Monday, May 14, 2012

Vera Sharav- Vicissitudes of Psychiatry's Diagnostic Manual Revisions

Subject: Vicissitudes of Psychiatry's Diagnostic Manual Revisions
Date: Mon, 14 May 2012 14:20:09 -0400
From: Veracare <>


Alliance for Human Research Protection (AHRP)
Advancing Honest and Ethical Medical Research

The proposed revisions to the Diagnostic Statistical Manual (DSM) of the American Psychiatric Association will continue the trend set by prior revisions: namely, expanding the number of people who, according to DSM diagnostic criteria, will be labeled as having a "mental disorder" for which a prescription for psychotropic drugs will be issued.
(Apologies for the length of this Infomail...)

The latest area of controversy focuses on the proposed revision of the definition "behavioral addiction disorder" extending the addiction diagnosis to include drug, alcohol and gambling.  It is estimated that the change would expand the number of people labeled as "addicts" by 20 to 30 million who would be entitled to treatment and disability payments costing taxpayers many hundreds of millions of dollars.   APA's chief executive, Dr. James Scully, Jr., defends the expansionist revision by reiterating the hackneyed claim that "The biggest problem in all of psychiatry is untreated illness, and that has huge social costs."  New Guidelines May Sharply Increase Addiction Diagnoses
Insightful critics have observed that the designation "mental disorder" for inclusion in each of the revised editions of the DSM can be traced to the availability of a drug that will be marketed as a remedy for the newly invented "mental disorder."  Indeed, the DSM is a driving force for rendering every human emotion and behavior that can be affected in one way or another by a psychotropic drug, to be classified as a symptom of a mental disorder. More than anything else, the DSM catapulted clinically ineffective drugs—such as SSRI antidepressants and (atypical) neuroleptics--into industry's most profitable blockbuster drugs—even as they have caused severe harm.
The DSM has been described as "a hideous distortion of medical science"--its objective is expansive and self-serving. The New York Times report by Ian Urbina (May 12, 2012) perfectly captures the seeming lack of insight (dishonesty ?) displayed by psychiatrists when questioned about their financial conflicts of interest. Urbina reports: 
"Dr. Charles O’Brien [University of Pennsylvania] who led the addiction working group, has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction. He has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving. He was the driving force behind adding “craving” to the new manual’s list of recognized symptoms of addiction."
“I’m quite proud to have played a role, because I know that craving plays such an important role in addiction,” Dr. O’Brien said, adding that he had never made any money from the sale of drugs that treat craving.  New Guidelines May Sharply Increase Addiction Diagnoses  Surely such an indication of dissociation must qualify for a DSM diagnosis and a psychotropic drug.
The DSM-I, published in 1952, included 106 disorders; the DSM-II, published in 1968, included 182 disorders; the DSM-III, published in 1980, included 265 disorders: its architect, Dr. Robert Spitzer of Columbia University, dropped psychoanalytic theories and concepts such as "reaction" and "neurosis" and replaced them with a classification system of descriptive diagnostic categories. Since the DSM -III, diagnoses of mental disorders are determined by symptom classifications using a system of checklists. A major flaw is the assumption that discreet mental disorders can be deduced from symptom patterns without regard for context or life stressors that may impact a human being’s state of mind.
  The DSM-III simplification of the diagnostic criteria resulted in millions of normal people to be mislabeled as having a "mental disorder."  The global influence of DSM-III surpassed all previous editions. The DSM became the primary determinant of treatment decisions, private and public insurance and disability eligibility, government funding for special education services, it is relied upon as a guide for pharmaceutical research, and has been widely used by criminal defense lawyers. 
In a BBC interview, 27 years after the publication of the DSM-III, Dr. Spitzer acknowledged that the DSM diagnostic criteria resulted in "exaggerated rates of mental disorders." When asked what the rate of exaggeration might be? He acknowledged that "no one really knows, but it might be 20%, 30%, even 40%."

Two opinion pieces critical about the DSM-5 revisions were published by the two most influential American newspapers. The Washington Post published an essay by Paula Caplan, PhD, "Psychiatry’s Bible, the DSM, is Doing More Harm Than Good" (April 27, 2012) and The New York Times, ran an OpEd by Allen Frances, MD, "Diagnosing the DSM" (May 12, 2012).  
Dr. Allen Frances, former chairman of psychiatry at Duke University who chaired the DSM-IV revision published in 1994, contributed to further increasing the number of people diagnosed with mental disorders—the number of disorders had grown to 297. Worst of all, it ushered in an epidemic of child abuse under the guise of medical intervention.  After the loosened DSM-IV diagnostic criteria pathologized normal childhood behavior, millions of children have been labeled with attention deficit disorder, autism spectrum disorder, and bipolar disorder, for which psychiatrists have wantonly been prescribing toxic drugs whose documented, severe adverse effects induced debilitating chronic physical disease, not to mention mental deterioration, and premature deaths.
After the damage had been done--and billions of dollars had been misspent on harm-producing treatments--Dr. Frances acknowledges in the Times OpEd that the DSM-IV had "failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children."
Elsewhere, he has expressed horror about some of the resulting consequences: “kids getting unneeded antipsychotics that would make them gain 12 pounds in 12 weeks hit me in the gut. It was uniquely my job and my duty to protect them. If not me to correct it, who? I was stuck without an excuse.” He has also criticized psychiatry’s ever expanding list of unvalidated disease designations, its reliance on demonstrably ham-producing drugs, and has acknowledged in an interview in WIRED that “there is no definition of a mental disorder. . . . These concepts are virtually impossible to define precisely.
Dr. Caplan, a clinical psychologist who served on two committees of the DSM-IV (until she resigned in protest about the pathologizing of per-menstrual cramps) has been a vocal critic about its lack of a scientific foundation:

