04/11/23

Guild Interests Behind DSM Diagnosis

Now in its 5^th edition, the DSM-5-TR, the text revision of the Diagnostic and Statistical Manual, was released in March of 2022. This happened to be the first update in almost ten years and it’s selling very well for the APA, the American Psychiatric Association. The paperback version, as well as the hardback and desk reference editions, are the top four best sellers in psychiatry for Amazon. Saul Levin, the CEO and medical director for the APA told Axios that the public has been dying to know more about mental illness. “I think what really caught the imagination was that we’re sitting at home now and looking to say, ‘Boy, I’m feeling depressed — let me now go and find out more about it.'”

It’s hard to tell from this quote if Dr. Levin’s comment was a reflection of APA sales data for impulse buys for the DSM-5-TR, but I doubt it. A quick look at the Amazon prices DSM-5-TR indicates the paperback edition sells for $110.76 and the hardcover for $174.90. The desk reference editions are more affordable at $49.14 and $59.99. A better explanation for its bestselling sales is the fact that psychiatry in the U.S. and increasingly around the world has been dominated by the DSM for the past 70 years. Wired Magazine said this so-called bible for psychiatry is used in prisons, hospitals, and outpatient clinics to diagnose patients, prescribe medications, dictate future treatment and to justify payment for these services.

Axios reported how mental health has gone mainstream, with younger workers demand it as an employee benefit. Ralph Lewis, a Toronto-based psychiatrist, said in Psychology Today that psychiatry is guilty of having oversold its ability to answer the problems of coping with life and regulating one’s emotions and behaviors. Life can be stressful and complicated, leaving people with a feeling they can’t cope. “Many assume that psychiatry has the answers to problems of coping with life and regulating one’s own emotions and behaviors.” The expectations are particularly intense on psychiatrists as medical specialists “who are designated as the ultimate gatekeepers for diagnosis of mental illnesses and, more broadly, mental disorders.”

Mental disorders are, by their very nature, difficult to define with specificity. Anxiety and depression are the most common reasons for seeking psychiatric help. There is much confusion among the general public, and even often uncertainty among psychiatrists, as to when to consider these experiences mental disorders: the diagnosis depends on severity, number of associated symptoms, degree of functional impairment, and persistence or recurrence. Unfortunately, psychiatric diagnostic classification systems and mental health awareness campaigns have overgeneralized the definition of mental illness.

Dr. Lewis said the tendency now is to pathologize everyday problems, labeling them as mental disorders. Here he referenced Saving Normal, by Allen Frances, a psychiatrist and the former chair for the DSM-IV. Frances said there should have been cautions in the DSM-IV warning about overdiagnosis and providing tips on how to avoid it. Professional and public conferences, and educational campaigns should have been organized to counteract drug company propaganda.

None of this occurred to anyone at the time. No one dreamed that drug company advertising would explode three years after the publication of the DSM-IV or that there would be the huge epidemics of ADHD, autism, and bipolar disorder—and therefore no one felt any urgency to prevent them. . . We missed the boat.

See “Medieval Alchemy” for more on Allen Frances and Saving Normal.

Dr. Lewis said the COVID-19 pandemic drove up the rates of anxiety, depression and several other mental disorders. Ironically, while the data are complicated, there does not appear to have been much of a rise in the actual rate of mental disorders. What seems to have happened is people’s perception they need psychiatric treatment increased. Although some of the increase represents people now seeking help for significant problems, there is also a phenomenon of these diagnoses being sought.

A diagnosis offers a person an explanation for their difficulties. It lets a person feel understood. It simplifies complexity, helping make sense of things and bringing a bit of order to the inexplicable and chaotic. It provides validation and legitimacy to one’s struggles, as well as sympathy, and it might offer justification for one’s shortcomings or behavioral difficulties. It also confers a sense of identity and group-belonging.

A diagnosis may deliver practical benefits such as sick leave, disability benefits, academic accommodations, and insurance coverage for therapy. Other factors include social media, the internet, and celebrity influence—think about the attention paid to Simone Biles when she withdrew from several events at the 2020 Summer Olympics. And don’t forget about pharmaceutical advertising—just ask your doctor. “In many ways, what we are witnessing is the success of, and unintended consequences of, years of mental health education and destigmatization campaigns.”

Not only does overdiagnosis lead to over-prescribing medications, it also trivializes severe mental illness. The CDC said more than 50% of Americans will be diagnosed with a mental disorder in their lifetime. One in five will experience a mental illness in a given year. “If everyone has a mental disorder, then no one does, and the concept of mental disorder becomes meaningless. It becomes harder for the people most in need of psychiatric services to access the already overloaded system.”

The CDC also stated there was no single cause for mental illness. Early adverse life experiences, the use of alcohol or drugs, feelings of loneliness or isolation as well as biological factors or ongoing chronic medical conditions like cancer or diabetes can contribute to the risk of mental illness. But psychiatry continues to press for the medical model of mental illness and it seems defending the legitimacy of DSM diagnosis goes along with it. This debate has continued without any real movement towards a resolution for the last fifty years.

Dr. Daniel Morehead lamented in “The DSM: Diagnostic Manual or Diabolical Manipulation?” that it would be hard to overstate the torrents of criticism because of the DSM. He said, “The DSM has been, and remains, the centerpiece of contemporary critiques of psychiatry.” Critics of the DSM were wrong. Psychiatry is not at odds with other medical specialties. “Psychiatry differs from them only in the sense that more of the diseases behind psychiatric syndromes lack full explication.”

This is not evidence of its inferiority, according to Morehead, rather it is evidence of the complexity of the human brain. The DSM is “simply the place where clinicians match diseases to treatments through the lens of medical syndromes—just like other doctors.” This seems to be the heart of the debate and the reason for the vigor with which psychiatrists like Dr. Morehead defend the medical basis of psychiatry and psychiatric diagnosis. In another article published around the same time, “Let’s End the Destructive Habit of Doubting Psychiatric Illness,” he said it is time to permanently retire the idea that mental illness may not be fully medical. It is a “pernicious and misleading idea” and he challenged all psychiatrists to no longer tolerate it—publicly or privately.

Dr. Morehead and others appear to recognize that psychiatry is facing an institutional crisis unlike anything it faced since David Rosenhan published “Being Sane in Insane Places” in the journal Science in 1973. Rosenhan has eight “pseudopatients” seek admission to twelve different psychiatric hospitals. Once admitted, they stopped simulating any symptoms of abnormality and waited to see how long it took before they were released. Their length of stay ranged from 7 to 52 days, with an average length of stay at 19 days. None of the pseudopatients were identified as such by hospital staff members; but other patients did.

For more on the Rosenhan study, see “A Censored Story of Psychiatry,” Part 1 and Part 2.

In their book, Psychiatry Under the Influence, Robert Whitaker and Lisa Cosgrove said the trustees of the APA called a meeting shortly after Rosenhan’s article was published. They lamented how the public did not view psychiatry as a medical specialty. The trustees recommended the formation of a task force that would define mental illness and become a preamble to publish the DSM-III. And they made Robert Spitzer the chair of the task force in 1974. Whitaker and Cosgrove said from that beginning, the APA trustees saw how creating a new diagnostic manual could also serve a guild interest.

Remaking psychiatric diagnoses could be part of a larger effort by psychiatry to put forth a new image, which, metaphorically speaking, would emphasize that psychiatrists were doctors, and that they treat real “diseases.”

By adopting the disease model and asserting that psychiatric disorders were illnesses, the APA addressed both its critics and its image problem. Whitaker and Cosgrove said this happened when the organization metaphorically put on a white coat and presented itself as a medical specialty. “This was an image that resonated with the public.” With hindsight, they said, it is easy today to see the ethical peril for the APA that arose when the DSM-III was published. While the APA had devised a new diagnostic manual that helped remake its image, “the peril was that the guild interests might now affect the story it told to the public about the nature of mental disorders, and the efficacy of somatic treatments for them.”

In an interview for Medscape in 2020, the now former chair of the department of Psychiatry at Columbia and former president of the APA, Jeffery Liberman discussed “The Future of Psychiatric Diagnosis” and biomarkers with Melissa Arbuckle, also of Columbia University. She is the vice chair for education and training in the Department of Psychiatry at Columbia. Robert Spitzer, the architect of the DSM-III, was a Professor of Psychiatry at Columbia until his retirement in 2003.

Lieberman acknowledged at the start of the interview there have been no biomarkers identified yet in research. “For the entire history of our discipline, as long as physicians have studied mental illness, we have not had a diagnostic test for it. It’s a clinical diagnosis.” Nevertheless, he has faith that someday there will be a diagnostic test for mental illness: “I do believe that certainly within my professional lifetime, and hopefully sooner rather than later, we will see a diagnostic test.”

The APA self-consciously tied its fate to the DSM in the aftermath of the institutional crisis after the Rosenhan study. It seems to have done so at least partially to affirm itself as a legitimate medical specialty, with the power and authority to prescribe medications. As T. M. Luhrmann noted in Of Two Minds, “psychopharmacology is the great silent dominatrix of contemporary psychiatry.” Prescribing medications is what psychiatrists do that other mental health professionals cannot do. “And as mental health jobs become defined more by their professional specificity, more and more psychiatrists spend more of their time prescribing medication.”

