… Saving Normal, his book

about the benighted DSM-V.

Recent discussion here.

[Click on the image for a bigger picture.]

… a dead ringer for Leonard Bernstein, is the subject of a forthcoming film about his campaign against the DSM.

Retired from a high-profile career as an academic psychiatrist, Frances now muses on the expensive and destructive medicalization of human experience in America.

In a recent post, I noted what I called his Post-Diagnostic Regret, his almost anguished reflection on his own implication in what another writer calls psychosprawl — the legitimation of so many behaviors as signs of mental illness that thirty percent of the country is now said to be mentally ill. This is great news for the pharmaceutical industry, America’s Fraud Queen.

In this piece, in Psychiatric Times (registration), Frances turns his attention to a recent, much-reported study.

The New York Times of Dec 20,2010 carried an alarming story. It seems that during the past decade, college students have suddenly become much more mentally ill. The rate of severe psychiatric disorder among those seen in school counseling services used to be 16%– now it has reached 44%. Ten years ago, 17% received psychiatric medicine– now it is 24%.

The jump, Frances suggests, is manufactured.

First, it’s far too easy for students to ace the DSM-IV tests for mental disorders. “[T]he severity and duration requirements included in DSM-IV were set too low, particularly in the criteria sets that define the milder forms of the depressive, anxiety, and attention deficit disorders.”

Second, impressionable and sometimes insecure students see endless slick ads encouraging them to palpate, as it were, their moods. “[P]rofit motivated skewing of public information about illness is rightly prohibited virtually everywhere else in the world,” Allen notes. He reminds readers that along with lavishing us with images of our mental fragility, drug companies have long “lavished physicians with industry-sponsored conferences, free trips and meals, free samples, biased research, and co-opted thought leaders. There [is] one drug salesperson for every seven doctors– sometimes outnumbering the patients in waiting areas. Not surprisingly, diagnosis and medication sales have skyrocketed and profits have risen astronomically.”

Side effects, lifelong stigma, insurance difficulties – these are obvious calamities for the wrongly labeled. More profoundly wounding is “the way a falsely diagnosed student sees himself at a crucial moment of identity formation– the reduction in the sense of personal efficacy, resilience, and responsibility.”

Every day’s a new… challenge … for the Harvard B School whizkid. She’s already suing the school for 25 mill because some mean people analyzed her work on ethics and uncovered research fraud. Now a different set of mean people have uncovered plagiarism all over her books. Her technique appears to be chiaroscuro — a scattering of pieces from this place and that for an overall intriguing mix of elements which must have caught the eye of the mean people.  “Gino never reached out to me for permission to use my words and my thoughts, something that high school students do on a regular basis when asking if they can use my articles for their school assignments,” said one of her, uh, sources. To which Harvard University says OUCHIE.

Wired magazine interviews Allen Frances, a retired Duke University psychiatry professor, and editor of the most recent edition [2000 – it’s currently being revised for a new edition] of the profoundly influential Diagnostic and Statistical Manual of Mental Disorders.

Frances has Post-Diagnostic Regret. He regrets the way his edition of the DSM has contributed to what Gary Greenberg, the article’s author, calls “absurdly high rates of diagnosis—by DSM criteria, epidemiologists have noted, a staggering 30 percent of Americans are mentally ill in any given year.” Francis regrets

having remained silent when, in the 1980s, he watched the pharmaceutical industry [America’s Fraud Queen] insinuate itself into the [American Psychiatric Association’s] training programs. [The APA produces the DSM.] (Annual drug company contributions to those programs reached as much as $3 million before the organization decided, in 2008, to phase out industry-supported education.)

The DSM’s vague and proliferating diagnoses have tended to “[create] … mental illness[es] where there previously [were] none, giving drugmakers… new target[s] for their hard sell and doctors, most of whom see it as part of their job to write prescriptions, more reason to medicate.”

As Greenberg notes, “[F]or all their confident pronouncements, psychiatrists can’t rigorously differentiate illness from everyday suffering.”

*************************
After years of reading, thinking, and writing about the university on this blog, UD has concluded that no division of the modern American university has more potential to do harm to the social fabric than academic psychiatry. The most brutal sports program, the most cynical MBA program – these don’t begin to approach the power to harm that organized, respected, and, in some cases, morally compromised diagnosticians have.

And now a post at total odds with this one.

********

My friend Barney Carroll has died, at 78,
his final view, from his apartment’s
picture windows, the glorious Carmel Valley.
He sent me a picture, last week, of what he saw.

********

Allen Frances, a fellow warrior against
corruption in medicine, wrote Barney’s obit.