"An undeserved aura of scientific precision surrounds the manual: It has “statistical” in its title and includes a precise-seeming three- to five-digit code for every diagnostic category and subcategory, as well as lists of symptoms a patient must have to receive a diagnosis. But what it does is simply connect certain dots, or symptoms — such as sadness, fear or insomnia — to construct diagnostic categories that lack scientific grounding. Many therapists see patients through the DSM prism, trying to shoehorn a human being into a category."

She has also criticized the DSM's overreaching stranglehold: Psychiatry estimates that within their lifetime, 50% of the American population will be "diagnosed" with a mental disorder.  A psychiatric label, Dr. Caplan points out, causes serious harm:

"it can cost anyone their health insurance, job, custody of their children, or right to make their own medical and legal decisions. And if patients take psychiatric drugs, they risk developing physical disorders such as diabetes, heart problems, weight gain and other serious conditions."

Dr. Frances become the most formidable vocal critic of the DSM-5 Task Force and its proposed revisions who was influential in persuading the Task Force to pull-back from adopting the diagnosis "psychosis risk syndrome" that would have expanded even further the prescribing of dangerous toxic drugs for children, and the proposal to eliminate the bereavement exclusion from major depressive episode (MDE) diagnosis which would have included just about everyone who ever mourned the loss of a loved one.
Those who formulated the DSM-III, -IV and 5 are stakeholders with significant financial interests in increasing the number of patients and in the drugs used to treat the diagnoses that they alone define in the DSM. What’s more, the APA leadership influences public health policy.
But Dr. Frances has a blind spot in regard to the commercially-driven interests in the enterprise. He steadfastly denies that financial interests had any influence on the crafting of the DSM even as he acknowledges that “the DSM drives the direction of research and the approval of new drugs."   He denies industry's influence on the DSM-IV or DSM-5 Task Force, claiming that "mistakes are the result of intellectual conflicts of interest" not financial conflicts of interests.”
Surely Dr. Frances is not unaware of the peer reviewed analysis by Dr. Lisa Cosgrove (Harvard University) and Dr. Sheldon Krimsky (Tufts University) documenting the financial ties of each committee of the DSM-IV (2006), and their comparison analysis of DSM-IV and DSM-5 panel members’ financial ties to industry. Their DSM-IV findings:
 "Our inquiry into the relationships between DSM-IV panel members and the pharmaceutical industry demonstrates that there are strong financial ties between the industry and those who are responsible for developing and modifying the diagnostic criteria for mental illness. Of the 170 DSM panel members 95 (56%) had financial ties to pharmaceutical companies. The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.  One hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug companies. The leading categories of financial interest held by panel members were research funding (42%), consultancies (22%) and speakers bureau (16%).
Drs. Cosgrove and Krimsky's comparison study of the DSM-IV and DSM-5 panel financial interests found, ironically, that APA's financial disclosure policy adopted for the DSM-5 panel was not accompanied by a reduction of financial conflicts. Instead, the financial ties to industry INCREASED  from 56% to 70%. Furthermore, APA’s disclosure requirement excludes speakers' bureau membership which provide fees for key opinion leaders (KOLs) who make presentations promoting products. Also exempt from APA’s disclosure requirement are "unrestricted research grants."
As Rob Waters wrote in Salon Magazine: “The fight over the DSM-5 pits some of the biggest egos in the world of psychiatry, but it’s more than a battle among 301.81s (narcissistic personality disorder). For people seeking help for life’s problems who don’t want to be labeled mentally ill or have their treatment limited to medication, and for clinicians who want to help people without reducing them to a category, the stakes are high.”'
 Vera Sharav
Cosgrove, L., Krimsky, S., Vijayraghavan, M. & Schneider, L.  (2006). Financial ties between DSM-IV panel members and the pharmaceutical industry. Psychotherapy and Psychosomatics, 75, 154-160.  Cosgrove, L., Krimsky, S. (2012) A Comparison of DSM-IV and DSM-5 Panel Members' Financial Associations with Industry: A Pernicious Problem Persists, PLoS Medicine

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