These things are pretty easy to write, and given the incredibly lucrative medicalization of normalcy at the heart of the newest edition of the Diagnostic and Statistical Manual of Mental Disorders, we’ll see more and more of this literary genre.

Or maybe less and less. It can be hard to write clearly when you’re on anti-psychotics.

Mental health clinicians should consider signing this petition. It explains why taking the fifth, if you will, would be a terrible error.

The author of a new book about growing is interviewed.

[G]etting a mental-health diagnosis can intersect with the adolescent search for self. Being diagnosed and using medication confers an identity, that of someone with a mental disorder. To an adolescent who is preoccupied with constructing an identity anyway, and looking for clues to who she is, that can be a big deal. Some adolescents feel that having a diagnostic label is clarifying and that it helps them. But others wrestle with it. They ruminate about what it means to be sick. They take that identity deep inside, and sometimes magnify it way out of proportion. A diagnosis event can have lasting, rippling consequences, and I think adults should be very cautious and careful before they impose a diagnostic label, or let a young person self-impose such a label, on what may be ordinary developmental struggles.

But hey. That’s nothing. Because of the work of Joseph Biederman and others, it’s now routine for American toddlers to be given powerful psychotropics.

What? You mean thousands of people aren’t attracted to meetings featuring Charles Nemeroff and Alan Schatzberg?

Allen Frances goes on to say that “Psychiatric diagnosis has become too important to be left in the hands of a small, withering, cash-strapped, incompetent association that feels compelled to regard its bottom line as a higher priority than having a safe, scientifically sound, and widely accepted diagnostic system.”

… is the name UD‘s blogpal Allen Frances gives the tendency of the people at the American Psychiatric Association to toss every human behavior they can think of into the soon-to-be released update of the Diagnostic and Statistical Manual of Mental Disorders. The new DSM will guarantee every American man, woman, and child forty acres, a mule, and a diagnosis.

Everybody gets to be something: depressed, pre-psychotic… Everybody gets the same diagnostic-labeling start in life. The children of the very rich will no longer get diagnosed before those of the middle class; everyone starts out with ADD or executive functioning disorder or what have you, and parity is maintained throughout the subsequent years, with adolescent, young adult, middle-aged, and elderly diagnoses following each American all the days of her life. As Frances writes, this “radical expansion of the boundaries of psychiatry … will increase by tens of millions the number of people presumed to be suffering from mental disorders.”

The key is indeed diagnostic exuberance, or what others have called psychosprawl. The combination of a regularly updated official manual massively increasing our diagnosable behaviors, under-informed pill-happy primary physicians, and unremitting advertising, means a psychotropic harvest the likes of which this country has never seen. To picture it, replace the turkey in this woman’s hands with a steaming tureen of tricyclics.

“Is the American Psychiatric Association getting carried away?” as Christopher Lane asks, in an interview about the notorious DSM.

“The risk is that the drug companies will seize on the milder conditions [listed in the DSM] and hype and exaggerate them through very canny marketing to the point where they’re basically represented as an under-reported problem…. The thresholds are [regularly] lowered for these disorders… and consequently vast numbers of the public are suddenly eligible for a diagnosis that they wouldn’t have been before.”

He notes that if the current version of the DSM gets published, children as young as four will be eligible for powerful anti-psychotic drugs, and people still grieving the loss of someone after two weeks will also be eligible for a mentally disordered diagnosis and powerful drugs.

Next month, activists plan to stage an “Occupy the APA” protest in Philadelphia during the organization’s annual conference to show their disdain.

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.”

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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.

Edward Shorter of the University of Toronto keens over the bloated corpse of the latest Diagnostic and Statistical Manual.

The pharmaceutical industry, writes Shorter in the Wall Street Journal, “seeks the largest possible market for a given drug, and advertises huge diseases, such as major depression and schizophrenia, the scientific status of which makes insiders uneasy.”

The DSM provides pharma a market-expanding facade of empiricism. Its ever-broadening girth is a result of “increased specificity” of diagnosis within these immense major disease categories, but the specificity “is spurious. There is little risk of misdiagnosis, because the new disorders all respond to the same drugs, so in terms of treatment, the differentiation is meaningless and of benefit mainly to pharmaceutical companies that market drugs for these niches.” As a commenter on Shorter’s piece puts it, “We’re slicing up illnesses in small portions, we’re treating illnesses with very different names and symptoms with basically the same medications, and we’re at least partly doing this because drug companies have discovered the primary marketing mantra of differentiation. ”

Smartly tricked-out pills for your tailor-made depression; a whole other set for your very own anxiety. Yet “these indications are more marketing devices than scientific categories, because most depression entails anxiety and vice versa.”

