We have been following the process of writing the DSM, which will establish the new diagnostic criteria for psychiatric disorders, through the DSM-5 Shadow Team, which has created quite a broo-haha, as you can see here and here. One of the diagnoses that has been proposed is internet addiction disorder. This is apparently an addition to disorders for addictions to sex, food, gambling, whatever you name it, but we don’t have time to cover everything. Fact is it is pretty hard to know what they are doing as the head of DSM-5, David Kupfer MD, has required all members to sign a nondisclosure agreement and not take any notes. He runs a pretty tight ship.

The behavior of the committee members has gotten pretty mean and nasty, and the DSM Anxiety Disorders, OCD, PTSD and Dissociative Disorders committee retaliated against me for writing about the DSM here. I mean, those dudes are pretty thin skinned. And what would you think about a bunch of guys that signs a confidentiality agreement before they even know what they are getting into? Now David Kupfer is herding them toward a deadline of 2010 for completion of the DSM-5 and many are starting to balk. Are they headed toward a precipice?

Background David Kupfer. Forground DSM-5 AD Committee: back row, L to R, Robert Pynoos, Roberto Lewis Hernandez, Gavin Andrews, Katharine Phillips, Matthew Friedman, Scott Rauch, Dan Stein. Front row, L to R, Eric Hollander, Michelle Craske, Murray Stein, Susan Bogels, Hans Ulrich Wittchen, David Spiegel, Robert Ursano

Nice group shot guys! Baaaa!!!

Almost a third of the committee is from foreign countries, which my guess is that they had to go abroad to find people who actually wrote papers but weren’t up to their necks in consulting arrangements with pharmaceutical companies. Part of the attempt to add credibility which seems to characterize this process, like telling members not to consult during the process of working on the DSM.

This week things are fraying more around the cracks. Dr Jane Costello from Duke University resigned from the Workgroup on Children’s and Adolescent Disorders; the reasons outlined in the letter include an overly hasty rush to change things when there is little scientific evidence to support the changes. Hmmm I wonder where I have heard that before? Dan Carlat MD reports on Armegeddon and the developments and on a letter from Robert Spitzer MD and Allen Frances MD to the American Psychiatric Association (APA) Board of Trustees warning of “disastrous unintended consequences” and asking for an outside review panel.

The problem is that the APA is a million or two dollars in debt, and has become addicted to having these new DSM books come out, because then everyone has to throw out the old one and buy the new one, and since they are the publisher they get the profit. With the pipeline of psychiatric drugs drying up there is less advertising from the pharmaceutical industry for their journals and meetings, therefore things are getting tight, and hence the pressure to hurry up the process. However I don’t think that generating income for the APA is a good reason to change diagnostic criteria for mental disorders, and their behavior is going to call into question their rights to do that. Not all psychiatrists (including me) are members of the APA, and there are many other mental health professionals who must live with the DSM.

Anyhoo back to internet addiction disorder, which I guess we should call IAD, it is of course compulsive use of the internet, with hourse spent trolling on line, with disruption of work and social life.

You can read an editorial advocating for its inclusion here.

It is considered to be a big problem in many Asian countries. The other side of this is people who get into Real-life or other online games like that and develop relationships where they start having sex with other peoples avators and then they get caught and kicked out of the house.

I have a treatment for my 12 year olds computer game addiction. It is…

…GET OFF THE COMPUTER!!!

Seriously if anyone wants to know my opinion about IAD, it is that I agree with Allen Frances MD head of DSM-4 that we should shun any new and suspicious looking psychiatric diagnoses as we don’t want to add to the throngs of people who feel like they have been labelled with a psychiatric diagnosis. My opinion is that the DSM process should be put on hold, that the text can be revised but diagnostic criteria should not be revamped until there has been the time to collect more data.

Cheers!

I have been writing about the DSM process which isn’t always easy to do because the head of DSM-5, David Kupfer, MD, runs a pretty tight ship with his committee members, making them sign confidentiality agreements and not take any notes. Well since he said that there would be a “paradigm shift” and the sky is the limit for coming up with new diagnoses, there has been a lot of interest in the process.