The disease model of mental illness has been a tremendous asset in the fight against stigma and the fight for parity in health care coverage. And it is clear that the disease model captures a good measure of the truth. Mental illness often has an organic quality. People can’t just pull themselves back together when they are hearing voices or contemplating suicide, and their illness is rarely caused by bad parenting alone. Yet to stop at that model, to say that mental illness is nothing but disease, is like saying that an opera is nothing but musical notes. It impoverished us. It impoverishes our sense of human possibility. (Of Two Minds, p. 266)

06/28/22

Time for a Fresh Look at Diagnosis

Allen Frances, chair of the DSM-IV Task Force, has been a vocal critic of modern psychiatry and diagnosis. He was selected by fellow psychiatrist Awais Aftab to do the first interview for Conversations in Critical Psychiatry, a series for Psychiatric Times that aimed to engage prominent individuals who have made important and constructive critiques of psychiatry. Dr. Frances said while he considered psychiatry to be one of the noblest of professions, it had drifted away from best practice. Too many psychiatrists, he said, are reduced to pill pushing with too little time to really know their patients well. And psychiatrists have not done enough to educate primary care physicians, who prescribe 80% of psychiatric meds, on “the principles of cautious prescribing, proper indications, full consideration of risks, and the value of watchful waiting and the tincture of time.”

I despair the diagnostic inflation that results from a too loose diagnostic system, aggressive drug company marketing, careless assessment, and insurance company pressure to rush to judgement. Diagnoses should be written in pencil, and under-diagnosis is almost always safer and more accurate than over-diagnosis.

With regard to the philosophy of diagnosis, he saw three approaches that he likened metaphorically to three kinds of baseball umpires. The first kind called balls and strikes as they are. The second called them as he saw them. The third said there were no balls or strikes until he called them. Frances likened Robert Spitzer, the architect of the modern DSM, to Umpire 1, along with most biological psychiatrists (See “The Quest for Psychiatric Dragons” Part 1 and Part 2 and “Where There’s Smoke …” for more on Robert Spitzer). “The credibility of this model has been destroyed as we have learned more about the unfathomable complexity of the human brain and the complete failure of genetics and neuroscience to provide useful answers about what causes psychiatric problems.” He thought most psychiatrists aspired to be like Umpire 2, doing their best to define mental disorders in useful ways without any pretention that it is the only way or that current constructs would withstand the test of time.

Dr. Frances expressed concern with the risks of over-diagnosis and advocated for a narrower system with higher diagnostic thresholds. He thought experts in each diagnostic area sought to expand their pet diagnoses and worried too much about missing patients (false negatives) rather than mislabeling patients (false positives). These experts were given a free rein in DSM-5, allowing mislabeling to dominate the field. This led to a checklist approach to diagnosis, which was not intended by the creators of the DSM.

The diagnostic exuberance of DSM 5 confuses mental disorder with the everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition. DSM 5 ambitiously mislabels normal diversity and childhood immaturity as disorder, creating stigma and promoting the excess use of medications.

Frances thought if anything in DSM could be misused, it would be misused. “Data drawn from research studies on highly selected patients in the hothouse environment of a university research clinic generalize very poorly to the hustle and bustle of primary care.” On Twitter he pointed to a study he said “blows to bits any hope that statistical modeling” could eliminate the many inherent limitations of “Evidence Based Medicine.” This study, “Many Analysts, One Data Set” concluded that uncertainty in interpreting research results was not just a function of statistical power or the use of questionable research practices. It was also a function of the many reasonable decisions made by researchers as they conducted their research. This did not mean that analyzing data and drawing research conclusions from the data was subjective. Rather, it meant “that many subjective decisions are part of the research process and can affect the outcomes.”

Frances said “Evidence Based Medicine” often generalized poorly to everyday practice because: 1) patients in controlled studies aren’t like unselected patients; 2) research settings differ from real life; 3) biases influence data analyses. “EBM provides a necessary guide, but shouldn’t be worshipped.”

Returning to the interview for Conversations in Critical Psychiatry, he noted how there was an inherent financial, intellectual and emotional conflict of interest that leads every medical specialty to recommend over-diagnosis. He recommended that specialty groups like the APA, the American Psychiatric Association, should never be permitted sole power to determine the diagnostic guidelines for that specialty. Contributions from primary care, public health, health economics and consumers are important. With regard to psychiatric diagnosis, he thought the APA had a special conflict of interest because the DSMs were such a valuable publishing property. The income is crucial for meeting its budget. “This makes frequent revision too tempting and results in an unseemingly hyping of the product.”

Soon after the publication of the DSM-5 in 2013, Allen Frances published an article in World Psychiatry, “The past, present and future of psychiatric diagnosis.” He said psychiatric diagnosis is facing a serious crisis caused by diagnostic inflation. “The elastic boundaries of psychiatry have been steadily expanding, because there is no bright line separating the worried well from the mildly mentally disordered.” Drug companies have used their marketing muscle to sell psychiatric diagnoses by convincing potential patients and prescribers that life problems were really mental disorders caused by chemical imbalances and curable by pills.

We are now in the midst of several market-driven diagnostic fads: attention-deficit/hyperactivity disorder (ADHD) has tripled in rates in the past twenty years; bipolar disorder has doubled overall, with childhood diagnosis increasing forty-fold; and rates of autistic disorder have increased by more than twenty-fold. In the US, the yearly prevalence of a mental disorder is reported at 20–25%, with a 50% lifetime rate, and Europe is not far behind. A prospective study of young adults in New Zealand has reported much higher rates and another of teenagers in the US found an astounding cumulative 83% rate of mental disorders by age 21.

He said the DSM-5 was prepared without adequate consideration of clinical risk/benefit ratios and did not calculate the large economic cost of expanding the reach of psychiatry. It has been unresponsive to widespread professional, public and media opposition “based on the opinion that its changes lacked sufficient scientific support and often defied clinical common sense.” A petition endorsed by fifty mental health associations, that called for an independent review, “using methods of evidence-based medicine, was ignored.” It was time for a fresh look at diagnosis.

On the podcast The Recommended Dose with Ray Moynihan, Frances said the tendency over the last forty years has been to turn the stuff of life into mental disorder. “The best customer for a drug, is someone who is basically well.” We get advertisements for drugs as frequently as we get advertisements for cars or brands of beer. When it comes to most psychiatric problems, people get better on their own in a few weeks. “My concern is that we’re way overmedicating the problems of everyday life and that parallel to that, we are terrifically neglecting people who are really sick.”

One of the areas he gave as an example of transforming ordinary life into mental illness is with mild forms of depression, that really aren’t depression, but are being diagnosed as major depressive disorder. “The drug companies have convinced the world that major depressive disorder is one entity, and that it is always a chemical imbalance, and that it always requires a chemical solution in the form of a pill.” Eleven percent of Americans are taking an antidepressant. Grief in particular is often over diagnosed and over treated with medication. Then there is anxiety; children who have temper tantrums; and so on. “In general, we have taken every day experiences, that are part of the human condition, and we’re over diagnosing them as mental disorders, and we’re way too often providing a pill, when there’s not really a pill solution for every problem in life.”

Children have been over medicalized with Attention Deficit Disorder, which should be properly diagnosed at around 2 or 3 percent of the U.S. population. In the U.S., by the time a child is 18, they have a 15 percent chance of getting the diagnosis. “This is absolutely ridiculous. We are turning immaturity into a disease.” There are also unwarranted increases in diagnosing childhood Bipolar Disorder. And there is a terrific overuse of antipsychotics in children with behavior problems. “I think we are doing a massive, worldwide experiment on immature brains, bombarding them with very powerful chemicals, with no knowledge whatever about what the long-term outcome will be; and without informed consent.”

He thinks the DSM-5 set off on in the wrong direction. Psychiatrists were worrying about underdiagnosis, when they should have been concerned with overdiagnosis. He said we have gone overboard in the developed world in giving too much treatment to people who can afford it, while neglecting people who can’t.

Then he was asked to comment on the role of good evidence that comes from systematic reviews, from summaries of evidence. Frances said evidence is absolutely crucial in making medical decisions, even though you can’t trust all of it. It takes time to gather enough reliable evidence to be confident. “But without evidence it’s a crapshoot that will be governed by commercial, for profit elements that so determine how people are treated.

I think the biggest role for change will come from the evidence-based guidelines and from a press that is educated to advertise to the people reading the article, not just the possible miracle medical benefit, which is always exaggerated, but also the possible realistic risks of side effects.

The biggest problem for the doctor is too little time. The more time you have to get to know the patient, the less likely you’ll be inaccurate in your diagnosis. “It’s the easiest thing in the world to give a diagnosis and to write a pill prescription. It’s the hardest thing in the world, often, to get rid of a diagnosis once it’s been established. . . A wrong diagnosis made in ten minutes can haunt for life.” Medication, given casually, can do great harm and you should be as careful in taking medication as you would be for a major life decision.

