An article in press in Psychiatric Times which I have posted here has been circulating around that represents a remarkable critique of the process of revising the Diagnostic and Statistical Manual (DSM-5) by the American Psychiatric Association, Chaired by David Kupfer MD. What’s more chilling is that it is authored by Allen Frances, MD, who chaired the committee to write DSM-4. Dr. Frances comes up with some pretty strong language, e.g.:
The work on DSM-5 has, so far, displayed an unhappy combination of soaring ambition and remarkably weak methodology.
He then goes on to explode the statements by Kupfer that the DSM-5 will lead to a “paradigm shift” in psychiatry, which he describes as an “absurd statement” based on the fact that there still is not a single lab test for diagnosis, and the gains are small and incremental in descriptive research. In the absence of evidence, changes in diagnostic criteria are arbitrary and often driven by a single strong member of the sub-committees. Furthermore, the incorporation of sub-threshold diagnoses as official psychiatric diagnoses will be a “bonanza” for drug companies who will expand their markets to new legions of the “newly” mentally ill and rush to “educate” doctors about the new criteria, which they will use to expand drug usage. It will also serve to expand stigma. The cost to research of having to re-do studies because the diagnosis has changed, or unintended consequences of diagnostic changes, are good arguments for his point that one should do as little as possible to change things.
Dr. Kupfer, however, was quoted as saying “There are no constraints on the degree of change.” Instead of being conservative and guarding against new and goofy diagnoses, they are letting the barn doors fly open. To whit, prodromal syndromes like “pre-psychotic” or at risk for mood disorder are being considered as diagnoses, which will create a whole group of “non-patient patients” who will be forever labeled even if they never develop the disorder. Also behavioral impulses like excess of food, sex, internet, or whatever are up for grabs as diagnoses. That will take something that is a moral problem and turn it into a medical disorder. Dr. Frances writes:
Getting as much outside opinion as possible is crucial to smoking out and avoiding unforeseen problems. We believed that the more eyes and minds that were engaged at all stages of DSM-IV, the fewer the errors we would make. In contrast, DSM-V has had an inexplicably closed and secretive process. Communication to and from the field has been highly restricted. Indeed, even the slight recent increase in openness about DSM-V was forced on to an unwilling leadership only after a series of embarrassing articles appeared in the public press. It is completely ludicrous that the DSM-V Workgroup members had to sign confidentiality agreements that prevent the kind of free discussion that brings to light otherwise hidden problems. DSM-V has also chosen to have relatively few and highly selected advisors. It appears that it will have no Options Book to allow wide scrutiny and contributions from the field.
The secretiveness of the DSM-V process is extremely puzzling. In my entire experience working on DSM-III, DSM-III-R, and DSM-IV, nothing ever came up that even remotely had to be hidden from anyone. There is everything to gain and absolutely nothing to lose from having a totally open process…
I have decided to write this commentary now only because time is beginning to run out and I fear that DSM-V is continuing to veer badly off course and with no prospect of spontaneous internal correction. It is my responsibility to make my worries known before it is too late to act on them. What is needed now is a profound mid-term correction toward greater openness, conservatism, and methodological rigor. I would thus suggest that the trustees of the American Psychiatric Association establish an external review committee to study the progress of the current work on DSM-V and make recommendations for its future direction.
Pretty strong language.
Add to Dr. Kupfer’s strategy of: 1) keep everything a secret; 2) make members sign confidentiality agreements; 3) allow no note taking; 4) ignore outside experts and comments; we can now add, 5) intimidate and ostracize academic psychiatrists whom you can’t ignore.
Readers know I have been writing about the DSM Shadow Team to keep track of the goings ons of the “real” DSM. Well apparently a post I wrote about a proposed Developmental Trauma Disorder in children really ticked them off, as I got an email from someone on the DSM Anxiety, OCD, PTSD and Dissociative Disorders committee whom I thought was a ”friend” un-inviting me to be an author on a paper about another topic (that was after I had already spent several days working on the paper). My crime? Stating that two of the committee members were from Brown and Dartmouth, where psychiatrist colleagues of theirs had gotten caught up in financial misconduct allegations. And one of them tried to kill himself. Seems like a lot of academic psychiatrists are doing that these days.
I have people point out to me all the time the fact that I come from a psychiatry department which has financial disclosure problems, like this one at Gooznews, and they usually make no effort to avert any implications about it, but I stand up and take it like a man.
The other thing that gets me is that the paper I was “invited” to co-author was a response to (drumroll) another one written by some psychologists on the relationship between dissociation and trauma and that I was invited because (drumroll) I had written a post about the paper critiquing it in my own unique and photo-shoppy way. Fact is I got an email from one of the psychologist authors of the paper calling me puerile and stating that he was embarassed to be from the same university… but inviting me to write a response for the journal… which I am doing now… hemph. I mean psychologists can get pissed but still debate… as for psychiatrists… well.
