DSM-5: Forensic applications (Part II of II)

Courts cling to DSM as "bible"

As alluded to yesterday, in Part I, mental health professionals know not to take the DSM (or the ICD, for that matter) too seriously. It's just convenient fiction, or at best "useful constructs," mainly used to attain insurance reimbursement.

Only, there's this curious phenomenon: In the legal system, where the consequences of error can be grave, DSM diagnoses have taken on a mantra of grand truth. Increasingly, I find myself being asked during court testimony about some nit-picky little criterion or another (such as the six-month specifier for pedophilia) as if it is sacred gospel, rather than the arbitrary creation of some idiosyncratic back-room committee.

One bold colleague, when asked on the witness stand to confirm that the DSM is indeed "the bible of psychiatry," answers with a resounding "YES!" But, he adds, "Bible is Greek for 'book,' and the DSM's are a collection of books or chapters submitted by sundry subcommittees and approved or not based on politics. As with the Christian Bible, some known books (like the Book of Thomas) did not make the cut."

I don't recommend that tactic unless you are well grounded in theological studies. I myself cannot state under oath that the DSM is "the bible," when the attorney is really seeking to have me confirm its status as a learned treatise, that is, sufficiently authoritative that it should be relied upon in court. It may be the only game in town, but it's hardly known for its empirical fidelity. The text's assortment of vague generalities are not even referenced, so we don't know where they came from. If you are going to testify about a specific mental condition, such as delusional disorder, I recommend relying on empirical research from reliable sources that you can cite. 

Turning now to specific changes in the DSM-5 of most potential relevance to forensic work....

The good news is that some of the more outlandish proposals -- such as parental alienation syndrome and hebephilia -- got a resounding thumbs-down. So, here's my first-glance summary of what's new and different. 

Sexual paraphilias

An attempt by an ambitious minority to add a slew of new sexual disorders fell flat. So, you won’t find hebephilia, paraphilic coercive disorder or hypersexuality in the DSM-5. They didn’t even make the appendix for "conditions for further study" (which is populated by such non-starters as caffeine use disorder, internet gaming disorder, and the more worrisome attenuated psychosis syndrome).

These defeats are a big blow for the civil commitment industry, which lobbied for them to replace the shady "not otherwise specified" diagnoses being used to justify indefinite detention of offenders who don't have legitimate mental illnesses.

The section does, however, contain a few pesky little wording changes that may come into play in forensic cases. Each  disorder except pedophilia in the paraphilias chapter now has two remission qualifiers. If the person has not been impaired for five years, the disorder can be said to be "in full remission." This is a nod to the reality that sexual kinks often come and go over time. But there's a catch: The remission must be while the person was "in an uncontrolled environment." Otherwise, a new remission specifier of "in a controlled environment" can be applied. I anticipate that government evaluators in sexually violent predator trials may use this language to argue that a prisoner whose predicate offense was decades in the past is still disordered and at risk today, despite no objective evidence of such.

Another important change is in the text accompanying sexual sadism disorder, which now reads more like it was written for adversarial deployment. There are now two types of sadists -- "admitting individuals" and deniers. For deniers, the fact of having "inflicted pain or suffering on multiple victims on separate occasions" may be sufficient for a diagnosis. As a "general rule," the text instructs, recurrent can be interpreted to mean "three or more victims on separate occasions."

As discussed yesterday in Part I, the DSM-5 does not provide citations to empirical research to back up its recommendations. This is especially problematic in the case of sexual sadism, because even most chronic rapists are not necessarily aroused by a victim's suffering; rather, the victim's suffering fails to inhibit their arousal as it would for other men. The fact of inflicting pain or suffering also says nothing about what is going on in the mind of the inflicter, and three is just an arbitrary number pulled from a hat. These new guidelines will only complicate a problematic diagnosis with abysmally poor reliability and no predictive validity.

Antisocial personality disorder

Early buzz was that this pejorative label -- which can be applied to essentially any chronic offender -- would be revised to more closely align it with the even more pejorative and controversial construct of psychopathy. But the APA abandoned all proposed personality disorder changes (including a radical move to drop half of them altogether and to place the rest of them on a dimensional spectrum), so this diagnosis remains unchanged.

The real news here comes from the field trials. In regard to reliability, antisocial personality disorder came in at the bottom of the barrel, down there with the new mixed anxiety-depressive disorder with a kappa reliability rating of only 0.2. Historically, kappas below 0.4 have been considered poor. Although DSM-5 chief statistician Helena Kraemer is arguing that lower kappas should be deemed "acceptable," a 0.2 essentially means that even trained professionals cannot agree on whether a given individual has a disorder. This makes antisocial personality disorder far too unreliable for use in court.

Speaking of empirically dubious disorders, intermittent explosive disorder got a change worth noting. Whereas the aggressive outbursts at the core of this disorder used to require physical aggression, now "verbal aggression" suffices. If you've ever reviewed psychiatric hospital charts, you know that this is how hospital technicians chart episodes of disquiet among patients. For example, I recently saw a chart notation that "John Doe was verbally aggressive" stemming from an incident in which the involuntarily hospitalized Mr. Doe muttered profanities at hospital orderlies who had barged into his room while he was sleeping and confiscated the gauze pads he was using for an acute injury. In short, look for upticks of this disorder wherever the powerless are concentrated.

Posttraumatic stress disorder

Psychologist Richard Samuels checks his DSM
"bible" during testimony in Jodi Arias murder trial

PTSD got some significant tweaking in the DSM-5, mostly in directions that could increase its prevalence. The requirement of experiencing “fear, helplessness or horror” in reaction to the trauma was eliminated. There are now four "symptom clusters" rather than three. A new symptom of "reckless or self-destructive behavior" has been added, and the symptom of irritable behavior or angry outbursts has some added language, "typically expressed as verbal or physical aggression toward people or objects" and "with little or no provocation" (have fun explaining that one in court!).

In clinical practice, these changes won’t much matter. As Greenberg noted, "Mostly we’re content to find a label that matches people in some vague way and then get on with the business of helping them figure out what's going on in their lives that landed them in our offices." However, in court the devil is in the details. Difference between an "and" or an "or," or a three-month versus a six-month time specifier, can be critical. Unfortunately, there are no side-to-side charts with the changes from DSM-IV to DSM-5 highlighted or crossed out. The biggest benefactor of all this tweaking will be psychological test companies, whose psychometric tests for PTSD will have to be revamped. So get out your pocketbooks now.