Originally posted on 5/19/2020

05/3/22

Medicalizing Normal, Human Grief

Well, it’s official. If your bereavement over the death of someone close to you “lasts longer than social norms and causes distress or problems,” it could be a psychiatric disorder. The symptoms of what is called Prolonged Grief Disorder (PGD) include: avoiding reminders that the person is dead; emotional numbness; feeling life is meaningless; feeling intense loneliness, being detached from others; intense emotional pain related to the death. PGD can be diagnosed if someone is experiencing these symptoms within 12 months of the death of a loved one for adults or within 6 months for children or adolescents.

Prolonged Grief Disorder is the newest disorder added to the DSM. After studies suggested that many people were experiencing persistent difficulties with bereavement, PGD was approved by the APA’s Board of Trustees and Assembly in the fall of 2020 and included in the text revision of the DSM-5 (DSM-5-TR) published in March of 2022. The APA CEO and Medical Director said including prolonged grief disorder in the DSM-5-TR will mean that mental health clinicians and family members will “share an understanding of what normal grief looks like and what might indicate a long-term problem.” The President of the APA was quoted as saying:

The circumstances in which we are living, with more than 675,000 deaths due to COVID, may make prolonged grief disorder more prevalent. . . . Grief in these circumstances is normal, but not at certain levels and not most of the day, nearly every day for months. Help is available.

The reaction by mental health professionals has not been all supportive of the APA adding grief to the DSM listing of psychiatric disorders. Debate over this action has been going on for over a decade and it seems the APA has been incrementally moving in this direction. In 2013 when the bereavement exclusion was removed from the DSM-5 diagnosis of major depression, Allen Frances, who was the chair for the DSM-IV, thought it was a dreadful mistake that flew in the face of clinical common sense. He ranked it as the second worst mistake within the DSM-5. In a 2012 NYT article, “Grief Could Join List of Disorders,” he said: “What I worry about most is that the revisions will medicalize normality and that millions of people will get psychiatric labels unnecessarily.”

A recent NYT article about the addition of PGD to the DSM, “How Long Should It Take to Grieve? Psychiatry Has Come Up With an Answer,” said the new diagnosis was meant to apply to a narrow section of the population whose struggles with bereavement and grief kept them from resuming their previous activities. Joanne Cacciatore, who runs a retreat for bereaved people and has written extensively on grief, said she utterly disagreed that grief could be a mental illness. “To me, that is an incredibly dangerous move, and short sighted.”

Ellen Barry, the author of “How Long Should It Take to Grieve?”, predicted the new diagnosis will most likely open a stream of funding for treatments, “and set off a competition for approval of medicines by the Food and Drug Administration.” She noted how Holly Prigerson other researchers are investigating naltrexone in clinical trials as a form of grief therapy. Donna Schuurman, an internationally recognized authority on grief, predicted in “The Grief Pill is Coming!” that it will become “another massive disappointment in a long line of pharmaceutical marketing deceptions.” Their hypothesis is that PGD is a disorder of addiction; and that patients with PGD continue to “crave” their loved ones after they have died, as a result of the positive reinforcement of their memories of loved ones.

The Origins of Prolonged Grief Disorder

The origins of PGD date back to the 1990s and the work of a psychiatric epidemiologist named Holly Prigerson. She was part of a research team examining the effectiveness of depression treatment in older adults. She noticed many individuals responded well to antidepressant medications, but seemed to be unaffected when she looked at the grief measures used in the study. Her observations were dismissed by psychiatrists on the research team. She was told grief was normal, but she didn’t ignore her observations; she did more research.

Her further research showed that for most people, symptoms of grief peaked at six months postloss, six months after the death. In “An Empirical Examination of the Stage Theory of Grief,” she said a depressive mood in normally bereaved individuals tended to peak around six months postloss. Yearning, not depressed mood was the significant psychological response to natural death. She suggested her findings should lead to a revision of the DSM.

The results also offer a point of reference for distinguishing between normal and abnormal reactions to loss. Given that the negative grief indicators all peak within 6 months, those individuals who experience any of the indicators beyond 6 months postloss would appear to deviate from the normal response to loss. These findings also support the duration criterion of 6 months postloss for diagnosing complicated grief disorder, or what is now referred to as prolonged grief disorder. Unlike the term complicated, which is defined as “difficult to analyze, understand, explain,” prolonged grief disorder accurately describes a bereavement-specific mental disorder based on symptoms of grief that persist longer than is normally the case (ie, >6 months postloss based on the results of the present study). Furthermore, prolonged grief disorder permits the recognition of other psychiatric complications of bereavement, such as major depressive disorder and posttraumatic stress disorder. Additional analyses are needed to examine grief trajectories among those meeting criteria for prolonged grief disorder.

So it seems that Prigerson’s work and that of others who built upon it, led ultimately to the recent action by the American Psychiatric Association making PGD a formal diagnosis. Around 5% of the population experience grief feelings which are profoundly different, longer-lasting and more harmful than the typical bereavement after the death of a loved one. And according to some mental health professionals, this grief can be reliably distinguished from other MH conditions such as depression or post-traumatic stress disorder. Maarten Eisma told Gizmodo, “It diverges from normal grief in its duration and intensity as well as in its impact on everyday life.”

Prigerson said the American Psychiatric Association “begged and pleaded” to define the syndrome conservatively as a year after death to avoid a public backlash. The concern was that everyone feels they still feel some grief at six months. “It just seems like you’re pathologizing love.” She estimated the criteria for PGD should apply to around 4% of bereaved people.

Those who oppose the new diagnosis seem to voice concerns similar to that of Allen Frances, that it gives individuals a diagnostic label unnecessarily; it medicalizes normal human grief experience. Joanne Cacciatore told Gizmodo that the diagnostic criteria for PGD unfairly targeted a subset of grieving people to be diagnosed with a mental illness. Her own research with bereaved parents suggested a majority could experience symptoms that could lead to a diagnosis of PGD or other psychiatric diagnoses up to four years after their child’s death. If this many parents can feel this amount of grief, “perhaps it is the measures that are flawed, not the grievers.”

For example, the criteria states that at one year, you can be diagnosed with PGD if you are intensely yearning for the person who died. What parent would not yearn for a child who died? Intense emotional pain? After such traumatic losses, what person would not feel intense emotional pain one year later?

Cacciatore thinks the diagnostic system is “absolutely broken, and we need an ethical change.” Psychological care should not depend soley on a diagnosis. She thinks we need better grief support education. We need more facilitators and facilities to care for people who are grieving.

Sheila Vakharia noted that in a world where thousands of Americans per week are dying in an ongoing pandemic, how can anyone’s grief over the losses they’ve experienced be considered abnormal? “For a diagnosis such as this to be released at this moment, it just feels tone deaf, and it feels decontextualized, both within the broader policy environment and with the fact that we are in a mass disabling and a mass death event—we’re in a global pandemic.”

For more information on diagnosing grief, see “The Death of Grief” and “Pathologizing Grief.”

02/25/20

Rethinking and Transforming Psychiatry

“We believe that a fundamental rethinking of psychiatric knowledge creation and training is in order.” This statement was made in a commentary published in the New England Medical Journal, “Medicine and the Mind—The Consequences of Psychiatry’s Identity Crisis.” The authors are two prominent Harvard researchers in psychiatry, Caleb Gardner and Arthur Kleinman, so their words cannot be dismissed as ‘anti-psychiatry.’ They went on to say biologic psychiatry has so far failed to produce a comprehensive theoretical model for any major psychiatric disorder. However, they think it would be “too great a loss,” to diminish its role drastically as suggested by Anne Harrington. Rather than contracting to an exclusive focus on biologic structure, “the field needs to expand if we are to meet the needs of real people.”

I have mixed feelings about their proposal. Their critique of biological psychiatry, the acknowledgment of over prescribing psychiatric medication, the abandonment of its social, interpersonal, and psychodynamic foundations are concerns I share. But they balked at Anne Harrington’s proposal in Mind Fixers to limit its scope to severe, mostly psychotic disorders. She said there is hardly any knowledgeable person who believes the so-called biological revolution of the 1980s made good on its therapeutic and scientific promises. “It is now increasingly clear to the general public that it overreached, overpromised, overdiagnosed, overmedicated, and compromised its principles.” If psychiatry needed to be rebuilt, as the authors said, won’t there have to be some dismantling first? Otherwise, there is a danger of building on an unstable, unreliable foundation.

Harrington pointed to how in 2013, just before the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Thomas Insel, who was then the director of NIMH, said the agency was re-orienting its research away from DSM categories; that is was critical to realize that “we cannot succeed if we use DSM categories as the ‘gold standard’” for diagnosis. He said it was like using the nature of chest pain or the quality of a fever to create a diagnostic system. Harrington said, “Put another way, there seemed to be little if any sound biology undergirding the psychiatric enterprise.”

In Psychology Today, Jonathan Shedler wrote, “A Psychiatric Diagnosis Is Not a Disease.” He said there was a circular logic to psychiatric diagnosis. “How do we know a patient has depression? Because they have the symptoms. Why are they having symptoms? Because they have depression.” He elaborated that psychiatric diagnoses were categorically different from medical diagnoses like atherosclerosis, myocarditis, or pneumonia, because they are descriptive rather than explanatory. “Medical diagnoses point to etiology—underlying biological causes.”

