Science

Editors of Psychiatric Bible Exhibit Pseudoscientific Delusional Syndrome

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The New York Times reports that the psychiatrists working on the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) have made several notable concessions to critics:

1. "Attenuated psychosis syndrome," which is not listed as a mental disorder in the current DSM, also will not be listed in the next one. Critics worried that the proposed label, intended for people who are not psychotic but might be one day, would lead to promiscuous drugging of teenagers and young adults who exhibit "delusional ideas," "perceptional abnormalities," or "disorganized speech." According to the Times, "70 percent to 80 percent of people who report having weird thoughts and odd hallucinations do not ever qualify for a full-blown diagnosis."

2. The editors also have ditched their proposed "mixed anxiety depressive disorder," which would have applied to people who exhibit "three or four symptoms of Major Depression" along with "anxious distress." The symptoms of major depression include depressed mood, lack of pleasure, weight loss, sleeping too little or too much, moving too little or too much, fatigue, feelings of worthlessness or excessive guilt, difficulty concentrating or making decisions, and recurrent thoughts of death. "Anxious distress" would have been marked by "feeling nervous & anxious," "not being able to control worrying," "having difficulty relaxing," restlessness, and "fear that something awful might happen." The Times says critics warned that the diagnosis would "unnecessarily tag millions of moderately neurotic people with a psychiatric label." The amazing part: Psychiatrists decided that was a drawback.

3. Speaking of the diagnostic criteria for major depression, the editors plan to add a caveat

The normal and expected response to an event involving significant loss (e.g, bereavement, financial ruin, natural disaster), including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode. The presence of symptoms such as feelings of worthlessness, suicidal ideas (as distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment of overall function suggest the presence of a Major Depressive Episode in addition to the normal response to a significant loss.

The editors explain that "many commentators noted the previous criteria erroneously implied that bereavement could be assumed to only last 2 months," and "we wanted to correct that misunderstanding." It's not clear who supposedly misunderstood what, but the current DSM says someone who otherwise meets the criteria for major depression gets an out if he is sad about "the loss of a loved one," unless "the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation." As critics such as Gary Greenberg have pointed out, these guidelines not only put an arbitrary 60-day limit on grief; they also do not recognize other legitimate reasons for sadness. The new language is an improvement in both respects, although the label still hinges on a clinician's opinion about what counts as a "normal and expected response."

While these three changes are all intended to address concerns about overdiagnosis, another proposal—"autism spectrum disorder," which would subsume Asperger's disorder and pervasive developmental disorder as well as autism—has triggered complaints that people who need help will no longer qualify for a DSM label. Instead of backing down on that issue, the editors are insisting their changes will have hardly any impact on diagnosis, which makes you wonder why they are bothering. Public statements by advocates of the new taxonomy suggest the revisions are indeed aimed at weeding out people who wrongly think they have a mental disorder (which ought to be a mental disorder itself, if it isn't already):

In a talk on Tuesday, Dr. Susan E. Swedo, head of the panel proposing the new definition, said that many people who identify themselves as "aspies," for Asperger's syndrome, "don't actually have Asperger's disorder, much less an autism spectrum disorder."

Got that? People "don't actually have" a disorder that Swedo thinks does not actually exist—and that officially won't exist if she gets her way. If that makes no sense to you, you are probably not a psychiatrist.

More on the depression exception and the Asperger's controversy here and here.

In a recent Washington Post op-ed piece, a psychologist argues that the DSM has "an undeserved aura of scientific precision" and "should be thrown out."

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64 responses to “Editors of Psychiatric Bible Exhibit Pseudoscientific Delusional Syndrome

  1. Public statements by advocates of the new taxonomy suggest the revisions are indeed aimed at weeding out people who wrongly think they have a mental disorder (which ought to be a mental disorder itself, if it isn’t already)

    People “wrongly” think they have a mental disorder for a very logical reason: It’s one way to get free stuff. Stop the supply of free stuff, and this problem will become inconsequentially small.

    1. So you are saying incentives matter? You get more of what you subsidize.

      1. A novel thought, I know.

    2. Most adult self-diagnosed Aspies are not out for govt cheese, they’re out for (a) excusing their personal deficiencies and (b) being part of a “community”.

      1. I’ve noticed a lot of hipsters seem to identify themselves as “aspies” just because they seem to think it’s “cool” for some reason. Note to hipsters: no it doesn’t, it makes you a douche.

