DSM-5 petition takes off like wildfire

I just checked back on the status of the petition by psychologists about the DSM-5 that I blogged about Sunday, and found that it's gaining momentum fast: 1,160 signatures as of this moment, and there will be a dozen more in the few minutes it takes me to upload this post!

The blaze of interest is especially remarkable because the petition was launched without any publicity at all, and has gained traction solely through word of mouth.

If you haven’t checked it out yet, I urge you to do so, and pass it along to others.

According to Allen Frances, chair of the DSM-IV task force and an outspoken critic of the current DSM-5 process, the American Psychiatric Association leadership is aware of the petition, but plans no formal response. Writing yesterday at the Psychiatric Times, he said:

They hope to ride out the storm of opposition mounting on all sides and dismiss it as the work of professional rivals or antipsychiatry malcontents. Characteristically, DSM-5 offers no rebuttal based on evidence. Instead, it stubbornly soldiers on in its promotion of radical diagnostic changes that are risky, untested, unsupported by a strong science base, and vigorously opposed by the field.

The really unexplainable paradox is the APA's systematic promotion of greater diagnostic inflation at a time when we are already so obviously plagued by diagnostic inflation, fad diagnoses, and false epidemics. Unless it comes to its senses, DSM-5 will promote greater drug use exactly when we have a public health problem caused by the inappropriately loose prescription of antipsychotics, antidepressants, antianxiety agents, pain medicines, and stimulants. The paradox is that, contrary to conspiracy theorists, the DSM-5 experts are not making their risky suggestions because of financial conflict of interest or the desire to line drug company pockets. They have the best of intentions, but are terminally naïve about how their suggestions will be misused....

Frances has another good commentary on the petition and its ramifications at his Psychology Today blog dedicated to the mounting crisis, DSM5 in Distress:

DSM 5 has lived in a world that seems to be hermetically sealed. Despite the obvious impossibility of many of its proposals, it shows no ability to self correct or learn from outside advice. The current drafts have changed almost not at all from their deeply flawed originals. The DSM 5 field trials ask the wrong questions and will make no contribution to the endgame.


But the DSM 5 deafness may finally be cured by a users' revolt. The APA budget depends heavily on the huge publishing profits that accrue from its DSM sales. APA has ignored the scientific, clinical, and public health reasons it should omit the most dangerous suggestions- but I suspect APA will be more sensitive to the looming risk of a boycott by users.

Again, I encourage you to join the movement now, by clicking on the link below and by spreading the word.

Psychiatrists ramp up opposition to forensic misuse of DSM

"Pedohebephilia" would make bad situation worse, they warn  

As you will recall, at a recent debate members of the American Academy of Psychiatry and the Law (AAPL) were virtually unanimous in giving the thumbs-down to three controversial sexual disorders being proposed for the fifth edition of psychiatry’s diagnostic manual.

Piggy-backing on that sentiment, the Academy's official journal has just published two additional calls for caution. 

DSM's forensic influence cannot be ignored

Ralph Slovenko, an eminent professor of law and psychiatry at Wayne State University Law School, leads off with an editorial that counters a key claim of the proponents of diagnostic expansion. The oft-repeated claim is that the legal implications of a diagnosis are irrelevant, and should not be considered.

Rebutting this head-in-the-sand mentality, Slovenko gives a comprehensive overview of the DSM's impact in myriad areas of the law, from parental termination to disability determinations. As evidence of the DSM's vast influence, he cites language written into the statutes in 16 states mandating its use for various purposes.

As his overview makes clear, courts and legislatures across the United States have ignored the fine print in the introduction to the Diagnostic and Statistical Manual, stating that use of the manual for forensic purposes risks misunderstanding and misuse.

A case in point: Use of a made-up category, "Paraphilia Not Otherwise – Hebephilia," as justification for preventive detention of men who have served prisont time for sexual relations with adolescent.

No basis for fictional "hebephilia" disorder

Next, two psychiatrists who were influential in developing the current edition of the DSM launch a full-on assault on the use of the bogus diagnosis "hebephilia" in sexual predator civil commitment proceedings.

Michael First, editor and co-chair of the DSM-IV-TR, and Allen Frances, chair of the DSM-IV Task Force, clarify the intention of diagnosing paraphilias, or sexual deviances, and why diagnosing offenders against adolescents with "hebephilia" (a diagnosis that does not exist in any formal diagnostic system) is a flagrant abuse of psychiatric nomenclature. This is not the first time these authors have tried to set the record straight, but their current analysis is especially detailed and unequivocal.

The alleged diagnosis paraphilia not otherwise specified, hebephilia, arose, not out of psychiatry, but rather to meet a perceived need in the correctional system. This solution represents a misuse of the diagnostic system and of psychiatry. That a large number of forensic mental health workers have been mistrained to regard paraphilia NOS as a valid diagnostic category in SVP proceedings should not be construed as proper representation of the views of the entire mental health field. Similarly, the very preliminary studies conducted by a few research groups should not be construed to indicate that hebephilia has any solid scientific support. Hebephilia is not an accepted mental disorder that can be reliably diagnosed and should not be treated as such in SVP proceedings.