The latest draft of the DSM fixes none of the problems with the previous DSM series, and even creates some new ones.

A new problem is the extension of “schizophrenia” to a larger population, with “psychosis risk syndrome.” Even if you aren’t floridly psychotic with hallucinations and delusions, eccentric behavior can nonetheless awaken the suspicion that you might someday become psychotic. Let’s say you have “disorganized speech.” This would apply to about half of my students. Pour on the Seroquel for “psychosis risk syndrome”!

DSM-V accelerates the trend of making variants on the spectrum of everyday behavior into diseases: turning grief into depression, apprehension into anxiety, and boyishness into hyperactivity. [One of Shorter’s commenters calls this disgusting development “psychosprawl.”]

If there were specific treatments for these various niches, you could argue this is good diagnostics. But, as with other forms of anxiety-depression, the SSRIs [a major category of pills] are thought good for everything. Yet to market a given indication, such as social-anxiety disorder, it’s necessary to spend hundreds of millions of dollars on registration trials to convince the FDA that your agent works for this disease that previously nobody had ever heard of.

See why your placebo with strong side effects costs so much?

And we haven’t yet touched on advertising and litigation budgets.

With DSM-V, American psychiatry is … defining ever-widening circles of the population as mentally ill with vague and undifferentiated diagnoses and treating them with powerful drugs.

A psychiatrist writes a letter to the Psychiatric Times about the ongoing preparation of the latest edition of the DSM-V, the humongous – and always getting more humongous – reference book on which insurance company payment for mental illness treatment is based:

[T]here are a bunch of pre-conditions for DSM revision, which include among others, that the new version must not be a radical departure, and must be consistent and compatible with the existing DSM, thus guaranteeing continuity and preventing disruptions in the diagnosis and treatment of existing patients, assuring continuity in education and training for residents in psychiatry and existing practitioners, and in managed care  and insurance coverage, and Treatment Guidelines and in psychiatric record-keeping, as well as research, unless we start labeling our diagnoses with vintage-like DSM numbers, like we label wines.

It is clear from the above pre-condition of continuity that there will be no significant departure from the established DSM path, and we can scratch the answer to our query, ie, “One psychiatrist” no matter how much he or she really wants to change the DSM [will be able to do so].

However, although they may consider introducing criteria to add dimensionality to designate severity, or the course of an illness, or degrees of impairment of symptoms, etc, for field-testing in accordance with the already existing studies on DSM defects, there will be no move in the direction of incorporating a brain-based, neurophysiologic paradigm, although there is a growing consensus which indicates that is the way to the future of psychiatric diagnosis.  We are still impeded by our attachment to the scientific studies of the past.  We appear to be rowing into the science of the future backwards, while anchored to the science of the past.

Background here.

A former psychiatrist, alarmed by what the profession’s become, reviews the latest farcical use of psychiatrists in a high-profile trial, and then considers the larger situation:

… These days, psychiatric diagnoses are based on the “Diagnostic and Statistical Manual of Mental Disorders,’’ published by the American Psychiatric Association. This hefty volume is a main money-maker for the association, upward of a million dollars in annual sales.

… It is … tarnished by many of the specialists being paid to be involved in studies of drugs to treat the illnesses they list as their expertise. The temptation for them to find a drug that will treat a diagnosis they can specify and in which they are the expert is significant.

The current conflict-of-interest investigations – including by Congress – into psychiatrists getting paid to do research that might prove the efficacy of the drugs they use to treat their patients are well documented. If a drug company can link a particular drug to a particular diagnosis, bingo – a blockbuster drug can earn over a billion dollars a year. The lucrative link between a diagnosis and a drug to treat it, when diagnosis itself is culture-bound and often subjective, pollutes the impartiality of the “Diagnostic and Statistical Manual,’’ and opens the courtroom door to the psycho-battles that demean and confuse…

The corruption not only of examining rooms and courtrooms, but also of universities, by ghost-writers, shills, and mercenaries, emerges more and more clearly. University Diaries looks forward, as always, to chronicling it.