Intellectual functioning and the death penalty

Last but not least, changes to the developmental disabilities section could make more criminals eligible for execution. Under the U.S. Supreme Court's Atkins standard, an IQ score of below 70 had been like a magic line in the sand, below which one becomes ineligible for capital punishment. However, the DSM-5's intellectual developmental disorder (renamed from mental retardation) drops IQ scores in favor of the more subjective construct of adaptive functioning, or the ability to live independently in the world.

"There are a lot of courts that are hostile to the basic legal doctrine the Atkins case established," death penalty lawyer David Dow told Reuters. "When you replace a test that is one part objective, one part subjective with a solely subjective test, it becomes easier for courts that are hostile to the constitutional principle of Atkins to evade that criterion."

"We believe that we are providing the courts with a more fine-grained means to consider adaptive functioning more comprehensively and more meaningfully," countered James Harris, of the DSM-5 work group.

Other specified or unspecified disorder

As I just mentioned, the devil is in the details. When a person does not meet minimum criteria for a diagnosis, clinicians can choose between the new categories of other specified disorder and unspecified disorder (the listed example being the unwieldy "other specified depressive disorder, depressive episode with insufficient symptoms"). These quick-and-dirty options are meant for use in the emergency department, where clinicians have little time and not much background information to go on. But the DSM-5 authors open the door for forensic misuse by stating their desire for "maximum flexibility for diagnosis." How's this for a loophole large enough to drive a Mack truck through:

"When the clinician is not able to further specify and describe the clinical presentation, the unspecified diagnosis can be given. This is left entirely up to clinical judgment."

Look to shady evaluators to misuse these "other" and "unspecified" labels to create nonexistent disorders for forensic use. That won't be anything new; it's essentially the same phenomenon we now see in sexually violent predator proceedings with the deployment of the DSM-IV-TR classifier "paraphilia not otherwise specified (NOS)," which these new categories replace. Such improper diagnosis may be legal, but that doesn't make it ethical.

Forensic caveat

One welcome change in the new manual is that the old cautionary statement about use of the DSM in forensic contexts gets more prominent play. Rather than being buried in the introduction, it's got its own little page in the DSM-5:

"... In most situations the clinical diagnosis of a DSM-5 mental disorder ... does not imply that an individual with such a condition meets legal criteria for the presence of a mental disorder or a specified legal standard...."

But when push comes to shove, judges and juries are going to do what they want to do, forensic cautions or no. As Texas lawyer Susan Orlansky -- whose client is slated for execution despite a lower-than-70 IQ -- told Reuters, "If the Texas court system is willing to ignore the DSM-IV, I don't know why they wouldn't be just as willing to ignore the DSM-5."

By all means take a moment to familiarize yourself with the changes in the new diagnostic manual that are relevant to your work. Just don't be conned into taking this whole diagnostic enterprise too seriously. After all, that's what the American Psychiatric Association is counting on to keep itself financially solvent.

I welcome comments, especially if you know of other changes of potential forensic relevance that are not listed here, or if you have a different take on the changes I highlighted.

And, if you are planning to attend the American Psychological Association convention in Honolulu, I invite you to my full-day CE training on psychiatric diagnosis in legal settings on July 31.

DSM-5: Much ado about nothing? (Part I of II)

Ambitious "paradigm shift" fizzles 

By now, you've seen the bad press about the American Psychiatric Association's new diagnostic codebook: Media pundits are labeling it "a manual run amok," so ambitious in scope that almost everyone qualifies for some mental illness or another.

But browsing through my crisp new copy, I find myself curiously dispassionate. Sure, it's even more bloated than the DSM-IV. But mainly, they just moved the chapters around and renamed a diagnosis here and there (dysthymia, for example, is now persistent depressive disorder). Even the typefaces will look familiar.

It's downright anticlimactic.

Remember when they first announced work on the new DSM? It was going to be a revolutionary "paradigm shift," aligning diagnoses with modern science. Disorders were going to be dimensional rather than categorical. All kinds of novel proposals were in play: Parental Alienation Syndrome. Paraphilic Coercive Disorder. Psychosis Risk Syndrome.

Then came the backlash. Prominent work group members walked out over the lack of science in the revision process. Petitions were launched. Special interest groups lobbied. ("Aspies," for example, were furious that psychiatry had bequeathed them an identity and were now taking it back.) The field trials fell apart. Even the National Institute of Mental Health announced it was breaking away from the DSM's diagnostic schema (although switching to its biology-worshipping Research Domain Criteria is like jumping from the frying pan to the fire).

Ultimately, the psychiatrists retreated. With both drug money and membership numbers down, the last thing the American Psychiatric Association needed was more negative flak. Especially when the DSM rakes in a steady profit, $5 to $6 million per year, giving them "fabulous riches" over time.

So, you'll find a few notable changes: There’s disruptive mood dysregulation disorder, a belated effort to undo the damage wrought by overdiagnosis of childhood bipolar disorder. Hoarding disorder and the Big-Pharma-inspired premenstrual dysphoric disorder made the cut. But overall, it's just business as usual.

In the short term, the new manual will give the APA's coffers a big boost. The book alone retails for $130 or more, and -- like a blockbuster Disney movie -- there will be ancillary products including cell phone apps, how-to guides, trainings, and such.

Eventually, however, the DSM will become increasingly irrelevant. It's already being superseded by the World Health Organization's International Classification of Diseases, which even on the APA's home turf of the United States is now required for insurance reimbursement. While some tout ICD codes as preferable, the only real advantage of the ICD is that it is freely available online.

By design, the DSM codes are almost precisely parallel to the ICD's. And the entire diagnostic enterprise, as psychotherapist Gary Greenberg explores in The Book of Woe, is an elaborate fiction -- a shell game perpetrated by psychiatrists on patients, insurance companies, and (most critically for our purposes here) the courts. Greenberg spent two years mucking about in the DSM-5 development trenches, where work group members frankly acknowledged that psychiatric diagnoses are just "fictive placeholders" or "useful constructs" rather than real conditions that carve nature at its joints.

Tomorrow, in Part II, I will highlight some specific changes (and non-changes) potentially relevant to forensic practice. 

If you are planning to attend the American Psychological Association convention in Honolulu, I also invite you to my full-day CE training on psychiatric diagnosis in legal settings on July 31.

Spring reading recommendations -- forensic and beyond

Marauding bands of juvenile killers. Gang rapist-kidnappers. Wife beaters.

We’re talking elephants, dolphins and parrots, respectively. That's my forensic psychology angle on Animal Wise, a fascinating new book by nature journalist Virginia Morell.

