The proposed revisions to the Diagnostic Statistical Manual (DSM) of the American Psychiatric Association will continue the trend set by prior revisions: namely, expanding the number of people who, according to DSM diagnostic criteria, will be labeled as having a "mental disorder" for which a prescription for psychotropic drugs will be issued. Indeed the chairman of the DSM-IV Task Force recently wrote: “The relentless march to medicalize normality out of existence is opening a new and especially ridiculous front.”
The latest area of controversy focuses on the proposed revision of the definition "behavioral addiction disorder" extending the addiction diagnosis to include drug, alcohol and gambling. It is estimated that the change would expand the number of people labeled as "addicts" by 20 to 30 million who would be entitled to treatment and disability payments costing taxpayers many hundreds of millions of dollars. APA’s chief executive, Dr. James Scully, Jr., defends the expansionist revision by reiterating the hackneyed claim that "The biggest problem in all of psychiatry is untreated illness, and that has huge social costs." New Guidelines May Sharply Increase Addiction Diagnoses
Insightful critics have observed that the designation "mental disorder" for inclusion in each of the revised editions of the DSM can be traced to the availability of a drug that will be marketed as a remedy for the newly invented "mental disorder." Indeed, the DSM is a driving force for rendering every human emotion and behavior that can be affected in one way or another by a psychotropic drug, to be classified as a symptom of a mental disorder. More than anything else, the DSM catapulted clinically ineffective drugs–such as, SSRI antidepressants and (atypical) neuroleptics into industry’s most profitable blockbuster drugs—even as they have caused severe harm.
The DSM has been described as "a hideous distortion of medical science"–its objective is expansive and self-serving. The New York Times report by Ian Urbina (May 12, 2012) perfectly captures the seeming lack of insight (dishonesty ?) displayed by psychiatrists when questioned about their financial conflicts of interest. Urbina reports:
"Dr. Charles O’Brien [University of Pennsylvania] who led the addiction working group, has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction. He has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving. He was the driving force behind adding “craving” to the new manual’s list of recognized symptoms of addiction."
“I’m quite proud to have played a role, because I know that craving plays such an important role in addiction,” Dr. O’Brien said, adding that he had never made any money from the sale of drugs that treat craving. New Guidelines May Sharply Increase Addiction Diagnoses Surely such an indication of dissociation must qualify for a DSM diagnosis and a psychotropic drug.
The DSM-I, published in 1952, included 106 disorders; the DSM-II, published in 1968, included 182 disorders; the DSM-III, published in 1980, included 265 disorders: its architect, Dr. Robert Spitzer of Columbia University, dropped psychoanalytic theories and concepts such as "reaction" and "neurosis" and replaced them with a classification system of descriptive diagnostic categories. Since the DSM III, diagnoses of mental disorders are determined by symptom classifications using a system of checklists. A major flaw is the assumption that discreet mental disorders can be deduced from symptom patterns without regard for context or life stressors that may impact a human being’s state of mind.
The DSM-III simplification of the diagnostic criteria resulted in millions of normal people to be mislabeled as having a "mental disorder." The global influence of DSM-III surpassed all previous editions. The DSM became the primary determinant of treatment decisions, private and public insurance and disability eligibility, government funding for special education services, it is relied upon as a guide for pharmaceutical research, and has been widely used by criminal defense lawyers.
In a BBC interview, 27 years after the publication of the DSM-III, Dr. Spitzer acknowledged that the DSM diagnostic criteria resulted in "exaggerated rates of mental disorders." When asked what the rate of exaggeration might be? He acknowledged that "no one really knows, but it might be 20%, 30%, even 40%."
Two opinion pieces about the DSM-5 revisions were published by the two most influential American newspapers. The Washington Post published an essay by Paula Caplan, PhD, "Psychiatry’s Bible, the DSM, is Doing More Harm Than Good" (April 27, 2012) and The New York Times, ran an OpEd by Allen Frances, MD, "Diagnosing the DSM" (May 12, 2012).
Dr. Allen Frances, former chairman of psychiatry at Duke University who chaired the DSM-IV revision published in 1994, contributed toward further increasing the number of people diagnosed with a mental disorder–the number of disorders had grown to 297. Worst of all, the DSM-IV ushered in an epidemic of child abuse under the guise of medical intervention. After the loosened DSM-IV diagnostic criteria pathologized normal childhood behavior, millions of children have been labeled with attention deficit disorder, autism spectrum disorder, and bipolar disorder, for which psychiatrists have been wantonly prescribing toxic drugs whose documented, severe adverse effects induced debilitating chronic physical disease, not to mention mental deterioration, and premature deaths.
