March 25, 2010

"DSM-5 and sexual disorders: Just say no"

Psychology urged to oppose psychiatric monopoly

When one introduces new chickens into an existing flock, the flock establishes a pecking order. The older birds peck the new ones into submission. With lower status, the new birds feel -- to anthropomorphise a bit -- inferior.

That's what happened when the upstart field of psychology pushed its way into the bastions of psychiatry. Psychiatrists bristled at the intrusion. Psychologists of necessity submitted to psychiatric authority. Now, years later, psychologists vastly outnumber higher paid psychiatrists in many mental health niches, but as a profession we still have an inferiority complex. Thus, we let a single psychiatric association in the United States dictate how mental functioning and impairment are conceptualized.

As the chorus of critical voices over the American Psychiatric Association's poorly drawn draft DSM-5 manual grows ever louder, some are urging psychology to issue a formal opposition paper. For example, Stephen Diamond, a clinical and forensic psychologist in Los Angeles, writes in Psychology Today that our profession's apathy "is a big part of the problem":
While clinical psychology has to some extent leaped onto this same biological bandwagon driven by contemporary psychiatry, seeking prescription privileges, some psychologists and other non-medical mental health professionals have practically written off the value and importance of psychodiagnosis today -- in part precisely due to its inherent medicalization, biological bias, dehumanizing labeling, and notorious inaccuracy…. [I]t is time for the leadership of the American Psychological Association to take a far more active and public role in the revision and direction of the DSM-5…. What, if anything, [is] the American Psychological Association is doing about DSM-V? Or about the hypermedicalization of psychology?
Allen Frances, the psychiatrist who chaired the DSM-IV task force, has become one of the most vocal critics of the manual's proposals. He too is calling on organized psychology to step up before it is too late. Taking his campaign directly to psychology and the general public, he hosts a "DSM5 in distress" column in the popular magazine Psychology Today that shines a spotlight by turn on various problematic aspects of the draft manual. In his recent call for an organized response from psychology, he writes that:
the American Psychiatric Association (APA) came to hold the DSM franchise only by historical accident…. Now that the DSMs have attained such importance, there have been repeated questions about the appropriateness of its continued sponsorship by more than just one professional organization…. The numerous problems that have bedeviled the development of DSM5 again raise the question whether the American Psychiatric Association should be sole steward of an official diagnostic system that impacts on all mental health disciplines…. Individual psychologists and the professional associations within psychology can play an important role in pointing the way forward for DSM5 and in protecting it from costly mistakes.
Perilous forensic consequences

Frances is increasingly focusing on the monumental potential for negative and unintended consequences in the forensic realm of the proposed changes:
The most obviously detrimental suggestions are in the paraphilia section, where the proposed change to the definition of paraphilia and the likely suggestion to introduce a new diagnosis of "paraphilic coercive rapism" will greatly compound the significant mischief already initiated by a seemingly trivial change in DSM-IV. More generally, even small changes in wording can result in large forensic confusion once parsed by lawyers in their peculiarly rigorous and tendentious fashion. The wording of every suggested option in DSM5 needs careful review by forensic experts.
"DSM-5 sexual disorders make no sense"

In a more recent column, Frances specifically targets the Big 3 sexual disorders that I have extensively blogged about. Of all of the DSM-5 work groups, he writes:
the Sexual Disorders Work Group has strayed furthest off the reservation. It has made a series of radical and dangerous suggestions that need to be dropped.... Each of the Work Group's suggestions is based on the thinnest of research support-usually a handful of studies often done by members of the committee making the suggestion. None has been subjected to, or could possibly survive, anything resembling a serious risk/benefit or forensic analysis.
As he points out, there are few researchers and little good research on sexuality. Consensus on the bounds of "normalcy" does not exist, and cultural bias plays a major role in what is defined as pathological (a point cogently made by Richard Green in his critique of the proposed hebephilia diagnosis). Especially important for my readers, "decisions regarding the diagnosis of sexual disorders can have profound and unanticipated forensic ... implications."

Regarding the three paraphilia proposals that will have the most impact in civil commitment proceedings in the United States, Frances had the following to say:

"Paraphilic Coercive Disorder"
This proposal was explicitly rejected for DSM IIIR and was given no serious consideration for DSM IV. The problem is the impossibility of reliably distinguishing between the small group of hypothesized "paraphilic" rapists (who would be given a mental disorder diagnosis) and the much larger group of rapists who are simple criminals.

The distinction has taken on huge significance because [of] SVP statutes mandating indefinite (usually in practice lifelong) inpatient civil psychiatric commitment for individuals who have (1) completed their prison sentence for a sexually violent crime, (2) have a diagnosed mental disorder, and (3) are deemed likely to repeat.... Although the SVP statutes have twice passed Supreme Court tests, they rest on questionable constitutional grounds and may sometimes result in a misuse of psychiatry.