In an addendum, Shedler said he appreciated the lively discussion his article inspired. He was surprised by some of the comments, from individuals he assumed to be psychiatrists, who had impugned his credentials to discuss psychiatric diagnosis. But he took comfort in knowing that Allen Frances, MD, Chair of the DSM-IV Task Force, had the same view. Frances also said mental disorders were not diseases, but constructs. They were descriptive, rather than explanatory.

There was a study published in Psychiatry Research, “Heterogeneity in Psychiatric Diagnostic Classification,” that examined the heterogeneous nature of categories within the DSM-5, and its consequences for clinicians, clients and the diagnostic model itself. Heterogeneity was found in specific diagnostic criteria, including symptom comparators, duration of difficulties, indicators of severity, and the perspective used to assess difficulties. Each of the three researchers called for dismantling, not expanding DSM diagnosis.

The lead researcher of the study, Kate Allsopp, said for Medical Express: “Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice.” Peter Kinderman, another author, said: “This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose.” He added the diagnostic system wrongly assumed that all distress resulted from disorder. John Read, who was the third author, said: “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or of what kind of help we need when distressed.”

Psychiatric Times published an interview with Allen Frances for Conversations in Critical Psychiatry. Although he thought psychiatry was among the noblest of professions, “I fear that too many psychiatrists are now reduced to pill pushing, with far too little time to really know their patients well and to apply the rounded biopsychosocial model that is absolutely essential to good care.” He despaired that diagnostic inflation resulted in a too loose of a diagnostic system. “Diagnoses should be written in pencil, and under-diagnosis is almost always safer and more accurate than over-diagnosis.” With regard to epidemiological studies that tend to exaggerate rates of mental disorders, Frances said:

Never believe the extremely high rates of mental disorders routinely reported by epidemiological studies in psychiatry—usually labelling about 25% of the general population as mentally ill in the past year, about 50% lifetime. This entire literature has a systematic, but unacknowledged, methodological bias that inherently results in over-reporting. Because epidemiology requires such huge samples—in the tens of thousands—it is prohibitively expensive to conduct clinical interviews. Instead phone surveys are done by non-clinicians following a highly structured format that allows no clinical judgment whether the symptoms reported cause sufficient clinically significant distress and impairment to qualify as a mental disorder. Since there is no sharp boundary between normal distress and mental disorder, not assessing for clinical significance includes among those labelled mentally ill many who are merely distressed. The rates reported in studies are really only upper limits, not accurate approximations of true rates. They should be, but never are, reported as such.

His final word on DSM was: “DSM should be seen only as a tool helpful in guiding clinical judgment, not as a replacement for it.”

Returning to “Medicine and the Mind” by Gardner and Kleinman, psychiatrist Sandy Steingard said she shared their wish that research funding would be allocated to fields other than basic biologic research. But she was surprised they appeared to support buttressing psychiatry’s hold as leaders in research and program development. “I need some convincing that the problems we agree exist will be best addressed within my profession. In recent years, I have been most impressed by approaches to mental distress that emanate from outside of psychiatry.”

Finally, there was an article published in Public Understanding of Science that aimed to analyze the ‘critical reception’ of the DSM-5—how it has been received, discussed and criticized by different categories of people: “The Critical Reception of the DSM-5.” They noted two major themes surrounding the critical reception of the DSM-5, the pseudo-scientific nature of the manual and its normalizing power. Mental health professionals, especially psychiatrists, were more invested in the debate on the scientific nature of the DSM-5. There was a more eclectic variety of audiences in the debate over the normalizing power of the manual.

In the first debate (the scientific nature of the DSM), we found opposing argumentative positions regarding whether or not the manual is a scientific tool and questioning the type of science to which the manual adheres. In the second debate (the normalising power of the DSM), opinions were also polarised: while some argued that the manual was potentially socially harmful, some pointed out its lack of inherent agency and others mentioned its potential benefits. Although these debates have been noted in previous studies (Demazeux, 2015; Ecks, 2016), our research aims to deepen the understanding of such discussions.

They concluded the DSM was not simply a scientific manual. Rather, it is “a social laboratory where political, sociological, ethical and psychological issues are discussed and confronted.” In order to critically analyze the DSM, the authors said it was important to consider the claims that challenge the APA’s narrative of the DSM, namely its scientific and democratic nature. They said a range of arguments interacted and overlapped “in differing and opposing ways.” This was said to nuance the idea often presented academic publications that critiques of the DSM were mostly fixed, repeating the same themes and antagonistic positions.

The above issues were not being discussed in fringe, antipsychiatry forums. Rather, they appeared in well-received, medical and psychological arenas: The New England Medical Journal, Psychology Today, Psychiatry Research, Medical Express, Psychiatric Times, the National Institute of Mental Health. The people addressing them: Allen Frances, Thomas Insel, Caleb Gardner, Arthur Kleinman and others are or were key individuals within the mental health, psychiatric, diagnostic fields. The time is coming where just discussing the issues and concerns will not be enough; change will be necessary.

Psychiatry and diagnosis need to be reined in. They have extended their “reach” too far as it is, and scaling back is a necessary and essential step before any future recasting of the role of psychiatric treatment for mental “disorders.” Anne Harrington’s suggestion to limit its scope to severe, mostly psychotic disorders is a good first step. Dr. Joanna Moncrieff, a psychiatrist, seems to share this view. In “Rethinking Modals of Psychotropic Drug Action,” and “The Psychoactive Effects of Psychiatric Medication,” she proposed a “drug centered model” of drug action, rather than the existing “disease centered model,” whose core assumption is that psychotropic drugs help correct “a biochemical abnormality that represents a biological substrate of a specific disease process.”

In The Myth of the Chemical Cure, Moncrieff acknowledged abandoning the disease-centered model would challenge “some of the most fundamental principles of modern psychiatry.” Yet she said it would also open the way “to a more honest practice” that requires its own specialist knowledge, and implements a more democratic treatment process:

Adopting a drug-centred model of drug action would require psychiatrists to become more informed about the effects of different psychoactive drugs, and become attuned to evaluating the subjective experiences of their patients in a more equal and reciprocal relationship. Where their function was to participate in mechanisms of social control this would be openly acknowledged and rigidly controlled rather than veiled, as currently, under the cloak of medicine.

In “The Psychoactive Effects of Psychiatric Medication,” she pointed out how re-orienting drug therapy towards a drug-centered model raised some questions about the validity and relevance of diagnostic systems like the DSM-5. The idea that psychiatric drugs exert “a disease- or disorder-specific action” has been one of the principal justifications for modern psychiatric classification. Using psychiatric drugs explicitly for their psychoactive effects would require a different understanding of the nature of psychiatric problems. It would break the link between diagnoses and treatment, “and enable a frank discussion about the purpose and ethics of the already frequent ‘off-label’ use of prescribed psychoactive medications, such as their use for behavioral control in children and the elderly.”

Gardner and Kleinman were not advocating going this far, but I think psychiatry needs a transformation. Long live the transformation!

12/10/19

Patients Deserve Better Than the DSM

Even before the fifth edition of the DSM was published in 2013 there were serious critiques of its reliability and validity. The then Director of the National Institute of Mental Health (NIMH), Thomas Insel, said it was at best, “a dictionary, creating a set of labels and defining each.” He went on to say its strength was its reliability, meaning it provided a way for clinicians to use the same terms in the same way. Its weakness was that it lacked validity. “Patients with mental disorders deserve better.” However, two weeks later, in a joint press release, Insel and the President-elect of the American Psychiatric Association, Jeffrey Lieberman, issued a statement. They said the NIMH had not changed its position on DSM-5. The DSM and the International Classification of Diseases-10 (ICD-10) remain “the contemporary consensus standard for how mental disorders are diagnosed and treated.”

The NIMH had developed a new research strategy to classify mental disorders based upon “dimensions of observable behavior and neurobiological measures,” known as Research Domain Criteria (RDoC). The project was to “transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.” RDoC was described as the framework for collecting data to formulate a new nosology. Insel said they realized they could not succeed if they used DSM categories as the “gold standard,” so the NIMH would be “re-orienting its research away from DSM categories.” Yet Insel emphasized for now, RDoC was merely a research framework, not a clinical tool.

The situation has not changed much in the past six years. RDoC is still a research framework and the DSM-5 is still “the best information currently available for clinical diagnosis of mental disorders.” Dissatisfaction with the DSM-5 and perhaps some impatience with the promises of RDoC, led Jonathan Raskin, a psychology professor at SUNY New Paltz, to ask, “What Might an Alternative to the DSM Suitable for Psychotherapists Look Like?” Raskin has been previously critical of the DSM-5, co-authoring a previous article, “DSM-5: Do Psychologists Really Want an Alternative?”

In “What Might an Alternative to the DSM Suitable for Psychotherapists Look Like?” Raskin said there seemed to be an uneasy relationship between psychotherapists and the medical model of the DSM diagnostic system they use. While more than 90% of psychologists and counselors say they use the DSM-5 they also expressed support for the development of an alternative. Writing for Mad in America, Jessica Janze quoted him as saying:

By seeing human suffering as a function of broken brains, the DSM often overlooks the complex and mutually determining interplay of psychological, sociocultural, contextual, and biological factors … While the DSM does not completely ignore psychosocial factors, it typically treats them as extraneous variables that influence, but are distinct from, the presumed primary cause of emotional suffering: a dysfunction inside the individual.

