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Dear Allen Frances — how to reduce the “proclivity of the violent” 08/07/2012

Posted by ALT in DSM-5, Pharmaceuticals.
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Dr. Allen Frances.  We’ve been hearing his name a lot this past year, haven’t we? [and not in conjunction with his excellent tan!]

A fine specimen of “middle way” protesting, which poses as activsm for real psychiatric reform, but does little more than reinforce psychiatric treatment-as-usual, perhaps with a few Orwellian language shifts along the way.  Here’s an instructive string of emails to prove the point — no DSM protest unless it’s Dr. Allen Frances APPROVED DSM protest

Anyhow, in a recent blog for the Psychiatric Times (“Mass Murderer Psychobabble Misses Gun Policy Point“), he writes that “there is no indication that psychiatry can change the statistics of violence or the proclivity of the violent.”

I beg to differ, and wrote him an email to tell him so.

***

From: ALT
To: Allen Frances
Subject: Response to your recent “Psychiatric Times” Blog

Dear Allen Frances,

In a recent blog for the Psychiatric Times, you state that “psychiatry has no way to predict mass murder and no way to prevent it.”  Hammering the point home later on, you write that “there is no indication that psychiatry can change the statistics of violence or the proclivity of the violent.”

Sir, I believe you are in error.

As you may be aware, there are many examples of psychotropic medications (commonly prescribed by psychiatrists to their patients) which list “suicidality,” or “suicidal ideation,” “acting aggressive, being angry, or violent,” “agitation,” and “mania,” as side effects in the Physician’s Desk Reference [PDR], a publication of the official FDA-approved labeling and information for all drugs.  A violent combination of effects, don’t you agree?

For example, clonazepam (Klonopin) and lorazepam (Ativan), two common benzodiazepines, list “suicidal ideation” or “potential to commit suicide” as a side effect.  Doctors are also cautioned about “paradoxical effects” – which could include aggression and hostility.  The Medication Guide for Serqouel, an antipsychotic medication, lists “thoughts of suicide or dying,” “feeling very agitated or restless,” “new or worse irritability,” “acting aggressive, being angry, or violent,” “acting on dangerous impulses,” and “mania” as symptoms that may occur in conjunction with use of Seroquel – something to be brought up with a doctor immediately.  And, perhaps most well-known of all, selective serotonin reuptake inhibitor [SSRI] antidepressants such as paroxetine (Paxil), fluoxetine (Prozac), and citalopram (Celexa) carry a black box warning about the potential to cause suicidality in children, adolescents, and young adults.   Furthermore, a 2004 booklet published by the FDA (which is also inserted at the end of every antidepressant entry in the PDR) lists, under a heading entitled What to Watch Out For in Children or Teens Taking Antidepressants: “thoughts about suicide or dying,” “attempts to commit suicide,” feeling very agitated or restless,” “acting aggressive, being angry, or violent” as potential side effects. 

The list of psychotropic drugs indicated in causing restlessness, agitation, aggression, suicidality, and violence goes on, as I’m sure you know.

There is also a legal precedent acknowledging the reality of drug-induced suicidality and homicidality.  Are you familiar with the case of Tobin v. SmithKline Beecham?  Donald Schell, a 60-year-old man with no psychiatric history, was having trouble sleeping.  His physician prescribed him Paxil, and 48 hours later he murdered his wife, daughter, and granddaughter—then shot himself.  The court awarded $8 million in damages and wrote in its opinion that “Paxil can cause some individuals to commit suicide and/or homicide,” and that “Paxil was the proximate cause of the homicides and suicides involved in this litigation.”*

You may be interested to know that the legal definition of proximate cause is “the primary cause of injury… proximate cause produces particular, forseeable consequences without the intervention of any independent or unforeseeable cause.”**

In other words, the court ruled that Paxil was the primary cause of Schell’s violent actions, and this was a forseeable consequence of his taking Paxil.

Bearing all of this in mind, I think the statement that “there is no indication that psychiatry can change the statistics of violence or the proclivity of the violent” is erroneous.  There is, in fact, something very simple psychiatrists can do:

stop prescribing drugs that, by their manufacturers’ own admissions, cause people to become aggressive, angry, violent, and suicidal.
 

Yours truly,

ALT

Mental health activist and writer
Not a member of the Church of Scientology
Not an “antipsychiatrist” (very much pro- “soul healing,” in fact)
 
 

 
* Tobin v. SmithKline Beecham Pharmaceuticals, 164 F.Supp.2d 1278, 1284.
** West’s Enyclopedia of American Law, Second Edition. (2008).

