Wrangling over psychiatry's bible

Check out this opinion piece in today's Los Angeles Times. (It cites yours truly on the forensic angle.) The writer, Christopher Lane, is the author of an excellent book on the making of the DSM-III, entitled Shyness: How normal behavior became a sickness.

Los Angeles Times
November 16, 2008

By Christopher Lane

Over the summer, a wrangle between eminent psychiatrists that had been brewing for months erupted in print. Startled readers of Psychiatric News saw the spectacle unfold in the journal's normally less-dramatic pages. The bone of contention: whether the next revision of America's psychiatric bible, the "Diagnostic and Statistical Manual of Mental Disorders," should be done openly and transparently so mental health professionals and the public could follow along, or whether the debates should be held in secret.

One of the psychiatrists (former editor Robert Spitzer) wanted transparency; several others, including the president of the American Psychiatric Association and the man charged with overseeing the revisions (Darrel Regier), held out for secrecy. Hanging in the balance is whether, four years from now, a set of questionable behaviors with names such as "Apathy Disorder," "Parental Alienation Syndrome," "Premenstrual Dysphoric Disorder," "Compulsive Buying Disorder," "Internet Addiction" and "Relational Disorder" will be considered full-fledged psychiatric illnesses.

This may sound like an arcane, insignificant spat about nomenclature. But the manual is in fact terribly important, and the debates taking place have far-reaching consequences. Published by the American Psychiatric Association (and better known as the DSM), the manual is meant to cover every mental health disorder that affects children and adults.

Not only do mental health professionals use it routinely when treating patients, but the DSM is also a bible of sorts for insurance companies deciding what disorders to cover, as well as for clinicians, courts, prisons, pharmaceutical companies and agencies that regulate drugs. Because large numbers of countries, including the United States, treat the DSM as gospel, it's no exaggeration to say that minor changes and additions have powerful ripple effects on mental health diagnoses around the world.

Behind the dispute about transparency is the question of whether the vague, open-ended terms being discussed even come close to describing real psychiatric disorders. To large numbers of experts, apathy, compulsive shopping and parental alienation are symptoms of psychological conflict rather than full-scale mental illnesses in their own right. Also, because so many participants in the process of defining new disorders have ties to pharmaceutical companies, some critics argue that the addition of new disorders to the manual is little more than a pretext for prescribing profitable drugs.

The more you know about how psychiatrists defined dozens of disorders in the recent past, the more you can appreciate Spitzer's concern that the process should not be done in private. Although a new disorder is supposed to meet a host of criteria before being accepted into the manual, one consultant to the manual's third edition -- they're now working on the fifth -- explained to the New Yorker magazine that editorial meetings over the changes were often chaotic. "There was very little systematic research," he said, "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."

Things are different today, the new consultants insist, because hard science now drives their debates. Maybe so, but still, I shudder to think what the criteria for "Relational Disorder" and "Parental Alienation Syndrome" will be. And I'm not the only one worrying. Spitzer is bothered by the prospect of "science by committee." Others, like forensics expert Karen Franklin, writing in American Chronicle, warn that advocacy groups are pressing for the inclusion of dubious terms that simply don't belong in a manual of mental illnesses….

My concern is the lack of proper oversight. If the proposed new disorders don't receive a full professional airing, including a vigorous debate about their validity, they will be incorporated wholesale into the fifth edition in 2012. Joining the ranks of the mentally ill will be the apathetic, shopaholics, the virtually obsessed and alienated parents. It's hard to imagine that anyone will be left who is not eligible for a diagnosis.

Christopher Lane, a professor of English at Northwestern University, is the author of "Shyness: How Normal Behavior Became a Sickness."

Lane's full opinion piece is online here.

As I have blogged about previously, one example of a proposed diagnosis with no established reliability or validity is "hebephilia." My response to the attempt to get that term added to the DSM-V was just published in the Archives of Sexual Behavior. You can see a free preview (the first page) of "The Public Policy Implications of 'Hebephilia' " here, but you need a subscription to get the entire article.

My blog post on the DSM-V revision process is here.

The Jury Expert

The new issue of The Jury Expert (a publication of the American Society of Trial Consultants) is now online. Articles include:

Just world jurors: A research review
How can just-world beliefs impact jurors?

Cross-examining the narcissistic witness
A follow-up to a previous Jury Expert article on preparing the narcissist to testify, this article focuses on how to cross-examine narcissistic witnesses.

Conceptual persuasion
A primer on the impact of graphics.

Juror reactions to successful women
Mitigating negative judgments by jurors about successful women attorneys, plaintiffs, defendants (or expert witnesses?)

Do liberals and conservatives punish differently?
Of course they do. This article explains the different themes of interest to jurors of different political persuasions.

The full issue is available here.

Incompetent bank robber cannot be forcibly medicated, court rules

I just came back from evaluating a convicted prisoner to see if he is competent to proceed with his appeal. He has been found "gravely disabled" and is being forcibly injected with an antipsychotic medication (Haldol Decanoate).

He was refusing to eat because he thought the food was poisoned. But what if he was eating his food and behaving himself, but still quietly harbored paranoid delusions?

That's when Sell would come in.

