… 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.”

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

… Andrew Scull titles his latest essay in the Times Literary Supplement. It looks to be a good summary of the ongoing scandal of the next edition of the Diagnostic and Statistical Manual of Mental Disorders, but you and I can’t read it without a subscription. Here’s an excerpt (from a post about it in Commonweal):

As diagnostic criteria were loosened [in DSM III], an extraordinary expansion of the numbers of mentally sick individuals ensued. This has been particular evident among, but by no means confined to, the ranks of the young. “Juvenile biopolar disorder”, for example, increased forty-fold in just a decade, between 1994 and 2004. An autism epidemic broke out, as a formerly rare condition, seen in less than one in 500 children at the outset of the same decade, was found among one in every ninety children only ten years later. The story for hyperactivity, subsequently relabelled ADHD, is similar, with 10 per cent of male American children now taking pills daily for their “disease”. Among adults, one in every seventy-six Americans qualified for welfare payments based on mental disability by 2007.

If psychiatrists’ inability to agree among themselves on a diagnosis threatened to make them a laughing stock in the 1970s, the relabelling of a host of ordinary life events as psychiatric pathology now seems to promise more of the same. Social anxiety disorder, oppositional defiant disorder, school phobia, narcissistic and borderline personality disorders are apparently now to be joined by such things as pathological gambling, binge eating disorder, hypersexuality disorder, temper dysregulation disorder, mixed anxiety depressive disorder, minor neurocognitive disorder, and attenuated psychotic symptoms syndrome.

Yet we are almost as far removed as ever from understanding the etiological roots of major psychiatric disorders, let alone these more controversial diagnoses (which many people would argue do not belong in the medical arena in the first place). That these diagnoses provide lucrative new markets for psychopharmacology’s products raises questions in many minds about whether commercial concerns are illegitimately driving the expansion of the psychiatric universe – a concern that is scarcely allayed when one recalls that the great majority of the members of the DSM task force are recipients of drug company largesse.

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New pathologies are breaking out all the time.

There’s a whole other category for Kim Kardashian.

(UD thanks David.)

One quarter of you have already been flushed out and diagnosed!

The massive “naturalist’s field guide” that is the Diagnostic and Statistical Manual of Mental Disorders has already tagged and bagged you.

A most serious problem, common to field guides, is the difficulty of separating entities that are similar in appearance.

The new emphasis on symptoms… has unfortunately encouraged a cursory “top-down” method that relies on checklists and ignores much of the narrative of …patients’ lives.

You coo like a mourning dove. But maybe you’re not depressed!

[P]sychiatrists using the DSM diagnosis “major depression” tend to mingle bereaved patients with both those afflicted by classic melancholia and those demoralized by circumstances. The mixing of similar-appearing patients who have conditions that are distinct in nature probably explains why use of this diagnostic category expanded over time and suggests why the effectiveness of antidepressant medications given to people with a diagnosis of major depression has, of late, been questioned. This tendency to blur natural distinctions may explain why other DSM diagnoses — such as post-traumatic stress disorder (PTSD) and attention deficit disorder — have been overused, if not abused.

And don’t forget Hartz Mountain Industries.

[A] diagnostic category based on checklists can be promoted by industries or persons seeking to profit from marketing its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety and depression.

The Australian commenter posing this question can look over here, at the States, to see what a national sedation policy might look like.

Not that every one of us has been zoned by Zeneca… mummified by Merck… Lalalanded by Lilly… but, you know, tens of millions of Americans have gotten there, and – out-of-it-wise – we’re way more advanced than the Aussies. Our best poets sing of it:

Let us go then, you and I,
Where America is spread out against the sky
Like a nation etherized upon a table…

In one particular way, Australia looked for awhile as though it might overtake us – i.e., in government-sponsored anti-psychotic dosing of children without psychotic symptoms.

To be sure, we’ve got Joseph Biederman (type his name into this blog’s search engine and enjoy).

But Australia’s got Patrick McGorry who, until he (under pressure from scientists around the world) abandoned the idea, thought it might be clever to experiment with giving fifteen-year-olds he determined to be “pre-psychotic” powerful antipsychotic drugs. Some people thought it wasn’t too cool to give “children who had not yet been diagnosed with a psychotic illness…. drugs with potentially dangerous side effects.” So last summer McGorry dropped the idea.