One psychiatrist’s change of heart – a template for broader psychiatric reform? 05/23/2012

Posted by ALT in DSM-5, Mental Health News.
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4 comments

Meet Dr. Robert Spitzer. 

 

This man has recently done something no other psychiatrist [to the best of my knowledge] has done: when confronted with an insurmountable critique of a view he had previously defended vehemently as “scientific,” he admitted he was wrong.  Publicly

And then he said he was sorry. 

Well done, sir.

On Monday, the New York Times ran a story about Spitzer’s public apology for the publication of a 2001 study claiming to prove that so-called “reparative” or “conversion therapy” is effective – some of the time, with highly motivated individuals —  in enabling homosexual individuals to “change” their sexual orientation to heterosexual. 

I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works.

- Dr. Robert Spitzer; Professor Emeritus of Psychiatry, Columbia University [emphasis added]

This was big news nationally – for homosexuals, gay advocates, and also various religious and “family”-oriented groups who have been using that “Spitzer 2001” citation for years to promote conversion therapy.

But I think this news is bigger than big (huge, even!) for the mental health advocacy community.  If we can understand Spitzer’s reasons for apologizing, and his path to doing it so publicly and with such grace, we will be one giant step closer to eliciting other much needed apologies in psychiatry, to bridging the gap between psychiatric professionals and patients.  A “truth and reconciliation” between psychiatry and its survivors is a real possibility, if more apologies are forthcoming.

Why did he change his mind?

On Monday, Spitzer gave a brief interview on NPR’s Talk of the Nation.  When bluntly asked, “Why did you change your mind?” he replied:

I changed my mind because I had been bothered for several years about it, and then when I was visited by Gabriel [gay journalist who had undergone conversion therapy]… and he described what it was like to be in therapy when he really didn’t get any benefit from it at all… and I just realized that I had to make – explain to people why I think I made a big mistake.

- Dr. Spitzer on NPR’s Talk of the Nation

Later guests on the show discussed some of the more “bothersome” aspects of the study.  It was rushed to publication and wasn’t “peer reviewed,” its data was not – really could not be – validated, as it was based entirely on self-reporting over the short term.

But more important were the philosophical and societal consequences of the study’s publication.  The legitimization of “conversion therapy” (which indirectly treated homosexuality as pathology)…

1. Was used by certain groups to perpetuate the stigmatization of homosexuals under the guise of “helping” them:

And what it [Spitzer’s study] allowed the Christian right to do is put a more benevolent face on anti-gay prejudice… Instead of angry denunciations from the pulpit, the Christian right could then say that they were actually caring for homosexuals, that they wanted to help gay people and that they wanted to help cure them.

- Gabriel Arana, gay journalist and activist

2.  Caused various homosexuals to internalize fundamentally negative, pathologized views of themselves

It [conversion therapy] stopped me from accepting myself, it lowered my self-esteem.  As I said earlier, it made me see myself as… as a leper without a cure.  And encouraging – I mean, and the premise of therapy is that there is something wrong with – fundamentally and innately wrong with the person, and if you can’t change it, then you’re sort of left with this disease that has no cure.  And I think that… affected [me] very much as a young adult.

- Gabriel Arana [emphasis added]

Regardless of your stance on homosexuality, I think the parallels to the broader debate about psychiatry are clear. 

Psychiatrists publish studies and papers in academic journals (about mental illness as brain disease, for example, or childhood bipolar disorder as a widespread and “undertreated” phenomenon, or the existence of such things as “dysphoric mood disorder,” “psychosis risk syndrome”, et al.) that are highly flawed, but touted as science.  This pseudoscience is used to legitimize various practices — like pharmacological intervention as first line treatment for mental distress, forced outpatient therapy, the DSM itself — that pathologize a variety of human experiences that simply ARE NOT pathologies in the strict sense of the word.  They’re not physical maladies of the body diagnosed by blood tests or other physical symptoms, their causes are not empirically known, they’re not like diabetes.  Countless people are taught to internalize the belief that a “biochemical imbalance” in the brain causes them to be fundamentally different from humanity – truly lepers without a cure – and only a semblance of normality is possible through pharmacology, symptom suppression, and denial of self.

To stand here before you as a person who ingested the intoxicating language of psychiatry and began to speak it as her own, who incorporated the clinical gaze and began to see herself entirely through its lens, brings a flood of emotions …  These emotions bring with them the pain that came with being labeled ‘abnormal’ and unacceptable by society for my most formative years; with carrying a diagnosis after my name that meant I would always be different, always fighting to appear like everyone else, struggling to manage life instead of living it.  I was bipolar, from my teenage years until age twenty-seven, and I was convinced it was all I ever would be.