Barney’s scientific contribution to psychiatric research was to introduce neuroendocrine techniques. He independently discovered the value of the dexamethasone suppression test (DST) as a biomarker of melancholia — the classic, biologically driven subtype of depression. This was the first, and remains one of very few, biomarkers in psychiatry. Barney’s 1981 paper on the DST was among the most highly cited papers in psychiatry. Its impact was immediate, with many replications and extensions.

Another of Barney’s enduring contributions was to educate colleagues in the discipline of proper clinical decision making. He clarified the Bayesian principle that context counts — that is, prior conditional probabilities greatly influence the utility of any clinical feature or laboratory test in making a diagnosis. Throughout medicine, biomarkers and clinical diagnostic features perform with much greater utility in high risk groups than in general populations.

Barney and Allen had both chaired Duke University’s psychiatry department, and they shared an anger at (to quote the subtitle of one of Allen’s books) “Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.” Both certainly know and knew that, as David Bowie wrote toward the end of his life, “On the whole, this whole world is run by brutes for the common and the stupid.” So they weren’t terribly optimistic that their protest could do much. Once it’s all come down to late-night comedy, it’s a bit late in the day.

But if, as Barney explained to me in a recent email, you’re a hopelessly inner-directed person, you can’t live with yourself if you don’t make a serious daily effort toward de-brutalization. Barney saw in Donald Trump late-stage outer-directedness, and regretted that “I won’t be around to see how it finally plays out with the orange man in the white house.” But he was fundamentally stoic – and typically observant – about the process of dying.

I am watching with detachment as I move along the path to allostatic collapse… What’s allostatic collapse? It’s just a fancy term for the end state of chronic deterioration that comes with terminal illness. We begin to fail piece by piece but we may hang on for years in a new state of compensated but pathologic equilibrium until even that cannot be sustained. Related constructs are chronic life stress and aging before supervening disease appears. My point of collapse is shaping up to be respiratory failure.

I had many questions to ask Barney about allostasis. Can’t ask them now. But he already, in his final sign-off, told me the most important thing.

Be well and be happy.

… is the slogan of the opioid-mad Sackler family, which takes its massive dope-earnings and ploughs them into high-profile gifts that glorify the Sackler name.

“It’s amazing how they are left out of the debate about causation, but also about solutions,” Allen Frances, [a retired] Duke psychiatrist, said of the Sacklers. “A truly philanthropic family, looking at the last twenty years, would say, ‘You know, there’s several million Americans who are addicted, directly or indirectly, because of us.’ Real philanthropy would be to contribute money to taking care of them. At this point, adding their name to a building — it rings hollow. It’s not philanthropy. It’s just a glorification of the Sackler family.” According to the American Society of Addiction Medicine, more than two and a half million Americans have an opioid-use disorder. Frances continued, “If the Sacklers wanted to clear their name, they could take a very substantial fraction of that fortune and create a mechanism for providing free treatment for everyone who’s become addicted.” Alfred Nobel, the inventor of dynamite, created the Nobel Peace Prize. In recent years, several philanthropic organizations run by the descendants of John D. Rockefeller have devoted resources to addressing climate change and critiquing the environmental record of the oil company he founded, now called ExxonMobil. Last year, Valerie Rockefeller Wayne told CBS, “Because the source of the family wealth is fossil fuels, we feel an enormous moral responsibility.”

… and we’ve got squads of psychologists, armed with the multimegaton DSM-5, to pick our presidents off one by one: George Bush ran into this guy (and not that I wanna do any armchair psychoanalysis, but the guy is a colleague, and we sat on an examining committee together once, and he spent his round of questioning listing his academic degrees and honors); and now our current leader has run into this guy.

UD‘s blogpal, Allen Frances, tries to introduce some sanity:

Among [John] Gartner’s most notable critics is psychiatrist Allen Frances, who wrote the guidelines for diagnosing narcissistic personality disorder — and who rejects any claim that Trump has it.

To meet the criteria for a narcissistic personality disorder, Frances said, Trump would have to display distress or impairment himself. One could argue he’s caused distress, Frances said, but he doesn’t appear to experience it.

“I think that this guy and other people like him mean well and are sincere and believe that somehow they have a professional responsibility to warn America about the horrors of Trump,” said Frances, an emeritus professor of psychiatry at Duke University. “But I don’t see them as knowing much about diagnoses.”

… The effort to apply a diagnosis to Trump, Frances said, “confuses bad behavior for mental illness.”

UD is exceedingly unfond of whatzisface, but rampant diagnosis-dumping is itself bad behavior.