        1. It also makes us legitimate autistics look bad in the process.

    3. It’s one way to get prescriptions for certain drugs you can’t get otherwise.

  2. I think I have a mental disorder. Almost every day when I get out of bed I think today is the day the world will start making sense.

    1. GET THIS MAN SOME MEDICATION! STAT!

  3. A society where no teenager ever has a strange thought is a pretty scary one, if you think about it.

    1. It makes sense if you think about it, LOL

      http://fake-privacy.tk

  4. Psychiatry is rent-seeking bullshit. Its entire purpose is to sell drugs, and it clads itself is pseudoscience about as intellectually rigorous as Humorism. There are people with mental problems, and they do need help, but until the field actually changes and stops blaming everything on a “chemical imbalance” without actually checking to see if these “chemicals” are “imbalanced” nothing will change.

    1. Psychiatry existed before the Pharmaceutical Era…

        1. You do realize the vast majority of psychiatric medications we physicians prescribe these days are inexpensive generics, right? Who exactly is luring us to prescribe meds that cost $4 for a month’s supply? Wow, maybe we can get a kickback of $1 per prescription.

          I don’t know any doc who says serious mental illnesses like schizophrenia and mania are “chemical imbalances”, perhaps non-physician psychologists and psychotherapists popularized those terms for those illnesses that need medications as opposed to counseling alone. If you wish to get into a discussion on neural pathways and neurotransmitters I will be happy to discuss with you. But please don’t call it pseudoscience.

          Unfortunately, all idiosyncratic psychotherapies and offbeat approaches get lumped in with the hard neuroscience that is the basis of treatment of severe psychiatric illnesses. Perhaps it would be better if people thought of the treatment of debilitating diseases of the brain as “psychiatry” and counseling/psychotherapy as “psychology”. If there was more of an effort to separate the two — and make the DSM reflect that — perhaps there would be far less controversy.

          1. Perhaps it would be better if people thought of the treatment of debilitating diseases of the brain as “psychiatry” and counseling/psychotherapy as “psychology”. If there was more of an effort to separate the two — and make the DSM reflect that — perhaps there would be far less controversy.

            That is pretty much my understanding.

            Psychiatry = neuroscience-based understanding of the brain, pharmaceutical-based treatment.

            Psychology = freudian psychoanalysis based approach ot the mind, talk-therapy based treatments.

            IIRC psychotherapists cannot prescribe medication, and psychiatrists don’t really do talk therapy. They just diagnose you and get you some meds, and then maybe send you to a therapist.

            1. That’s not the distinction. Psychologists are researchers while psychiatrists are the ones meeting with patients.

              You’re possibly thinking of the divide between the Freudian/psychoanalytic school and the newer, somewhat more scientific paradigms.

  5. In a talk on Tuesday, Dr. Susan E. Swedo, head of the panel proposing the new definition, said that many people who identify themselves as “aspies,” for Asperger’s syndrome, “don’t actually have Asperger’s disorder, much less an autism spectrum disorder.”

    So I am back to just being a run of the mill asshole.

    1. Oh, I’m sure libertarians will still qualify for the autism spectrum.

      1. Based on the self-reporting around here, we’re all shoo-ins. Now, where’s my free drugs? I want some good shit, too.

        1. Everyone is on a spectrum from full-on autism to being a full-on extroverted social butterfly who loves human interaction.

          From what I saw at the LP convention in Vegas, LPers tend toward the aspy-ish end of that scale.

      2. I thought libertarians believed autism was two-dimensional?

    2. hehe, you said assburger

    3. Many self-diagnosed “aspies” probably just have social anxiety. Not the same thing.

  6. I tell you, I get no respect, no respect. I go see a shrink and he tells me I’m crazy, I say to him, “What? I’m not crazy! I want a second opinion!” He says, “You want a second opinion? You’re ugly too!’

  7. I wonder if they’ll help me. I have Lack of Money Disorder. It stresses me out all day, gets in my head, hurts my self-esteem, distracts me constantly from What’s Important.

    Once Uncle Sugar fixes that, then he can invade South Africa and alleviate my Candice Swanepoel Deprivation Disorder.

  8. The new language is an improvement in both respects, although the label still hinges on a clinician’s opinion about what counts as a “normal and expected response.”

    The entire DSM, and psychiatry in general, hinges on one’s opinion of normal behavior. How else could homosexuality go from disorder to normal behavior, and prepubescent fidgetiness go the other way.