Most disturbingly, an ad hoc and idiosyncratic suggested diagnosis -- Paraphilia Not Otherwise Specified -- has become a frequent justification for the psychiatric commitment of rapists who are really no more than simple criminals. Raising this diagnosis to official status would greatly compound this misuse of civil psychiatric commitment.
"Hypersexuality Disorder"
This is the strangest of constructs.... The fundamental problem with "hypersexuality" is that it represents a half baked, poorly conceptualized medicalization of the expected variability in sexual behavior.... The authors are trying to provide a diagnosis for the small group whose sexual behaviors are compulsive -- but their label would quickly expand to provide a psychiatric excuse for the very large group whose misbehaviors are pleasure driven, recreational, and impulsive. The offloading of personal responsibility in this way has already captured the public and media fancy and would spread like wildfire. Making an official mental disorder category of "hypersexuality" would also have serious unintended forensic consequences inthe evaluations of sexually violent predators (SVP).
This new category would extend the traditional definition of Pedophilia ... to include pubescent teenagers. Clearly, sex with underage teenagers is reprehensible and deserves appropriate punishment under the penal code. It is, however, anything but clear when (and if) sexual behaviors with teenagers should qualify as a mental disorder. This diagnosis would be subject to the same misuses in SVP cases as has been described above.
With such widespread and vigorous opposition, it's hard to imagine these nutty proposals slipping into the DSM-5. But, stranger things have happened in the field of psychiatry.

Related article:

DSM-5 and "Psychosis Risk Syndrome": Not Ready For Prime Time
Dr. Frances' latest piece, in Psychiatric Times, is on Psychosis Risk Syndrome, one of the scariest diagnostic proposals. If adopted, it would likely lead to a wave of false-positive errors in which teenagers are wrongly identified as future schizophrenics and placed on dangerous antipsychotic medications.
Hat tips: Ken Pope, Andrew H.
Graphics credit: Raul Crimson (Creative Commons license 2.0)


Daniel Grant said...

Not only am I concerned about the impact of some of the DSM-5 changes to adults but What about the impact on/to adolescents. I work in a Juvenile detention center and 80+% of the individuals who have issues with anger and have seen a psychiatrist prior to detention have been diagnosed with bipolar disorder and begun on 2,3 or more medications for this disorder. After careful evaluation and observation in the facility we most often document a pattern of behavior related to conduct disorder and sometimes including Intermittent explosive disorder but do not find symptoms related to bipolar disorder. Depending on the severity of the behavior we may use a single medication. Most often we find the anger is related to limit setting. This is a problem with an existing diagnosis which makes it difficult to try to get the youth to become responsible for his own behavior. We also get a number of youth charged with a sex related crime. As the research with adolescents on your website has shown most often this is not a repeated behavior and is treatable but with the changes in DSM-5 these youth would most likely be given one of the proposed psychiatric disorders and treated by society and the courts counter to what research has shown. I refer those interested in adolescene and development to the work of Laurence Steinberg.

Philip said...

The concept of mental illness was invented to explain the unusual and disturbing actions of individuals at a time when better and more valid explanations were not generally available. The mental illness explanations also legitimized the incarceration and mistreatment of these individuals.

The concept of mental illness is exactly analogous to the concept of witchcraft, which was invented in pre-scientific times to explain adverse phenomena such as crop failures and epidemics.

The problem is not DSM 5. The problem is DSM. The psychiatric-pharmaceutical consortium has succeeded in promoting the false and spurious notion that virtually every human problem is a mental illness and needs to be “treated” by drugs.

Perhaps the most profound tragedy in this sordid affair is the embracing by professional psychology of this spurious and destructive conceptual framework. Psychology is the science of human behavior! Yet our professional associations and individual members have endorsed DSM as if it were the Holy Grail. A large portion of our licensing exam is based on DSM, which is a bit like requiring Ag majors to know the signs of witchcraft and the various methods witches use to destroy crops.

What we don’t need is more psychological involvement and input into DSM 5. What we need is to exit stage. Psychology needs to distance itself from the so-called mental health field and begin developing areas of expertise and methods of effective intervention in the very many behavioral problem areas that beset the human race, e.g. crime, obesity, addiction, exploitation, discrimination, traffic accidents, poverty, pollution, war, etc., etc..

Philip Hickey, PhD

Anonymous said...

Dr. Hickey.

Your comment is the perfect illustration of what I mean when I say that psychology has sociology envy. Psychology is not the science of human behavior; that’s sociology. Psychology is the study of the human mind. For me the DSM is the perfect symbol of how far psychology and psychiatry has wandered off into the sociological realm.

All the classical psychologists where medical doctors (William James, William Wundt, Carl Jung, etc). But they did not see psychology as mental medicine; they saw medicine as applied philosophy. All three of the psychologists I mentioned were explicit on that point. The original purpose of medicine and psychology was to provide concrete data to illustrate and justify traditional philosophical conclusions. This is why, to this day, a PhD is a Doctorate in Philosophy (in field X).

I agree with you that mental illness is a failed construct but that’s because I don’t think that medicine and human behavior was ever intended to be the focus of psychology at all. Put another way, my problem with “mental illness” as a construct is not the mental part but the illness part because illness has come to be defined exclusively in a cultural normative sense. Again, that’s not because I don’t believe that people can’t be physically ill or engage in behavior that is inconsistent with cultural norms. It’s that I don’t recognize the treatment of the body or the treatment of non-normative human behavior as the practice of psychology; the former is medicine and the later is sociology.

It’s interesting that you and I would both like to see the DSM in the trash can but for the exact opposite reasons. I guess the enemy of my enemy is still my friend.

Neuroskeptic said...

I strongly disagree with Diamond that diagnosis means "inherent medicalization, biological bias" etc. The problem is misdiagnosis, and losing sight of the problems with diagnosis.

I'm also a little concerned at the idea of psychologists riding to the rescue of the mental health field at the expense of psychiatry because the last time that happened it didn't end well (Freudianism - OK, he was a neurologist, but he wrote psychology).

Balance is everything...