writer who based his theories (though poor grasp of them) on psychoanalytic theory from....psychiatry! Then mixed it with nonsensical science fiction and called it a religion to gain tax and governmental protections, and intentionally recruited (foolish) celebrities to sell it to the world. Good call.

    Good call indeed!   I wish that somebody would fund a study of the class of people who buy into the schermiance schermology stuff.  That way we might end up with a scientifically formalized definition of bat-brown bs barmy.  Would that require a major revision of DSM-5, I wonder ?
    And your answer shows a very detailed investigation of Scientology then? This is a page for scientifically minded people. Science I remind you would involve observation of the thing not just regurgitating what someone else said. please.

    logicman
    And your answer shows a very detailed investigation of Scientology then? This is a page for scientifically minded people. Science I remind you would involve observation of the thing not just regurgitating what someone else said. please.

    That is what I call jumping to conclusions without a parachute.

    Quite apart from my being an engineer and my seeing at first hand how these scammers use a very basic and inaccurate resistance meter to suck punters in; quite apart from my being a - somewhat literate - avid reader of science fiction who thinks that L Ron Hubbard's books are batsh*t crazy bad; quite apart from the many documentaries containing interviews  with former victims and former officials of this pyramid scheme, I also wrote -

    Adolf Hitler - World's Best-Selling Children's Author.

    You may also wish to read  what others have written here:
    My experience in the Church of Scientology
    Scientology Ad ????
    California Science Center Has To Pay Fee To Not Show Intelligent Design Film


    You've seen my parachute - now show me yours.  :-)


    .
    Your polka-dot parachute is cute, but all of those round holes in it don't sustain much air time.

    Aren't all of those links and documentaries... regurgitations? And what do your personal opinions on fiction works have to do with a science blog?

    You know so much about that resistance meter, too. Have you watched it used in an auditing session? Or did you walk by a Dianetics booth and smirk?

    Oh - lastly, a pyramid scheme, by definition, requires someone at the top benefiting financially. Why does Scientology Church management make next to nothing, and categorically far less than your greedy ***?

    I thought scientists got over conspiracy theories a while ago.

    logicman
    Have you watched it used in an auditing session? Or did you walk by a Dianetics booth and smirk?
    Yes and yes of course.

    Why does Scientology Church management make next to nothing, and categorically far less than your greedy ***?

    ad hom ?
    I am retired and living on UK state pension and no other income.  Oh, yes, I buy lots of old books for research and make between minus 90 and minus 100 bucks a month from my articles here.  Greedy?

    Re science fiction - that is my sarcastic classification of Hubbard's ideas about dianetics.  If you don't like me calling it science fiction, let's agree to call it woo.

    It is a pyramid selling scheme for books about dianetics which would not otherwise make dime one on the open market.

    I do not have time too discuss the scientology cult's garbage any further, except for:

    Scientology is "Corrupt, sinister and dangerous" In the Courts of Victoria it was found to be a "sham".  The "Church" resorts to lies and deceit whenever it thinks it will profit it to do so.
    IN THE HIGH COURT OF JUSTICE - FAMILY DIVISION.
    Royal Courts of Justice 23rd July, 1984.
    B&G (Wards)
    It is a cult
    John Hasenkam
    In Australia there have been legal actions against Scientology regarding deprivation of liberty. There has been a concerted media campaign that has made that mob become rather worried about its status in Australia. They shouldn't worry, 99.99*% of Australians know they are nuts and nothing will change that. Unlike the USA, Australia is tolerant of most religions but very intolerant of wackos. Scientology is madder than a cut snake. 
    I have in fact done some Scientology and read many of his books (Scientology books). That you don't like his science fiction is neither here nor there. Instead of relying on someone else to tell you what to think why don't you read a couple of his books and listen to a few of his lectures yourself? Then we talk.

    John Hasenkam
    Oh that may sound scholarly but it is crap. If one were to read every claim by every person in relation to mental illness one would never stop reading because when it comes to mental illness everyone is a bloody genius who knows how to solve mental health problems. All my life I've been hearing similiar crap, like schizophrenics are just misunderstood spiritual giants or depression is some adaptive response(it is, in a way, but as one psychiatrist noted: never seen a depressed person benefiting from the depression). or that ADHD once had a selection advantage(being explorers). All those woeful analyses don't address the reality that our brains express a huge number of genes so it is to be expected that mental illness would figure prominently in developmental quirks, whether these be genetic, epigenetic, physiological or environmentally driven problems. 
    It is not for us unbelievers to ponder the purported wisdom of Scientology. Scientologists have to do what everyone else has to do: prove their arguments. Show us the results with proper independently conducted studies which show that their so called therapies work. Show us the underlying rationale that has empirical support, not logical support because when it comes to psychology and psychiatry a series of syllogisms may sound convincing but without empirical support it is just another story. 