    1. Dang, Tulpa. Nice, pithy summary of the problem with the whole enterprise.

    2. Please give examples of which parts of the DSM or psychiatry in general refers to “normal” behavior as a basis for determining illness. This quote about “normal and expected response” I sincerely doubt would be part of the actual diagnostic criteria.

      Or, we can look at another way. Should people with very high blood glucose not be considered likely to have diabetes, because their level is outside of that lab’s “normal” range? Why are we labeling the free spirits who just want to have a different sugar level than the rest of us?

      It is amazing to me that people want to blame psychiatrists for the existence of mental illness. The brain is an organ just like all other parts of your body, and it can suffer diseases too. For those of you who think psychiatric disorders are just make-believe, please provide your home address. We have many people with severe schizophrenia in our ER every day — many agitated, threatening, and actively hallucinating — who we can send right over for you to help out, since psychiatric illness and treatment are just pretend concepts invented by power-hungry psychiatrists.

      1. You seem to be defensive about all the turds in your punch bowl. Is there anything you would like to talk about?

        1. Not defensive at all. I do have over 25 years working in an emergency room and have a long history of advocating for compassionate, non-coercive and collaborative care for people with mental illness. I see people every day who are so severely mentally ill it would break your heart. What does hurt me is when lay people wish to dismiss their tragic conditions as “bullshit”.

          1. Right, because Aspergers and schizophrenia are really similar types of disorders with equally scientifically valid diagnostic criteria…

      2. Crack open your DSM-IV-TR and look at the diagnostic criterion for borderline personality disorder. I’m seeing “excessive”, “abuse”, “inappropriate”, etc… all of which are judgement calls. Presumably ear-piercing or tattoos don’t count for “self-injuring behavior” because they’re normal; likewise drinking a cup of coffee every morning doesn’t count as “substance abuse” while waking and baking with Mary Jane does.

        Plus, the choice to include certain criteria and not others reflects the writers’ choice of “normal”.

        And don’t compare it to a blood test…scads of research has shown a causal relationship between chronic high blood glucose and severe health problems. Not the same for “chronic feelings of emptiness”… and of course, no one has ever been locked up in a psych ward because they refused to get an insulin prescription or lay off the Skittles.

        1. Just remember one thing: diagnoses are not intended to be made by lay people reading a manual of diagnostic criteria. The only people legally entitled to make diagnoses have many years of training and education; most (not all) of them are able to tell the difference between people with serious disorders and those who are just neurotic like the rest of us. Unless you are so qualified, the manual might seem a bit simplistic, but there are only so many modifiers one can use to describe behavior.

          1. Just remember one thing: diagnoses are not intended to be made by lay people reading a manual of diagnostic criteria. The only people legally entitled to make diagnoses have many years of training and education

            Remember Tulpa, it’s only TOP MEN who are going to decide to involuntarily commit you to the psych ward based on these vague criteria. You have nothing to worry about.

            (for the record, I agree with most of what you’ve written here, Anacreon. But on this, Tulpa is definitely in the right.)

            1. Coeus sez: “Remember Tulpa, it’s only TOP MEN who are going to decide to involuntarily commit you to the psych ward based on these vague criteria. You have nothing to worry about.”
              This is not what Anacreon said and I suspect you know that.

              1. Tulpa spoke if being involuntarily committed based on the vague and subjective definitions in use. Ancreaon said it wasn’t an issue because of the expertise of the people making the decisions.

                Saying that someone’s concerns aren’t warranted because of the comparative superiority of the people making the decisions is the very essence of the TOP MEN meme.

                You should really read the whole sub-thread before you start dropping your turds of wisdom on it.

                1. Oh yeah, I forgot. This is a Reason thread where some posters actually think phrases like “turds of wisdom” represent intelligent discourse.

                  1. Awww. Bernie haz a sad ’cause I pointed out he didn’t actually read what he was correcting me on. It’s ok. Lot’s of people can’t read. I’m sure if you practice you’ll be able to get up to a 3rd, or even 4th grade level.

                    1. Of course I did read the thread. I was dissenting from the expressed opinion. Apparently some posters can only respond with ad hominem attacks and vulgarity.

                    2. Still not hearing how I’m wrong there, bernie. You only get the real arguments when you give them.

                      The only reason I’ve expended so much brain power on you thus far is because I’m bored and working overtime in an unfamiliar timezone. I clarified my statement, despite the fact that you left nothing of substance. I’ve already responded to your dissent with far more than was warranted. You’ve now wasted two responses and said absolutely nothing of import.