David Kupfer, MD, Head of DSM-5

I recently wrote about the editorial by Allen Frances MD, head of DSM-4, criticizing the current process of DSM-5, and now there is a nasty response from the DSM-5 group, authored by Alan Schatzberg MD, James Scully MD, David Kupfer MD, and David Regier MD, that psychiatry blogger Daniel Carlat MD offered to edit for them to make it more respectful. Lol. A blogger offering to help the leaders of academic psychiatry tone down their language. Lol again.

I mean the damn editorial hasn’t even been published yet.

In their response to Frances Kupfer et al make dubious claims that “attorneys” had advised them to have committee members sign confidentiality agreements to protect “intellectual property”. They also charge Frances (as well as Robert Spitzer MD, who founded DSM and has been making the email rounds with criticism of the current process) with greed in wanting to retain royalties from a book he wrote about DSM-4 which would become outdated after the release of DSM-5. I mean anyone in the business knows that book royalties pale in comparison to the hundreds of thousands of dollars to be had doing pharmaceutical industry consulting and speaking. In fact one could even argue that doing things like editing books (which have essentially no revenue, because hardly anyone buys them) is a feather in the cap that helps you get those more lucrative gigs.

One of the diagnoses on the table is Female Sexual Dysfunction (FSD), a “disease” that if accepted would surely drive the drug companies to “identify and treat” these poor lassies with drugs like the testosterone patch (see “Wow A Drug To Have Sex Once More a Month? Sign Me Up!“) or Viagra or whatever psychotropic they could drug out of the medicine cabinet.

Turns out the medicalizing women’s sexuality may not be such a good idea. There is a long and jaded history of evil meddling by medical doctors in this area. The publication of the book Feminine Forever, whose thesis was that post-menopausal women become shriveled asexual crones due to an estrogen deficiency led doctors to put an entire generation of post-menopausal women on hormone replacement therapy (HRT), which in turn was later found to have caused tens of thousands of deaths from heart attack and other problems.

Then there were Masters & Johnson, the famous sex research team who concluded that women had more frequent orgasms than men.

Masters & Johnson on Meet the Press

This “research” however was based on looking through peep holes at brothels, and later their “research sessions” they conducted with each other. Virginia Johnson was Dr. William Masters secretary, and they “partnered” to have sex on a nightly basis for “research” purposes for years. Their report on 67 patients with unwanted homosexuality showing a 70% conversion to heterosexuality using “conversion therapy” was later disclosed as a fraud when noone could find any evidence of the patients. This bizarre “research team” should hardly be taken seriously about women’s orgasms.

Turns out that the DSM-4 has ‘Female Hypoactive Sexual Desire Disorder’ and ‘Female Hypo Orgasmic Disorder’ (I mean did the guy try going down on her?) as well as Dyspaerunia (painful sex). As a recent editorial pointed out, maybe the 43% of women with some type of so-called sexual dysfunction are acting “appropriately”.

I mean, maybe they’re with jerks and don’t feel like doing it?

The American Journal of Psychiatry has been soliciting editorials on the DSM-5 process. Too bad they rejected the editorial by Robert Spitzer MD who founded the DSM, and for FSD they have only this lame piece by a trio of MDs whose pharma disclosures read like a phone book. Lol. Sort of.

Ray Moynihan had a good piece in bmj on FSD (“FSD: The Making of a Disease”) in which he outlines how industry has moved in a serious way to pour cash in the “research and education” of this newly minted disorder, the rife conflicts of interest in the field, and the attempt by drug companies to medicalize female sexuality.

After 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 psychiatric bloggers about bullying by members of the American Psychiatric Association (APA), as well other commentary here and here and here. I seem to have wandered from a fairly tongue in cheek exercise in the DSM Shadow Team, founded to track the goings on of a secretive committee and have a little fun in the process, into a field of landmines.