 – psychiatric survivor and activist Laura Delano, in a speech at “Occupy the APA”

Psychiatric survivors are in a position very similar to that of the gay community after the publication of Spitzer’s 2001 study, except for the fact that many scholarly publications (including the DSM), faulty clinical trials, “treatment advocacy” organizations, and public institutions are replicating the same kind of errors and prejudices, day after day.  An unrelenting campaign of stigmatization and “for your own good” interventionism. 

An apology is long overdue.

If he’s in the mood for apologizing…

Maybe Dr. Robert Spitzer might like to reconsider some of his other scholarly publications.  The most of famous of which is… the DSM-III.

Technically Spitzer is not the author of the first edition of the Diagnostic and Statistical Manual to include the “modern” mode of classifying mental illnesses by their symptoms – and leaving causation completely out of the question.  But he is almost universally acknowledged as the main architect of that third and pivotal edition (I guess appointing yourself head of all 25 development committees will do that for you) and certainly was its defender for years.

When I say what I’m about to say, I’m not being sarcastic or vindictive  – I’m being sincere.

Maybe Spitzer (and his colleagues) are nearly ready to apologize to psychiatric survivors at large.  Maybe the time for truth and reconciliation has come.

Spitzer is reaching the end of his career and perhaps even his life (he suffers from late stage Parkinson’s Disease).  Priorities are changing.  Misgivings long buried are being brought to the surface and addressed.  An interaction with a “survivor” of the policies born of his conversion therapy research was the catalyst for a change of heart, publicly declared.

Has the time for truth and reconciliation come?  As psychiatric survivors continue to lift their voices and share their stories, to graciously and meticulously expose the flaws in the pseudoscience, psychiatry as a profession has a chance (just as Spitzer did) to explore buried conflicts, half-acknowledged truths that have been hidden from the light of day for years.  Will they acknowledge the damage that has been done, will they apologize, will they move forward in partnership with psychiatric survivors?   

Some may say it’s unlikely, but because of Spitzer’s actions, we know at least that it is possible.

DSM critique in the New England Journal of Medicine is not what it seems 05/21/2012

Posted by ALT in DSM-5, Mental Health Research.
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I heard the rumors of a fight, and I came a-running. 

Fisticuffs, you say? I’m in!

This morning, I read [here] that the following inflammatory remarks were published in this week’s New England Journal of Medicine:

 … [Only when psychiatrists address] psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations … by the causal processes and generative mechanisms known to provoke them … will psychiatry come of age as a medical discipline and a field guide [the DSM – Diagnostic and Statistical Manual] cease to be its master work.

- Paul McHugh, MD and Phillp Slavney, MD in the NEJM [emphasis added]

Damn, that’s cold.  And did I mention it was published in the New England Journal of Medicine (!), which is “one of the world’s most prestigious medical journals… cited in scientific literature more frequently than any other biomedical journal”?  All kinds of doctors, clinicians, and practitioners read this thing!

A big deal.

Sounds like the authors are saying mental illness is fundamentally NOT like diabetes, that psychiatry as a discipline will continue to suffer from its immaturity and crippling inferiority complex (“we wanna be scientists, too!”) as long as diagnosis doesn’t rest on a firmly established foundation of physical pathology, and that the DSM is a poor substitute for that kind of a foundation.

Them’s fighting words.  Words that might make the NEJM readership think twice before handing out diagnoses and their accompanying pharmacological interventions like the proverbial candy.

Don’t believe every rumor you hear

Having matured a bit from my high school days of running directly to join the ring of kids chanting “fight, fight, fight!”, I decided to get a little context.  Who are these guys -– researchers? psychiatrists? some other kind of doctors? — and what does the rest of their NEJM editorial say?

“These guys” are two psychiatrists, professors at the Johns Hopkins School of Medicine.  Paul McHugh, the lead author, is a rather famous one.  He’s attended Harvard, designed a famous cognitive test often used as a dementia/Alzheimer’s diagnostic tool (a mere 11 questions!), served on the Presidential Council of Bioethics under GW and on a lay panel put together by the Catholic Church to look into the abuse of young boys by priests – none of these things being very high recommendations in my book.  The two, together, have written a popular paperback for the general public entitled The Perspectives of Psychiatry which takes the biopsychiatric/disease-based approach to mental health.

And their editorial?  It starts off very nicely with a critique of the DSM-delineated “field guide” method of diagnosis – the main problem being that clinicians no longer think too long or hard about causation.  This promotes a “rote-driven” method of treating folks, and as the authors so rightly state “identifying a disorder by its symptoms does not translate into understanding it.”  Or treating it effectively, if long-term studies of schizophrenia outcomes are any indication.