After the damage had been done–and billions of dollars had been misspent on harm-producing treatments–Dr. Frances acknowledges in the Times OpEd that the DSM-IV had "failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children." Elsewhere, he has expressed horror about the resulting consequences: “kids getting unneeded antipsychotics that would make them gain 12 pounds in 12 weeks hit me in the gut. It was uniquely my job and my duty to protect them. If not me to correct it, who? I was stuck without an excuse.” He has also criticized psychiatry’s ever expanding list of unvalidated disease designations, its reliance on demonstrably ham-producing drugs, and has acknowledged in an interview in WIRED that, “there is no definition of a mental disorder. . . . These concepts are virtually impossible to define precisely.”
Dr. Caplan, a clinical psychologist who served on two committees of the DSM-IV (until she resigned in protest about the pathologizing of per-menstrual cramps) has been a vocal critic about its lack of a scientific foundation:
"An undeserved aura of scientific precision surrounds the manual: It has “statistical” in its title and includes a precise-seeming three- to five-digit code for every diagnostic category and subcategory, as well as lists of symptoms a patient must have to receive a diagnosis. But what it does is simply connect certain dots, or symptoms — such as sadness, fear or insomnia — to construct diagnostic categories that lack scientific grounding. Many therapists see patients through the DSM prism, trying to shoehorn a human being into a category."
She has also criticized the DSM’s overreaching stranglehold: Psychiatry estimates that within their lifetime, 50% of the American population will be "diagnosed" with a mental disorder. A psychiatric label, Dr. Caplan points out, causes serious harm:
"it can cost anyone their health insurance, job, custody of their children, or right to make their own medical and legal decisions. And if patients take psychiatric drugs, they risk developing physical disorders such as diabetes, heart problems, weight gain and other serious conditions."
Dr. Frances has become the most formidable vocal critic of the the DSM-5 Task Force and its proposed revisions who was influential in persuading the Task Force to pull-back from adopting the diagnosis "psychosis risk syndrome" that would have expanded even further the prescribing of dangerous toxic drugs for children, and the proposal to eliminate the bereavement exclusion from major depressive episode (MDE) diagnosis which would have included just about everyone who ever mourned the loss of a loved one.
Those who formulated the DSM-III, -IV and 5 are stakeholders with significant financial interests in increasing the number of patients and in the drugs used to treat the diagnoses that they alone define in the DSM. What’s more, the APA leadership influences public health policy.
But Dr. Frances has a blind spot in regard to the commercial interests that drive the entire enterprise. He steadfastly denies that financial interests had any influence on the crafting of the DSM even as he acknowledges that “the DSM drives the direction of research and the approval of new drugs." He denies industry’s influence on the DSM-IV or DSM-5 Task Force, claiming that "mistakes are the result of intellectual conflicts of interest" not financial conflicts of interests.”
Surely Dr. Frances is not unaware of the peer reviewed analysis by Dr. Lisa Cosgrove (Harvard University) and Dr. Sheldon Krimsky (Tufts University) documenting the financial ties of each committee of the DSM-IV (2006), and their comparison analysis of DSM-IV and DSM-5 panel members’ financial ties to industry. Their DSM-IV findings:
"Our inquiry into the relationships between DSM-IV panel members and the pharmaceutical industry demonstrates that there are strong financial ties between the industry and those who are responsible for developing and modifying the diagnostic criteria for mental illness. Of the 170 DSM panel members 95 (56%) had financial ties to pharmaceutical companies. The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders. One hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug companies. The leading categories of financial interest held by panel members were research funding (42%), consultancies (22%) and speakers bureau (16%).
Drs. Cosgrove and Krimsky’s comparison study of the DSM-IV and DSM-5 panel financial interests found, ironically, that APA’s financial disclosure policy adopted for the DSM-5 panel was not accompanied by a reduction of financial conflicts. Instead, the financial ties to industry INCREASED from 56% to 70%. Furthermore, APA’s disclosure requirement excludes speakers’ bureau membership which provide fees for key opinion leaders (KOLs) who make presentations promoting products. Also exempt from APA’s disclosure requirement are "unrestricted research grants."