First and Frances issue a strong call against adding the pretextual diagnosis of "pedohebephilia" to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders:

Among several radical proposals made by the DSM-5 Sexual Disorders Workgroup is the backdoor introduction of the hebephilia diagnosis into the DSM-5 by expanding the existing well-accepted pedophilia category to include sexual arousal to pubescent individuals and renaming the broadened construct pedohebephilic disorder. There is no apparent need or compelling rationale to include hebephilia in DSM-5 beyond the research interests of a few scientists and the questionable use of hebephilia in SVP proceedings.

Despite opposition from forensic psychiatry, no doubt the wheels will grind on. After all, as legal scholar Charles Patrick Ewing describes in Justice Perverted, preventive detention has taken on a life of its own, becoming a lucrative and self-perpetuating industry. More on psychology's role in that very soon….

Related resources:

On my website, I have created a page of resources on the hebephilia controversy. But if you really want to immerse yourself in these diagnostic controversies, the place to visit is the "DSM-5 Paraphilias Controversy." On one page, blogger Andrew Hinderliter has amassed an impressive array of literature on the disputed paraphilias, including not only hebephilia, hypersexuality, and sexual sadism but also related hot-button topics such as transvestic fetishism.

My comprehensive historical review of hebephilia is now available online. Or, for a shorter version, there's always my oldie but goodie blog post, from Halloween of 2007: "Invasion of the hebephile hunters: Or, the story of how an archaic word got a new lease on life."

Rape as psychiatric illness: Battle heats up

Prosecutor lobbying for new diagnosis

Even after writing and teaching about the pretextual use of psychiatric diagnosis for legal purposes, I found this one jaw-dropping:

The committee tasked with revising the sexual disorders in the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) includes a prosecutor who specializes in prosecuting sex offenders as an invited advisor.

The prosecutor, Paul Stern of Washington, is now lobbying for a new psychiatric disorder for rapists, something that was considered and rejected from an earlier DSM. In an upcoming article in the Archives of Sexual Behavior, he reassures readers that creating this new "Paraphilic Coercive Disorder" would not increase the number of men involuntarily detained as Sexually Violent Predators. Au contraire: It would reduce the number of SVP commitments by improving diagnostic precision.

Stern lambastes psychologists and psychiatrists for engaging in "dangerous" legal analysis, while in the next breath asserts that he knows better than scientists about the validity of a psychiatric diagnosis for rapists! He dismisses concerns about the reliability and validity of the proposed diagnosis from two leading scientists, Raymond Knight and Vernon Quinsey. Likewise, he dismisses as an ideologue Dr. Allen Frances, psychiatry professor emeritus at Duke University and chair of the DSM-IV Task Force.

This article certainly did not seem good evidence of psychiatry as objective, value-neutral science, as Stern argues it should be.

Frances critiques "Paraphilia NOS"

Dr. Frances, meanwhile, continues to sound the alarm over poorly thought out diagnostic proposals for the DSM-5. His concerns arose out of his experience heading up the DSM-IV revision process. Witnessing the many unintended consequences of diagnostic expansion, such as epidemic stigmatization of children, he now regrets that he did not more carefully examine the reliability and validity of proposed diagnoses before approving them for inclusion.

In this week's Psychiatric Times, Frances squarely tackles the creation of psychiatric labels to justify the involuntary detention of criminal rapists.

The most disturbing turbulence at the boundary between psychiatry and the law is the misuse of a makeshift psychiatric diagnosis (“Paraphilia Not Otherwise Specified, nonconsent”) to justify the involuntary, indefinite psychiatric commitment of rapists. This is a disguised form of preventive detention (often for life), a violation of due process, and an abuse of psychiatry. The mental health professions have been placed in the position of providing a dangerous fig leaf to cover an unfortunate correctional gap created by fixed sentencing….

The Supreme Court has chosen to dance around the legal definition of a qualifying mental disorder. It has left this critical question up to the inconsistent and largely uninformed discretion of each lower court. This has led to huge confusion and very questionable practice. Many evaluators in SVP hearings have been led astray by a complete misunderstanding of the intent of the DSM-IV. They have applied the essentially made-up diagnosis ... to justify the psychiatric commitment of rapists who without this "diagnosis" would be regarded as no more than common, if particularly heinous, criminals….

This paradoxical gulf between the original intention of DSM-IV and SVP forensic evaluator misinterpretation of it leads to great confusion in the handling of expert mental health testimony in individual cases. The diagnosis "Paraphilia NOS, nonconsent" is clearly misguided -- almost always incorrect and inappropriate in forensic proceedings, but it has been accepted by enough mistrained "experts" to have acquired a patina of undeserved respectability that may (in a perverse self fulfilling prophecy way) lead to its acceptance.

Wisconsin exemplar: Bartow v. McGee

Frances urged the U.S. Supreme Court to hear the appeal of convicted rapist Michael McGee in order to clarify this issue. McGee's civil commitment rested on two contested diagnoses, "Paraphilia Not Otherwise Specified-Nonconsent" and "Personality Disorder Not Otherwise Specified."

McGee argued in his appeal that these "NOS" diagnoses are "bogus," invented by government psychologists to justify the continued confinement of men like him after they have completed their criminal sentences. He pointed out that the diagnosis of Paraphilia NOS-Nonconsent represents a minority fringe viewpoint that was specifically rejected by mainstream psychiatry.