But things go sour real fast as we get to the “what’s to be done about it” part.  We simply must establish causation for psychiatric disorders, and – guess what?—the authors have already done that! 

The causes of psychiatric disorders derive from four interrelated but separable families: brain diseases, personality dimensions, motivated behaviors, and life encounters.

-McHugh et al.

Good, good.

They have also helpfully sorted out some common psychiatric disorders into the four families, or “causal perspectives”:

It’s written in a table so it MUST be true!

Right there, in the NEJM (remember – prestigious medical journal read by everybody), we’ve got schizophrenia neatly categorized as “brain disease.” 

Oh, dear.

I diagnose thee… Flipfloppers!

Contrast the NEJM editorial with the polite phrasing the authors used in the aforementioned co-authored The Perspectives of Psychiatry, chapter 6:

The continuing failure to identify a particular cerebral pathology or pathophysiology in these disorders [manic depression and schizophrenia] undermines attempts to proclaim them as diseases with complete confidence.  They remain mysteries in the sense that a confirmation of their essential nature is lacking…

- authors Paul McHugh, MD and Phillp Slavney, MD in The Perspectives of Psychiatry [emphasis added]

And yet they feel comfortable, only a few years after these words were published, with proclaiming schizophrenia as a “brain disease,” without providing any citations for new, groundbreaking research whatsoever.  Clearly this “DSM critique” is not what it seems.

Middle way protestors all the way

As it turns out, these guys are total middle way DSM protestors – the only thing they’d like to fight is the bad public image of the DSM, not the institution of psychiatric diagnoses masquerading as science, and all of the poor treatment that goes along with such posturing (symptom suppression via pharmaceuticals, coercive treatment, et al.).

According to McHugh and Slavney, “no replacement of the criterion-driven diagnoses of the DSM would be acceptable; clinicians are too accustomed to them.”  Rather, the only solution is for everyone [clinicians, researchers, families, patients] to embrace their causation groupings – and for that to be coded and billable, too, one can only presume.

In no other field would you continue to reach for an admittedly blunt, ineffective tool simply because it’s “what people are used to.”  Surely there are some other possiblities?

I believe that there is another way – instead of fitting people and their “symptoms” into predetermined boxes, we could communicate with each unique individual, offering our support and encouragement (help) when it’s wanted, and offering our respectful non-interventionism and acknowledgement of the humanity of the suffering individual when our “help” is neither helpful nor desired.

I believe there is life after the DSM – and I’d like, as a society and a community, to live it!

Dystopian Dreams of a World Without the DSM 05/15/2012

Posted by ALT in DSM-5, Patient Rights and Advocacy, Philosophy/Spirituality.
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A world without psychiatry’s “Bible,” the DSM [Diagnostic and Statistical Manual].  I can see it now…

In this world, much like our own, there is still suffering.  There is still poverty, crime, crushing sadness, despair.  There is still violence.  Regrettably, there may even still be some people who choose to take their own lives, preferring death over the pain of the moment.

But things are a helluva lot better in this world.  Not perfect, mind you.  Nevertheless a far more hospitable place for humans to be (in distress or not).

Not a utopia

I don’t promise you a utopia, because I have learned that utopian thought is always a trap.  It inevitably leads to State supervision of, well, everything.  We’ve got to maintain that perfect agreement about what constitutes the perfect order, right?   At any cost.  Moreover, utopian thought requires the mechanization (and consequently dehumanization) of the culture, the community, the human beings involved therein.

A feature of nearly all utopias has been addiction to elaborate social machinery like schooling and to what we can call marvelous machinery. Excessive human affection between parents, children, husbands, wives, et al., is suppressed to allow enthusiasm for machine magic to stand out in bold relief…

All machines are merely extensions of the human nervous system, artifices which improve on natural apparatus, each a utopianization of some physical function. Equally important, the use of machinery causes its natural flesh and blood counterpart to atrophy, hence the lifeless quality of the utopias. Machines dehumanize, wherever they are used and however sensible their use appears. Yet the powerful, pervasive influence of utopian reform thinking on the design of modern states has brought utopian mechanization of all human functions into the councils of statecraft.”

- John Taylor Gatto in “The Lure of Utopia

So I give you, instead, some dystopian dreams of a world without the DSM.

In this world…

Psychiatrists, as a profession, en masse, have admitted: WE WERE WRONG.