What was particularly chilling about this episode is that the email was copied to all the members of the committee, implying that I was now persona non grata and should be shunned by what are in fact my peers in the anxiety disorders and trauma community of academic psychiatry. I was debating whether to talk about this here but to take this “hit” in silence just re-inforces the mafia type atmosphere of bullying and intimidation that rules the day in academic psychiatry. This lack of transparency and honesty and abuse of power has led to the dreadful situation which academic psychiatry is in today, where they are universally despised by try and play it off as the evil machinations of scientology and other conspiracy theories. I, for one, however, am not going to play along with that game anymore.
Who knows, they may have been behind the anonymous letters sent to the Dean of my university complaining about another post that led them to ask that my university’s name be removed from this blog with which I complied, or the threats to go to the state medical board.
[Update: See Dan Carlat MD blog for followup to this post].
You know, Doug, this University inside political crap is (obviously expected in most work places)just unbelievable. My mother had a similar collegue problem where she was a Professor at a University, it was all ego-power BS, I’ve seen it all.
Stick the finger up at that “un-invitation” in a salute that place frankly deserves!
I applaud you writing candidly about this, and thanks, because it’s informative and thought provoking to say the least.
Hi Doug,
Keep up the courageous work! I can’t believe that the DSM-V committees are considering such weak prodromal diagnoses after rejecting Developmental Trauma Disorder. The last thing psychiatry needs right now is a secret cabal.
Keep up the good work.
I love your Photoshop pictures!
Two points:
They have proven absolutely that the DSM-V has no claim to being scientific. Secrecy is totally antithetical to scientific pursuit.
Be of good cheer. Ad hominem arguments and being persona non grata are two of the highest awards of merit available in this field.
Oy. Frankly, I don’t know what to make of all this DSM miasma.
I witnessed enough whackadoodliness at the recent APA conference (e.g. self-medicating with Powerpoints on personality disorders, especially borderline personality disorder, to the exclusion of well-studied “impulse-control” conditions such as ADHD) to doubt the wisdom of psychiatry as an organized body. As my husband the scientist says, “I think those guys are more into dogma than data.”
At the same time, I have the highest respect for many individual psychiatrists. Will they have the pointy elbows that might be required to have their voice heard, or are they too well-balanced, sane and non-narcissistic? I don’t know. Since, in my opinion, the best researcher-clinicians have received pharma funding to some degree and I understand that excludes them from the DSM festivities, well, that provides cold comfort.
But on this point, Dr. B: “Also behavioral impulses like excess of food, sex, internet, or whatever are up for grabs as diagnoses. That will take something that is a moral problem and turn it into a medical disorder.”
The truth is, some people truly do have neurobehavioral impulse-control problems; and being morally judged for their lack of inhibition has never helped their efforts. It only adds to their isolation and fuels their excesses. I cannot tell you the number of people with ADHD who, once they started medical treatment, finally were able to kick their “checking every headline in the world on the Internet at 2 a.m” habit and go to sleep. Why would anyone NOT want these people to gain the ability to regulate their impulses? I just don’t understand it.
[...] Read Dr. Bremner’s article: DSM-V Shadow Team: Retaliations & Beware of Consequences [...]
[...] Bremner notes an in-press article at Psychiatric Times by Allen Frances, a psychiatrist who chaired the DSM-IV [...]
DB wrote:
“…Also behavioral impulses like excess of food, sex, internet, or whatever are up for grabs as diagnoses…”
LOL. All these patterns are trivial to interrupt: it’s been known in NLP for ages that this is so. NLP-adherents haven’t worked out why, though. Not yet, anyway. One thing I’m pretty clear on, though: one can’t change habitual behaviour with drugs. Nor with coercion. And certainly not by denouncing a person as a witch (sorry, that should read “diagnosing a person as mentally ill, on spurious grounds”)! It seems cruel, to me, to oblige a patient to exist in a reality, the only purpose of which appears to be to justify the continued existence of people who are unwilling to assist them!
Matt
[...] Read Dr. Bremner’s article: DSM-V Shadow Team: Retaliations & Beware of Consequences [...]
thank you for your blog, your work…
Great Article. I am going to send it in a mailing. The more I glean about the new DSM, the more I want to vomit.
Also , great LOL cat.
Sorry Matthew, I’ve known longtime instructors of NLP who ultimately found it did not help with their ADHD symptoms, which certainly weren’t “trivial” — to have or deal with.
This is my first comment at your site, directed by the writings, in order, of Philip Dawdy at Furious Seasons, Dr Daniel Carlat of the Carlat Report Blog, and of ClinPsych. You may have read my comments at those sites in the past as Therapyfirst, but I have changed my alias to the above skillsnotpills after I have reached critical mass after how pretty much everyone has written off psychotherapy as an intervention for mental health care needs. So, I still reinforce the nonpharmacological interventions, but start by reinforcing the need for skills, albeit however the patient can access such needs.