Raskin was skeptical of RDoC, saying the approach was misguided, because “it may not be possible to diagnose and explain all forms of human suffering in terms of underlying biological processes.” This wasn’t to say biology was irrelevant. “Psychological, social, and contextual factors influence biology just as much as biology influences them.” An alternative manual should contain five elements:

Psychosocial factors are placed on equal footing with biological factors;
It must categorize problems, not people;
It must be scientifically grounded;
It must be collaboratively developed;
It must be usable across orientations, professions, and constituencies.

In “Heterogeneity in Psychiatric Diagnostic Classification,” Allsopp, Read and Corcoran analyzed five key chapters of the DSM-5 on ‘schizophrenia’, ‘bipolar disorder’, ‘depressive disorders’, ‘anxiety disorders’ and ‘trauma-related disorders.’ It was created to provide a common diagnostic language for mental health professionals and provide a definitive list of mental health problems, along with their symptoms. But the authors found that the psychiatric diagnoses all used different decision-making rules to codify the respective lists and their symptoms. There was a significant overlap of symptoms between diagnoses. And they told little about the individual patient and what treatment they needed. Neuroscience & News Research said: “The authors conclude that diagnostic labeling represents ‘a disingenuous categorical system.’”

Kate Allsopp said while the diagnostic labels created the illusion of an explanation, “they are scientifically meaningless and can create stigma and prejudice.” She hoped their findings would encourage mental health professional to think beyond diagnoses and consider other explanation of mental distress. Peter Kinderman said the study provided more evidence the biomedical diagnostic approach in psychiatry is not fit for its purpose. “Diagnoses frequently and uncritically reported as ‘real illnesses’ are in fact made on the basis of internally inconsistent, confused and contradictory patterns of largely arbitrary criteria.” It seems to assume all distress results from disorder, and relied heavily on “subjective judgments about what is normal.” Professor John Read concluded: “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or of what kind of help we need when distressed.”

The Superior Health Council of Belgium published “DSM(5): The Use and Status of Diagnosis and Mental Health Problems” in June of 2019. The Report said there were several problems with the DSM and ICD and they recommended both be used with caution. DSM categories should not be at the center of care planning. At a clinical level, classifications do not provide a picture of symptoms, nor do they help manage needs and prognosis, “because they lack validity, reliability and predictive power.”

From an epistemological point of view, classifications are based on the assumption that mental disorders occur naturally, and that their designations reflect objective distinctions between different problems, which is not the case. The boundaries between people with a disease and those who are free from it are more dimensional than categorical.

The Report recommended a “multi-layered” diagnostic process, starting with a narrative description of the individual’s symptoms. These symptoms should then be re-contexualized, classifying them on the basis of a limited number of general syndromes. And finally, they should discuss these symptoms in terms of a continuum from crisis to recovery in order to assess the need for care, the level of crisis and the recovery perspective. Diagnoses should remain as working hypotheses and DSM and ICD use should be limited to broader categories of disorders. “Disorders should not be considered as a static characteristic, but rather as interactive.” Diagnostic labels should be used with caution.

It seems psychiatry is facing another crisis like that which occurred in the 1970s with Rosenhan’s classic “Being Sane in Insane Places.” Critiques of the validity and reliability of the most recent edition of the DSM have not faded and seem to be gaining more credibility. The Superior Health Council of Belgium said the diagnostic labels of the DSM-5 lack predictive power and should be used with caution. Yet it is “the contemporary consensus standard for how mental disorders are diagnosed and treated.” Paraphrasing the words of Thomas Insel: “Patients with mental disorders deserve better” than the DSM.

For more on concerns with psychiatric diagnosis, the DSM-5 and RDoC on this website, try: “The Quest for Psychiatric Dragons, Part 1,” “The Quest for Psychiatric Dragons, Part 2,” “Psychiatry Has No Clothes” and “Psychiatry’s Mythical Phoenix.”

02/19/19

The Death of Melancholia, Part 2

Dr. Bernard Carroll died of lung cancer on September 10, 2018. The New York Times heralded him as the “conscience of psychiatry,” but the work that brought him that label happened later in his professional career. At the youthful age of 28, he published a paper, “Resistance to Suppression by Dexmathasone of Plasma 11-O.H.C.S. Levels in Severe Depressive Illness,” that essentially argued there was a “blood test” for severe depression. The dexamethasone suppression test (DST) measures the body’s ability to suppress cortisol, a stress hormone. But it was too late. Melancholia had already died at the hands of Emil Kraepelin.

In a 1968 article in the British Medical Journal, Dr. Carroll announced that when the test was administered to people with the severest species of depression — a paralyzing gloom then called melancholia, or endogenous depression — their bodies were shown to have trouble suppressing the hormone. People with other kinds of mood disorders had normal scores.

He thought it could be a confirmatory test for a diagnosis of depression—not as a way to actually make a diagnosis in the first place. But nothing happened. The DSM was in the midst of an extreme makeover as psychiatry fought for survival (See “The Quest for Psychiatric Dragons” Part 1 and Part 2 for more on this). Its architects weren’t interested in two distinct kinds of depression. Melancholia was lumped into “major depression” with several other mild and moderate disorders. Edward Shorter said:

Barney’s application of the DST to serious depressive illness was a huge step forward in establishing a biological base for serious depression. . . . It identified a biologically homogeneous group of serious depressives that could then be studied with the tools of molecular biology . . . . [But] the DST was pushed aside before anyone had a chance to do this, and one of the few biological tests in psychiatry has since then lain fallow.

Melancholia had successfully separated from the Hippocratic theory of humors by the late nineteenth century, and was gathering credibility as a distinct mood disorder. However, “Emil Kraepelin … killed off melancholia and prompted its replacement with depression.” In How Everyone Became Depressed, Edward Shorter carefully documented how this took place between the fourth and eighth editions of Kraepelin’s book, Psychiatry: A Textbook for Students and Physicians. By 1913 Kraepelin had convinced himself that what were presented as separate illnesses were instead “a single disease process.” He said: “It is, as far as I know, entirely impossible to discern any particular boundaries among these individuals clinical pictures, that until now have been separate.”

Shorter said Kraepelin’s influence in renaming melancholia “depression” was enormous. But alone, it was not enough to explain how “everybody became depressed.” Freud and the influence of psychoanalysis upon American psychiatry would also play a crucial role. Ironically, Freud had little interest in depression and only wrote about it within one paper, “Mourning and Melancholia” in 1916. It was one of his disciples, Karl Abraham, who wrote about depression as a neurosis, rather than about melancholia or manic-depression. Abraham thought depressive affect to be as widespread as anxious affect, with both conditions often occurring in the same person. “This was the beginning of neurotic depression as a diagnosis separate from the other big depressive illnesses.”

Otto Fenichel then became a central figure in the acceptance of neurotic depression among psychoanalysts. In his book Outline of Clinical Psychoanalysis, written in 1933, he commented how all varieties of neuroses could develop depression. After moving to Los Angeles in 1938, his revised and expanded edition said: “Neurotic depressions are desperate attempts to force an object to give the vitally necessary [narcissistic] supplies, whereas in the psychotic depressions the actual complete loss has really taken place and regulatory attempts are aimed exclusively at the superego.”

To understand why depression became such a huge diagnosis, we thus have the role of psychoanalysis, the thread that begins with Karl Abraham and passes through the émigré analysts, to make depth psychology such a popular conveyor belt for neurotic depression. It is almost unimaginable to us today that psychoanalysis once represented the very heart and soul of psychiatry.

Meticulously, Shorter then traced the wanderings of neurotic depression through the maze of psychoanalysis and its importance to American psychiatry. Depression had become a significant diagnosis by the time of World War II. “By World War II depression had become the standard term for any accumulation of symptoms involving fatigue, anxiety, and so forth. But this was a depression that was far from melancholia.” Many of the patients who received the diagnosis did not appear depressed. A psychiatrist at the University of Toronto said in 1952: “An outstanding feature of mild depression is that the patient rarely complains of feeling depressed and often does not appear particularly despondent.”

Then in 1974 the American Psychiatric Association chose Robert Spitzer to chair the Task Force to revise the DSM-II. He was a junior figure who at the time had developed an interest in the classification of psychiatric disorders. Shorter said he had little exposure to clinical psychiatry “and did not have that deep intuitive understanding of psychological illness that many senior clinicians acquire.” His strong will and determination to impose his own ideas infuriated other Task Force members and made him difficult to work with. Melvin Sabshin said:

Dr. Spitzer had had an immense degree of effort and dedication to the process of developing a new nomenclature. The problem in that, however, has been that Dr. Spitzer has not necessarily thought through how one goes about educating psychiatrists or other mental health professionals and is so exceedingly sensitive to any negative input (to which he responds as if there were an attack on his knowledge, integrity, etc.) that it is difficult to deal with him.

Shorter said Spitzer saw himself in a political, not a scientific battle in formulating the DSM-III. The goal was to win, not necessarily to establish scientific exactness. Above all he wanted to triumph over the despised psychoanalysts. He was determined to exterminate the diagnosis neurotic depression, which had become a favorite of the analysts. “He negotiated a number of political concessions that made little scientific sense.”

