A Disorder Is Manufactured

One of the most obvious and pervasive examples of the fraudulent medicalizing of everyday life can be seen in the pathologizing of childhood through the historically recent invention of the attention deficit hyperativity disorder (ADHD) diagnosis. Children grow up, but therapeutic relations based on fraud don’t dissolve into a “normality” disorder diagnosis overnight. The American Psychiatric Association put its official stamp of approval on these relations in it’s new Diagnostic and Statistical Manual (DSM-5), the latest edition of the shrink bible, by adding an adult version of this fabrication.

Clinical Psychiatric News, as you would expect, has published an article on this fabrication by a doctor who believes, as it were, in the legitimacy of this fraud. The story, as if ADHD were a good grade, bears the heading, Adult ADHD: Making the diagnosis. Making up the diagnosis is more like it.

Adult attention-deficit/hyperactivity disorder is a common and treatable psychiatric condition the diagnosis of which is made more challenging because the disorder looks different than the classic picture in children.

I imagine this is the place to note that speed, the most common “treatment” for ADHD, affects adolescents and children differently than it does adults. Speed is now being peddled, not only as a illicit recreational drug, but also over the counter as a legal “performance enhancer” after the introduction of this invented disorder. Of course, it’s “performance enhancing” qualities are generally restricted to the short-term. We are talking about a drug, drugs work by disabling the brain.

The adult presentation of ADHD is more subtle than in children. It includes disorganization and poor time-management skills; impulsivity with poor self-control often demonstrated via rude comments and frequent interruption of others; emotional difficulties rooted in low self-esteem and poor affect regulation; and difficulty in concentrating and completing even simple tasks.

As with most other psychiatric fabrications, the person so diagnosed could also be said to be suffering from a profound alienation disorder. In so doing one must note that alienation is something that occurs in social relationships and between people, such as between a psychiatrist and his victims. Should we have a bad apple here, perhaps the reason is because somebody has managed to infest the barrel with worms.

The adult version of this fraud has a long way to go before it has anything like the pervasive presence that the adolescent or juvenile version has, but I expect that that presence, owing to the now official status of the disorder, is on it’s way.

“It’s a very controversial area outside of psychiatry but also inside psychiatry,” according to Dr. [Robert D.] Davies [University of Colorado psychiatrist]. “A psychiatric colleague of mine had diagnosed an adult patient with ADHD and then wanted to refer him to me. I asked why. He said, ‘Because I don’t believe in it.’”

Obviously the Church of Biological Psychiatry has some work to do before this diagnosis sells speed the way it’s adolescent and juvenile version does, but needless to say, that uphill slope is being mounted at this very moment. With the diagnosis now being  given official “disease” status, how long can it be before more and more spontaneously generated cases of adult ADHD start crawling out of the woodwork?

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More Or Less Biology In Psychiatry–That Is The Question

Much newsprint has been wasted recently on the split between the APA (American Psychiatric Association) and the NIMH over the revision of the DSM (Diagnostic and Statistical Manual of Mental Disorders)  that is going to be called the DSM-5. In my view, letting the 100,000 manuals bloom is not going to be any better of a solution than letting the 100,000 diagnoses bloom in the long run. If we are going to treat every patient as an individual, for the sake of the individuality of his or her condition (and genetic makeup), that’s going to make for a whole lot of variation in disorder (and/or order) expression.

The New York Times covers the story, regarding the NIMH APA divide, in a story with the heading, Psychiatry’s Guide Is Out Of Touch With Science, Experts Say. Of course, it always depends on which experts you ask. The experts the mass media is still slow to consult, and the New York Times is no exception in this regard, are those experts with lived experience on the receiving end of mental health treatment.

While typically critics of the DSM have tackled the subject from one side of the political psychiatric spectrum, here comes mob boss Thomas Insel, godfather of the NIMH, attacking from the other. In the first instance, you have people who object to the biology in biological psychiatric theory, (Theory, now there’s as important a word as any.) in the second, you have a group that doesn’t think the APA is biologically grounded enough.

The expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, said in an interview Monday that his goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.

The DSM focuses on symptoms precisely because we don’t know the causes. Dr. Thomas R. Insel, apparently, thinks otherwise.

Precision seems to be a big part of the problem. In psychiatric diagnosis, theoretical speculations aside, there are no precision tools.

The creators of the D.S.M. in the 1960s and ’70s “were real heroes at the time,” said Dr. Steven E. Hyman, a psychiatrist and neuroscientist at the Broad Institute and a former director at the National Institute of Mental Health. “They chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal.’ But this is totally wrong in a way they couldn’t have imagined. So in fact what they produced was an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, but they don’t have five diseases — they have one underlying condition.”

Or, a possibility not considered here, we’ve got five misdiagnoses floating around for which there was no underlying condition in the first place.

Solution. The NIMH is developing it’s own manual, Research Domain Criteria, or RDoC.