And now – under equally strong pressure from an outraged scientific community, McGorry has gone one step further.

Concerns about the overmedication of young people and rigid models of diagnosis have led the architect of early intervention in Australian psychiatry, Patrick McGorry, to abandon the idea pre-psychosis should be listed as a new psychiatric disorder.

The former Australian of the Year had previously accepted the inclusion of pre-psychosis – a concept he and colleagues developed – in the international diagnostic manual of mental disorders, or DSM, which is being updated this year.

Drug companies must be mildly dismayed. (Only mildly, because they’ll find a way around this.) Popular American news shows are pointing out that for most people anti-depressants are placebos with serious side effects. Critics are attacking the idea of a grief pill. And now the packed-with-potential idea of pre-psychosis (who ain’t pre-? and when will they figure out that an even niftier idea is clinically pre-neurotic?) is being savaged simply because some people think giving symptom-free people immensely powerful drugs is unethical!

Zoom in on the bigger picture here, if you will. Through incessant advertising, and through incentivized research professors at our universities, the drug industry is slowly rebuilding our basic human self-appraisals. We simply cannot get through life without pills.

The remarkable American Psychiatric Association (until recently ruled by Alan Schatzberg) makes money two ways:

1.) Publishing, and regularly revising with an eye toward broadening the categories under which people can be considered mentally disordered, the Diagnostic and Statistical Manual of Mental Disorders.

2.) Making the people who work for the APA devising these broader categories sign confidentiality agreements so that the APA can without hindrance from the scientific community enlarge the number of Americans who must buy psychotropic drugs.

Now, as Allen Frances notes, the APA has gone a step further, loosing its lawyers to stalk bloggers who use the letters DSM in their blog’s name. It’s all part of protecting psychiatry’s, and pharma’s, enormous investment in retaining ownership of the who’s mentally disordered franchise.

The anti-DSM movement finds its poet. This guy can really write.

Psychiatrists get paid for treating mental illness. There is a strong motivation for them to look at things they used to attribute to chronic personality, or just life, and see them as psychiatric illness. If you have an unstable personality disorder I am afraid psychiatry has little to offer, but if we call you bipolar or cyclothymic we treat you with antidepressants and mood stabilizers, and get paid to do so.

… An apparently scientific argument is said to be “not even wrong” if it is based on assumptions that cannot possibly be falsified or used to predict anything. I am afraid after nearly 20 years in the belly of the beast of psychiatry I come to no other logical conclusion than that for the most part the DSM and the psychiatry behind it are “not even wrong.” … Because of this purely descriptive, medicalized approach untied to verifiable pathology, if I as a doctor want to see bipolar disorder as irritability and daily mood swings (as many do), than that to me is being “bipolar.” I can also look at it as a byproduct of a very challenging environment superimposed on temperament, but I cannot prove that it is or is not “bipolar disorder.” I can only prove that I choose to interpret some symptoms as diagnostic of that particular label. When the definition of the construct cannot escape subjective description or self report we cannot escape the arguments by certain groups with competing interests that we are either “under” or “over” diagnosing disorders. Whether we are or are not depends on what kind of world you want to live in and how you want to conceptualize what people tell you.

University psychiatrists who unwarily hand out diagnoses and pills to students, or who, as researchers sometimes compromised by industry affiliations, lend academic legitimacy to pseudo-science, have much to answer for.

… the Threshold is UD‘s title for the massive, ever more massive, Diagnostic and Statistical Manual, with its infinitely embellished mental debility stories, in one of which you’re sure to find your sad, anxious, confused, discontented self.

By the simple expedient of having lowered the threshold for clinical disorders to include pretty much anything you’re experiencing right now, the editors of the upcoming DSM have broadened their market share to Everybody. Somewhere inside the Thousand and One Nights of the American Psychiatric Association lies a take-this-pill tale tailored to you, and to all of your children.

With this latest DSM, there’s absolutely no reason for you to put off spending the rest of your life taking psychotropic drugs.

… Libra, is “the megaton novel James Joyce would have written if he’d moved to Iowa City and lived to be a hundred.”

But Joyce is more likely to have written the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The DSM’s predecessor, four, has a thousand pages, and we may be sure that five will have many more than that. It’s a megaton psychotropic prescription machine. As Allen Frances, editor of earlier, more sane, DSMs, writes, “DSM-5 is suggesting many new and untested diagnoses and also markedly reduced thresholds for old ones.”