As Rob Waters wrote in Salon Magazine: “The fight over the DSM-5 pits some of the biggest egos in the world of psychiatry, but it’s more than a battle among 301.81s (narcissistic personality disorder). For people seeking help for life’s problems who don’t want to be labeled mentally ill or have their treatment limited to medication, and for clinicians who want to help people without reducing them to a category, the stakes are high.”
1. Cosgrove, L., Krimsky, S., Vijayraghavan, M. & Schneider, L. (2006). Financial ties between DSM-IV panel members and the pharmaceutical industry . Psychotherapy and Psychosomatics, 75, 154-160.
2. Cosgrove, L., Krimsky, S. (2012) A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry : A Pernicious Problem Persists, PLoS Medicine
THE NEW YORK TIMES
Addiction Diagnoses May Rise Under Guideline Changes
May 11, 2012
By IAN URBINA
WASHINGTON — In what could prove to be one of their most far-reaching decisions, psychiatrists and other specialists who are rewriting the manual that serves as the nation’s arbiter of mental illness have agreed to revise the definition of addiction, which could result in millions more people being diagnosed as addicts and pose huge consequences for health insurers and taxpayers.
The revision to the manual, known as the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., would expand the list of recognized symptoms for drug and alcohol addiction, while also reducing the number of symptoms required for a diagnosis, according to proposed changes posted on the Web site of the American Psychiatric Association, which produces the book.
In addition, the manual for the first time would include gambling as an addiction, and it might introduce a catchall category — “behavioral addiction — not otherwise specified” — that some public health experts warn would be too readily used by doctors, despite a dearth of research, to diagnose addictions to shopping, sex, using the Internet or playing video games.
Part medical guidebook, part legal reference, the manual has long been embraced by government and industry. It dictates whether insurers, including Medicare and Medicaid, will pay for treatment, and whether schools will expand financing for certain special-education services. Courts use it to assess whether a criminal defendant is mentally impaired, and pharmaceutical companies rely on it to guide their research.
The broader language involving addiction, which was debated this week at the association’s annual conference, is intended to promote more accurate diagnoses, earlier intervention and better outcomes, the association said. “The biggest problem in all of psychiatry is untreated illness, and that has huge social costs,” said Dr. James H. Scully Jr., chief executive of the group.
But the addiction revisions in the manual, scheduled for release in May 2013, have already provoked controversy similar to concerns previously raised about proposals on autism, depression and other conditions. Critics worry that changes to the definitions of these conditions would also sharply alter the number of people with diagnoses.
While the association says that the addiction definition changes would lead to health care savings in the long run, some economists say that 20 million substance abusers could be newly categorized as addicts, costing hundreds of millions of dollars in additional expenses.
“The chances of getting a diagnosis are going to be much greater, and this will artificially inflate the statistics considerably,” said Thomas F. Babor, a psychiatric epidemiologist at the University of Connecticut who is an editor of the international journal Addiction. Many of those who get addiction diagnoses under the new guidelines would have only a mild problem, he said, and scarce resources for drug treatment in schools, prisons and health care settings would be misdirected.
“These sorts of diagnoses could be a real embarrassment,” Dr. Babor added.
The scientific review panel of the psychiatric association has demanded more evidence to support the revisions on addiction, but several researchers involved with the manual have said that the panel is not likely to change its proposal significantly.
The controversies about the revisions have highlighted the outsize influence of the manual, which brings in more than $5 million annually to the association and is written by a group of 162 specialists in relative secrecy. Besieged from all sides, the association has received about 25,000 comments on the proposed changes from treatment centers, hospital representatives, government agencies, advocates for patient groups and researchers. The organization has declined to make these comments public.
While other medical specialties rely on similar diagnostic manuals, none have such influence. “The D.S.M. is distinct from all other diagnostic manuals because it has an enormous, perhaps too large, impact on society and millions of people’s lives,” said Dr. Allen J. Frances, a professor of psychiatry and behavioral sciences at Duke, who oversaw the writing of the current version of the manual and worked on previous editions. “Unlike many other fields, psychiatric illnesses have no clear biological gold standard for diagnosing them. They present in different ways, and illnesses often overlap with each other.”
Dr. Frances has been one of the most outspoken critics of the new draft version, saying that overly broad and vaguely worded definitions will create more “false epidemics” and “medicalization of everyday behavior.” Like some others, he has also questioned whether a private association, whose members stand to gain from treating more patients, should be writing the manual, rather than an independent group or a federal agency.