As many of you know, under the 2003 case of the Sell v. United States, for a defendant to be forcibly medicated to restore competency, a court must find that:

• important government interests are at stake
• involuntary medication will significantly further those interests by being "substantially likely" to restore the defendant's competency
• the medication is substantially unlikely to have negative side effects
• the medication is medically appropriate

In a boon to good, old-fashioned talk therapy, the Sell ruling also mandated a showing that less intrusive and noxious treatments will not work.

In New Jersey, a federal judge just ruled that the government did not meet the burden of proving those things in the case of a paranoid bank robbery defendant named Wayne Moruzin. Prosecutors had claimed there was a good chance that Haldol injections would stop his paranoia and hallucinations and make Moruzin fit for trial. But a U.S. District Court judge said they didn't provide enough evidence of that, considering the health dangers of antipsychotics such as Haldol.

I've never met anyone who liked taking Haldol. It makes you feel like a drugged-out zombie, and it can cause severe and permanent health problems.

But such a ruling always leads to the question, what will happen next? The government can try to civilly commit Moruzin, or they can just wait and see if he gets better - which is unlikely without medication.

The ruling parallels a U.S. District Court decision in January of 2007 involving a different mentally ill bank robber. In that case, though, the robber had already pleaded guilty in three other bank heists and was serving a 36-year sentence.

The cases don't break new legal ground, but they do continue an interesting trend.

The New Jersey Law Journal report on the Moruzin case is available online at law.com.

NYT reports on public defender crisis

The current budget crisis is adding to the inequities in the criminal justice system. As workloads mount and budgets decrease, public defenders across the nation find themselves unable to adequately represent their impoverished clients. On Sunday, the New York Times reported on the catastrophe:

Citing Rising Workload, Public Lawyers Reject Cases
By ERIK ECKHOLM

MIAMI — Public defenders' offices in at least seven states are refusing to take on new cases or have sued to limit them, citing overwhelming workloads that they say undermine the constitutional right to counsel for the poor.

Public defenders are notoriously overworked, and their turnover is high and their pay low. But now, in the most open revolt by public defenders in memory, the government appointed lawyers say budget cuts and rising caseloads have pushed them to the breaking point.

The full article in Sunday's New York Times is here.

Don’t Tase Me, Bro!

Have you ever:

• Drawn a picture of an SUV?
• Worn a hoodie?
• Refused an order to sod your lawn?
• Given the wrong account of history?

These are among dozens of acts for which people have been arrested, suspended from school, gone to jail, or faced other sanctions in just the past few months. No kidding.

It's all documented by Phil Leggiere on the new civil libertarian blog, "Don’t Tase Me, Bro!"

Check it out here. If you like it, you can add it to your feeds.

5th-grader suspended for vampire drawing

Perhaps I am too fixated on Halloween (I promise to stop now!), but I found this story out of Savannah, Georgia fascinating, with its hysterical and racist undertones. Of course, this 5th-grader's troubles were nothing compared to what happened to high schooler Tim Masters when he drew scary pictures.

Halloween drawing scares teacher, gets student in hot water

Fifth-grader Jordan Hood thought the bloody vampire he drew in art class was scary, but he had no idea it would elicit a horrifying response from one of his teachers.

Tuesday morning, Jordan was assigned to draw a scary Halloween mask in art class.

By the end of the day, Jordan was being told he could not return to Pooler Elementary School until he passed a psychological evaluation....

During art class Tuesday, Jordan drew a scarred vampire with bloodshot eyes and with blood dripping from its nose, mouth and down its cheeks. Art teacher Lloyd Harold helped the boy shade the sketched eyes to give the drawing an even creepier look.

"The assignment was to draw a scary mask or picture - basically a Halloween activity," Harold said.

As a final gory touch, Jordan used a red marker to write "I Kill For Blood" under his drawing.

The picture was not destined for the cover of Fangoria magazine, but it fulfilled the requirement for fifth-grade Halloween art.

However, when Jordan's homeroom teacher, Melissa Pevey, saw the drawing, she found it disturbing. Pevey was concerned enough to contact assistant principal Valerie Johnson and Campus Police.

But it wasn't blood and gore that bothered Pevey.

She believed the blood looked a lot like gang-related teardrop tattoos, and she thought the words "I Kill For Blood" could be tied to an infamous Los Angeles street gang known as The Bloods.

Jordan's mother, LaKisha Hood, was shocked to find that her son's art lesson had evolved into a gang investigation.

"They told me the droplets could actually be a gang symbol for the number of people he killed," she said.

Burnsed said the district has asked teachers to be wary of anything that might be harmful to students. He also said the district has provided gang-identification training.

He did not know whether classroom teachers were trained in gang symbolism.

"The teacher was concerned and referred it to the Campus Police," Burnsed said. "(Campus Police Capt. Joan) Sasser wasn't sure that it meant anything."

So they resolved the issue by requiring Jordan to undergo psychological testing with Gateway Mental Health.

Jordan's family didn't want him to miss school, so he went in for testing first thing Wednesday morning - getting him back to school in time for the fall dance that afternoon.

Although he only lost about two hours of instruction, his mother fears the incident also might cost him a bit of innocence and trust.

"He didn't know anything about gang symbols until the teacher accused him," she said. "We moved to Pooler thinking he'd be in a more diverse school with better opportunities.

"And so far, it hasn't been a pleasant experience."

The full story is here. I have previously highlighted the story of Tim Masters, who was convicted of murder in large part due to a series of "scary doodles."

Hat tip: The excellent blog, Don't taze me, Bro!