Frances offers an example:

‘Attenuated psychosis syndrome’ will have a ridiculously high false positive rate ( 80-90%), no effective treatment, would promote unnecessary exposure to harmful antipsychotics, and would cause needless worry and stigma. Since studies prove conclusively that the symptoms are so very rarely predictive of psychosis, why in the world would DSM-5 give someone the stigmatizing and absurdly misleading label ‘attenuated psychosis syndrome’ and open the door to inappropriate antipsychotic use? Recognizing all these risks, a large portion of schizophrenia and prodromal researchers are sensibly opposed to the inclusion of ‘attenuated psychosis syndrome’ in DSM-5. But unaccountably, the work group stubbornly clings to its proposal and, without the petition, there is a good chance it may sneak into DSM-5.

In great part, the DSM-5 is a work of the imagination. Like all ambitious novels, it exhibits enormous scope and imaginative energy. Told from the point of view of a detached omniscient narrator, it chronicles the plummeting of populations into pre-psychosis, and their ultimate rescue by “the number one revenue producer of all classes of drugs,” anti-psychotics. Its pages evoke a les misérables America, massively prodromal, holding out its butyrophenone-bowl on every street corner.

[With each revision of the Diagnostic and Statistical Manual of Mental Disorders], the number of diagnosable conditions increases. With each increase, psychiatry is criticized for ‘creating’ diagnoses to: 1) increase revenue to clinicians; 2) partner with big pharma to expand the mental health market; or 3) simply raise money for the DSM publishers. Consequently, in the absence of research demonstrating that new definitions meaningfully advance the utility of our diagnoses, our credibility with the public and our medical colleagues is challenged with each DSM revision.

Psychiatric Times

… the forthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the absolutely immense text packed with every imaginable psychological permutation.

Allen Frances, editor of an earlier DSMV, cautions against what some are calling psychosprawl:

The greatest problem in the past 15 years of psychiatry has been diagnostic inflation and the over-treatment of people who really don’t need it. This misallocates scarce resources away from those who do most desperately need and can most use our help. I fear DSM-5 because it threatens to further medicalize normality and spread psychiatry too thin.

… this book. It shows a child’s hand grabbing a massive number of pills. [Scroll down to read some of the book.]

Your Child Does Not Have Bipolar Disorder is a richly deserved attack on one of Harvard University’s most prominent professors, Joseph Biederman, a man whose financially self-interested insistence on this serious diagnosis continues to damage and stigmatize millions of young children.

The book’s author, Stuart Kaplan, a professor at Penn State, also has a blog on which he worries, in a day-to-day way, about the psychiatric profession maintaining Buy-Bipolar Biederman’s regime. He notes that although the diagnosis is gradually (thanks to books like Kaplan’s, and to Biederman’s having been sanctioned for taking and not disclosing drug money) being discredited, the editors of the latest, in-progress DSMV are still saying things like this:

… ‘[C]lassic’ adult [bipolar disorder] clearly does present in pre-pubertal children as well as in adolescents, although it may be rare in the younger age group. Unambiguous agreement about this fact weighed heavily in the Work Group’s deliberations.

Kaplan goes to town on this:

The use of the wording “unambiguous agreement about this fact” is a coercive rhetorical device that has held sway for more than 15 years in the pediatric bipolar scientific literature. Instead of providing evidence, the Work Group attempts to persuade the reader that everyone who is smart and important knows this to be true. In truth the assertion is unfounded and has no place in sophisticated scientific discussions of bipolar disorder in children. The clause “although it may be rare in the younger age group” suggests some hesitation on the part of the Work Group in endorsing the existence of Bipolar Disorder in pre-pubertal children.

That the committee accepted as fact that bipolar disorder exists in children raises the issue of the use of the word fact in psychiatry as contrasted with its use in other sciences and in everyday conversation. The use of word “fact” in scientific papers in psychiatry is highly unusual. The use of the word in this context by the DSM-V Work Group is jarring to regular readers of the scholarly literature in psychiatry. In this scientific literature, papers end with conclusions preceded by discussions that are expected to point out the limitations of the scientific work. Conclusions are usually modest, tentative and limited. The word fact is almost never used.