This new article by Allen Frances, MD, who chaired the DSM-4 committee, criticizes the secretive approach by the current DSM-5 chair David Kupfer MD, who has insisted on secrecy, no note taking, confidentially agreements, and now I would add bullying of psychiatrists like myself who offer outside commentary. Dr. Kupfer has built up the Department of Psychiatry at the University of Pittsburgh into a research machine through developing the infrastructure of administrative personnel who help with the process of writing and submitting research grant applications for funding by the National Institute of Health (NIH). He is said to call out a “priority score” whenever he hears someone present research. Grants coming from Pittsburgh have the reputation of being technically excellent but not always exciting. It seems like he has brought this mass war enterprise approach to the DSM.

David Kupfer, MD, Chair of the DSM-5 Committee

All of this has gotten me reflecting on academic freedom. I mean, have not one but three organizations telling me to shut up (not counting the people in my personal life): the VA, my university (that which cannot be named here) and academic psychiatry. To whit, I am supposed to get approval to talk to the press from my local VA PR guy, but what this amounts to is that when I get contacted about something that they care about (i.e., Iraq), they shelve it and never get back to me. I mean, if you don’t think that pointing a gun at someone, pulling the trigger, and killing them can’t wreck your marriage or make you suicidal, that’s not my problem, so I don’t really get excited about getting censored about that stuff.

The current behavior of academic psychiatry in the DSM process is more troubling. By stiffling debate and creating a corporate type approach they are going against the very principles of science and academic freedom. One can only conclude that they feel insecure about the validity of their deliberations.

I also get upset about what I feel is my university treating me like an employee of a corporation rather than a professor in a university. I mean they should be glad to have their name associated with this blog when contrasted with other situations in which their name was associated with more questionable practices and they never said anything about it. For shame. And there are other professor bloggers who are much more lippy than I am and they list their universities on their blogs.

There are numerous examples of where a failure of academic freedom for exchange of ideas has had disastrous consequences, e.g. 30 million die in China applying Lisenko’s bogus scientific theories to agriculture which results in mass famine. In fact there is an organization dedicated to academic freedom. This is from wikipedia.

AFAF (Academics For Academic Freedom) [3] is a campaign for lecturers, academic staff and researchers who want to make a public statement in favour of free enquiry and free expression. Their statement of Academic Freedom has two main principles:

1. that academics, both inside and outside the classroom, have unrestricted liberty to question and test received wisdom and to put forward controversial and unpopular opinions, whether or not these are deemed offensive, and
2. that academic institutions have no right to curb the exercise of this freedom by members of their staff, or to use it as grounds for disciplinary action or dismissal.’

AFAF and those who are part of the campaign believe that it is important for academics to be able to express their opinions – not just full stop, but to put them to scrutiny and to open further debate. They are against the idea of telling the public Platonic ‘noble lies’ and believe that people should not be protected from radical views.

Well said.

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].

Recently a bogus letter was written to the head of the DSM V Committee, David Kupfer MD, by several psychiatrists, arguing that Dissociative Identity Disorder (DID) should be removed from the DSM. Here is the letter:

Letter asking for removal of DID from DSM

They didn’t have any solid reason to ask for this, other than the fact that they thought it was an “embarassment to psychiatry.” Here is their argument:

Due to the assumption that trauma is a primary etiological factor, the DID diagnosis has resulted in wrongful accusations of sexual abuse on the basis of recovered memories, not only in North America but throughout the developed world (references). DID has caused mockery of psychiatry, and, for patients, has led to misdiagnosis (13) and inadequate treatment of depression (14) [not only depression, but other disorders that it’s distracted attention away from; also, this reference seems rather thin to make a strong statement on. Perhaps it would be better not to reference this, but simply assert that treatable causes of problems are missed when the DID diagnosis is applied].

They conclude

There are overwhelming reasons to question the validity of Dissociative Identity Disorder. We respectfully urge you as members of the Work Group and the Task Force to drop the category of dissociative disorders from the upcoming DSM-V because it is scientifically unjustified, clinically harmful to patients and their families, and it undermines the credibility of psychiatry.