Under the new criteria, people who often drink more than intended and crave alcohol may be considered mild addicts. Under the old criteria, more serious symptoms, like repeatedly missing work or school, being arrested or driving under the influence, were required before a person could receive a diagnosis as an alcohol abuser.
Dr. George E. Woody, a professor of psychiatry at the University of Pennsylvania School of Medicine, said that by describing addiction as a spectrum, the manual would reflect more accurately the distinction between occasional drug users and full-blown addicts. Currently, only about 2 million of the nation’s more than 22 million addicts get treatment, partly because many of them lack health insurance.
Dr. Keith Humphreys, a psychology professor at Stanford who specializes in health care policy and who served as a drug control policy adviser to the White House from 2009 to 2010, predicted that as many as 20 million people who were previously not recognized as having a substance abuse problem would probably be included under the new definition, with the biggest increase among people who are unhealthy users, rather than severe abusers, of drugs.
“This represents the single biggest expansion in the quality and quantity of addiction treatment this country has seen in 40 years,” Dr. Humphreys said, adding that the new federal health care law may allow an additional 30 million people who abuse drugs or alcohol to gain insurance coverage and access to treatment. Some economists have said that the number could be much lower, though, because many insurers will avoid or limit coverage of addiction treatment.
The savings from early intervention usually show up within a year, Dr. Humphreys said, and most patients with a new diagnosis would get consultations with nurses, doctors or therapists, rather than expensive prescriptions for medicines typically reserved for more severe abusers.
Many scholars believe that the new manual will increase addiction rates. A study by Australian researchers found, for example, that about 60 percent more people would be considered addicted to alcohol under the new manual’s standards. Association officials expressed doubt, however, that the expanded addiction definitions would sharply increase the number of new patients, and they said that identifying abusers sooner could prevent serious complications and expensive hospitalizations.
“We can treat them earlier,” said Dr. Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania and the head of the group of researchers devising the manual’s new addiction standards. “And we can stop them from getting to the point where they’re going to need really expensive stuff like liver transplants.”
Some critics of the new manual have said that it has been tainted by researchers’ ties to pharmaceutical companies.
“The ties between the D.S.M. panel members and the pharmaceutical industry are so extensive that there is the real risk of corrupting the public health mission of the manual,” said Dr. Lisa Cosgrove, a fellow at the Edmond J. Safra Center for Ethics at Harvard, who published a study in March that said two-thirds of the manual’s advisory task force members reported ties to the pharmaceutical industry or other financial conflicts of interest.
Dr. Scully, the association’s chief, said the group had required researchers involved with writing the manual to disclose more about financial conflicts of interest than was previously required.
Dr. O’Brien, who led the addiction working group, has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction.
He has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving. He was the driving force behind adding “craving” to the new manual’s list of recognized symptoms of addiction.
“I’m quite proud to have played a role, because I know that craving plays such an important role in addiction,” Dr. O’Brien said, adding that he had never made any money from the sale of drugs that treat craving.
Dr. Howard B. Moss, associate director for clinical and translational research at the National Institute on Alcohol Abuse and Alcoholism, in Bethesda, Md., described opposition from many researchers to adding “craving” as a symptom of addiction. He added that he quit the group working on the addiction chapter partly out of frustration with what he described as a lack of scientific basis in the decision making.
“The more people diagnosed with cravings,” Dr. Moss said, “the more sales of anticraving drugs like Vivitrol or naltrexone.”
THE WASHINGTON POST
Psychiatry’s bible, the DSM, is doing more harm than good
By Paula J. Caplan
April 27, 2012
About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.
After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.
Since the 1980s, when I first made public my concerns about psychiatric diagnosis, I have heard from hundreds of people who have been arbitrarily slapped with a psychiatric label and are struggling because of it. About half of all Americans get a psychiatric diagnosis in their lifetimes. Receiving any of the 374 psychiatric labels — from nicotine dependence disorder to schizophrenia — can cost anyone their health insurance, job, custody of their children, or right to make their own medical and legal decisions. And if patients take psychiatric drugs, they risk developing physical disorders such as diabetes, heart problems, weight gain and other serious conditions. In light of the subjectivity of these diagnoses and the harm they can cause, we should be extremely skeptical of them.