Are there “facts” in psychiatry comparable to the physical constant of the speed of light in physics, the periodic table in chemistry, the function of the adrenal gland in biology, or the boiling point of water on the earth at sea level in everyday life? There may be some (e.g., need for an adequate environment for infants and children for psychological growth and development) but most so called facts in psychiatry are brief stand-ins or proxies for many inferences and theories that shift and change abruptly. For example, the diagnosis of bipolar disorder in adults is based to some degree on the diagnosis of Manic Depressive Insanity first developed by Kraepelin. The veracity of his observations and theories about psychosis are part of the brew of the current diagnosis of Bipolar Disorder. The diagnosis is based to limited degree on Kraepelin’s theories and a large number of other hypotheses many of which are disputable. Fact as the acceptance of some immutable truth does not enter into the discussion.

When the DSM-V Work Group refers to the unambiguous fact that the disorder exists in prepubertal children, does the Work Group have any specific age range in mind? Preschoolers? Children ages 10 years to 12 years? Children ages 6 years to 12 years? Each of these age groups has been the subject of controversy related to bipolar disorder in children, but they are lumped together without any discrimination between them. Similarly, the use of the word “rare” by the DSM-V Work Group remains inexplicably undefined. The expression “rare” has a specific meaning in medicine, referring to a prevalence of 1 or less cases per 1500. Is this what the DSM-V Work Group means? There is a startling lack of precision in the discussion of the existence of pediatric bipolar disorder in childhood by the DSM- V Work Group. Many people, myself included, believe it is closer to the truth to assume, until proven otherwise, that this prepubertal “disorder” does not exist at all.

The misdiagnosis monster lives: the stake must still be driven in to the heart of the beast.

Beast? Why the strong language?

Because the diagnosis is doing terrible things to children; and because the only people benefiting seem to be the people who sell all those pills under the child’s hand on the book’s cover.

The bipolar monster was loosed because American university professors, in cooperation with drug companies, created it. Indeed the problem that confronts us now, as Kaplan says, is how to kill it.

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.”

Alison Bass writes:

… [O]ne of the members of the DSM-V task force is Catherine Lord, a professor at the University of Michigan, who gets big royalties from a diagnostic test she helped develop (known as ADOS) that is used to diagnose autistic spectrum disorders in children. As it turns out, the subcategories for the ADOS test fit very neatly into the new criteria proposed for the autistic spectrum disorders in the DSM-V.

Now, according to an APA disclosure report I found online, Lord has agreed not to accept more than $10,000 from “industry sources” each year from the time the DSM-V is approved until its publication (the report says that will be in 2012, but recently the APA agreed to delayed publication of a new DSM until 2013).

What I want to know is: does this agreement include all the royalties Lord currently receives from the ADOS diagnostic test and the expensive bucket of toys that come with it? And if so, what happens after the DSM-V is published when all those royalties start flooding back in?

More importantly, should Lord have been allowed to sit on the DSM-TV task force in the first place and influence major policy changes in psychiatric diagnoses that will affect millions of vulnerable children? I think not.

These are quotations from a BBC special on the next edition (it will come out in 2012) of the psychiatric DSM.

The catch-all mental disorder category NOT OTHERWISE SPECIFIED — which will apparently be abundantly featured in the forthcoming edition — allows UD (and you too) to anticipate lifelong toxic drug treatment for something or other.

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“The relationship between the pharmaceutical industry and the American Psychiatric Association” is at the heart of Diagnostic and Statistical Manual.

“Each edition doubles the number of diagnoses.”

“A seemingly small change in adding diagnostic criteria can create a whole other population to prescribe a medication for… Most of the categories have a not-otherwise-specified diagnosis…. A person is exhibiting some mood symptoms but those symptoms are not that severe. When you have that kind of (NOS) prescription, you are inadvertently pathologizing what could be a normal part of [life].”

“If you create a criteria, and people appear to meet the criteria… well, many kids appear to have the criteria for bipolar pediatric disorder… This leads to treatment with a group of medicines that are among the most toxic in medicine…. Children of one, two, three, are put on these drugs…”

“There are barely short-term studies, let along long-term studies, on childhood bipolar disorder.”

“The majority of DSM panel members have financial ties to the industry. In the panels on mood disorders and schizophrenia, one hundred percent do… These are THE categories for which drugs are the standard treatment.”

“Psychiatry is undergoing a crisis of credibility… Senator Grassley has asked the APA leadership for their financial records…”

“The APA must develop more rigorous COI policies… Unrestricted research grants, for instance, are currently excluded in their COI policy…”

“The DSM decisions are worth $25 billion to the drug industry.”