Not long ago, it was taboo in science circles to claim that animal have minds. But the burgeoning field of animal cognition, having broken out of the strait jacket imposed by 20th-century behaviorism, is now mounting a full-on challenge to the notion of an evolutionary hierarchy with humans at the top. Morell, a science writer for National Geographic and Science magazines, traveled around the world interviewing animal scientists and observing their research projects on everything from architecturally minded rock ants and sniper-like archerfish to brainy birds, laughing rats, grieving elephants, scheming dolphins, loyal dogs, and quick-witted chimpanzees.

She found cutting-edge scientists who not only regard animals as sentient beings, but even refer to their study subjects as trusted colleagues. Professor Tetsuro Matsuzawa in Kyoto, for example, has set up his lab so that when the chimpanzees "come to work" each morning, they enter on elevated catwalks and sit higher than the humans, which makes them feel more comfortable. He cannot understand why humans feel so threatened by his discovery that chimpanzees are capable of holding much more information in immediate memory than can we humans.

"I really do not understand this need for us always to be superior in all domains. Or to be so separate, so unique from ever other animal. We are not. We are not plants; we are members of the animal kingdom." 

 

 

YouTube video of Alex the parrot showing his cognitive skills

Animal researchers are realizing that not only do all animals have individual personalities, but some -such as chimpanzees and dolphins - even develop cultures. This engaging and thought-provoking book can be read on many levels. It is highly informative while also being quite entertaining. But on a deeper level, it probes the moral dimensions of science.

Morell’s 2008 National Geographic article in from which the book grew is HERE. Her Slate article, "What are animals thinking?" is HERE.  My Amazon review (if you are so inclined, click on "yes," this review was helpful) is HERE.


The Signal and the Noise

If you haven't yet read Nate Silver's important The Signal and the Noise, it’s past time to grab a copy. Silver’s analytic method is central to forensic psychology. Best known for his spot-on predictions of U.S. presidential races, Silver argues that accurate predictions are possible in some (limited) contexts -- but only when one learns how to recognize the small amount of signal in an overwhelming sea of noise. And also when one approaches the prediction using Bayes's Theorem. This is one of those engrossing books that really stays with you, and has very practical applications in forensic assessments. I find it especially useful in writing reports. Plus, it helps one understand current events involving prediction, like the story of six Italian scientists being sent to prison for failing to predict a deadly earthquake. (Earthquakes are inherently unpredictable, and Silver explains why.) 

* * * * *

Speaking of forensic report writing, if you want to tune up your own report writing skills, or you are teaching or supervising students, I highly recommend Michael Karson and Lavita Nadkami's book, Principles of Forensic Report Writing, due out at the end of this month. Karson and Nadkami take an innovative and thoughtful approach, helping us to think outside of the box about this essential aspect of our trade.


Other  recommendations

Beyond forensics, here a few other worthwhile books I've read recently:

If American history interests you, check out bestselling author Tony Horwitz's Midnight Rising, about John Brown's ill-fated raid on Harpers Ferry and its role in the abolitionist movement, or Tim Egan's The Big Burn, about the massive fire in the U.S. Northwest that helped change the political landscape and establish the national Forest Service. Both are engrossing and educational; I listened to the audio versions during lengthy road trips.

* * * * *

If you are into dystopic fiction, I recommend Hillary Jordan's When She Woke. In the not-distant future, the government has gone broke, and can no longer afford to maintain its massive prison system. So, instead of incarceration, law-breakers -- in a modern-day riff on The Scarlet Letter -- are dyed bright colors for the length of their sentences. In a globally warmed Texas ruled by Christian fundamentalists, Hannah Payne wakes up bright red, for the crime of aborting her baby. This edge-of-your-seat tale isn't too far-fetched, given current trends, as laws are being passed in Oklahoma and elsewhere to criminalize abortion, and as the public shaming of sex offenders (who in the novel are "melachromed" blue and killed on sight by vigilantes) becomes more and more entrenched.

* * * * *

Finally, I'm just launching into Gary Greenberg's hot-off-the-press book on the DSM, The Book of Woe: The DSM and the Unmaking of Psychiatry, and I can already tell it's going to be a doozy. More on that soon, time permitting....

Upcoming trainings: Assessment; personal injury; sexual violence; ethics in diagnosis

If you are planning to be in or around Florida, New Jersey, Hawaii or London over the next few months, here are some recommended forensic trainings on the horizon:

April 19 and onwards: Sexual violence workshops (London) 

Building on the success of the 2011 sexual violence workshops sponsored by the British Psychological Society (at which I spoke), Middlesex University is hosting another round of BPS-sponsored workshops on various aspects of sexual violence. Multiple-perpetrator rape is the topic of the first workshop, coming right up on April 19. (Also check out the new book, the first-ever text on this topic.) Next up are a June 27 workshop on "negotiating ethical sexual relationships," a Sept. 17 workshop on "intersectionality and sexual violence," and a fourth workshop on the investigation and prosecution of rape (date yet to be decided). All the workshops will be held at Middlesex University's Hendon Campus. More details are HERE.

April 20: Assessing Emotional Damages in Personal Injury and Employment Discrimination Cases (New Jersey)

William Foote, president of the American Psychology-Law Society (APA Division 41), will be presenting a five-stage model for assessing psychological damages in personal injury and workplace discrimination cases at the spring conference of the New Jersey Psychological Association. To find out more about this all-day training, click HERE.

May 3-5: New Directions in Forensic and Clinical Assessment (Florida)

Many big names in forensic psychology will descend upon Miami for this training sponsored by Division 42 (Psychologists in Independent Practice) of the American Psychological Association. The three-day conference will feature trainings on risk assessment, malingering, trial consultation, the DSM-5, intellectual disability, and much more. Information and registration can be found HERE. 


July 31: Controversial Psychiatric Diagnoses in Legal Settings (Hawaii) 

Yours truly is the trainer at this all-day continuing education workshop at the American Psychological Association's annual conference, along Honolulu's idyllic Waikiki Beach. I will focus on the scientific and practical limits of psychiatric diagnoses in forensic cases, and provide ethics guidance on how to present diagnostic testimony in court. Details are HERE; I'd love to see you there!