    While I am often a critic of psychiatry I am also of the opinion that psychiatrists and psychologists remain in the best position to improve our approach to mental illness. The challenges are beyond the comprehension of most because they do not appreciate our epistemic limits in developing adequately powerful models to address the complexities inherent in human behavior. I remain of the opinion that it may well be intrinsically impossible to ever develop the accuracy of analysis we enjoy in other sciences. 

    As Dr. G notes a major problem we face is that too many people have unrealistic expectations of what is possible in addressing mal-adaptive behaviors. We all want a quick fix for a condition that may have taken decades to become symptomatic. Society expects miracles from psychology and psychiatry and groups like Scientology are happy to claim to provide such miracles. Psychiatrists in particular are often aware that the best they can do is help the patient manage their condition, that cure in the strict sense is too often not possible. Scientologists and others who think quick and complete cures are possible do not appreciate the inherent complexities and display a hubris with regard to the claims about understanding human behavior. As for those anti-psychiatrists who regard mental illness as a spiritual gift: that's insane. 



      



    I get what you are saying. Thing is that Scientology does work but then again it is not addressed to mental illness although I can say from personal experience that I have changed things that would have been labeled this and that in in certain hands I would have ended up on medication. There is definitely something to be learnt there for anyone earnestly seeking for ways to help people. Yes, independent studies would be great and one day I am sure they will be done.

    My son was diagnosed with Aspergers Syndrome at the age of six without a single blood test and a cursory medical exam, but with exhaustive psychological testing. He had developed normally until the age of four and then went into a sharp decline with intense anxiety and OCD, he also developed horrible allergies and an a rash over most of his back. We tried to help him with medications and social skills training and counseling. Nothing seemed to help. After much searching by his father and I and two open minded doctors, he was found to have Lyme Disease (Borrelia Burgdorferi). He had developed encephalopathy and had hypoperfusion of the temporal lobe. Blood testing and a SPECT scan, which are quantifiable and good scientific indicators helped make the diagnosis. Lyme Disease is a clinical diagnosis. Had any of these tests been performed when I first made the assertion that something wasn't right and my son had definitely changed, we might have saved many years of pure He**. The DSM has to go.

    Hank
    Dr. John M. Grohol of PsychCentral says I am all wrong in what this means, that the NIMH is not leaving DSM behind, even though the director used phrases like "Patients with mental disorders deserve better" and "The weakness is its lack of validity".

    Grohol says "This is “science” journalism at its worse" and there are two things wrong with that sentence.  The most important one is that when "science" is put in scare quotes, you have left the world of evidence and reason behind.  And he did, there is none in his rebuttal. He just says the NIMH has nothing to replace it with yet and may never have this new Research Domain Criteria (RDoC) project finished.

    Well, that is true. But it doesn't matter - like if someone says they have to move to Kansas so you should stop seeing each other, they may say 'things changed' later but they still want to break up with you.
    logicman
    if someone says they have to move to Kansas so you should stop seeing each other, they may say 'things changed' later but they still want to break up with you.
    But if they already live in Kansas you may want to get hold of a copy of DSM-5.  ;-)
    Hank
    Lois Holzman, who promotes "alternative and radically humanistic approaches in psychology, therapy, education and community building" thinks the NIMH is going the wrong way by becoming too empirically focused.

    She does say one funny thing: "I wonder why no major media outlet is covering this story" - meanwhile, acquaintances who write at USA Today consistently are impressed we can get any scientist to return an email or phone call and they cannot. A million readers a month is major and we aren't writing for gas station attendants, that is why our emails get returned.  

    If giant media corporations don't cover the 20-year journey of DSM it's because most people have never heard of DSM and don't care about spats between psychiatrists, the NIMH and therapists. The bulk of the public think the whole field is nonsense.

    Anyway, her commentary agrees DSM is bad medicine, but for a different reason. She regards the scientific approach itself as an obstacles to understanding cognitive issues.  NIMH Wants to “Fail Better” than the DSM-5 Did.
    Here's the kind of science we find in some parts of the DSM-5:

    Do you think autoandrophelia, where a woman is aroused by the thought of herself as a man, is a real paraphelia?

    No, I proposed it simply in order not to be accused of sexism, because there are all these women who want to say, “women can rape too, women can be pedophiles too, women can be exhibitionists too.” It’s a perverse expression of feminism, and so, I thought, let me jump the gun on this. I don’t think the phenomenon even exists.

    That's Blanchard on the subject.

    Read more: http://motherboard.vice.com/blog/heres-how-the-guy-who-wrote-the-manual-...
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