In its Jan. 27, 2010 decision, the Seventh Circuit Court of Appeals used tortured logic to reject McGee's appeal:

We must inquire only whether the diagnosis was so patently lacking in credibility and validity that its consideration by the factfinder in the Wisconsin courts resulted in a denial of constitutional rights…. We cannot conclude that the diagnosis of a rape related paraphilia is so empty of scientific pedigree or so near-universal in its rejection by the mental health profession that civil commitment cannot be upheld as constitutional when this diagnosis serves as a predicate.

This case represents a perfect opportunity for the U.S. Supreme Court to clarify the nature of a "mental disorder" that justifies civil detention, Frances wrote:

The Court should resist the great temptation to continue to dodge this thorny, but basic, constitutional rights issue.... The Supreme Court must step up to the plate and provide clarity about what qualifies legally as a mental disorder in I was responsible for writing the final version of Paraphilia section in DSM-IV) that the diagnosis "Paraphilia NOS, nonconsent" is indeed 'patently lacking in credibility or validity' and is 'empty of scientific pedigree.' But I cannot argue that it is 'near universal in its rejection by the mental health profession' SVP commitments.

Lower courts have faced a peculiar difficulty in interpreting expert testimony in SVP cases. The wording used by the appeals court in the McGee case clearly illustrates the problem. I would argue (with some authority sincebecause a sizable segment of the community of SVP evaluated have been mistrained into believing that "Paraphilia NOS, nonconsent" is a valid DSM-IV diagnosis.

Clearly, the Supreme Court should accept McGee for review and dispel confusion on what constitutes a mental disorder in SVP cases. McGee is a perfect test case raising a crucial constitutional question that should not be decided haphazardly and inconsistently based a basic misunderstanding of psychiatric diagnosis.

Frances's plea was published a little late. On June 7, the U.S. Supreme Court declined to hear the case.

If prosecutor Stern gets his way, the Paraphilia NOS-Nonconsent controversy will be moot, as the DSM-5 (due out in three years) will include the more legitimate-sounding twin, Paraphilic Coercive Disorder. But the DSM-5 task force may be shooting itself in the foot by publicly aligning itself with a partisan advocate. If an SVP defense attorney had co-authored the opinion piece with Stern, it might appear less partisan and, by implication, pretextual.

To put that in scientific terms, if lobbyists look at least superficially nonpartisan, their claims of scientific legitimacy for this new disorder might have more face validity. Which, as we know, is still a far cry from construct validity.

The abstract of Mr. Stern's article, "Paraphilic Coercive Disorder in the DSM: The Right Diagnosis for the Right Reasons," is HERE, along with contact information if you want to request the full article.

Dr. Frances' article in Psychiatric Times, Rape, Psychiatry, and Constitutional Rights -- Hard Cases Make For Very Bad Law, is HERE. (You must first register, but it's free and easy.)

Related blog posts:

Scientist razes proposed "Paraphilic Coercive Disorder" (Nov. 6, 2009 blog post explaining scholar Raymond Knight's position on this diagnosis - RECOMMENDED)

Fed court OK's unorthodox diagnoses for sex offenders

Graphics credit: DSM-5 (a Spanish punk rock band!)

"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).

"Pedohebephilia"

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)

Leading psychiatrists critique proposed sexual disorders

• Dangerous.
• Unnecessary.
• Sloppy.
• Inaccurate.

These adjective express the sentiment of prominent forensic psychiatrists about a set of controversial new sexual disorders being proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Four critiques in the current issue of the flagship journal of the American Academy of Psychiatry and Law follow two well-attended meetings in which forensic psychiatrists were "decidedly negative" toward the proposed paraphilias, in the words of psychiatrist Howard Zonana.

Pandering to legal pressure 

A primary concern of forensic psychiatrists is that the proposals are being developed not based on clinical need or scientific discovery but, rather, to meet demands from the legal system. Specifically, broadening of paraphilias will make it easier to:

• Increase prison terms for Internet pornography users 
• Win civil detention for repeat sex offenders who have no genuine mental disorders

"The sexual disorders in the current and proposed DSM contain a potpourri of categories that increasingly intersect with the criminal justice system," notes Zonana, a psychiatry professor at Yale:

"Caveats saying the DSM is designed for clinical and not legal purposes notwithstanding, our classification system has difficulty distinguishing what we consider criminal behavior from culturally unacceptable behavior and mental disorder. Several current proposals continue this trend and seem more responsive to criminal justice concerns than mental illness considerations. They also lack sufficient specificity to warrant being called a disorder."

Loosening categories will reduce accuracy

J. Paul Fedoroff echoed Zonana's concern about legal influence, and also highlighted the reduction in accuracy that the diagnostic expansions will engender:

"The [proposals] raise more questions than answers. The proposed revisions to current DSM-IV-TR criteria will decrease the specificity of ascertained and diagnosed conditions by dramatically loosening the diagnostic categories. While the proposed changes may increase diagnostic reliability, they will certainly decrease diagnostic accuracy. Given the consequences of mistaken diagnosis, the proposed revisions are both unhelpful and dangerous."

Federoff, chair of  AAPL's Sexual Behaviors Committee, also directs both the Sexual Behaviors Clinic at Royal Ottawa Mental Health Care Centre and the forensic research program at the University of Ottawa Institute of Mental Health Research. 