Fremantle to host Australian forensic conference

I hope all of you Aussies out there are aware of the exciting forensic psychology conference coming up in April. The theme is timely: "The Times are a Changin': Controversies, Competencies, and DSM-5." Robert Krueger, a personality researcher at the University of Minnesota and a member of the Personality Disorders Workgroup for the DSM-5, will give a keynote focusing on issues specific to using the DSM-5 personality disorders in court. The other keynote speaker is Jane Goodman-Delahunty of Charles Sturt University, a prominent psychologist and attorney who will speak about psychological injuries from workplace harassment. The setting, for those of you who might want to travel to Australia to attend, is the western city of Fremantle, which bills itself as the best preserved 19th Century seaport in the world. (The conference alternates between eastern and western Australia; when I gave a keynote there two years ago, it was held in the idyllic resort setting of Noosa, in southern Queensland.) The website for the April 18-20 event is HERE; the full program  can be downloaded HERE. Don't procrastinate too long, as early-bird registration ends March 18.

Panorama of the Swan River Settlement (Fremantle), 1831 (Source: Wikipedia Commons)

APA rejects "hebephilia," last standing of three novel sexual disorders

To hear government experts on the witness stand in civil detention trials in recent months, the novel diagnosis of "hebephilia" was a fait accompli, just awaiting its formal acceptance into the upcoming fifth edition of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM).

They were flat-out wrong.

In a stunning blow to psychology's burgeoning sex offender processing industry, the Board of Trustees of the American Psychiatric Association rejected the proposed diagnosis outright, not even relegating it to an appendix as meriting further study, its proponents' fall-back position.

The rejection follows the failure of two other sexual disorders proposed by the DSM-5's paraphilias subworkgroup. These were paraphilic coercive disorder (or a proclivity toward rape) and hypersexuality, an inherently hard-to-define construct that introduced the committee members' value judgments as to how much sex is within acceptable limits.

After abandoning those two disorders, the subworkgroup clung tenaciously to a whittled-down version of its proposed expansion of pedophilia to cover sexual attraction to early pubescent youngsters (generally in the age range of 11-14), ignoring widespread opposition from both within and outside of the APA.

The buzz is that senior psychiatrists in the APA were unhappy with the intransigence of psychologists in the subworkgroup who communicated the belief that if they just stuck to their guns, they could force the ill-considered proposal into the new manual, despite a lack of scientific support.

All three proposed sexual disorder expansions were widely critiqued by mental health professionals, especially those working in the forensic contexts in which they would be deployed. They led to a spate of critical peer-reviewed publications (including a historical overview of hebephilia by yours truly, published in Behavioral Sciences and the Law), and an open letter to APA leadership from more than 100 professionals, including prominent forensic psychologists and psychiatrists in the U.S. and internationally.

The unequivocal rejection sends a strong signal of the American Psychiatric Association's continuing reluctance to be drawn into the civil commitment quagmire, where pretextual diagnoses are being invoked as excuses to indefinitely confine sex offenders who have no genuine mental disorders. In marked contrast with the field of psychology, psychiatry leaders have expressed consistent concerns about the use of psychiatric labels to justify civil detention schemes.

Next time around, the APA might want to do a better job selecting committee members in the first place. The "paraphilias subworkgroup" was heavily biased in favor of hebephilia because of its domination by psychologists from the Canadian sex clinic that proposed the new disorder in the first place, and is the only entity doing research on it. But what a waste of time and energy to create a committee that comes up with wild and wacky proposals that are only going to end up getting shot down when the rubber meets the road.

Backpedaling on paradigm shift

As regular readers of this blog know, the DSM-5 developers' grand ambitions to bring forth a revolutionary "paradigm shift" produced alarm among mental health professionals and consumer advocacy groups both in the United States and internationally. The British Psychological Society, the UK's 50,000-member professional body, issued a strongly worded critique, and a coalition of psychological associations garnered more than 14,000 signatures on a petition opposing the wholesale lowering of diagnostic thresholds for disorder.

Yesterday's news release marked an about-face, with the APA now stressing that diagnostic changes in the DSM-5 were intended to be "very conservative."

"Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry," said David J. Kupfer, MD, chair of the DSM-5 Task Force.

Consistent with this, several of the proposed changes that generated the most widespread alarm were rejected. The Board of Trustees rejected the highly controversial "attenuated psychosis syndrome" that could have created an epidemic of false positives, stigmatizing eccentric young people and lowering the threshold for prescribing potentially harmful antipsychotic drugs. It also backed away from an equally controversial, and complex, revamping of the personality disorders. These conditions, as well as a contentious Internet gaming disorder, will all be placed in "section 3" of the new manual as conditions meriting further study.

Allen Frances, the DSM-IV Task Force chair and a high-profile critic of the DSM-5 project, called the spin that the DSM-5 will have minimal impact on psychiatric diagnosis and treatment "misleading":

"This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings…. Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM's teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and 'behavioral addictions' will soon be mislabeled as psychiatrically sick and given inappropriate treatment."

Among the controversial diagnostic changes that will go forward in the DSM-5, due to be published in mid-2013:

• Asperger’s syndrome is being eliminated as a separate disorder (it will be folded into an autism spectrum disorder)
• Depression is being expanded to include some grief reactions
• A brand-new "disruptive mood dysregulation disorder" has critics fearing psychiatric labeling of children who have temper tantrums

Two other sets of changes have particular relevance to forensic practitioners. Substance abuse disorders have been reframed as "behavioral addictions," which Frances warns could be a "slippery slope" leading to "careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets."

Posttraumatic stress disorder (PTSD) will be included in a new chapter on trauma and stress-related disorders, with four distinct diagnostic clusters instead of the current three, and "more attention to the behavioral symptoms that accompany PTSD." Some worry that the reconfigured PTSD may lend itself to misuse of the hot-button diagnosis in forensic cases.

Yesterday’s APA news release outlining the changes can be found HERE. My hebephilia resource page is HERE.

Forensic psychiatrists reject hebephilia - yet again!

Will American Psychiatric Association heed professional consensus?

Twenty years ago, Humbert Humbert went to prison for a series of sexual assaults on his 12-year-old stepdaughter, whom he famously nicknamed "Lolita." Now, as his lengthy prison term draws to a close, Wisconsin is petitioning to have the 60-year-old literature professor indefinitely detained as a Sexually Violent Predator.

The venue for last week's trial of Vladimir Nabokov's fictional protagonist was the annual convention of the American Association of Psychiatry and Law (AAPL) in Montreal. The central question, decided by audience vote, was whether the controversial diagnosis "hebephilia" qualified as a legitimate mental disorder justifying Mr. Humbert's indefinite civil detention.