I applaud what I see and read as direct transparency, and hope you will succeed in further exposing the charlatans in our profession who claim to be physicians and leaders, but who are instead just whores and cowards, and as well all who embrace or just silently condone the lame and more overtly obscene, and in my opinion evil, intentions and goals by said whores and cowards to just basically line their pockets for selling out the profession of psychiatry.
Bit of a run on sentence above, but I am tired and annoyed people are interested in dialogue and reasonable discourse with uninterested and unreasonable cretins who unfortunately do have some power, as long as those in authority go unopposed or exert disgusting influence. I have been a whistleblower about treatment issues and inappropriate politics in treatment settings in the past, and have been screwed. So, I just leave you and interested readers this point of view, that I also left at Dr Carlat’s site earlier this evening:
I would rather be vilified for doing what is right, than glorified for doing what is wrong.
If that statement resonates in you, do what is right. The old guard in psychiatry, as a whole, are truly lost and not worthy of respect or consideration as leaders. We as a collective responsible majority, if there is such a group in psychiatry, need to rise and refute those who’s agenda is selfishness, greed, irresponsibility, and risk for outright harm to the patients.
You can give my position some consideration, or watch the terminal course of the profession of psychiatry play out. It is truly your call as an invested professional, or caring patient, or involved family or other provider.
Thank you for the opportunity to comment.
Skillsnotpills, board certified psychiatrist for more than 10 years.
Ha ha! Therapyfirst! Welcome! And we admonish you to return to your first nomer!
yeah TF don’t confuse us LOL
True. The DSM is not a scientific document. For a critical summary http://www.zurinstitute.com/dsmcritique.html
Straw man, Nola. No one ever said the DSM is a scientific document or a perfect instrument. Obviously, some diagnoses carry stronger scientific research than others.
But your link strikes me a rather paranoid and extreme (and I wonder how Dr. B will view your denouncement of PTSD as nothing more than a major lobbying effort): # “The DSM is a powerful tool of social control, as its criteria is a primary tool used to judge who is normal or abnormal, sane or insane or who should remain free or be hospitalized against their will.”
[...] postades online av psykiatern Doug Brenner, som enligt honom själv har fått utstå repressalier från andra psykiatriker för [...]
I am not sure what is paranoid or extreme in claiming the process, by which additions or changes are made to the DSM, to be non- scientific ……….One telling example is the declassification of homosexuality as a mental disorder. Homosexuality was listed as a mental disorder in the DSM until 1974, when gay activists demonstrated in front of the American Psychiatric Association Convention. The APA’s 1974 vote showed 5,854 members supporting and 3,810 opposing the disorder’s removal from the manual. At that time, the American Psychiatric Association made headlines by announcing that it had decided homosexuality was no longer a mental illness. Voting on what constitutes mental illness is truly bizarre and, needless to say, is political and unscientific.
Nola Nordmarken
Contributing author
Zur Institute
http://www.zurinstitute.com/dsmcritique.html
naaaahhh, go back to your statement and defend that, Nola: “The DSM is a powerful tool of social control, as its criteria is a primary tool used to judge who is normal or abnormal, sane or insane or who should remain free or be hospitalized against their will.”
Nola: The statement from your – btw very interesting – critique of the DSM you were asked to defend, just got proven right when it got labelled “paranoid”. B-e-a-u-t-i-f-u-l, Gina, thanks!
[...] yesterday’s post on the Diagnostic and Statistical Manual (DSM) process “Retaliations and Beware of the Consequences” blew through the roof for record page views and stimulated similar confessions from other [...]
The DSM is a subjective document. Nora points out the absurdity of homosexuality being labeled a disorder, and then voted on to ascertain whether it is or not. Voting on labeling someone for life?
We can all do better than that. Nora is not paranoid. That word gets tossed around by people who cannot back up their claims with scientific evidence. Thos epeople are liars.
[...] On June 23rd, 2009, an article in press at Psychiatric Times was posted by Doug Bremner, MD on his health blog, igniting debate through the medical community. That article was an editorial authored by Allan [...]
[...] DSM-V Shadow Team: Retaliations & Beware of Consequences An article in press in Psychiatric Times which I have posted here has been circulating around that represents a remarkable critique of the process of revising the Diagnostic and Statistical Manual (DSM-5) by the American Psychiatric Association, Chaired by David Kupfer MD. What’s more chilling is that it is authored by Allen Frances, MD, who chaired the committee to write DSM-4. Dr. Frances comes up with some pretty strong language, e.g.:… [...]
I’m writing an article about the proposed developmental trauma disorder and wanted to see the post you mention in this blog about it, but the link isn’t there anymore. Any way I can see what you said?
[...] June 23rd, 2009, an article in press at Psychiatric Times was posted by Doug Bremner, MD on his health blog, igniting debate through the medical community. That article was an editorial authored by Allan [...]