Spitzer had collapsed the two depressions of melancholia and nonmelancholia, in use in psychiatry for over two centuries, into a single depression, called major depression, and ensured that it was the only diagnosis you could get into unless you were seeing a psychoanalyst and could qualify for neurotic depression. Major depression, often simply called “depression,” went on to become the diagnosis of one-tenth of the United States population.

Max Fink, one of the pioneers of biological psychiatry commented on the paradigm shift from manic-depression to major depression: “When it was manic depressive illness, it was a small number of people. When it became major depression . . . 50 percent of the people are depressed. That’s absurd. That means there’s something wrong with the label.”

12/18/18

The Death of Grief

The field of psychiatric diagnosis suffered a significant loss in the spring of 2013 with the death of the bereavement exclusion. It was not a peaceful ending, as several experts fought desperately to keep it alive within DSM-5. But the efforts of psychologists like Joann Cacciatore and psychiatrists such as Allen Frances were not successful. The American Psychiatric Association published the DSM-5 without the bereavement exclusion and effectively eliminated any diagnostic distinction between bereavement and major depression. Grief, for all intensive purposes, was dead.

Dr. Joann Cacciatore, a psychologist who specializes in counseling individuals affected by traumatic death, lamented this passing in her article, “The Death of Grief, the Birth of Mental Illness.” She said: “Grief is not a disease, it is not an illness, it is not depression. It is in fact, an expression of love. Grief can only be a disease if love is.” She noted how the change increased the likelihood that grief would be misdiagnosed as Major Depressive Disorder and then mistakenly treated with psychotropic medications. “There is no sound evidence that they are effective for grief. Research shows that bereaved parents are already medicated earlier than can be justified by current evidence.”

We are saddened and disappointed by the recent announcement that the DSM-5 task force has finalized the decision to eliminate the bereavement exclusion from the Major Depressive Disorder diagnosis in the upcoming edition of the manual. This move will allow clinicians, including counselors, general physicians, social workers, and psychiatrists, to diagnose a major mental disorder in bereaved parents and other grieving individuals as early as two weeks following the death of a loved one should they meet the DSM-5’s criteria for depression. Importantly, many of you will recognize these criteria which include sadness, feelings of emptiness, crying, sleep and weight changes, guilt and regrets, and loss of interest or energy. Yet, all of these symptoms are quite common in grief, and particularly after the death of a baby or child which evokes enduring and intense reactions in parents.

Allen Frances, a psychiatrist and chair of the DSM-IV, repeatedly pleaded with the APA to not medicalize grief in “Last Plea to DSM 5: Save Grief from the Drug Companies.” He even ranked it as the second worst mistake within the DSM-5. He noted it would be a “bonanza for drug companies, but a disaster for grievers.” Frances referenced and quoted the concerns of Joann Cacciatore, Russell Friedman (the co-founder of The Grief Recovery Institute Educational Foundation) and Jerry Wakefield, a professor of Social Work. Frances said: “The DSM 5 medicalization of grief has been opposed by editorials and scientific papers in the major medical and scientific journals, by hundreds of newspaper articles.”

After 40 years and lots of clinical experience, I can’t distinguish at two weeks between the symptoms of normal grief and the symptoms of mild depression- and I challenge anyone else to do so. This is an inherently unreliable distinction. And I know damn well that primary care doctors can’t do it in a 7 minute visit. This should have been the most crucial point in DSM 5 decision making because primary care docs prescribe 80% of all antidepressants and will be most likely to misuse the DSM 5 in mislabeling grievers. . . . Grief is a normal and inescapable part of the human condition, not to be confused with psychiatric illness. Let us respect the dignity of mourning and treat it medically only when it becomes melancholia.

Another eminent psychiatrist, Ronald Pies, disagreed with Allen Frances. He believes eliminating the bereavement exclusion was a reasonable decision. Pies said grief and depression are distinct constructs and bereavement does not “immunize” the person from major depression. He said the bereavement exclusion was removed from the DSM-5 for two main reasons: 1) major depression is potentially a lethal disorder, “with an overall suicide rate of about four percent”; and 2) there is no clinical or scientific evidence to distinguish bereavement-related grief from major depression. “Disqualifying a patient from a diagnosis of major depression” after the death of a loved one “closes the door on potentially life-saving interventions” (meaning medication).

It is important to understand that the DSM-5 criteria merely allow the diagnosis of MDD when the recently bereaved person meets all required symptom, severity, duration, and impairment criteria for MDD. Nothing in the manual compels a diagnosis of MDD shortly after bereavement.

In conclusion, Pies said while normal grief should not be medicalized, neither should major depression be normalized simply because it occurred “in the context of recent bereavement.” Dr. Pies seems to be arguing that the problems of a “falsely positive” in diagnosis of major depression in the context of bereavement are outweighed by the dangers from a “false negative” in diagnosis. Yet there are some who would strongly dispute this conclusion. Instead they see removing the bereavement exclusion as an example of how psychiatry relentlessly seeks to expand its reach.

In “Elimination of the Bereavement Exclusion: History and Implications,” psychologist Philip Hickey gave a history of the DSM and how the bereavement exclusion was first added, then whittled away over time. He noted how the DSM-I did not suggest its “disorders” were chemical imbalances or “illnesses-just-like-diabetes.” Rather, the “disorders” were conceived as reactions of the personality and believed to be of “psychogenic origin.” Hickey then gave a couple of quotes from the DSM-I illustrating his point.

The emphasis on psychological explanations was not merely a reflection of Adolf Meyer’s influence, but a reflection of the fact that a great many psychiatrists at that time (1952) subscribed to this position and were entirely comfortable with these types of psychoanalytic explanations.

But the introduction of antipsychotic and antidepressant medications in the 1950’s changed things. They offered a pathway to “prima facie medical legitimacy.” What was needed was a label that posed as a diagnosis; time for a 15-minute med check; and a quickly-written prescription. “No longer would it be necessary to delve collaboratively and time-consumingly into a client’s childhood conflicts, current fears, or counter-productive relationships.” Don’t be too quick to dismiss Hickey’s rhetoric. In an address to the American College of Neuropsychopharmacology in 2000, Allen Frances said the DSM system and psychopharmacology grew up together “and have had a strong influence upon one another.”

The psychopharmacological revolution required that there be a method of more systematic and reliable psychiatric diagnosis. This provided the major impetus for the development of the structured assessments and the research diagnostic criteria that were the immediate forerunners of DSM-III. In turn, the availability of well-defined psychiatric diagnoses stimulated the development of specific treatments and increasingly sophisticated psychopharmacological studies.

Hickey said as more psychiatric drugs came to market in the 1960s, “it became increasingly clear the psychogenic framework of the DSM-I had to go.” Thus a movement to develop a cause-neutral diagnostic system began with the DSM-II and continued on through the DSM-III under the guidance of Robert Spitzer. The concept of cause-neutrality, according to Hickey, meant that: “regardless of why a person is despondent, if he scores five or more yeses on the checklist, he has major depression, the ‘illness,’ and therefore needs medical treatment.” Over time, as the use of DSM diagnostic criteria became central to the conceptualization of depression and grief, the bereavement exclusion included by Robert Spitzer in the DSM-III seemed more and more problematic for mainline psychiatry. And bereavement as a cause of grief-related depression became increasingly irrelevant.

The death of grief is inversely related to the birth and growth of what Hickey called the biological-pathology perspective. The bereavement exclusion was finally pronounced dead with the publication of DSM-5 in 2013. “The bogus cause-neutral perspective (in reality the bogus biological-pathology perspective) was now the de facto psychiatric position, with no exceptions.”

The notion that one can gain an understanding of a person’s sadness by ignoring its causes and contexts, and simply bumping his superficial presentation against a fabricated checklist, and seeing if he scores hits on at least five, is simply inane. It’s like trying to understand a poem by counting the words. Anyone with the slightest compassion or understanding of human experience can see this.

For more on the concerns with psychiatric diagnosis see: “Where There’s Smoke …” and “Psychiatric Huffing and Puffing.” For more on the APA actions on bereavement, see: “Pathologizing Grief.”

02/24/17

Misdiagnosing Substance Use

Allen Frances doesn’t like the DSM-5 and you can hear him say so here. He said our mental health system was in a mess. And he is afraid that with DSM-5, it will get even worse. “People who are essentially normal are being diagnosed with mental disorders they don’t have.” Small changes in the diagnostic system can result in tens of millions of normal people qualifying for a diagnosis. He used himself as an example, stating how he would qualify for several of the DSM-5 disorders. Typical symptoms of grief over his wife’s death, lasting beyond two weeks, would have signified him as having a Major Depressive Disorder.

Anther mistake was combining what had been two different diagnoses of substance use in the DSM-IV—Substance Abuse and Substance Dependence—into one: Substance Use Disorder. Substance Abuse was when someone had recurrent, but intermittent, trouble from recreational binges. Substance Dependence was a continuous and compulsive pattern of use, often with tolerance and withdrawal. The majority of substance abusers “never become addicted in any meaningful sense.”