                      There are plenty of places on the internet that will treat your faux sense of propriety with the respect you seem to feel it deserves. If you want further response from me, then I’m afraid you’ll have to pull your head out of your ass and actually make a cogent argument.

        2. “‘Normal’ is what everyone else is and you are not.” –Star Trek: Generations”

  9. Those guys clearly know which way is up!

    http://www.Get-Privacy.no.tc

  10. How many years did you edit the Harvard Law Review?

    Kneel before your betters, plebe!

    1. Please tell me that’s going to become a new H&R meme. I saw that comment in an earlier thread. Truly one of the most breath-takingly stupid comments in the history of the internet.

  11. Having a psychiatric disorder enables on to obtain prescriptions for prescription drugs.

    I’m just sayin’.

    I obliquely refer to the possibility that some psychiatrists/patients might actually want to have a good excuse to prescribe medication.

    1. There are two meds that people might want to get from psychiatrists inappropriately: psychostimulants (ritalin, amphetamines) for ADHD-type diagnoses, and benzodiazepines (xanax and valium probably the best-known to lay folk). The former are Schedule II so closely monitored, but you are correct they are likely overprescribed. The benzos are only Schedule IV so not so eyebrow-raising; many of us can quickly see through those people wanting them inappropriately, but I do have no doubt they can get into the wrong hands pretty easily.

      The rest of psychiatric meds you really wouldn’t want to take; many can have severe side effects, while others really wouldn’t do anything for you if you didn’t have target symptoms, and certainly would not give you a buzz.

      1. What about Prozac and other anti-depressants?

        1. People might get them who do not need them, but they are not really abusable, and most have fairly limited side effect profiles, so there is not the issue with them as with the other two I described. Their full effects typically take 4-6 weeks or longer, you can’t just pop one to “get happy”. These are definitely over-prescribed, but mostly by internal medicine/family practice docs; psychiatrists actually are responsible for only about 20% of total antidepressant prescriptions in the US.

  12. Psychology and psychiatry- two nuts in the same turd- are bullshit.

    1. Can you clarify? Are there any brain diseases that are legitimate, or is it all bullshit?

      1. Real brain diseases cause physical disability. I have one of those. Three separate neurologists diagnosed it.

        1. Do strokes that cause speech problems, memory impairment, confusion but no physical symptoms count? How about Alzheimer’s? No real physical symptoms to that.

          I can keep going if you like.

          1. Strokes clearly fuck up nerve control to parts of the body, including within the brain. Getting the way you talk fucked up is a physical condition. I would put Oldtimer’s under the physical category as well.

            All the “take these to make you happier/work harder/get along” stuff is bullshit.

            1. How about a disease that makes you hear people talking to you? And sometimes those “voices in your head” tell you to kill yourself, or hurt other people, or do other bad things. That is a common clinical picture for schizophrenia. Medications can make those voices go away in many patients, and also help control paranoia, delusions, and other devastating symptoms.

              Think those voices are make believe? PET scans of schizophrenia patients show the same part of the brain responsible for auditory, that lights up when they hear a person in the room talking — the same part of the brain lights up when they say they are hearing voices. So they really are hearing voices — and their brain disease is causing it.

              I’m not sure where people are getting meds to work harder or go along, perhaps in the old Soviet gulags or Chairman Mao? And the main target of antidepressants is not to make you happier per se — it is to help with the other symptoms, such as appetite and sleep difficulties, anhedonia (lack of desire for pleasurable activities), anxiety, etc.

              1. PET scans of schizophrenia patients show the same part of the brain responsible for auditory, that lights up when they hear a person in the room talking — the same part of the brain lights up when they say they are hearing voices. So they really are hearing voices…

                And you, as a physician, do not believe that to be a “physical” symptom? A confirmed biological response to non-existent stimuli? Could I ask you what IS a “physical” symptom if not that? Can you also explain to me, a layperson, the analogous biological abnormality associated with, say, ADHD or Asperger syndrome? You know, since all psychiatric diagnoses are scientifically equal and all.