… … A wondrous land where professors of psychiatry hide their financial involvement in companies that promote new diagnostic techniques these same psychiatry professors have promoted in seemingly neutral scientific publications … You’ve just crossed over into … The conflict of interest twilight zone…

[The] fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was …published by the American Psychiatric Association (APA) in May 2013… [O]ne of the main claimed innovations in the DSM-5 is that it promotes the use of ‘dimensional‘ or quantitative measures of symptoms... [Why] is the DSM promoting symptom scales? Or more to the point, why is it suddenly promoting them now, given that dimensional measures have been used in psychiatry for 60 years? This is where it gets interesting.

The head of the [American Psychiatric Association’s] DSM-5 task force, David Kupfer, stands accused of failing to disclose a conflict of interest which – arguably – means that he has a financial stake in the concept of dimensional assessment.

It all started with a paper in the journal Archives of General Psychiatry (now JAMA Psychiatry) called Development of a computerized adaptive test for depression. The first author was statistician Robert. D. Gibbons of the University of Chicago (a veteran of psychiatric statistics). The last (senior) author was David Kupfer.

The Gibbons et al paper presents a software program to help rate the severity of depression, an ‘adaptive’ questionnaire. Whereas a normal questionnaire is just a fixed list of items, the new system chooses which questions to ask next based on your responses to previous ones (drawing questions from a bank of items adapted from existing depression scales). The authors say this provides precise measurement of depression across the full continuum of severity.

… He (and Gibbons and colleagues) seem to be preparing to sell their computerized adaptive test (CAT). They have incorporated a company, Psychiatric Assessment Inc. (PAI).

This raises the disturbing notion that Kupfer, in his capacity as computerized dimensional product seller, could benefit financially from his prior championing of dimensional assessment in his capacity as DSM-5 head.

Or, as UD’s blogpal Allen Frances puts it, more succinctly:

While using his DSM 5 pulpit to strongly promote the value of dimensional diagnosis, the DSM 5 Chair (and several associates also working on DSM 5) were secretly forming a company that would profit from the development of commercially available dimensional instruments. And unaccountably, he failed to disclose this most obvious of conflicts of interest while simultaneously lauding the DSM 5 conflict of interest policy.

Or, as UD‘s blogpal Bernard Carroll puts it, more colorfully:

Peddle unproven psychiatric screening scales backed up by black box statistics (a distressing specialty of Dr. Gibbons); publish a glowing report in JAMA Psychiatry, which you have infiltrated (Ellen Frank and Robert Gibbons are on the editorial board); get your corporate people inside the DSM-5 process (David Kupfer, Robert Gibbons, Paul Pilkonis); slant the DSM-5 process to endorse, however weakly, the kind of products you intend to market; start a corporation without telling anybody and establish a website with advance marketing that touts your new academic publication in JAMA Psychiatry while highlighting Dr. Kupfer’s key role in DSM-5; loudly proclaim … the advent of population-wide screening but before doing any serious field trials or acknowledging that most positive screens will be false positives. This is the usual dodgy hand waving of wannabe entrepreneurs, whose vision is obscured by dollar signs. Oh, and did I mention regulatory capture of NIMH for over $11 million in funding while not producing a product worth a tinker’s damn?

The only thing this group seems to have failed to do is get Virginia’s Governor Bob McDonnell in on it.

[Joseph] Biederman, along with Charles Nemeroff, who was then at Emory University, and Alan Schatzberg of Stanford (the 116th President of the American Psychiatric Association) are in many ways poster boys for [pharma corruption]. Ironically, it was Schatzberg, during his presidency in 2009, who responded vehemently to Allen Frances’s criticisms of the DSM 5 task force by pointing to the $10,000 in royalties Frances was still receiving from DSM IV. Apparently, the $4.8 million in stock options Schatzberg had in a drug development company, or the fat fees he received from such companies as Pfizer, had no similar distorting effect on his judgment — just as the $960,000 Charles Nemeroff received from GlaxoSmithKline (while reporting only $35,000 to his university) had no influence on him. And just as the millions of dollars that Biederman and his associates at Harvard received for creating a new diagnosis and a massive new market for antidepressants and second-generation antipsychotics among young children (drugs associated with massive weight gain, metabolic disorders, diabetes, and premature death) had nothing to do with their behavior!

Nemeroff is now at the University of Miami, but that’s not a scandal because Miami isn’t a respectable university. The scandal lies at respectable places like Stanford and Harvard, which will “turn a blind eye to ethical failings if the money on offer is sufficiently tempting.”