Hypersexuality: Pathologizing young adults

Both Zonana and Federoff critiqued the conceptual and practical problems with the big three proposals that were resoundingly rejected in an audience poll after a debate at last year's AAPL meeting. These include hypersexuality, pedohebephilia and paraphilic coercive disorder (which the DSM revisers recently agreed to shelve). Wrote Zonana:

"The amount of time a person spends thinking about and engaging in sexual behavior varies enormously across the life cycle, with a sharp peak in adolescence and early adulthood. The most striking feature of the current criteria for hypersexuality is that, in my experience, it will be especially hard to find a young adult of college age who does not meet all of the criteria. The same will be true of many adults. The amount of time adolescents spend fantasizing and engaging in sex-related behavior is enormous.... To call this a mental disorder will include far too many false positives."

Pedohebephilia: Confusing illegality with disorder

Zonana, Federoff, and two other prominent forensic psychiatrists – Johns Hopkins University psychiatry professor Fred Berlin and Columbia University professor Michael First – all criticized the proposal to expand pedophilia to include adults with sexual interests in minors who have reached puberty.

"What is the great need to expand the definition to make more diagnoses?" asked Zonana. "Their rationale seems to conflate law enforcement with mental illness even more. There certainly are no new good treatments to justify a need to identify more cases."

“Our culture has initiated a 'war on sex offenders' and the legal system has geared up to wage it. Since we have made the diagnosis almost completely overlap with the crime, we have become overly enmeshed with legal goals.”

Federoff agreed:

"With the broadening of the age range of interest that will satisfy the diagnosis, more people will be labeled. By definition, expansion of the range of diagnostic criteria reduces sensitivity (true positives). Is this a good idea?"

Critical voices encouraged

Introducing the critiques, Richard B. Krueger, a psychiatry professor at Columbia University and medical director of the New York State Psychiatric Institute's Sexual Behavior Clinic, invited others to submit input – especially in published form:

"We hope that these articles will stimulate further discussion and submission of thoughtful criticism. Forensic psychiatrists are particularly well suited to offer commentary concerning the use or misuse of paraphilia diagnoses in legal proceedings, and observations on any aspect of the proposed criteria would be welcome. Indeed, editors of relevant journals have been generous in publishing commentary and articles. The Journal of the American Academy of Psychiatry and the Law, Sexual Abuse, the Archives of Sexual Behavior, the Journal of Sex Research, and The Journal of Sexual Medicine have published criticisms of DSM-5. There is still time to submit comments. Even if suggestions are not actually incorporated or reflected in the revised criteria, the published record would be valuable and relevant for the future."

While I would certainly echo Krueger's encouragement, I am skeptical that some members of the DSM-5 Sexual Disorders Work Group will willingly give up their pet diagnoses – especially the scientifically suspect pedohebephilia construct that is already being misused on a widespread basis in Sexually Violent Predator cases.

As psychiatrist John Sadler noted in his book dissecting the conflictual history of the DSM's, Values and Psychiatric Diagnosis, the DSM committees claim openness and seek input, “but how such input is to influence the actual decision-making process is not discussed.”

At any rate, Krueger makes the excellent point that having a formal record of the opposition will be important in the future. If any of these three proposals makes it into the DSM-5, vigorous Daubert challenges by increasingly sophisticated attorneys will be certain to follow. Indeed, use of any of the paraphilias in court only calls attention to the scientifically weak underpinnings of the entire category. As Zonana points out:

"The work group has a difficult set of disorders to contend with. The category lacks a principled basis for considering inclusions and exclusions, which makes it vulnerable to societal pressures rather than advances in science. The proposals discussed should not be accepted in their current form, as they create more problems than they solve."

Daubert challenges will be especially likely in that the American Psychiatric Association has decided not to conduct any formal field tests of the proposed paraphilias. This means that even their interrater reliability -- far easier to establish than actual scientific validity (accuracy) -- will remain in doubt. Unofficial field trials being conducted at the Sand Ridge Detention Center in Wisconsin and in California will not alleviate this concern, as the coordinators of these trials have a vested interest in a positive outcome. It's something like hiring the fox to guard the chicken coop.

I predict that the paradoxical consequences of this shaky endeavor are going to come back and bite organized psychiatry in the future. As I wrote in the conclusion to my historical review of hebephilia's sudden emergence:

Significant unintended consequences are likely if novel syndromes of primary benefit to the sex offender commitment industry are incorporated into the upcoming edition of the DSM. First, at a time of mounting controversy over partisan influence and lack of scientific rigor in the DSM diagnostic system, critics will seize on this as a glaring example of arbitrary and unscientific use of psychiatric diagnosis in the service of a pragmatic goal. This could have the paradoxical effect of reducing the scientific credibility of the DSM and the fields of psychiatry and psychology more broadly. In the forensic arena, where the diagnosis will most often be invoked, it may paradoxically invigorate defense challenges on the grounds that psychiatry is being deployed in a pretextual manner. In the end, hebephilia will come to haunt not only those who are civilly committed on pretextual grounds, but the entire mental health field, for years to come.

As always, the Journal of the American Academy of Psychiatry and Law is available online for free downloading. The current issue includes some other interesting articles, including a critique by forensic psychologist Brian Abbott of a current push in the sex offender industry to combine actuarial scores with clinical judgment. I encourage you to check it out (HERE). 