And now a post at total odds with this one.

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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.

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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.

… … 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.

Well, wow. The psychic landscape around here resembles the setting of Waiting for Godot – raw.

Or it’s like Mad Max – a Hobbesian war of all against all, played out on America’s busiest media highways, with desperate gangs (TheraPeuts, PsychíaCrips, DataDevils) truncheoning each other for the biggest piece of the pathology pie.

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Our depressed nation has long taken its orders from the Diagnostic and Statistical Manual of Mental Disorders; but the DSM has – like much of its clientele – grown mulish, morbidly obese… Even as each edition trumpets new and improved deficits, the high-tech, data-gathering world is passing it by.

So the DSM is in denial. Facing obsolescence and repudiation, its editors brightly inform us that it remains America’s go-to book for the blues.

But, you know, the bottom line isn’t about this approach or that approach to psychic disturbance. The bottom line is that more and more observers are simply disgusted at the massive numbers of people in this country who have been persuaded – by television commercials, by the DSM, by doctors – to think there’s something clinically wrong with them for which they have to take pills for years. (‘[S]ome pharmaceutical companies that have enriched themselves by selling psychiatric drugs are now cutting back on further research on mental illness. The ‘withdrawal’ of drug companies from psychiatry, Steven Hyman, a psychiatrist and neuroscientist at Harvard and former NIMH director, wrote last month, “reflects a widely shared view that the underlying science remains immature and that therapeutic development in psychiatry is simply too difficult and too risky.” Funny how this view isn’t incorporated into ads for antidepressants and antipsychotics.’) The DSM has helped to make a lucrative fetish of pseudo-debility in the American population, and as long as there’s money in it and a total absence of biomarkers, it will, it seems, keep doing that.

Even when we get somewhere with biomarkers it won’t make any difference. Do you think an absence of any discernible ground for mental illness will stop a person who has been taught by this culture to think of herself in that way? To think of all of life’s difficult passages as illnesses rather than difficult passages? “The struggle of psychiatry since 1980 has not been to fashion more and more illnesses, but rather to convince us that when we are unhappy, anxious, compulsive, etc., we have a mental illness. In this they have been successful, at least to judge from the vast increase in numbers of people seeking treatment. It’s a predictable outcome of the DSM approach to mental suffering.” The science can tell us what it likes; until we stop liking the image of ourselves as debilitatingly neurotic it won’t make any difference.

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Remember what Nietzsche said about the DSM.

“The DSM is a mobile army of metaphors, metonyms, anthropomorphisms, in short a sum of human relations which have been subjected to poetic and rhetorical intensification, translation and decoration … The DSM is an illusion of which we have forgotten that it is illusion, a set of metaphors which have become worn by frequent use and have lost all sensuous vigor… Yet we still do not know where the drive to produce DSMs comes from, for so far we have only heard about the obligation to have DSMs…”

… to you, maybe… But to the American Psychiatric Association, with its eminent leaders, the Diagnostic and Statistical Manual of Mental Disorders is an absolute goldmine.

Very thoughtful essay on the big new Diagnostic and Statistical sampler, bursting with psychiatric diagnoses for everyone in the family. Like Adam Phillips (“[H]appiness is the most conformist of moral aims. For me, there’s a simple test here. Read a really good book on positive psychology, and read a great European novel. And the difference is evident in one thing — the complexity and subtlety of the moral and emotional life of the characters in the European novel are incomparable. Read a positive-psychology book, and what would a happy person look like? He’d look like a Moonie. He’d be empty of idiosyncrasy and the difficult passions.”), Patricia Pearson perceives the philosophical destitution of a culture that’s handed the task of self-consciousness over to clueless family physicians — nice people desperately paging through the DSM for tranquilizers. To be sure, the difficult passions are difficult. That doesn’t mean you should pill them away.

A New Yorker writer anticipates the release, next month, of the latest Diagnostic and Statistical Manual of Mental Disorders. He finds it bizarre and unsettling, as does UD, that so many Americans are willing to medicalize their experience of life. Their children’s experience of life. He wonders why this organization, the American Psychiatric Association, retains its mental illness franchise.

The market for mental disorders is already enormous, thanks in part to the relentless effort of the A.P.A. to use the D.S.M. to convince us that our psychological suffering is best understood as diseases that should be treated by doctors.