December 10, 2009

New Scientist expose of psychiatry’s "civil war"

Proposed diagnoses of hebephilia and paraphilias NOS critiqued

On Saturday, the world's leading science and technology news weekly is publishing a scathing expose of the political and financial shenanigans underlying the DSM-V revision process. Accompanying the report in the New Scientist is an editorial calling for a halt to the print version of the American Psychiatric Association's money-making diagnostic bible:
The final wording of the new manual will have worldwide significance. DSM is considered the bible of psychiatry, and if the APA broadens the diagnostic criteria for conditions such as schizophrenia and depression, millions more people could be placed on powerful drugs, some of which have serious side effects. Similarly, newly defined mental illnesses that deem certain individuals a danger to society could be used to justify locking these people up for life.

Given such high stakes, we should all be worried by the controversy. Proponents of some of the changes are being accused of running ahead of the science, and there are warnings that the APA is risking "disastrous unintended consequences" if it goes ahead with plans to publish DSM-V, as the new manual will be known, in 2012.
"Psychiatry’s civil war" is the title of the hard-hitting expose by award-winning science writer Peter Aldhous, San Francisco bureau chief for New Scientist magazine.

As Aldhous reports, professional disputes over the form and content of the upcoming edition "are getting ugly." He notes that respected Duke University scholar Jane Costello has resigned from the work group on childhood and adolescence disorders, citing a lack of scientific rigor across the whole DSM revision. "I felt that there was not enough empirical work being achieved or planned," she says.

In a sidebar, Aldhous shines a spotlight on controversial proposals of pivotal importance to forensic psychology, including the pseudoscientific diagnosis of "hebephilia" that I have previously blogged about:
You may have never heard of "hebephilia", but this obscure diagnosis has huge significance in the courts. If it becomes accepted it could lead to hundreds of sex offenders who have served their jail time being locked up indefinitely - on grounds that some say are spurious.

The proposed diagnosis has been condemned by critics as dangerously blurring the boundary between paedophilia and normal male attraction to teenage girls -- which isn't necessarily acted upon. Karen Franklin, a forensic psychologist in El Cerrito, California, argues that the diagnosis makes a disease out of preferences that have been shaped through human evolution. "People didn't used to live so long and mating started earlier," she says.

The work group is also considering whether some men are specifically turned on by rape -- a proposed condition termed paraphilic coercive disorder. Again, the evidence is based largely on measurements of penile blood flow in response to sexual images and stories, and the validity of the condition is hotly contested.

The rows over hebephilia and paraphilic coercive disorder aren't academic, because 20 US states have passed laws that allow sex offenders who have served their sentences to be detained indefinitely in a secure hospital if they are deemed "sexual predators." This can only be done if the offenders have a psychiatric disorder that increases their risk of reoffending -- which few do, according to DSM-IV.

Franklin says that if hebephilia and paraphilic coercive disorder make it into DSM-V, they will be seized upon to consign men to a lifetime of incarceration.
In a call to put the brakes on this speeding train, the New Scientist's accompanying editorial points out that this would hurt the coffers of the American Psychiatric Association, which has earned more than $40 million since 2000 from DSM sales. But, the editorial concludes, "it's hard to see who else stands to gain from the current exercise -- and if the critics' dire predictions come to pass, patients will be the biggest losers."