Forensic fallout of revamping personality disorders

What is a personality disorder?

Your answer likely depends on whether you are a mental health professional, a layperson, or a member of the legal profession, where the term can have a highly scripted meaning with weighty implications.

In fact, the Supreme Court of Washington just ruled that the precise definition is so critical that a judge's refusal of a defense request to define it for a jury invalidated a civil detention order. That's because in Washington, a convicted sex offender cannot be civilly committed to a state hospital unless he has either a personality disorder or a "mental abnormality" that makes him more likely than not to commit sexually predatory acts in the future. The legal distinction between these two conditions derives from the DSM's axial system, under which most illnesses are listed on Axis I but personality disorders are categorized as "Axis II," because they are conceptualized (not always accurately) as more chronic and enduring than acute Axis I disorders.

At the trial of Curtis Pouncy, the prosecution-retained psychologist, Richard Packard, had testified that Curtis Pouncy had both conditions. The jury ultimately found Pouncy to be a Sexually Violent Predator (SVP), but it did not state whether this finding was on the basis of a personality disorder, a mental abnormality, or both. Explained the Supreme Court in overturning the commitment:

"The phrase 'personality disorder' is not one in common usage and is beyond the experience of the average juror. It is a term of art under the DSM that requires definition to ensure jurors are not 'forced to find a common denominator among each member's individual understanding' of the term…. We have no way of knowing from the verdict whether the jury found that Pouncy was an SVP because he suffered from a mental abnormality or a personality disorder. And, if the jury agreed Pouncy suffered from a personality disorder, we have no way of knowing what definition the jury used in reaching this conclusion…. We cannot say the failure to instruct on the definition of 'personality disorder' in no way affected the final outcome of the case; accordingly, it was not harmless. A new trial is required."

The government of Washington is so interested in the precise meaning of the term that in 2009 it actually codified the definition for purposes of SVP civil commitment. Tagging off of the definition in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the Revised Code of Washington Section 71.09.020(9) now defines a personality disorder as:

"an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. Purported evidence of a personality disorder must be supported by testimony of a licensed forensic psychologist or psychiatrist."

As Constance Holden reports in the current edition of Science magazine, "Personality disorders are hard to pin down. They don't have a common defining mood or behavior, people don't get hospitalized for having one, and a drug won't cure one."

If that sounds tricky, wait until the American Psychiatric Association adds layer upon layer of new complexity, and in the process completely scraps the definition as reified by government entities such as the Washington state legislature. Under a draft proposal rolled out last month for the new DSM-5* (due out in 2013), the old personality disorders are barely recognizable and some have disappeared altogether.

• First off, the overarching definition will be new. Now, personality disorders are defined more briefly as:

"the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual's cultural norms and expectations."

Both self-identity and interpersonal functioning are then further defined. For example, poor interpersonal functioning involves failure to develop empathy, intimacy, cooperativeness, or "complexity and integration of representations of others."

• Next, one rates the person on a set of six traits (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy) to determine whether the general adaptive failure is "associated with extreme levels of one or more" of these.

• Finally, there are the specific personality "types," whittled down from the current 10 to only five: Schizotypal, Borderline, Obsessive-Compulsive, Avoidant, and Antisocial/Psychopathic. Note that psychopathy will make its grand debut, while narcissistic exits stage left.

In his erudite competency opinion in the Brian David Mitchell case, Judge Dale Kimball leaned heavily on narcissistic personality disorder as an explanation for the defendant's presentation. If the Personality Disorders Work Group for the DSM-5 gets its way, that diagnosis will go the way of of hysteria and melancholia. Of course, as the judge wisely pointed out, DSM diagnoses are not directly applicable to ultimate legal issues:

"[I]t is not particularly necessary for the court to determine a specific diagnosis in determining competency.... [E]ither an Axis I or Axis II condition could potentially render a defendant incompetent. And, on the other hand, a defendant could have an Axis I and/or Axis II condition and still be competent."

So, what do you get when you combine five personality types with six crosscutting traits? "A camel -- a horse made by committee," psychologist Drew Westen of Emory University told Science magazine.

And in forensic contexts, how will terms such as "culturally adaptive," "empathy," "cooperativeness," "negative emotionality," and "antagonism" be operationalized? Based on research into how forensic evaluators decide about other value-laden constructs such as psychopathy and risk, dare I predict partisan allegiance will rear its ugly head?

Paul A. Siciliano at Basically Law has more on the Pouncy decision. Psychologist Simone Hoermann has commentary on the DSM-5 personality disorders revamp at her Personality Disorders blog.

*The current DSM and all previous editions are designated by Roman numerals, but the APA has decided to use Arabic numerals starting with the fifth edition.

Photo credits: (1) Vagamundos (Creative Commons license 2.0); (2) Kaptain Kobold (Creative Commons license 2.0) 

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DSM-5 POSTSCRIPT: Following much brouhaha, the American Psychiatry Association ultimately did not adopt the more radical proposed changes to the personality disorders for the DSM-5, nor did it remove Narcissistic Personality Disorder (much beloved in some psychiatric quarters) as one of the types. However, the entire axial system (i.e., the distinction between Axis I mental disorders versus Axis II personality disorders) was eliminated. Meanwhile, contemporary research is suggesting that personality disorders -- for example Borderline and Antisocial disorders -- are not nearly as enduring or lifelong as the DSM definitions continue to suggest.