Psychiatric diagnosis is unregulated, so the doctor who met briefly with the aforementioned patient wasn’t required to spend much time understanding what caused her heart to race or to seek another doctor’s opinion. If he had, the patient would have realized that her bipolar diagnosis wasn’t necessary or appropriate. Neither on her ER trip nor in later visits to therapists did anyone explain how sleep deprivation impairs the body’s ability to handle pressure.
In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.
According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.
When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.
Over the next 10 months, the woman lost her friends, who attributed her normal mood changes to her alleged disorder. Her self-confidence plummeted; her marriage fell apart. She moved halfway across the country to find a place where, on her dwindling savings, she and her son could afford to live. But she was isolated and unhappy. Because of the drug she took for only six weeks, she now, more than three years later, has an eye condition that could destroy her vision.
This patient is well-educated and white, and before her illness, she was wealthy. Research reflects that she was more likely to be diagnosed as mentally ill than a man in her circumstances. Racism, classism, ageism and homophobia can also affect who receives a psychiatric diagnosis.
It would be less troubling if such diagnoses helped patients, but getting a label often hinders recovery. It can lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is causing the patient’s suffering.
The marketing of the DSM has been so effective that few people — even therapists — realize that psychiatrists rarely agree about how to label the same patient. As a clinical and research psychologist who served on (and resigned from) two committees that wrote the current edition of the DSM, I used to believe that the manual was scientific and that it helped patients and therapists. But after seeing its editors using poor-quality studies to support categories they wanted to include and ignoring or distorting high-quality research, I now believe that the DSM should be thrown out.
An undeserved aura of scientific precision surrounds the manual: It has “statistical” in its title and includes a precise-seeming three- to five-digit code for every diagnostic category and subcategory, as well as lists of symptoms a patient must have to receive a diagnosis. But what it does is simply connect certain dots, or symptoms — such as sadness, fear or insomnia — to construct diagnostic categories that lack scientific grounding. Many therapists see patients through the DSM prism, trying to shoehorn a human being into a category.
At a convention in Philadelphia starting May 5, the DSM’s publisher, the American Psychiatric Association, is due to vote on whether to send the manual’s next edition, the DSM-5, to press. The APA is a lobbying group for its members, not an organization with patients’ interests as its top priority. It has earned $100 million from sales of the current edition, the DSM-IV.
Allen Frances, lead editor of the current DSM, defends his manual as grounded in science, but at times he has acknowledged its lack of scientific rigor and the overdiagnosing that has followed. “Our net was cast too wide,” Frances wrote in a 2010 Los Angeles Times op-ed, referring to the explosion of diagnoses that led to “false ‘epidemics’ ” of attention deficit disorder, autism and childhood bipolar disorder. The current manual, released in 1994, he wrote, “captured many ‘patients’ who might have been far better off never entering the mental health system.”
Frances has even said that “there is no definition of a mental disorder. . . . These concepts are virtually impossible to define precisely.”
Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.
Patients should not be limited in their choices of treatment, but they should be better informed. If someone knows about the many ways that suffering can be addressed, including a drug or a treatment with potential benefits and harms, and they still want to try it, they should be able to.
While patients who think they have been harmed by a diagnosis can file a lawsuit or a complaint with a state licensing body, that almost never happens. However, this weekend marks a big change, as some people are speaking up: About 10 people who received diagnoses from the current DSM edition are filing complaints against the manual’s editors. (I have worked with the patients to prepare their complaints, and I’m filing my own as a concerned clinician.)
The complainants allege that the DSM’s editors failed to follow the APA’s ethical principles, which include taking account of scientific knowledge and respecting patients’ welfare and dignity. They are asking the APA to order the editors to redress the harm done to them — or in one case, to a deceased relative — and to anyone else hurt by receiving a label. They want the APA to hold a public hearing about the dangers of psychiatric diagnosis to gather information about the extent of the damage and look for ways to minimize it. Additionally, they are asking the APA to make clear to therapists and to the public that psychiatric diagnoses are not scientific and that they often put patients at risk.
As the patient labeled as bipolar told me: “If I had never been diagnosed, I probably would still be married, would live close to family and friends and not be so lonely, and would not be living on the financial edge.”
Paula J. Caplan, a clinical and research psychologist, is a fellow in the Women in Public Policy Program at Harvard’s Kennedy School of Government. She is the author of “They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal.”