“This whole business of sub-clinical disorders… will interest the drug industry enormously…”

“This could cause the rates of mental disorder to sky-rocket. … The pharmaceutical industry will be thrilled with broader, more open descriptions of disorders…”

Now UD, let’s calm you down.

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UD thanks Daniel Carlat.

Arnold Relman, in the New York Review of Books:

Nearly a half-century ago, Stanford economics professor Kenneth Arrow, later a Nobel laureate, convincingly argued that medical care cannot conform to market laws because patients are not ordinary consumers and doctors are not ordinary vendors. He said that sick or injured patients must rely on physicians in ways fundamentally different from the price-driven relation between buyers and sellers in an ordinary market. This argument implied that, contrary to the assumptions of antitrust law, market competition among physicians cannot be expected to lower medical prices. And since physicians influence decisions to use medical services far more than patients do, the volume and types of services provided to patients—and hence total health costs—need to be controlled by forces other than the market, such as professional standards and government regulation. But Arrow’s argument was largely ignored in the rush to exploit health care for commercial purposes that ensued after the passage of Medicare and Medicaid in 1965.

When the organizations that set professional standards — the whorish American Psychiatric Association, for instance — are themselves market law conformists, what hope for change? That organization, speaking of excess volume and types of services, is even now revising the profession’s diagnostic manual to medicalize more and more non-medical human behaviors. There’s money in it.

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Update: Recall Marcia Angell in the New York Review of Books:

Since there are no objective tests for mental illness and the boundaries between normal and abnormal are often uncertain, psychiatry is a particularly fertile field for creating new diagnoses or broadening old ones. Diagnostic criteria are pretty much the exclusive province of the current edition of the Diagnostic and Statistical Manual of Mental Disorders, which is the product of a panel of psychiatrists, most of whom, as I mentioned earlier, had financial ties to the pharmaceutical industry. [Christopher] Lane, a research professor of literature at Northwestern University, traces the evolution of the DSM from its modest beginnings in 1952 as a small, spiral-bound handbook (DSM-I) to its current 943-page incarnation (the revised version of DSM-IV) as the undisputed “bible” of psychiatry—the standard reference for courts, prisons, schools, insurance companies, emergency rooms, doctors’ offices, and medical facilities of all kinds.

Given its importance, you might think that the DSM represents the authoritative distillation of a large body of scientific evidence. But Lane, using unpublished records from the archives of the American Psychiatric Association and interviews with the principals, shows that it is instead the product of a complex of academic politics, personal ambition, ideology, and, perhaps most important, the influence of the pharmaceutical industry. What the DSM lacks is evidence. Lane quotes one contributor to the DSM-III task force:

There was very little systematic research, and much of the research that existed was really a hodgepodge—scattered, inconsistent, and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest.

Lane uses shyness as his case study of disease-mongering in psychiatry. Shyness as a psychiatric illness made its debut as “social phobia” in DSM-III in 1980, but was said to be rare. By 1994, when DSM-IV was published, it had become “social anxiety disorder,” now said to be extremely common. According to Lane, GlaxoSmithKline, hoping to boost sales for its antidepressant, Paxil, decided to promote social anxiety disorder as “a severe medical condition.” In 1999, the company received FDA approval to market the drug for social anxiety disorder. It launched an extensive media campaign to do it, including posters in bus shelters across the country showing forlorn individuals and the words “Imagine being allergic to people…,” and sales soared. Barry Brand, Paxil’s product director, was quoted as saying, “Every marketer’s dream is to find an unidentified or unknown market and develop it. That’s what we were able to do with social anxiety disorder.”

Some of the biggest blockbusters are psychoactive drugs. The theory that psychiatric conditions stem from a biochemical imbalance is used as a justification for their widespread use, even though the theory has yet to be proved. Children are particularly vulnerable targets. What parents dare say “No” when a physician says their difficult child is sick and recommends drug treatment? We are now in the midst of an apparent epidemic of bipolar disease in children (which seems to be replacing attention-deficit hyperactivity disorder as the most publicized condition in childhood), with a forty-fold increase in the diagnosis between 1994 and 2003.[18] These children are often treated with multiple drugs off-label, many of which, whatever their other properties, are sedating, and nearly all of which have potentially serious side effects.