Who will write the next DSM?

Would you believe: Pfizer, Eli Lilly, Wyeth, Merck, AstraZeneca and Bristol-Myers Squibb?

Or, at least, those are some of the BigPharma corporations with whom members of the task force charged with creating the 5th Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders have contracts.

It shouldn't come as a surprise. But it ought to alarm the public, given BigPharma's enormous and growing influence in so many spheres of public life all around the world.

More than half of the experts involved in the previous edition of the psychiatric bible also had monetary relationships with drug makers, according to a Tufts University study. The percentage was up to 100 percent for experts working on certain severe mental illnesses, such as schizophrenia. (The New York Times story on that 2006 research is here.)

A just-published book, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders, has more on this construction of difference as illness. Trends that author Peter Conrad notes include the medicalization of "male" problems such as baldness and sexual impotence, and the pathologizing of children's behavior and appearance (short kids now have idiopathic short stature which requires synthetic human growth hormone).

Another new book, The Rise of Viagra, further documents the pathologizing of sexual variation, including an effort by BigPharma's spin doctors to create public hysteria and a new market for medicines to treat Female Sexual Dysfunction."

Meanwhile, as I've blogged about elsewhere, the sex offender industry is lobbying for new diagnoses to medicalize illegal sexual conduct, including "hebephilia" for men who are sexually attracted to teens, and "Paraphilia Not Otherwise Specified-Nonconsent" for men who rape.

Look for all these, and more, as possible candidates for the new and expanded DSM-V. Each edition of the DSM contains more diagnoses than its predecessor, and each diagnosis is supposedly treatable with meds. DSM-I (1952) listed 106 mental disorders, DSM-II (1968) had 185, DSM-III (1980) had 265, and DSM-IV (1994) has 357. That's an average of about 84 new diagnoses per edition, so the DSM-V should have 440 or more diagnoses.

Hopefully, this week's blog post by New York Times health writer Tara Parker-Pope about the conflict of interest signals that the public will be kept informed.

The consumer watchdog group Integrity in Science, a project of the Center for Science in the Public Interest, is also following the scent of money. See my Amazon book list, Critical Perspectives on Psychiatry, for other books on the DSM and the construction of illness.

Open letter opposing DSM-5 paraphilias expansion

Photo credit: Dr. Joanne Cacciatore

As readers of this blog are aware, proposals to expand the sexual disorders in the American Psychiatric Association's upcoming DSM-5 have generated significant controversy among forensic psychologists and psychiatrists. Now, forensic psychologists are banding together to urge APA President John Oldham to reject the proposed diagnoses of pedohebephilia, paraphilic coercive disorder and hypersexual disorder. The text of an open letter drafted by Richard Wollert, an Oregon psychologist with extensive experience in sex offender treatment and evaluation, follows. If, after reading it, you would like to become a signator, just click on the indicated link, and provide Dr. Wollert with your name and professional credentials. Don't delay, as I understand that this important letter is being submitted very soon. 

CLICK HERE TO ADD YOUR NAME TO THE LETTER

 

Dear Dr. Oldham:

As a mental health professional and/or sex educator I am writing to you to encourage the American Psychiatric Association to leave invalid sexual disorders out of DSM-5. 

In 1999, the Dangerous Sex Offender Task Force of the American Psychiatric Association issued a strongly worded statement about psychiatry's failed efforts to meaningfully define and classify sexual deviance. In contrast to the cautious approach advised by the Task Force, a Paraphilias Subworkgroup of the DSM-5 is vigorously lobbying for the adoption of three highly controversial expansions of sexual disorders (Hebephilia, Paraphilic Coercive Disorder, and Hypersexual Disorder). The expansions would be a major mistake, due to poor reliability, unproven validity and -- most of all -- the potential for vast and harmful unintended consequences. 

The Subworkgroup is now proposing to add a "Hebephilic" type to Pedophilia, extending the diagnosis of Pedophilia from covering those with sexual attractions to prepubescent children to those with sexual attractions to pubescent children under age 15. It also proposes to add new diagnoses of "Paraphilic Coercive Disorder" and "Hypersexual Disorder" to the Appendix as "Criteria Sets for Further Study." I am dismayed by each of these recommendations for the following reasons. 

Hebephilia lacks conceptual coherence. Most men are attracted to sexually maturing 14-year-olds, as reflected in the large number of industrialized countries where the age of sexual consent is 14 (Green, 2010). Normative attractions may be criminal when acted upon, but they should not be labeled as mental disorders. "Hebephilia" is an archaic term that languished in psychiatric obscurity until the passage of modern civil commitment laws in the United States (Franklin, 2010). Since then, some evaluators who confuse statutory rape with mental disorder have invoked Hebephilia as a condition that justifies civil commitment (Ewing, 2011). Such usages do not provide a cogent explanation for behavior that is illegal in the United States but legal in other countries being classified as a mental disorder. Finally, Hebephilia lacks adequate diagnostic reliability (Wollert and Cramer, 2011). Most of the research has been conducted by a single Canadian research team that is overly represented on the Paraphilias Subworkgroup. Although the DSM-5 Task Force has indicated that final decisions about proposed revisions will be made on the basis of field trial data, a November 2011 change in the proposed criteria for the diagnosis rules out the application of even this meager safeguard. 