About two years ago, to spur a move in that direction, Dr. Insel started a federal project called Research Domain Criteria, or RDoC, which he highlighted in a blog post last week. Dr. Insel said in the blog that the National Institute of Mental Health would be “reorienting its research away from D.S.M. categories” because “patients with mental disorders deserve better.” His commentary has created ripples throughout the mental health community.

Consider, ripples sent throughout the mental health community, ripple throughout the “mental illness” community (i.e. the mental health ghetto). Now whether “patients with mental disorders” are going to get “better” treatment thereby is a big leap. Too big a leap in fact to make. So sorry, my poor victims of standard psychiatric malpractice!

Whatever you call it, my guess is that this switch still represents a way of billing insurance companies, the most important role for patient consumers a psychiatrist assumes. Of course, given that this paradigm change is all about biological explanations, I expect the treatment the insurance companies will be paying for is a chemical fix. Given this situation, the extent to which pharmaceuticals damage patients is still the great unasked question biological psychiatrists do their best to avoid asking.

Pre-psychosis In The News

Attenuated psychosis syndrome, alternately called psychosis risk syndrome, pre-psychosis and prodromal disorder is going into section 3 of the DSM-5. This is the section for disorder labels that need more review, and which will not be reimbursable. The bad news is that it is in the DSM at all, and being in the DSM, it’s going to be considered as a disorder. The good news is that it is not an “official” disorder label, insurance companies are under no obligation to pay for it, and so its not likely to explode into an epidemic next year.

Researchers, it seems, much less fastidious than DSM revisers, are intent in studying people afflicted with this fictitious and elusive label. The latest rage in pseudo-scientific discoveries concerns this nebulous early stage in the development of psychosis. An article in the Detroit Free Press, Schizophrenia may give early warning signs, is typical.

Researchers in Chapel Hill looked at brain scans of 42 children, some as young as 9, who had close relatives with schizophrenia. They saw that many of the children already had areas of the brain that were “hyper-activated” in response to emotional stimulation and tasks that required decision-making, said Aysenil Belger, associate professor of psychiatry at the UNC School of Medicine and lead author of the study.

Now whether psychiatrized families actually think differently from non-psychiatrized families is anyone’s guess, and it could always be the topic for additional research should anybody choose to go there.

People who have a parent or sibling with schizophrenia are about 10 times more likely to develop the disease than those who do not. Signs of the illness typically begin in the late teens to mid-20s. These include declines in memory, intelligence and other brain functions that indicate a weakening in the brain’s processing abilities. More advanced symptoms may include paranoid beliefs and hallucinations.

Perhaps this sounds like an astonishing figure until you realize that it actually means 1 in 10 people rather than 1 in 100 people.  This is to say that among the 1 in 100 people that get described as psychotic, 1 in 10 of their closest relatives could also be so described. Unlike in the rest of the world where the rate stays more or less at 1 %. 1 in 10 means that chances are, if you are in a family haunted by the phenomenon of psychosis in one of its members, 9 out of 10 of it’s members most probably wouldn’t be described as psychotic anyway.

“Of all the people who seem to have compromised circuitry in their brain, if we come back and image them in later years, some may be moving toward the cluster of symptoms for schizophrenia while others may have other types of deficits,” such as bipolar disorder or attention deficit disorder, Belger said.

The article goes on to add, “Still others may avoid serious disorders altogether”, but the damage has been done. If you were an agent of the inquisition, let’s say, looking for witches, you are not going to be questioning the existence of witches. If you want to find fault in anyone, or anything, no problem. Just conduct a fault finding mission. If you are out to praise those people, well, hunting for future “mental illnesses” is just not the way to do so.

I think these researchers have better things to be doing with their time. We really have a problem when the DSM starts predicting disorders in people.  Ignoring any fork in the pathway that may lead to dysfunction, from functionality, is a major shortcoming, I would imagine. Ditto, in the case of paths that lead to folly from reason and wisdom. You are postulating that mental and emotional disturbances are a matter of predestination, and I imagine such leaps of faith belong in the realm of superstition rather than in the realm of scientific inquiry and skepticism.

This doesn’t mean that pre-psychosis isn’t going to make it’s way as a reimbursable disorder in a future edition of the DSM. I imagine, if things continue going the way they are going, it will. There is a lot of nonsense in the DSM. I would say maybe 100 % of the DSM is sheer nonsense. All the same, quite literally, even a listing as a category for diagnosis won’t make future psychosis a real disorder in present time.

Allen Frances And The DSM-5

Allen Frances, Duke University psychiatry professor emeritus, isn’t so much a critic of the Diagnostic and Statistical Manual of Mental Disorders as he is a critic of the DSM revision process. Apparently he has a love/hate relationship with the manual itself. He doesn’t object to the DSM, psychiatry’s label bible, so much as he objects to what he sees as a rushed and flawed job that could result in a shoddy product. He objects to a process that he thinks will produce a lower quality product than a more thorough going process would produce.