The rousing theatrical performance featured an all-star cast of attorneys and psychologists, presided over by Toronto Judge Maureen D. Forestell. New Jersey Assistant Attorney General Mark Singer served as prosecutor. His expert witness was prominent psychiatrist Richard Krueger, a member of the paraphilias subworkgroup that has proposed adding "hebephilia" to the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A hebephilic qualifier would extend pedophilia to men with sexual preferences for children who have entered puberty, such as the fictional Lolita.

Defending Mr. Humbert was preeminent Wisconsin attorney Robert LeBell. His expert was Washington psychologist Richard Wollert, who has published peer-reviewed articles on SVP-related topics and testifies for the defense in civil commitment proceedings. Appearing as the court's expert was prominent Canadian psychiatrist John Bradford, an advisor on paraphilia (or sexual deviance) to the DSM-IV, past president of the AAPL and clinical director of the Sexual Behaviors Clinic in Ottawa.

After a spirited and sometimes heated trial, the 131-member audience was given electronic clickers and voted overwhelmingly -- 82 percent -- against including hebephilia as a diagnosis in the DSM-5, due out in mid-2013. A majority also voted against even including the controversial diagnosis in a DSM-5 appendix as a condition meriting further study.

Third time's the charm?

This marks at least the third time in two years that respected professional bodies have voted against the idea of hebephilia as a new mental disorder. At a 2010 vote in Oslo, Norway, members of the International Association for the Treatment of Sexual Offenders (IATSO) were near-unanimously opposed to the newly proposed sexual paraphilia. U.S. forensic psychiatrists followed suit a month later at the 2010 AAPL conference, overwhelmingly voting against hebephilia as well as two other proposed paraphilias, "paraphilic coercive disorder" (aka rape) and hypersexuality, both since scrapped.

Earlier this year, more than 100 professionals, including prominent forensic psychologists and psychiatrists in the U.S. and internationally, sent an open letter to the DSM-5 revisers, urging them to nix hebephilia. Since then, at least two peer-reviewed articles have been published deconstructing its legitimacy, one in the respected Journal of Nervous and Mental Diseases ("Hebephilia and the Construction of a Fictitious Diagnosis" by forensic psychologists Paul Good and the late Jules Burstein) and the other a broad review ("Hebephilia as mental disorder?") by scholars Bruce Rind and Richard Yuill in the Archives of Sexual Behavior.

Rind and Yuill said they undertook their extensive review of the historical and cross-cultural evidence after hebephilia proponent Raymond Blanchard (a member of the DSM-5 paraphilias subworkgroup) and his colleagues at Toronto's Centre for Addiction and Mental Health brushed aside numerous published criticisms of the proposed disorder (see Table 1). Building on their earlier research, Rind and Yuill argue that hebephilia -- generally defined as sexual attraction to young pubescents in the age range of 11 to 14 -- is a biologically normal trait found to varying degrees in both human males and our closest mammalian relatives, such as higher apes. They blast hebephilia as a bold example of naked moral values masquerading as science:

"Blanchard et al. … did not invoke comparative evidence…. They did not invoke any evidence…. They declared it a disorder by fiat, bypassing scientific analysis in favor of a pre-given conclusion supportable only because it is, for the current time and place, culturally resonant. Had their pronouncement been the opposite (i.e., hebephilia is functional), their article would never have been accepted in a peer-reviewed journal without massive evidential backing. Strongly resonant opinion can facilely pass through without the kind of scrutiny demanded of non-resonant views."

Why hebephilia still clings to life, despite so much opposition and so little scientific support, is beyond me. It's like an unwanted house guest who just refuses to take the hint and pack his suitcase.

The evidence at trial 

In attacking the government's diagnosis of his client, defense attorney LeBell focused on the dearth of empirical studies on the condition, other than by researchers at a single Toronto clinic, and the likelihood of "false positive" diagnoses in legal cases.

The wording of the proposed new diagnosis has been changed again and again over the past couple of years. In its current iteration, pedophiles are defined as those who have "an equal or greater sexual arousal from prepubescent or early pubescent children than from physically mature persons, as manifested by fantasies, urges, or behaviors." (The requirements that the fantasies or urges be "recurrent" or "intense" have been removed, broadening the potential pool of sufferers.) Hebephiles are now defined as those with sexual attractions to "pubescent children" in Stages 2 to 3 of Tanner's pubertal stages (e.g., early development of pubic hair and breasts).

Defense expert Wollert testified that the problem of "false positives" -- people incorrectly identified as having a condition -- was extraordinarily high even in the controlled setting of the research laboratory. This problem would be much more acute in the forensic trenches where the hebephilia diagnosis is being deployed, he testified.

One insurmountable problem would be reliably identifying a sexual abuse victim's Tanner stage of pubertal development. Complicating this issue, testified the court's expert, John Bradford, Tanner Stages are highly variable. Because they reflect hormonal developments rather than specific ages, one could not assume a specific Tanner stage based on the age of a victim. About two years ago, alarming research indicated that girls are entering puberty far earlier than in previous generations; this month, a large study by the American Academy of Pediatrics identified a similar trend in boys.

Wisconsin psychiatrist Lynn Maskel, who organized and moderated the mock trial, labeled hebephilia a "weed diagnosis in the botanical garden of DSM."

"The question is not if sex with pubescent year old girls illegal, or if it is immoral," she told the audience of forensic psychiatrists. "The question to the psychiatric field is: Is it a disorder? And if it is, does this translate, for the expert witness, into a requisite mental disorder found in the specific SVP statute?"

Meanwhile, back in the real courtroom trenches …

In my seminal review, published in 2010 in Behavioral Sciences and the Law, I traced hebephilia's sudden emergence and rapid spread in legal discourse to the advent of Sexually Violent Predator laws, which require that the individual being considered for civil detention have a mental disorder that makes him qualitatively different from the garden-variety offender.

Since that article's publication, the introduction of hebephilia in U.S. courts has continued unabated, despite the lack of an official imprimatur by the American Psychiatric Association. In a string of SVP cases brought under the Adam Walsh Act, federal judges in North Carolina have ruled that the faux diagnosis is not a legitimate basis for civil detention.

However, other courts have been less circumspect. For example, just yesterday, in a narrow, 4-3 opinion, New York's high court upheld the civil commitment of a repeat sex offender named "Shannon S." based on the purported conditions of "paraphilia NOS" and "hebephilia." Mr. S. had engaged in a series of forcible rapes of adolescent girls, ages 13 through 16.

As the dissenters conceded, Shannon S. was a "very bad actor" and "the community may well be safer if he is kept behind bars."