                1. Damn, old article is old. Why am I posting here? Whoops.

  13. Anacreon sez: “We have many people with severe schizophrenia in our ER every day — many agitated, threatening, and actively hallucinating — who we can send right over for you to help out, since psychiatric illness and treatment are just pretend concepts invented by power-hungry psychiatrists.”
    Back in the 50’s when I was in grade school my mother was diagnosed with schizophrenia. Anyone who thinks this is not a real mental disorder has not lived with one who suffers the symptoms. I know what an actively hallucinating person is like. At that time no drugs existed to manage the behavior. She was violent. I was 8 years old when I remember my younger brother pleading for his life as she was about to crush his head with the toaster in a rage. My father feared for the safety of me and my younger brother and sister and had to go to court and have the woman he loved committed to the local State Hospital. State of the Art treatment circa 1957 was electro shock therapy.
    As drugs were developed to treat this curse my mom was eventually able to live at home with my fathers care. She was on the drugs (prolixin is a name I remember) for the last 40+ years of her life. I shudder to think what would have come of her were it not for these chemicals. Thank you medical research!

    1. I am very sorry to hear of your mother’s illness. Your story is, unfortunately, not atypical, and you are absolutely correct about the time frames. Thorazine started to be used for schizophrenia around the time you indicate the state commitment occurred; the 60’s brought a number of newer drugs such as haldol and the prolixin you remember. Today there are even far more benign and effective medications to treat psychosis, but we are still far from ideals. I am glad she was able to be back at home for the last forty years and I can imagine it was difficult at times — but living at home, with family, is the goal we have for every patient.

      1. Question for Anacreon.
        I have had many discussions with some “advocates” for the mentally ill who say victims of schizophrenia have the “right” to refuse medication. Apparently the side effects of the drugs are more severe on some patients than others. I am sure I am biased because of my mothers experience but I find it hard to believe that many of the homeless who suffer mental illness would not be better off if they were receiving some sort of medication. I also assert that because of some brain diseases there are folks out there who can not comprehend what their “rights” may be. What do you think?

        1. Patient rights are very strong in mental health, and indeed patients can refuse psychoactive medications in most states — even when they are on an involuntary hold for evaluation and treatment — unless they are considered to be emergently dangerous to themselves or others. There are legal processes that can be undertaken to remove a patient’s right to refuse meds, and the burden of proof on the treating physician or hospital is to demonstrate exactly what you wrote — that someone’s current mental state prevents them from adequately being able to discern the risks and benefits of medications. Even if incompetency to refuse meds is granted by a judge, it will typically be time-limited, such as not to exceed 30 days. Hopefully in that time frame an individual will improve sufficiently so that they become willing participants in their medical care, but not always.

          For non-hospitalized individuals, there are only a few locales where patients can have an outpatient legal decision to prevent refusing meds, and these can be quite difficult to enforce. There are “depot” antipsychotic injections that can last two weeks to 30 days, and for some patients who decompensate quickly or who have difficulty remembering to take their meds, these can be very helpful.

          1. However, too many individuals discontinue their outpatient meds, for a variety of reasons. Unfortunately, with the more severe mental illnesses, this can often lead to a major exacerbation of their symptoms, causing re-hospitalization.

            Psychiatric hospitals have a lot of recidivism. If every patient was better engaged and thus more consistent with their treatment, we would likely see much less need for psychiatric hospital beds. 

  14. Jacob: “many commentators noted the previous criteria erroneously implied that bereavement could be assumed to only last 2 months,” It’s not clear who supposedly misunderstood what…

    As critics such as Gary Greenberg have pointed out, these guidelines not only put an arbitrary 60-day limit on grief.”

    Sloppy, Mr. Sullum… don’t take pot shots at people when you provide your own evidence that they’re right two sentences later.

  15. As one of those “Aspies who isn’t an Aspie and there is no such thing as Aspergers anyway,” I do in fact reject the “mild form of autism” nonsense.

    Saying that Aspergers is “a mild formn of autism” is equivalent to saying that an IQ of 95 is “a mild form of mental retardation,” or that deafness and blindness are the same condition — call it the “sensory deprivation spectrum.”

    The real reason so many want AS to be called autism is of course unwarranted, legally enforceable, special accommodations — e.g., “my kid has AS, give him more time on the test, or let him take it in a separate room, or …”

    Once AS is in the DSM, it will simply become the new ADHD (which itself once was “the new dyslexia”).

    Lay off an Aspie (cf, “Adam”)? That’s am ADA lawsuit.

    Researcher applying for government-funded research grants? “AS in DSM” opens up a whole new font of taxpayer money.

    Etc.

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