The two DSM IV diagnoses have radically different implications for treatment planning and for prognosis. Artificially lumping them together in DSM-5 forces inaccurate diagnosis, loses critical clinical information, and stigmatizes as addicts, people whose substance problem is often temporary and influenced by contextual and developmental factors.

Hasin et al., “DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale,” presents the rationale used by the DSM-5 workgroup for substance use disorders for its changes, particularly combining abuse and dependence into one disorder. They recommended the combination as well as dropping one diagnostic criteria (legal problems) and adding one (craving). Two criteria are required to diagnose a Substance Use Disorder. The number of criteria met will indicate mild (2 to 3 criteria), moderate (4 to 5), and severe disorders (6 or more). The following chart, taken from the article, illustrates the changes from DSM-IV to DSM-5.

Frances is not alone in seeing value with two distinct types of substance use disorder. Carleton Erickson in The Science of Addiction noted how the distinction allowed for the differentiation between individuals with drug-related problems who could stop using when they wished (substance abusers), and others who had the disease of chemical dependence. Chemically dependent people have a dysregulation of the mesolimbic dopamine system and generally cannot stop using drugs without intensive intervention into their drug use problems. “According to these criteria, drug abuse in intentional, ‘conscious,’ or voluntary. Drug dependence is pathological and unintended.”

In his article, “DSM-5 Made a Mistake Eliminating Substance Abuse,” Allen Frances indicated the DSM-5 workgroup for substance use disorders based its rationale for dropping Substance Abuse on studies suggesting the distinction was hard to make. He said the results of the studies were not definitive. Moreover, their interpretation was flawed by what he said was a basic DSM-5 misunderstanding of the nature of psychiatric diagnosis. “All DSM disorder overlap with other DSM disorders and also frequently with normality.” Fuzzy boundaries among near diagnostic neighbors are common and not a sufficient excuse to collapse clinically valuable distinctions.

Carleton Erickson’s discussion of the degrees of severity with drug problems helps to illustrate this misunderstanding. He indicated there were mild, moderate and severe forms of both drug abuse and drug dependence. Most people don’t think in terms of severity with substance use problems. You either have a problem or you don’t; you either abuse drugs or you don’t. He then illustrated their relationship to drug-seeking behavior as follows.

Drug Abuse	Drug Dependence	Drug-Seeking
Mild		Little/None
Moderate		Some
Severe	Mild	A Lot
	Moderate	Even more
	Severe	All the Time

The overlap referred to by Frances occurs between severe drug abuse and mild drug dependence. The inability of psychiatric diagnosis to make a clear distinction here seems to have led to the decision to collapse the abuse and dependence diagnoses into one category in the DSM-5.

I think another overlap between drug abuse and drug dependence happens with regards to self-control. A distinction is necessary between self-control of thoughts, feelings and behavior when drinking and control of the drug intake itself. Any substance use can lead to a loss of self-control over an individual’s thoughts, feelings and behavior. When that loss of control results in recurrent, intermittent trouble, there is a drug abuse problem. The severity of this type of loss of self-control and the related intermittent trouble varies.

Not everyone who abuses a drug experiences the classic sense of losing of control over how much of the drug they use. A loss of control over drug intake—a continuous and compulsive pattern of use—is only evident within drug dependence. And again, the severity of this loss of control over drug intake varies. So I’d adopt Erickson’s degrees of severity with drug abuse and dependence problems as seen below.

Loss of Self-Control in Abuse	Loss of Control over Drug Intake in Dependence
Mild
Moderate
Severe	Mild
	Moderate
	Severe

A substance abuse problem with severe trouble related to loss of self-control may be indistinguishable from a substance dependence problem with mild loss of control over drug intake. Both people would look at their severe “trouble” and attribute it to drinking or drugging too much. Given an equal motivation to avoid further “trouble,” the substance abuser would likely have an easier time maintaining abstinence. Carleton Erickson said chemical dependence is not a “too much, too often, withdrawal” disease; it’s a “I can’t stop without help disease.” There is a pathological, compulsive pattern to substance use.

There does seem to be a “fuzzy boundary” between Substance Abuse and Substance Dependence. Nevertheless, the distinction still carries some clinical and diagnostic value. I agree with what Allen Frances said: “The change was radical, creates obvious harms, and provides no apparent benefit.” What should clinicians do? Frances suggested they simply ignore the DSM-5 change. He said it was appropriate and clinically preferable to continue making the distinction.

There is nothing sacred or official about the DSM-5 choices — I know because I made the choices for DSM-IV. The ICD coding system is official; the DSM codes are just one groups’ fallible adaptation of them. It is of great significance that the official coding in ICD-10-CM does not follow the DSM-5 decision to eliminate Substance Abuse. Instead, ICD-10-CM retains the DSM-IV terminology and continues to provide separate Substance Abuse and Substance Dependence codes for each of the major classes of substances.

The ICD-11 workgroup, currently in the final stage of development before field tests, will continue to separate Substance Dependence and Harmful Substance Use. The guidelines for dependence are revised and simplified into three diagnostic features: impaired control over substance use; increasing priority in life and physiological features. Severity qualifiers were suggested only for alcohol intoxication. They also introduced a new diagnostic category, with no equivalents in ICD-10 or DSM-5: single episode of harmful use. Frances commented:

The DSM-5 mistake thus places it out of line with ICD-10, ICD-11, previous DSM’s, and well established clinical practice. Clinicians remain truer both to clinical reality and to ICD coding when they ignore the new DSM-5 lumping of substance use disorders and instead continue to distinguish Substance Abuse from Substance Dependence. DSM’s are explicitly meant to be used only as guides, not worshiped as bibles. Clinicians are free to ignore DSM whenever it makes mistakes that go against clinical common sense and the International coding system.

01/24/17

Herding Pharma “Cats”

The Chinese government released a report in September of 2016 by the State Food and Drug Administration (SFDA) that found fraudulent clinical trial practices on a massive scale. The SFDA concluded that over 80% of clinical trial data was fabricated. The scandal was the result of a “breach of duty by supervision departments and malpractice by pharmaceutical companies, intermediary agents and medical staff.” More than 80% of the applications for the mass production of new medications have been cancelled, with warnings by the SFDA that further evidence of malpractice might still emerge.

Radio Free Asia also reported the SFDA indicated much of the clinical trail data was incomplete at best. But it also failed to meet basic analysis requirements or was untraceable. “Some companies were suspected of deliberately hiding or deleting records of adverse effects, and tampering with data that did not meet expectations.” Apparently, this came as no surprise to industry insiders. “Clinical data fabrication was an open secret even before the inspection.”

Many of the new drugs were combinations of existing ones. Clinical trial outcomes were written beforehand, and their data presented so it agreed with the fabricated outcomes. A doctor at a top Chinese hospital said the problem lay with the failure to implement regulations governing clinical trial data. “Guangdong-based rights activist Mai Ke said there is an all-pervasive culture of fakery across all products made in the country.” Reporting for Pharmafile, Ben Hargreaves said:

The root of the issue is then not regulation, with regulation for clinical trials running on similar lines to Western practises, but in the lack of adherence to them. China’s generic drug industry has struggled with quality problems and therefore there is a temptation for companies to manipulate data to meet standards. The report found that many of the new drugs were found to be a combination of existing drugs, with clinical trials outcomes written beforehand and the data tweaked to fit in with the desire outcomes.

Sadly, clinical trial problems are not unique to China. An editorial published in the British journal The Lancet Psychiatry described multiple issues beginning with how subjects are recruited, moving on to determining what the control group should be, and ultimately defining meaningful outcome measures. Sometimes, trial recruits receive “care” they didn’t agree to. “Researchers and ethics review boards need to examine the ethical arguments and practical procedures from other areas of medicine where consent is problematic.” If such trials are done, regular and rigorous monitoring is essential. Patient safety and autonomy needs to be a priority.

In his discussion of the editorial, Justin Carter elaborated on one of the problems with recruiting subjects. An individual was recruited into a study on three antipsychotics while under a forced commitment order from a judge. “The psychiatrist who recruited him was in charge of the study and was his treatment provider and was also empowered to report on the patient’s progress to the judge.” The individual died by suicide during the drug trial.

The work of Irving Kirsch and others has shown the problem with inert placebos (sugar pills). The side effects from medication make it easy for participants to guess which study group they are in.

And when the trial is over and the data in, do the outcome measures really provide something meaningful for people’s lives? If the ultimate goal is for people to fell better and resume their prior level of functioning, should outcome measures by primarily patient self-reports, clinical assessment, or differences shown by imaging or the as-yet-to-be-clearly-identified biomarkers?

Given the problems running and interpreting psychiatry trials, it is essential to learn how even the most successfully tested interventions work in real clinics with the broad patient population. Implementation, uptake, and effectiveness in real-life settings must be analysed, and delivery of new innovations modified accordingly. Future research should be thought of not as a plain linear process from innovation to trial to implementation, but as a virtuous circle where research feeds into the clinic and vice versa.