We shouldn’t have done it,” they will humbly concede.  “We shouldn’t have insisted it was a fact that the ‘disorders’ we outlined in the DSM were objective, scientific, distinct pathologies (just like diabetes!) when we had virtually no proof of that.  We shouldn’t have told our patients that they had ‘faulty genes’ or ‘faulty brains,’ that they were doomed to suffer chronically, for the rest of their lives, from the effects of chemical imbalances of neurotransmitters in their heads when we literally had no way of measuring balances of neurotransmitters [in the brain] in the first place, no way to establish a baseline for what is ‘normal’ and what is not.

And we certainly shouldn’t have partnered with drug companies, we shouldn’t have accepted their bribes, their promises of prestige and honor, allowing them such tremendous influence over the development of the diagnostic criteria.  We shouldn’t have turned a blind eye to the terrible, terrible harm the pharmaceuticals they were so enthusiastically peddling were doing to our patients, to our communities.  We should’ve looked further than the drug company-sponsored ‘research,’ we should’ve listened to what our patients were telling us, the facts that were staring us in the face, if only we were willing to take off the blinders so kindly provided us in our years of PhD training in pharma-sponsored schools and research hospitals.

Folks, we were wrong, and we’re deeply sorry for the harm we’ve caused.  We’d like you to send back your DSMs (don’t worry, we’ll cover the postage), so that we can dispose of them in a safe and secure manner.”

(Dumping them down the drain, so to speak, simply won’t do.)

Interring them in an underground tomb, however…

Now, as my significant other likes to say, there are three kinds of apology:

Type One: “I’m sorry you didn’t like it, but I fully intend to do it again.”
Type Two: “I’m sorry it happened, but it wasn’t really my fault.”
Type Three: “I’m sorry I did it, I take full responsibility for my actions, and I will make sure not to do that again.”

This will be a full-on, Type 3 apology, and it’s going to force all psychiatrists to ask of themselves some very serious questions about their profession, their practice, their beliefs about humankind.  The self-proclaimed “soul healers” are going to do some critical thinking and some soul searching (like this).  With humility and a greater sense of empathy, many (but probably not all) will emerge on the other side, repentant, contrite.

We move forward, having abandoned the purely “biopsychiatric” approach to mental illness, with a renewed commitment to seeing mental distress and madness for what they are (instead of trying to fit them to a biopsychiatric model that was flawed from the start, given its roots in pharmaceutical marketing campaigns, NOT actual observation of the process).

We move forward.

Our cultural narrative about mental distress has fundamentally changed.

Once this monumental apology has been issued, the books sent back, the labels redacted, “bipolar disorder,” “schizophrenia,” and “dysphoric mood disorder” won’t exist anymore as such.  [oh wait, I guess Dysphoric Mood Disorder doesn’t quite exist yet… well, give it time, give it time.]

But there will still be people convinced of the coming apocalypse, walking circles around the city at night with visions of destruction surrounding them.  There will still be children throwing terrible tantrums day in and day out.  There will be racing thoughts, deep depressions, panic attacks; there will also be euphoria, epiphanic realizations of the oneness of humanity, creation, deep outpourings of love and spiritual healing.

Yes, there will still be “extreme states of consciousness” – some of which will be quite distressing to the people who experience them.

But our cultural narrative explaining the presence of such extreme states will have changed dramatically.  When they are no longer catalogued “symptoms” of a fearsome “disease” that some people get and some people don’t, but just one part of a vast spectrum of human experiences possible to all humankind, it will no longer be feasible to adopt an us and them mentality.

“Mental illness” as the “bad genes” of “unfit stock” manifested? Not anymore.  We weed out our old eugenical ideas about “the mentally ill,”  roots and all (and that includes the idea that there exists a class of people called “the mentally ill” and another class called “the normal” and that the one is fundamentally different from and dangerous to the other).

Goodbye, weed. Move over and make room for the flowers!

We understand that “it” (extreme states of consciousness and diasgreements with consensual reality) could happen to any one of us – and that if it does happen, each and every human deserves to be treated with compassion, respect, lovingkindness… like this.

In practical terms, we don’t give folks forced “intramuscular medication” (time-released injections), we don’t electroshock people against their will, we don’t chain them, humiliate them, perform experiments on them, stigmatize them, silence them, lie to them “for their own good,” condemn them to a slow, drug-induced death, brand them again and again as a “danger to society,” something fundamentally different, other.  We don’t do any of these things because we refuse to violate anyone’s humanity  — and we recognize that when we do this to someone else, we open the door to having it done unto us.

People are able to define, for themselves, their subjective experiences of reality.

Without a so-called “scientific” definition of mental illness spelled out in the DSM, readymade for the force-feeding, people will be left with a blank page on which to write out their own truths.  Truths about our society, our world, and what is “acceptable” in these contexts.  Truths about what it means to be well, right-minded, living right.