"But, they added, "to put him there on the fiction that he has some sort of mental condition other than a tendency to commit the crimes for which he was convicted (and has served his time) is and should be constitutionally unacceptable."

Judge Robert Smith, writing for the minority, labeled as "absurd" the premise that attraction to adolescent girls is abnormal, as the government's two experts testified: "What is abnormal about appellant, and others who commit statutory rape by having sex with girls below the age of consent, is not that they find the girls attractive, but that they are willing to exploit them for their sexual pleasure -- in other words, they commit statutory rape."

Smith labeled hebephilia and the similarly disputed diagnosis of "paraphilia not otherwise specified" (rape) as "junk science devised for the purpose of locking up dangerous criminals." While such a practice might seem appealing from a public safety viewpoint, it creates "dangers of abuse," he eloquently warned:

"Many sex offenders are, or could reasonably be found to be, dangerous, and in common parlance they all have mental abnormalities: Mentally normal people do not commit sex crimes. Thus, unless 'mental abnormality' is defined with scientific rigor, such statutes could become a license to lock up indefinitely, without invoking the cumbersome procedures of the criminal law, every sex offender a judge or jury thinks likely to offend again.

"Some will intuitively respond: Not a bad idea. But it is a very bad idea, because not even a concern for public safety should be allowed to trump certain fundamental rules. Among them are that criminals can be confined only for crimes they have committed, after their guilt is proved beyond a reasonable doubt in a procedure in which they receive the many protections that our Constitution gives to those accused of crime, and that even when convicted they can be incarcerated for no more than the term of the maximum sentence provided by law. If the present sentences for sex offenders are too short, the Legislature should make them longer, but it should not, and constitutionally cannot, simply substitute civil for criminal proceedings as a means of keeping dangerous criminals off the streets."

As Judge Smith seems to recognize, it's a slippery slope. Bogus psychiatric diagnoses for sex offenders now, political dissidents (or others) tomorrow. That's the way they rolled in the former Soviet Union, after all.

Pretextual court rulings aside, the paraphilias subworkgroup has had more than two years to produce evidence for the reliability and validity of hebephilia, and it has not done so.

It is clear to most observers that hebephilia is not accepted by the relevant professional community. What remains unclear is whether the Board of Trustees of the American Psychiatric Association will get the message in time to prevent yet another in a veritable maelstrom of public-relations disasters and historical mistakes.

* * * * *

Additional resources: My resource page on hebephilia is HERE.

Of related interest: DSM-5  field trials discredit the American Psychiatric Association, by Allen Frances, Huffington Post, 10/31/2012

Happy Halloween!

Mysterious mental illness epidemics hit sexual predators in Arizona, Illinois

European sex offenders largely spared pejorative conditions

First responders racing to scene of a pedophilia outbreak

A survey of Sexually Violent Predator cases in eight U.S. states has revealed striking disparities in psychiatric disorders.

Almost two-thirds of the worst-of-the-worst sex offenders in Arizona suffer from pedophilia, and more than half have bad cases of a strange-sounding new disease called "paraphilia not otherwise specified." That is almost double the rate of pedophilia cases in Minnesota (with 35 percent) and, similarly, much higher than the rate of paraphilia not otherwise specified in Wisconsin (37 percent).

Meanwhile, a whopping 94 percent of sex offenders in Illinois suffer from personality disorders, most commonly antisocial personality disorder and an oddball affliction called "personality disorder not otherwise specified." That’s more than double the rate of personality disorders in Wisconsin, where only 41 percent of sex offenders have any personality disorder, mostly antisocial personality disorder.

The cause of the strange outbreaks remains shrouded in mystery. Could the dry climate in the U.S. Southwest produce more pedophiles? Perhaps the Chicago winds lend themselves to an infiltration of antisocial characters? Or, there is always the possibility of circumscribed contagions within the containment facilities for sex offenders in these two geographically discreet states (as in Legionella pneumophila).

Quarantining suspected antisocial virus carriers returning from court

The researchers who discovered the pattern attribute some of the variation to sampling differences. The Florida and Texas samples may have lower rates of mental illness, they write, because those samples included men who were referred for civil commitment but found not to meet criteria. In contrast, the samples from the other states consisted of men who were either civilly committed or on their way to being committed, having lost probable cause hearings in court.

The researchers are Shan Jumper, clinical director of a detention facility in the personality disorder-ridden state of Illinois and a leader of a national consortium of SVP facility administrators, and colleagues Mark Babula of Ohio and Todd Casbon of Indiana.

The three surveyed the SVP population in Illinois and compared their results with previously collected data from Arizona, California, Florida, Minnesota, Texas, Washington and Wisconsin. The study appears in the current issue of the International Journal of Offender Therapy and Comparative Criminology.

On average, pedophilia was the most common diagnosis among SVPs, assigned in 49% of cases nationwide. This was followed by paraphilia not otherwise specified (47%), antisocial personality disorder (43%), and personality disorder not otherwise specified (36%). Other sexual paraphilias, or abnormal sexual predilections, such as voyeurism, exhibitionism and sexual sadism, were assigned far less frequently.

Illusory differences?

All kidding aside, I would be willing to bet that there’s not a whole lot of genuine difference among the detained sex offenders in one state as compared with another. If that is so, then the dramatically different rates of diagnosis among the eight states is further evidence that these diagnoses – invoked as a legal basis for involuntary detention – are being applied arbitrarily, even whimsically, and lack sufficient reliability or validity.

Further support for evaluator differences as accounting for the large discrepancies is the fact that rates of these mental disorders are far lower in European countries that do not require mental illness as a basis for preventive detention of dangerous sex offenders. In one German survey, for example, about one-third of men who were civilly detained had molested children yet only 7 percent were diagnosed with pedophilia, suggesting the diagnosis is reserved for those with a demonstrable sexual orientation toward children.

The intriguing question of why forensic evaluators in certain of the 20 U.S. states with Sexually Violent Predator statutes are more likely to assign a given diagnosis than are their counterparts in other states remains a mystery.

The irony of the "NOS" label

With the advent of SVP laws, "NOS" categories of paraphilia (sexual deviance) and personality disorder have steadily gained popularity among sex offender evaluators in the United States.

The irony of assigning the label of "not otherwise specified" as if it is a bona fide mental disorder meriting involuntary detention largely escapes notice. But what an evaluator is actually conceding in assigning that descriptor is that the individual does NOT meet the minimal criteria for any established mental disorder, as catalogued in the American Psychiatric Association’s diagnostic manual, the DSM-IV-TR.