Paraphilic Coercive Disorder (PCD) was initially proposed for inclusion in DSM-5 as a diagnosis that would be limited to men who preferred rape over consensual sex. Because only a very small percentage of rapists prefer rape over consensual intercourse (American Psychiatric Association, 1999), clinicians are unable to reliably apply this label (Wollert, 2011). This is one reason for the American Psychiatric Association's consistent rejection of rape-based paraphilias in three previous editions of the DSM (Zander, 2008). In the face of overwhelming opposition, the Subworkgroup has taken the fallback position of recommending PCD only for inclusion in the Appendix as a condition meriting "further study." However, this would confer an undeserved back-door legitimacy to the invalid construct. Rather than a mental disorder, rape is a crime for which the proper placement is prison. 

The proposed criteria for Hypersexual Disorder (HD) are the product of a recent ad hoc literature review by Martin Kafka, a member of the Subworkgroup. His review indicated their validity has not been empirically confirmed. Given the inherent difficulty in determining at what point a normal human drive becomes abnormal, it is not surprising that the proposed diagnosis is marred by conceptual confusion and vague verbal anchors (Moser, 2011). Its poor reliability and validity will translate to a high rate of false positives in both civil commitment trials and outpatient clinics that serve the community in general. With the proposal becoming a magnet for ridicule both by academic scholars and the popular press, it too has been relegated to the Appendix. However, the Appendix was not intended as a storage site for criteria sets that, like Hypersexuality Disorder, have never been tested. 

These three proposals all lack adequate empirical support. They will increase false positive diagnoses by labeling behaviors that are normative, developmental, or criminal as mental disorders. Promoting the misclassification of juveniles and other vulnerable populations as dangerous sex offenders, they will undermine the reputation of forensic practitioners and those who study sexual behavior. Collectively, professions that endorse the use of unreliable diagnoses run the risk of losing their credibility. 

The British Psychological Society, the American Counseling Association, and the Society for Humanistic Psychology and many other divisions of the American Psychological Association have all submitted petitions or letters of concern to the American Psychiatric Association regarding revisions proposed for the DSM-5. These documents express concerns about the lack of empirical support for many DSM-5 proposals, the likelihood of “false-positive epidemics” flowing from decreased diagnostic thresholds, and the negative effects of "over-medicalizing" human behavior. They also point out that the prevention of false-positive epidemics should take precedence over "nomenclatural exploration" and that the temptation to adopt new diagnoses should be tempered by the recognition that diagnostic labels tend to be confounded with normative social expectations. 

I share these concerns as they apply to sexual disorders. I further support the adoption of sexual disorder criteria sets only after they have been established to have high true positive rates and acceptable false positive rates. Therefore, I urge the DSM Task Force to remove the Hebephilia qualifier from the proposed diagnosis of Pedophilia, and to eliminate Paraphilic Coercive Disorder and Hypersexual Disorder from any inclusion in the DSM-5. 

Sincerely, 

CLICK HERE TO ADD YOUR NAME TO THE LETTER

(email your name and professional credentials to Dr. Wollert)

References 

American Psychiatric Association (1999). Dangerous sex offenders: A task forcereport of the American Psychiatric Association. Washington D. C.: American Psychiatric Association.

Ewing, C. P. (2011). Justice perverted: Sex offense law, psychology, and public policy. New York: Oxford University Press. 

Franklin, K. (2010). Hebephilia: Quintessence of diagnostic pretextuality. BehavioralSciences and the Law, 28, 751-768. 

Green, R. (2010). Sexual preference for 14-year-olds as a mental disorder: You can’t be serious!! [letter to the editor]. Archives of Sexual Behavior, 39, 585-586. 

Moser, C. (2011). Hypersexual Disorder: Just more muddled thinking [letter to theeditor]. Archives of Sexual Behavior, 40, 227-229. 

Wollert, R. (2011). Paraphilic Coercive Disorder does not belong in DSM-5 forstatistical, historical, conceptual, and practical reasons [letter to the editor]. Archives of Sexual Behavior, 40, 1097-1098. 

Wollert, R. & Cramer, E. (2011). Sampling extreme groups invalidates research on the Paraphilias. Behavioral Sciences and the Law, 29, 554-565. 

Zander, T. (2008). Commentary: Inventing diagnosis for civil commitment of rapists. The Journal of the American Academy of Psychiatry and the Law, 36, 459-469.

DSM-V: Will shoddy manual implode years before launch date?

The DSM-V debacle continues to expand like a mushroom cloud following a nuclear explosion. Media pundits right and left are commenting critically on the draft manual, published online after years of cloak-and-dagger secrecy.

As most of you know by now, the American Psychiatric Association has granted the public a very brief window in which to comment online on the draft proposals. I haven't seen an explanation of how public input will be tallied or used. Will a popularity contest influence psychiatric diagnosis? We've seen how well citizen input works here in California, where the initiative process has brought government to a standstill. Can you imagine neurologists setting up a website to get lay input on a new diagnostic scheme for brain tumors? This debacle only underscores the point that the DSM is more politics than science.