Those who reject the DSM are already doing this:

In the culture of the Icarus Project some years ago we developed a rough prototype of a document we call a Wellness Map (or affectionately a “Mad Map”.) It’s a very practical document to be written in good health and shared with friends and loved ones and it starts with the simple (yet not always easy to answer) question:

How are you when you’re well? What does wellness look like to you?

This question is followed by: What are the signs that you’re not so well?

and eventually: What are the steps that you and your community need to take to get you back to wellness?

-Sascha Altman DuBrul, in his essay “Mad Pride and Spiritual Community: Thoughts on The Spiritual Gift of Madness

Maps of wildly diverse terrains, pages and pages of difference!  What’s right for me may not be right for you – and that’s a beautiful thing.   As you can see, this is no utopia.  We don’t have to agree about what “perfect order” is [and then single-mindedly enforce that order everywhere]; we don’t even have to strive for perfection at all!  We just have to be honest, creatively living our lives each day, mapping out our mental, emotional, and spiritual geographies, all the while respecting our fellow humans as they do the same.  And most importantly…

We offer our compassionate, “un-professional” support to our fellow human beings in distress (and out of it!).

This is crucial.  We humans weren’t made to be lonely – not in joy or grief, and certainly not in madness.  We long to share our experiences, to bond, to connect, to feel the lovingkindness of someone else’s attention, care.

So in distress and out of it, we can follow as an example the standard of care provided by luminaries like Loren Mosher and John Perry .  In distress and out of it, let’s be with each other, without judgment (diagnosis) or manipulation (“for your own good interventionism”), without “professional opinions” (self-fulfilling prophecies of chronicity and doom) or prescriptions (forced care).

Let’s make maps together; let’s be fellow geographers of the human condition.  Allow for grief in response to the deep sadness that is inevitably a part of life.  Allow for terrible fear, at times, and unbelievable joy.  Allow for madness as a transformative process, when it occurs; the birthing of a new consciousness.  Allow a safe passage, in loving company, through difficult times.  Allow our fellow human beings to emerge, on the far side of their extreme states of consciousness, “weller than well.”

We move forward.  We don’t look back.

DSM-5 round three: can other cries of protest be heard over the clamor of “middle way” voices? 05/09/2012

Posted by ALT in DSM-5.
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The third and final “draft” of the DSM-5 has been posted, and the various work group members (you remember them, don’t you?) have asked for feedback from the general public.  It’s open for comment until June 15th.

I was going through the new draft, checking up on some of my favorite controversies over diagnostic criteria, their intersection with work group member conflicts of interest and pharmaceutical dollars (there being no shortage of any of these things), and thought I might share a few developments.

First, some good news

[Though let me first state that the ultimate good news would be if this thing never went to press at all, if the whole paradigm of labeling, pathologizing, and dehumanizing embodied by this “bible” (aptly named, as it is certainly more of a quasi-religious text with a life of its own that one must both believe in and claim as his own (my schizophrenia, my bipolar, my depression) than a scientific manual containing objective facts) were abandoned.  If we let people describe, by themselves and for themselves, their experiences, their realities; if we abided by the Universal Declaration of Mental Human Rights and Freedoms

SIGH.

But if it’s going to go to print, it would be great if the damage were minimized… so I refer to the following as “good news items” despite my caveat.]

  • Psychosis Risk*” (or “Attenuated Psychosis Syndrome”) – a proposed disorder characterized by “strange thoughts” or hallucinations at least once a week with the potential to become psychotic — will not be included as an official disorder in the DSM-5.  This will likely prevent untold thousands of “preventative” prescriptions of anti-psychotics, self-fulfilling prophetic progressions into “chronic schizophrenia” (a phenomenon that really only exists in large numbers where folks are psychiatrized the American way), etc.  A very good thing.
  • “Mixed Anxiety Depression” isn’t going to be in there either.  This was another label that would have vastly expanded the boundaries of what is considered pathological, what might be remedied pharmacologically.
  • Rather, they (and quite a few others), will be included in the newly invented “Section III”  a sort of purgatory where diagnoses that “need more study” will be named, and tentatively described, but [I gather] will not be official.  Whatever that means.
  • And a small victory for lovers of acronyms everywhere: our beloved “NOS” [Not Otherwise Specified]remains in this draft of the DSM.  For awhile there all the “NOSes” had been transfigured into “NECs” [Not Elsewhere Classified], which simply doesn’t have the same ring to it, and isn’t nearly as punny…er, funny. 

    NOS [Not Otherwise Specified – a “classification” that refuses to be classified] … nosology [the scientific classification of diseases]… get it???