If you flip through the personality disorders section of the DSM, you will notice all manner of symptoms. Stop any random stranger on the street, and he or she is likely to manifest at least a few. For example, consider these:

• Angry reactions to perceived attacks on character or reputation (paranoid personality)
• Use of physical appearance to draw attention to oneself (histrionic personality)
• Envy of others (narcissistic personality)
• Feelings of inadequacy (avoidant personality)
• Difficulty disagreeing with others for fear of losing their support (dependent personality)
• Reluctance to delegate unless others conform to one's standards (obsessive compulsive personality)

The label of "personality disorder not otherwise specified" is given to individuals who are thought to have some smattering of symptoms of one or more personality disorders, but do not meet the full criteria for any. Most often, this label carries the specifier, "antisocial traits." What this actually means is that the individual does not meet even the minimal criteria for a diagnosis shared by a large proportion -- anywhere from 40 to 60 percent -- of garden-variety criminals in prison. (Of course, to qualify for a personality disorder, the person must suffer distress or impairment in functioning as a result of his symptoms. But, in a tautology, evaluators often say that this condition is met by the mere fact of arrest and incarceration.)

Harkening back to the original justification for SVP laws, the US Supreme Court stressed, in the landmark cases of Hendricks (1996) and Crane (2002), that the goal of civil commitment was to isolate a handful of mentally disordered predators who were qualitatively different from the run-of-the-mill criminal. How a diagnosis that essentially admits that the individual does not even qualify for an established disorder can meet that threshold is beyond me.

Click HERE to request the article, “Diagnostic Profiles of Civilly Committed Sexual Offenders in Illinois and Other Reporting Jurisdictions: What We Know So Far,” from the first author.

Hebephilia update: DSM-5 workgroup stubbornly clinging to pet diagnosis

Salvador Dali*: The Average Bureaucrat

A few weeks ago, I reported on an open letter to the American Psychiatric Association, calling for it to reject three controversial expansions of sexual paraphilia diagnoses that are being promoted by government evaluators in civil commitment cases.

A lot has happened since then. The only one of the three controversial diagnoses still in the running for official status has been altered for the umpteenth time. An esteemed journal is issuing a scathing critique. And the open letter is generating buzz in the blogosphere.

The open letter has garnered more than 100 signatures, many from prominent forensic psychologists and psychiatrists in the U.S. and internationally. If you intend to sign on but haven’t yet, act now because I understand it will be submitted very soon. (Click HERE to review the text; click HERE to email your name and professional title to co-author Richard Wollert.)

Hebephilia gets yet another makeover 

This week, the Sexual Disorders Workgroup for the upcoming fifth edition of the APA's diagnostic manual toned down its proposal to turn sexual attraction to young teens into a mental disorder. As psychiatrist Allen Frances explains at his DSM5 in Distress blog, hebephilia is still there -- you just have to read the small print to see it:

Dali: Enchanted Beach with Three Fluid Graces

Confronted by universal opposition from the rest of the field, the DSM 5 group has been forced progressively to whittle down their pet, but they so far have refused to just drop it altogether. 'Hebephilia' first lost its free-standing independence and was cloaked as Pedohebephilia. When this didn't fly, the term was dropped altogether in the title but the concept was slipped into the definition of Pedophilia -- which was expanded out of recognition by having a victim age cut-off of 14 years. No one accepted this outlandish suggestion and now finally the work group comes back with ‘early pubescent children' and tries to keep 'hebephilia' as a term in the subtype. The instability of the criteria sets associated with this concept is additional evidence that the fervor for its adoption stems from emotional loyalty rather than reasoned review of its weak conceptual and research base. How can the group vouch for the reliability of the diagnosis when the concept and criteria are changing every month? This is no way to develop a diagnostic system.

The staunch insistence on this transparent attempt to turn statutory rape into a mental disorder owes in large part to the makeup of the sexual disorders workgroup. As Frances notes, "the most wayward of all the DSM 5 work groups" is "lopsidedly dominated" by psychologists from a sex clinic up in Toronto, whose ambition is "to find a place in DSM 5 for their pet diagnosis."
Although the group's other outlandish proposals, Paraphilic Coercive Disorder and Hypersexuality, have been shelved for the time being, Frances worries that putting them in the appendix "for further study" is still risky:

Recognizing that the jig is up on the grand design, members of the DSM 5 sexual disorders work group have been heard saying they may have to settle for an Appendix placement for their three hothouse creations. This would create forensic dangers. We have learned from the abuse of "Paraphilia Not Otherwise Specified" in Sexually Violent Predator cases that any (even remote) legitimization by DSM 5 is certain to be misconstrued and misused in the courtroom. 

Come on guys. This is absolutely absurd just on the face of it…. So back to the drawing board, DSM 5 sexual disorders work group. The grand dream is lost -- now at least make sure you don't mess up on the fine print.

On the professional listservs today, some conspiracy theorists were speculating that the new wording signifies a plot to enhance the standing of physiological testing in sex offender assessment. The latest proposed criteria for "pedophilia, hebephilic type" require "equal or greater sexual arousal from prepubescent or early pubescent children than from physically mature persons." How to determine that fuzzy standard? Enter the penile plethysmographer, a new niche career track, penis cuff at the ready to measure who is aroused by what.

"There is withering criticism already that the DSM is being expanded to sell more drugs," wrote one colleague. "Now it appears that psychiatry and psychology are conspiring to use the DSM to spur PPG tests -- tests which risk leaving patients with traumatic and indelible memory traces. Do most psychiatrists really want to open this door?!"

Orwellian thought police? 

The mere idea of allowing the American Psychiatric Association to dictate "normal" sexuality frightens English Professor Christopher Lane. Lane, whose book Shyness: How Normal Behavior Became a Sickness exposed the unscientific inner workings of the DSM-III committee, expressed shock over the first listed criterion for the shelved disorder of hypersexuality: "Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior." On his Side Effects blog, Lane mused:

Dali: Femme a Tete de Roses

"Excessive time"? What exactly does that mean, and according to whose standards? That's not a small or trivial matter to settle when the APA is talking in vague generalities about the nation’s libido -- how much sex it wants and how much sex the APA thinks it should think about wanting. The APA is talking about how much time Americans can devote to sexual fantasy before it suggests that we’re mentally ill if our preoccupations are stronger than those set by the relevant task force.