 

Signed:

1.     Paul R. McHugh, M.D. Distinguished Service Professor of Psychiatry at Johns Hopkins University.

2.     Harrison Pope, Jr., MD, MPH, Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts; Director, Biological Psychiatry Laboratory, McLean Hospital, Belmont Massachusetts 

3.     James Hudson, MD, ScD, Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts; Director, Biological Psychiatry Laboratory, McLean Hospital, Belmont Massachusetts 

4.     Elizabeth Loftus, PhD, Distinguished Professor, University of California-Irvine.

5.     Richard J. McNally, Ph.D., Professor and Director of Clinical Training, Department of Psychology, Harvard University, Cambridge, MA.

6.     Harold Merskey, DM, FRCP, FRCPC, FRCPsych., Professor Emeritus of Psychiatry.

7.     Joel Paris, M.D. (M.B., B.Ch.)

8.     August Piper, M.D., independent practice of psychiatry, Seattle, WA.

9.     Numan Gharaibeh, MD (MB, BCh), Principal Psychiatrist, Western Connecticut Mental Health Network, Danbury, CT.

10. Pamela Freyd, Ph.D.

11. Brian Boffi, MD, Principal Psychiatrist, Western Connecticut Mental Health Network, Torrington, Torrington, CT.

12. Alexander Miano, M.D.

13. Joanne Iurato, PhD, Clinical Director, Western Connecticut Mental Health Network, Danbury, CT.

14. Donna Pellerin, M.D., Medical Director of Inpatient Services, Danbury Hospital, Danbury, CT.

15.  Jennifer Ballew, DO, Principal Psychiatrist, Western Connecticut Mental Health Network, Waterbury, CT

The letter includes references to papers written by themselves which are mere opinion pieces, with no reference to actual research studies, such as our paper showing smaller amygdala volume and hippocampal volume on MRI in women with childhood sexual abuse and the diagnosis of DID. They make silly references to popular movies about DID and claim that embarrassment about over dramatization of the disorder should be the basis for changing psychiatric nosology.

The leader of their merry band is Paul McHugh, MD, former Chair of Psychiatry at Johns Hopkins Medical School, who got the job because they hate all things behavioral there, and would hire only someone who would trash his own, and who was once described as an “evil leprechaun”.

Dr Paul McHugh debates lolcat.

The letter is a shoddy piece that says “we think this is so, therefore make these changes,” exactly the kind of thing that irks me about the whole DSM process, and led us to form the Shadow Team and to square off against the authors of a special issue of Journal of Anxiety questioning the validity of the PTSD diagnosis.

We’re not gonna take it.

The group that wrote the letter includes people who have profited by working as expert witnesses on behalf of parents accused in courts of childhood abuse, but make no disclosure of that fact. I am not sure who they think they are protecting, but I surely wouldn’t want to have one of them as my psychiatrist or psychologist. This anti-trauma bias of the DSM is why we formed the DSM Shadow Team in the first place. Head of the DSM committee, David Kupfer MD, has said that he wants to cut down on the number of psychiatric diagnoses in DSM V. He also simply skipped forming a committee to review the Dissociative Disorders. So which of the diagnoses is he going to drop? It certainly isn’t going to be any of the one generating billions of dollars for the pharmaceutical industry, like major depression.

Since they don’t seem to have anything better to do, and it is a spring day, I thought I would let them dance around the Maypole together for a while.

From L to R: Numan Gharaibeh MD, August Piper MD, Pamela Freyd PhD, Joel Paris MD, Joanne Iurato PhD, Elizabeth Loftus PhD, Donna Pellerin MD (in front), Harold Merskey MD, Richard McNally PhD, James Hudson MD, Harrison Pope MD (in front), Paul McHugh MD (green hat) (not included in picture) Brian Boffi MD, Alexander Miano MD, Jennifer Ballew DO