And now the bad news

This baby IS still going to press, whether we like it or not.  Moreover, it’s the middle way detractors’ critique that is being heard and addressed by the media and the APA itself, as is all too clear in this third and final draft. 

Middle way protestors (like Allen Frances, for example) are against the DSM-5 in particular, criticizing the development process, the addition of so-called “unscientific diagnoses,” financial conflicts of interest of the developers, etc. 

The idea being that we simply need a better process for creating this thing.  And that the botched development of the DSM-5, which will result in flaws that could’ve been avoided with more rigorous procedures, is a risky business because it might turn the tide of public opinion against the very institution of the DSM; which would be terrible because we need some kind of DSM in order to treat mental illness at all. 

But there’s another camp, led by people like Paula Caplan – I like to think of it as the true DSM detractors.  Instead of being against the DSM-5 in particular, this camp (including myself) is against the institution of the DSM, period. Instead of arguing that the DSM-5 is marginalizing, stigmatizing, unscientific, it argues that the practice of diagnosing people itself is all of these things and worst of all… dehumanizing! 

In the final draft of the DSM-5 , the Middle Way Critique is addressed, or at least acknowledged, but the Work Group Members stubbornly persist in expanding diagnostic criteria and opening the door for more and more pharmacological interventions (“first line treatments,” they say, mostly in their private publications), their conflicts of interest and grant monies often all too obviously influencing this process. 

What can we do about it?  Who knows what can be done to stem the rising tide of the “Therapeutic State,” armed with an ever more expansive and “inclusive” definition of mental illness!

But we can start by leaving a strongly worded comment or two on the DSM-5 website about what this “bible,” and the pseudo-scientific/religious beliefs it outlines, has done to our society, our humanity.


*Yes, I linked to an Allen Frances article.  Please don’t take that as an endorsement, however!!

A call for survivor stories from Paula Caplan 03/16/2012

Posted by ALT in DSM-5, Survivor Voices.
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I received a request from Paula Caplan today calling for psychiatric survivor stories.  I promised to post it here [see below].  Paula is one of the most vocal critics of the forthcoming DSM-5, and she will be speaking in Philadelphia on May 5th as part of the “Occupy the APA” festivities.  Your survivor stories will be an extremely important contribution to the cause of telling the American Psychiatric Association to stop labeling, dehumanizing, and condemning human beings who happen to experience things differently.  If you have a story to share, please consider doing so!

***

(from Paula Caplan)

Paula J. Caplan, author of They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, would like to receive one-page (yes, just one page, please) brief summaries — even bullet points will be fine — from people who have been harmed in any way by psychiatric diagnosis. These are to post on her psychdiagnosis.net website, where she has had 53 stories of harm but wants more recent ones. The writer will have the choice of having their real name, a pseudonym, initials only, or “anonymous” used when their story is posted. The one page should consist of the following information:

(1)Psychiatric label(s) I was given

(2)What was happening that seems to be why they gave me the label(s)

(3)The kinds of harm I suffered because of getting the label(s)

Please send by March 23 to paulacaplan@gmail.com

DSM-5 conflicts of interest hit mainstream media; protestors rally, but is it for the right reasons? 03/14/2012

Posted by ALT in DSM-5, Mental Health Policy and Inititatives, Patient Rights and Advocacy.
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I’m no journalist.

I did write for my high school newspaper (I can recall a particularly riveting article about different styles of shoes!), but these days I’m strictly a blogger, cavalierly inserting humor, my own biased opinion, and all manner of distractions and sidetracks into my “articles.” 

Nevertheless, this ABC news article from yesterday (“DSM-5 Under Fire for Financial Conflicts of Interest”) follows the exact argument I put forward in my little piece entitled “For the DSM-5 Task Force, Being Greasy Never Been So Easy!”  Whoa, did I inadvertently produce some journalism here?

I have to admit, I liked my title better.

Ok, ALT; stop patting yourself on the back!

Done.  Now let’s dig in.

The ABC story was fueled by the publication of an academic analysis of the conflicts of interest of the various DSM-5 committees, conducted by the same researcher (Lisa Cosgrove) who published a similar analysis in the days of DSM-IV development. 

As I wrote awhile ago, it’s practically a conflict-of-interest OLYMPICS!  Cosgrove found that about ¾ of the work groups have a majority of members with major ties to the pharmaceutical industry.  Some standout groups include:

- Mood Disorders Group: 67% of members report ties to industry

- Psychotic Disorders: 83%

- Sleep/Wake Disorders: 100%

Moreover, when comparing the figures from the DSM-5 to her previous analysis of the DSM-IV workgroups, Cosgrove has found that in about half the work groups, conflicts of interests have only gotten worse.  