Among the best commentaries I've seen this week are Sally Satel's op-ed in the Wall Street Journal and Allen Frances' piece in Psychiatric Times. Science magazine also has an interesting analysis of the proposed behavioral disorders, which would medicalize harmful habits like gambling, overeating, and down the line perhaps "Internet Addiction." All three articles touched on the negative forensic consequences of the radical proposed changes.

"Prescriptions for Psychiatric Trouble"

Psychiatrist Sally Satel, a resident scholar at the American Enterprise Institute, lecturer at Yale University School of Medicine, and a brilliant thinker, critiqued psychiatry's endless drive to expand mental disorder, placing ever-larger "swaths of the population under the umbrella of pathology." As Satel points out, the DSM-V continues the troubling tradition, launched 30 years ago with publication of the manual's third edition, of elevating reliability over validity:

[J]ust because two examiners concur that a person qualifies for a particular diagnosis does not mean that he has an authentic mental illness. How do we know, for example, that a person diagnosed with major depressive disorder (the formal designation for pathological depression) is not actually suffering from a bout of natural if intense sadness brought on by a shattering loss, a grave disappointment or a scathing betrayal?

The manual will not help us here. In fact, a number of changes proposed for the DSM V (e.g., new diagnoses for binge eating, hoarding and hypersexuality) are likely to inadvertently place large swaths of normal human variation under the umbrella of pathology.

Both she and Allen Frances, former chair of both the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, believe that Psychosis Risk Syndrome may be the scariest example of overinclusion. Hundreds of thousands of young people, especially the poor and minorities, could be given this highly stigmatizing label and medicated with extremely dangerous drugs, even though these medications are not very effective and the broad majority of these youngsters would not go on to develop psychoses if left alone.

In his critique in Psychiatric Times, aptly titled "Opening Pandora's Box," Frances notes that the DSM-V "would create tens of millions of newly misidentified false positive 'patients.' " Not only could almost anyone qualify for at least one of the new diagnoses (which include such nebulous constructs as Mixed Anxiety Depressive Disorder, Minor Neurocognitive Disorder, Temper Dysfunctional Disorder with Dysphoria, and -- in a big nod to America's 12-Step religion -- Addiction Disorder), but thresholds are being lowered for many existing disorders as well.

Forensic applications: Disastrous unintended consequences

One of the DSM-V developers' most troubling weaknesses is their profound "insensitivity to possible misuse in forensic settings," Frances notes. As an example, he cites Pedohebephilia, "one of the most poorly written and unworkable" proposals in the draft:

Expanding the definition of pedophilia to include pubescent teenagers would medicalize criminal behavior and further the previously described misuse of psychiatry by the legal system. Certainly, sex with under-age victims should be discouraged as an important matter of public policy, but this should be accomplished by legal statute and appropriate sentencing, not by mental disorder fiat.

Two other potential "forensic disaster[s]" are Hypersexuality Disorder and Paraphilic Coercive Disorder, both of which will be used to expand the pool of sex offenders eligible for indefinite civil commitment on the basis of purported mental disorder.

In Frances' opinion, based on having worked on the three previous editions of the DSM and knowing many of the drafters of the current version, critics are missing the mark by focusing on alleged financial and/or professional conflicts of interest. Rather, the DSM-V work group members are sincere and well meaning, but have a natural, "and seemingly irresistible," tendency to expand the boundaries of diagnoses in order to identify and treat all potential sufferers. This "diagnostic imperialism" produces a fatal blind spot:

Unfortunately, Work Group members … [miss] the fact that every effort to reduce the rate of false negatives must inevitably raise the rate of false positives (often dramatically and with dire consequences). It is inherently difficult for experts, with their highly selected research and clinical experiences, to appreciate fully just how poorly their research findings may generalize to everyday practice -- especially as it is conducted by harried primary care clinicians in an environment heavily influenced by drug company marketing…. [T]he DSM5 suggestions display the peculiarly dangerous combination of nonspecific and inaccurate diagnosis leading to unproven and potentially quite harmful treatments.

Frances strongly argues that the time to weed out implausible and even "incoherent" proposals is now, not after the proposed field testing:

I feel it is my responsibility to raise clear alarms now because the past performance of the DSM5 leadership does not inspire confidence in its future ability to avoid serious mistakes.... Field trials are arduous and expensive and make sense only for testing the precise wording of criteria sets that have a real chance of making it into the manual -- not for the many poorly written and far out suggestions that have just been posted. It seems prudent to identify and root out problems now lest they sneak through in what will likely be an eventual mad rush to complete DSM5....

Because of the secretive and closed nature of the DSM5 process, the expectable enthusiasms of the experts who comprise the Work Groups have not been balanced, as they must always be, with real world practical clinical wisdom and a careful risk/benefit analysis of the possible unintended consequences of every suggestion.

It would be reckless now to rely on the complacent assumption that all these problems will eventually come out in the wash. By its previous actions and inactions, the DSM5 leadership has sacrificed any "benefit of the doubt" faith that their process will be self-correcting in a way that guarantees the eventual elimination all of the harmful options.

Note: If you want to read Sally Satel's op-ed, do it now; after seven days, Wall Street Journal articles are only available by subscription. I highly recommend that forensic experts and attorneys carefully review Frances' article, and note his recommendation for greater forensic oversight. At minimum, if new diagnoses without established validity are included in the manual, the DSM should add a caveat that they are never to be used as grounds for civil commitment.

Special hat tip to the ever-helpful JANE