He himself was one of the architects of the DSM-IV. The DSM-IV was notorious for raising the “mental illness” rate throughout the world. The DSM-5 is expected to smooth out a few more of the wrinkles in the DSM-IV. Although current criticism of the DSM revision process may make the DSM-5 less of an open Pandora’s Box, or contagion zone, than no criticism whatsoever would, the publication of the DSM-5 is expected to raise the rate of mental illness around the world substantially again. Make no mistake about it; what is going on here, with the hoopla surrounding the revision and publication of this manual, is the selling of “mental illness”!

His latest jabs at this process on his Huffington Post blog have been aimed at the price tag. A recent blog post of his bore the title, DSM-5 Costs $25 Million, Putting APA in a Financial Hole. The DSM-5 has cost 5x the amount already that the DSM-IV cost. The APA is in the hole right now because of this price tag.

The American Psychiatric Association just reported a surprisingly large yearly deficit of $350,000. This was caused by reduced publishing profits, poor attendance at its annual meeting, rapidly declining membership, and wasteful spending on DSM-5. APA reserves are now below “the recommended amount for a non-profit (reserves equal to a year’s operating expenses).”

$350,000 in the hole to be exact because of a multi-million dollar revision process owing in part to the objections of critics such as Allen Frances.

APA has already spent an astounding $25 million on DSM-5. I can’t imagine where all that money went. As I recall it, DSM-IV cost about $5 million, and more than half of this came from outside research grants. Even if the DSM-5 product were made of gold instead of lead, $25 million would be wildly out of proportion. The rampant disorganization of DSM-5 must have caused colossal waste. One obvious example is the $3 million spent on the useless DSM-5 field trial, with its irrelevant questions, poorly conceived design, and embarrassing results.

The DSM-5 was due to be published in 2012. Because of the objections of many psychologists and the likes of Allen Frances publication was suspended for a year. The revisers of the DSM-5 are also going out of their way to get input from interested parties. Actually, and to be more precise, the revisers are busy at damage controll by giving the appearance of giving an ear to critics for public relations purposes. The upper echelon of the APA don’t want democracy. Dialogue is not what coming up with “mental disorder” labels is all about. There is, for example, no No Mental Disorder Not Otherwise Specified category in the manual.

If stage one were field testing, stage two is quality control. Stage one a disaster, in his view; he sees quality control as the issue in a more recent post, Follow The Money, on these monetary difficulties lost to the DSM-5 revision process.

APA was faced with 2 choices: 1) go ahead with Stage 2 to clean up the mess; or 2) declare Stage 2 unnecessary and publish a poorly edited, unreliable, and untested DSM-5. APA chose the second option and is rushing toward a forced, premature birth of DSM-5.

Actually, as pointed out above, publication had been suspended earlier, and so this would entail suspending publication yet again. This suspension proposed by Allen Frances also begs the issue of the rising tab and the debt. If the DSM-5 revision has cost $25,000,000 already, continuing to haggle over the minutae and specifics of “mental disorder” labels is not going to bring this tab down.

Since there is no pressing need to publish the DSM-5 quickly, let’s follow the money. The APA budget depends heavily on the huge publishing profits generated by its DSM monopoly. APA needs the money badly. It is losing paying members; other sources of funding are also on a downward trend; and its budget projections require a big May 2013 injection of DSM-5 cash.

Is there a pressing need to publish the DSM-5 at all? Oh, yeah! The money! The patients? Well, they’re going to rot anyway, and so we might as well take advantage of them and their plight. What can they do?

As someone with a history of activism in the psychiatric survivor movement, I have objections to the DSM-I through 5. Our problem stems precisely from the fact that these psychiatrists, with their medical degrees, and their drug company ties, are putting professional interests ahead of their patients’ health. These medical doctors are putting their own standing above the health of their patients to the detriment of their patients’ health. Allen Frances, the retired psychiatry professor, is as guilty as any of them.

Allen Frances is playing a double game. If he has to settle for a shoddy product, to him it’s better than no product at all. This product could be “medicalizing normal”, as he puts it, right and left. This represents a glitch the next edition can potentially clear up. He can immediately start projecting his wishes onto a revision of the DSM-6. He may not be alive then, but his followers can continue to opt for a little more rigor in the revision efforts. I just don’t see how any amount of rigor is going to resolve the basic lack of real science you’ve got in the DSM. There is no real science involved in the selection of “disease” labels by committee.

We don’t really have a potentially bad edition of a good book going on here. We just have another bad edition of a bad book that was a bad idea to start with. The DSM should be scrapped altogether for other approaches that don’t owe so much to biological bias and drug industry profiteering. Lives are on the line, and as long as the current toxic paradigm, supported by the DSM, is in operation, more of those lives are going to be lost. The APA can find other ways to fund its nefarious activities. The DSM is basically fraud, but unfortunately it’s a fraud that it appears is going to continue for some time to come. Again, and emphatically, it should be scrapped entirely!