Does that initiative seem to overreach a bit, even to the point of sounding almost Orwellian? It does so to me. If we're to have criteria, are quotas next, including for fantasy? It’s as if the East Coast offices of the APA had morphed into those of the Thought Police in Orwell's 1984, warning citizens that they’d overstepped their "sexual thought quota" for the week and must be rationed -- or punished accordingly.

Lane analyzed hebephilia through his characteristic historical lens:

It's an archaism, a throwback literally to 19th-century psychiatry, but refers to practices that were as central to the Classical age -- and thus to Western democracy -- as were Socrates, Plato, and especially Plato’s Symposium, one of the foundational books in the West on eros and love.

The APA is already trying to determine how long normal grief should last before it’s thought pathological. Its brisk, jaw-dropping answer: two weeks. Do we really want the same organization dictating how often we can think about sex? These kinds of proposals can only end badly.

Leading journal tackles the controversy

The good news this week, which should have all of us jumping up and down with joy, is that the APA has caved in under massive public pressure and dropped its plan for a new psychosis risk disorder. This disorder would have put thousands if not millions of youngsters at risk of being dosed up with dangerous antipsychotic drugs based on a suspicion that they might go crazy in the future. Mixed Anxiety Depression has also bit the dust.

Dali: Daddy Longlegs of the Evening Hope

But, as featured in a special issue of the esteemed Journal of Nervous and Mental Diseases due out in June on the raging diagnostic controversies, there are still many battles ahead as the bloated DSM-5 enters the final stretch. The special issue will tackle diagnostic inflation, pharmacological conflicts of interest, controversies with the newly revamped personality disorders, and problems with diagnostic reliability in the recent field trials. Hebephilia, often neglected amidst controversies with wider impact such as psychosis risk syndrome and the pathologization of normal grief, merited an article in this special issue.

 In "Hebephilia and the Construction of a Fictitious Diagnosis," forensic psychologists Paul Good and the late Jules Burstein make a strong case for abandoning this faux disorder, which will only make the APA more of a laughingstock in the future.

Good and Burstein catalog an assortment of empirical problems. These range from the difficulty of reliably measuring "recurrent and intense" sexual arousal to problems determining the pubertal status of a young teenage victim. They also challenge the very idea that sexual attraction to pubescent minors is a mental illness, rather than merely illegal.

Although the Sexual Disorders Workgroup hides behind a fictive notion of a pure and ethereal "science," Good and Burstein clearly believe that hebephilia, if added to the DSM-5, will be mainly invoked in a partisan manner in forensic proceedings, in order to justify harsher punishment and involuntary civil detention. Because of its power to do harm, they say, its scientific grounding should be especially strong. If it does manage to worm its way into the DSM, they say, it should still be challenged in court:

We believe the admissibility of the proposed revision to DSM-5 that would include Hebephilia as a type of Pedophilia could be challenged in a court of law based on current legal standards. For example, since there is no professional consensus or general acceptance in the scientific community to support the notion of Hebephilia as a mental disorder, it would have difficulty passing the Frye test for admissibility. Similarly, without a widely established body of peer-reviewed, validation research and repeated studies showing inter-rater reliability in the laboratory and among clinicians in the field, Hebephilia would also have difficulty meeting the criteria specified in the Daubert standard.

Indeed, this is just what has been happening to hebephilia in federal court, where at least three civil detention petitions in a row have been thrown out due to the level of controversy in the field over this purported condition.

With all of this tumult, it seems that the DSM-5 excesses are producing a backlash against the American Psychiatric Association and, indeed, fueling disenchantment with the whole enterprise of psychiatric diagnosis.

As Frances writes, the turnaround on psychosis risk syndrome came about due to a combination of:

• extensive criticism from experts in the field
• public outrage
• uniformly negative press coverage
• abysmal results in DSM-5 field testing

For the first time in its history, DSM 5 has shown some flexibility and capacity to correct itself. Hopefully, this is just the beginning of what will turn out to be a number of other necessary DSM 5 retreats. Today's revisions should be just the first step in a systematic program of reform.… This is certainly no time for complacency. Much of the rest of DSM 5 is still a mess. The reliabilities achieved for many of the other disorders are apparently unbelievably low and the writing of the criteria sets is still unacceptably imprecise.

Who needs reliability? 

Frances calls for slowing down the process to allow for additional field testing and, more importantly, an independent scientific review of all the remaining controversial DSM-5 changes. But the DSM-5 folks are taking a different tack. Faced with field trial results showing very poor reliability -- not much better than chance -- for many of their proposed diagnoses, they want to change the definition of what counts as minimally adequate.

Dali: Autumn Cannibalism

It’s pretty ironic: The DSM-III went down in history for elevating the importance of reliability at the expense of validity. Remember, diagnostic reliability just means that similarly trained raters see a certain symptom presentation and call it by the same label. It says nothing about external validity, or whether the label is meaningful in explaining a real-world phenomenon. But reliability is basic. If a diagnostic label cannot be reliably applied, you can't even start talking about its validity. And now, the same psychiatric organization that reified the kappa reliability statistic as the be-all, end-all of science is trying to tell us that traditional kappa levels are unrealistically high for psychiatric research.

Historically, psychiatric reliability studies have adopted the Fleiss standard, in which kappas below 0.4 have been considered poor. In the January issue of the American Journal of Psychiatry, Helena Kraemer and colleagues complained that this standard is unrealistically high, and lobbied for kappas as low as 0.2 -- traditionally considered poor -- to be deemed "acceptable."

Former DSM-III guru Robert Spitzer and colleagues object to this proposal in a letter in the latest issue of the Journal. "Calling for psychiatry to accept kappa values that are characterized as unreliable in other fields of medicine is taking a step backward," they state. "One hopes that the DSM-5 reliability results are at least as good as the DSM-III results, if not better."

Alas, just wishing won't make it so. Despite its grandly stated ambitions, the DSM-5 will likely go down in history as a major gaffe by American psychiatry in its continuing struggle for world dominance.  

Remember to check out the open letter 

and send in your name, if you are in agreement with it.

Further reading:

• American Sex and American Psychiatry: The APA is trying to determine how much sex we can fantasize about by Chris Lane at Side Effects
• DSM 5 Rejects 'Hebephilia' Except for the Fine Print: Now the devil is in the details by Allen Frances at DSM5 in Distress
• Wonderful News: DSM 5 Finally Begins Its Belated and Necessary Retreat: Perhaps this will be the beginning of real reform by Allen Frances at DSM5 in Distress

*Salvador Dali: "One day it will have to be officially admitted that what we have christened reality is an even greater illusion than the world of dreams."