Check it:

[click to enlarge]

It appears that the APA thought transparency alone would be a solution to their metastisizing “conflict of interest” problem. 

Well, they’re wrong.  We can clearly see the giant, throbbing tumor now, but the fact is it’s still there.

The whole point of disclosing conflicts of interest is determining whether someone is unencumbered enough to participate in a decision-making/fact-finding process.  For this to be in any way legitimate, there must be some threshold where the person’s conflicts of interest are too great, where they are removed from the process. But the APA apparently has no limit. 

Oh, sure, they say something about “no more than $10,000/year directly from the pharmaceutical industry and no more than $50,000 in pharma stock options” … but with major gaps in their disclosure policy and no dollar amounts made public, how can we be sure this is any less of an empty gesture than the rest of their carefully choreographed “transparency” dance?

DSM detractors say the darndest things…

A wave of protest against the DSM has been building over the past few months, but I’m not sure that I’ll be able to unite with the mainstream (or “middle way”) DSM protesters.  Here’s why:

Middle way protestors are against the DSM-5 in particular, criticizing the development process, the addition of so-called “unscientific diagnoses,” financial conflicts of interest of the developers, etc. 

The idea being that we simply need a better process for creating this thing.  And that the botched development of the DSM-5, which will result in flaws that could’ve been avoided with more rigorous procedures, is a risky business because it might turn the tide of public opinion against the very institution of the DSM; which would be terrible because we need some kind of DSM in order to treat mental illness at all.  The DSM detractors quoted in this article all seem to fall into that camp; Allen Frances, David Elkins, and Cosgrove herself. 

But there’s another camp, which I and many others belong to.  Instead of being against the DSM-5 in particular, we’re against the institution of the DSM, period. Instead of arguing that the DSM-5 is marginalizing, stigmatizing, unscientific, we argue that the practice of diagnosing people itself is all of these things and worst of all… dehumanizing! 

In ABC’s coverage, only the “middle way” DSM detractors are represented.  And I find myself feeling a little piqued by what they have to say.  For example:

Dr. Allen Frances, who chaired the revisions committee for DSM-4, said the new additions would “radically and recklessly” expand the boundaries of psychiatry.

“They’re at the boundary of normality,” said Frances, who is professor emeritus of psychiatry at Duke University. “And these days, most diagnostic decisions are not made by psychiatrists trained to distinguish between the two [normality and mental illness, presumably]…”

- From ABC News article “DSM-5 Under Fire for Financial Conflicts of Interest

The boundary of normality?  He speaks as if he knows exactly where that is!  And that the DSM-IV catalogs “diseases” that fall well beyond it.

I beg to differ.

Take so-called “schizophrenia,” or psychosis, for example.  As John Perry so nicely puts it:

In my opinion, the real pathology in psychosis does not reside in the “mental content,” the images and the symbolic sequences.  All of that appears to be a natural psychic process, present and working in all of us.  This is normal madness, so to speak.  The schizophrenic “disorder” lies rather in the ego, which suffers from a constricted consciousness… The problem of the prepsychotic state is how to discover the impassioned life, and nature has its own answer in the form of a turbulent ordeal, a trial by immersion in the source of the passions – that is, a psychosis.

- John Perry, in The Far Side of Madness

[If you liked that quote and have some time on your hands, read this!]

From Perry’s point of view, psychosis is often a naturally transformative and healing process, somewhat like childbirth.  If there is such a thing as a “boundary of normality” (which I doubt), it falls well within it.  Psychosis is the “normal” response of a psyche needing to heal.

Here’s another rather disturbing quote from the middle camp:

“My best hope would be for the APA to respond in a substantive way to the concerns we’ve raised.  They have an opportunity here to make a correction that would give the appearance, if not the reality of developing a diagnostic instrument that’s objective and has integrity.”

- Lisa Cosgrove, in the ABC News article DSM-5 Under Fire for Financial Conflicts of Interest; emphasis added

A semblance of objectivity and integrity – not necessarily the real thing – is her best hope for the DSM committee??

And our best hope for dessert is a big slice of "pretend pie"!

Way to aim high!

A question

Should all the DSM-V detractors put aside their differences and join together to protest the DSM-V, or are the two camps far enough apart that their protests really can’t align?

As you ponder, consider this: a large DSM-5 protest (Occupy the APA) is planned for May 5th in Philadelphia at the site of the APA convention.  The middle way camp will necessarily be inside the convention (most of them belong to the APA, after all), while the rest of us will be standing outside, barred from entry.

It appears that more than mere distance separates our two camps.

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