Another issue pointed to by Carter was the validity and reliability of the diagnosis or classification system used to determine who to include and who to exclude from the trials. The DSM system, now in its fifth edition (DSM-5), is the current “bible” for assessing and diagnosing problems the psychiatric medications in clinical trials are supposed to “treat” in the U.S. Yet there have been questions about the reliability and validity of the DSM dating from an argument raised by Robert Spitzer and others in the 1970s that ushered in changes still embedded in the DSM-5. Rachel Cooper gave a brief history of the reliability questions with the DSM in “How Reliable is the DSM-5?” You can also refer to “Psychiatry Has No Clothes,” “Where There’s Smoke …”, and “The Quest for Psychiatric Dragons,” Parts 1 and 2.

A few weeks before the release of the DSM-5, Thomas Insel, then the NIMH Director, announced the NIMH would be “reorienting” its research away from DSM categories. The agency’s new approach is called the Research Domain Criteria (RDoC) project. For now, RDoC is a research framework and not a clinical tool. But NIMH has high hopes for it: “RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders.” While Tom Insel has moved on to work for Alphabet (Google), RDoC is alive and well within NIMH. You can keep up with news about RDoC on the “Science News About RDoC.”

The Science Update for February 16, 2016 noted the March 2016 issue of the journal Psychophysiology would be devoted to the RDoC initiative. Dr. Bruce Cuthbert said the special issue was a unique opportunity for researchers to engage with one another and reflect on work being done in various laboratories throughout the country. He thought it was encouraging to see many investigators already engaged in the kind of work RDoC advocates. “What this shows is that while the RDoC acronym may be new, the principles behind RDoC are certainly not new to psychiatric research.”

If the principles behind RDoC are not new to psychiatric research, how can it bring “a new generation of research to inform how we diagnose and treat mental disorders” in order to transform clinical practice? It sounds a lot like using the same deck of cards to just play a new card game. RDoC may not be the transformative framework it’s touted to become.

Added to these issues is the failure of pharmaceutical companies to publically report the results of clinical trials, as they are required by law to do. New reporting rules will take effect on January 18, 2017. But advocates for transparency in clinical research have cautioned the success of the new rules will depend upon the willingness and vigor of government enforcement of those rules. The failure to enforce the existing rules, which went into effect in 2008, led to widespread noncompliance with reporting requirements. If the FDA had fined the violators, they could have collected an estimated $25 billion.

Reporting for STAT News, Charles Piller said studies have indicated only a small fraction of trials will comply with the law. Yet there are no current plans to increase enforcement staffing at the FDA and NIH. That’s a big problem, according to Ben Goldacre, an advocate for full disclosure in clinical research. Francis Collins, the NIH director said they are serious about this and will withhold funds, if needed. “It’s hard to herd cats, but you can move their food, or take their food away.”

The legislation that created ClinicalTrials.gov emerged from numerous cases of drug manufacturers withholding negative trial results, making drugs look more effective and less harmful. Efforts to market the antidepressant Paxil for teenagers more than a decade ago stimulated the push for better reporting. A recent analysis in the journal BMJ found that GlaxoSmithKline, Paxil’s manufacturer, failed to disclose 2001 data showing the drug to be no more effective than a placebo, and was linked to increased suicide attempts by teens.

Writing for Time, Alexandra Sifferlin reported on a new study that suggested many of the medical reviewers for the FDA go to work for the drug companies they oversaw while working for the government. One of the study’s authors said: “I don’t think there is overt collusion going on, but if you know in the back of your mind that a major career opportunity after the FDA is going to work on the other side of the table, I worry it can make you less likely to put your foot down.”

Returning to the Francis Collins metaphor, it seems that the willingness to try and herd Pharma cats is dependent on whether or not you are afraid they will scratch you in the attempt.

07/15/15

Pathologizing Grief

In January of 2015, an article on “Complicated Grief” was posted in The New England Medical Journal blog. The author described complicated grief as “intense grief after the death of a loved one that lasts longer than expected according to social norms and causes functional impairment.” While it was said that psychotherapy is a first-line treatment, the author reported that antidepressant medication is commonly used. This is just the latest stage in a rather complicated refashioning of grief from a normal human experience into a mental disorder.

The symptoms of complicated grief were said to be: “persistent, intense yearning, longing, and sadness.” Along with these “symptoms” can be a sense of disbelief or failure to accept the reality of the person’s death. Persistent thoughts or images of the deceased can occur. Ruminating on the circumstances of the death, with feelings of anger or guilt was said to be common. Avoiding situations that remind the person of the loss is common. Holding on to the deceased by repeated reminiscing, viewing, touching or smelling the deceased person’s belongings can occur as well.

People with complicated grief often feel shocked, stunned, or emotionally numb, and they may become estranged from others because of the belief that happiness is inextricably tied to the person who died. They may have a diminished sense of self or discomfort with a changed social role and are often confused by their seemingly endless grief.

Complicated grief is not a psychiatric diagnosis, although you wouldn’t know that from reading the above description. It explicitly uses diagnostic-like language in its discussion in an attempt to gain legitimacy for “Prolonged Grief Disorder” to be included in the International Classification of Diseases, 11th edition, due for release in 2017. The boat has passed on inclusion in the DSM, which went through its own controversy over grief when the DSM-5 removed the bereavement exclusion (BE) from the existing Major Depression Disorder (MDD) in 2013.

Within the DSM, the bereavement exclusion meant that a diagnosis of MDD could not be made if the loss of a loved one was a better explanation for the observed symptoms of depression. However, the time frame to avoid the grieving process from qualifying as MDD has been progressively shrinking. Within the DSM-III, the BE was one year; within the 4th edition, it was two months. Now in the DSM-5, bereavement is no longer an excuse. If you meet the diagnostic criteria for MDD over a two-week time period, you are just as depressed as anyone else, according to the DSM.

Joanne Cacciatore, who has specialized in the psychotherapeutic treatment of grief and bereavement for almost twenty years, has been an outspoken critic of these changing guidelines and pseudo-diagnoses. In March of 2012 she wrote an essay opposing the proposed elimination of the BE from the DSM-5. Her eloquent essay reached 100,000 readers in two weeks. She stated her opposition to both of the above ‘time limits’ for grief, and pointed to the historical movement of the DSM to medicalize normal human emotion. She said:

We should not, ethically or morally, medicalize grief. To do so is to medicalize love. We rarely mourn for that which we do not love. I can only begin to imagine what the sages, and mystics, and shamans of the past might think of a society which does so.

Allen Frances was also openly critical of the DSM-5 and its changes with regard to bereavement. In his own blog on the Huffington Post in March of 2012, he published Dr. Cacciatore’s open letter to the Board of Trustees of the American Psychiatric Association. She pointed to the arbitrariness of the two-week time frame, stating that it not only contradicts common sense, but rests on weak scientific evidence. To her knowledge there was no empirical evidence to support it.

One thing in which the literature is clear: long-term psychological distress is common in this population and other populations suffering traumatic deaths. In my experience both as a researcher and clinician in the field and also as a bereaved parent, the DSM-5 proposal is radical, unnecessary, challenges what it means to be human, and for some may be dangerous.

But the APA was not moved. Frances tried again in January of 2013, as the DSM-5 was preparing to go to press at the end of the month. He said: “The American Psychiatric Association has just four more weeks to reverse this dreadful mistake that flies in the face of clinical common sense and is unsupported by the limited available science.” He put together his own top ten list of harmful changes in the DSM-5, and medicalizing grief was number two. In case you aren’t aware, Dr. Frances’ credibility in voicing these concerns come from his long career as a psychiatrist and as the person selected by the APA to chair the DSM-IV. He said:

After 40 years and lots of clinical experience, I can’t distinguish at two weeks between the symptoms of normal grief and the symptoms of mild depression — and I challenge anyone else to do so. This is an inherently unreliable distinction. And I know damn well that primary care doctors can’t do it in a 7-minute visit. This should have been the most crucial point in DSM-5 decision-making because primary care docs prescribe 80 percent of all antidepressants and will be most likely to misuse the DSM-5 in mislabeling grievers.

Returning now to the essay “Complicated Grief,” let’s look at Dr. Cacciatore’s response. She commented how the bereaved were again at risk of being diagnosed and “treated” for “absolutely normal feelings and experiences” after a painful and traumatic loss. Responding to the above description of complicated grief, she said:

Ha! Social norms? Around grief? Talk about pathology! Western culture’s “social norms” and expectations around grief, especially when traumatic, are as abnormal and avoidant as any society could get. The average bereavement leave is three days, many bereaved parents are medicated within days or weeks after a traumatic loss (even in the presence of data to suggest these medications can be harmful and iatrogenic), and mourners are expected, and then pressured, to get back to ‘life-as-usual’ often within weeks or mere months, even after traumatic death. And our social networks often fail as others’ tolerance wanes in the months and years that follow.

Perhaps there is better guidance for conceiving a time frame for grief and bereavement in the book of Ecclesiastes (3:1-8) than in the DSM. There the Preacher said there is a season and a time for everything under heaven. Notice that he doesn’t try and quantify “season” or “time.” A time to be born and a time to die; a time to weep and a time to laugh; a time to mourn and a time to dance; a time to keep silent and a time to speak. When weeping turns to laughing, when mourning is replaced by dancing, then the season of grief has run its course. However, when individuals attempt to pathologize human emotion by blurring the line between grief and psychiatric disorder, it is a good thing that people like Joanne Cacciatore and Allen Frances choose to speak up and not remain silent.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag: DSM