Fun interview with Gary Greenberg about the Diagnostic and Statistical Manual controversy. Greenberg’s much more radical in his dismissal of the latest edition of America’s Icelandic psychosaga than UD‘s buddy Allen Frances (“We agree that the DSM does not capture real illnesses, that it’s a set of constructs. We disagree over what that means. He believes that that doesn’t matter to the overall enterprise of psychiatry and its authority to diagnose and treat our mental illnesses. I believe it constitutes a flaw at the foundation of psychiatry. If they don’t have real diseases, they don’t belong in real medicine. Al’s … really trying to keep scrutiny off of the whole DSM enterprise. That’s why he’s been so adamant that you don’t throw the baby out with the bathwater — he believes that the DSM-IV, for all of its flaws, its still worthwhile. I disagree.”). He has a new book attacking the DSM from many angles. It’s called The Book of Woe: The DSM and the Unmaking of Psychiatry and its cover is done up just like the posters for Psycho.

UD is mulling going to Politics and Prose bookstore to hear Greenberg talk. The guy has a sense of humor.

— as King Henry might have said if he’d been around today to watch the entire nation go the way of Alexandra, Virginia, where forty percent of the population is currently on antidepressants. Who told so many people that, whatever they were experiencing, they had to take pills of uncertain utility and serious side effects? Possibly for years?

Despite escalating outrage and dismay at hugely growing numbers of Americans being told they are mentally ill and must be medicated, the psychiatrists who have just completed the latest DSM (the medical and insurance establishments’ official list of mental disorders) stuffed it full of yet more ways for us to think of ourselves as mentally ill.

Inevitably, those among us even somewhat eccentric are increasingly unprotected from pharma’s it’s a mad mad mad mad world business model. Children are especially vulnerable; they must rely on the common sense and protective instincts of their parents to keep doctors like Kajoko Kifuji from laying waste to them.

We all know about the hundreds of thousands of twitchy little boys who are having ADHD meds thrown at them; we should also, as UD‘s pal Allen Frances points out, think about gifted kids, whose sometimes unusual affect also excites the madness mongers. He quotes an expert on gifted children: “When pediatric diagnoses are carelessly applied, gifted children are frequently mislabeled with ADHD, autistic, depressive, or bipolar disorders.”

… from the collective “rich, fat, tired” mind of America is about to released. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders – a megaton Memories of Overdevelopment, As I Lay Diagnosing, and Diazepam Comes for the Archbishop – will soon hit the shelves.

Stephen Dedalus, in Ulysses, called Irish art “the cracked looking-glass of a servant.” The DSM is the cracked looking-glass of a master. It is our pill-dependent, Alexandrine culture’s most soul-searching, compendious, self-expression yet.

Allen Frances, who was there when the DSM started to explode, has consistently warned against pathologizing an entire country. Many other people – and many mental health organizations – have done the same. But our family practitioners remain weirdly dependent upon this obese mashup, this encyclical of enervation.

The best that can be said about it is that it adequately conveys what we have become.

… How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, talks about how doctors diagnose personality disorders.

The most recent edition of the DSM series, DSM-IV in 1994, had a whole slew of personality disorders, including histrionic, narcissistic, borderline, and so forth. The editor of DSM-IV, Allen Frances, was a psychoanalyst, and the list is a kind of last gasp. The problem is that patients who qualified for one, tended to qualify for almost all of them. The individual “disorders” were quite incapable of identifying individuals who had something psychiatrically wrong with them; the “disorders” had become labels for personality characteristics that are found in abundance in the population.

Moreover, who needed labels? Psychiatrists had a seat-of-the pants definition of a PD: “If your first impression of your patient is that he is an asshole, then he probably has a personality disorder.”

*******************************

You begin to see the basis of Steven Cohen’s defense.

UD‘s blogpal Allen Frances is currently down the street from her house, at the National Institutes of Health, where UD‘s father spent his whole career as an immunologist. Frances is lecturing to a group of journalists about what he calls diagnostic inflation, or the tendency of the culture, led by profit-seeking pharmaceutical companies, and abetted by the authors of the paradigmatic postmodern work of our time, Diagnostic and Statistical Manual of Mental Illnesses, to designate everyone, from as young an age as possible, mentally ill.

It hasn’t happened yet in this election cycle, but UD anticipates American presidential and vice-presidential debates revolving mainly around a clash of diagnostic claims. You can see how easily it could have been done in this latest round, with Biden’s inappropriate affect, Ryan’s compulsive swallowing, Obama’s first-debate narcolepsy, and (most troubling) Romney’s disclosure at the Al Smith dinner that he hasn’t had an alcoholic drink in sixty-five years. All of these people are mentally ill, and all of the people who will run for these offices in the future are mentally ill. Americans will have a choice between borderline psychotic and psychotic.