February 9, 2010
DSM-V: Get ready, get set . . . here it comes!
Simultaneously, controversies grow on multiple fronts. On the one hand, we've got psychiatrists arguing that it's time to wrest the discipline back from all of those pesky non-psychiatrist interlopers. Writing over at the Psychiatric Times, Steven Moffic says the DSM-V should include an express clause saying only psychiatrists are qualified to use the manual.
Don't hold your breath. As long as psychiatrists keep charging many times the fees of other mental health practitioners, I guarantee that economic forces will keep Dr. Moffic's wish from coming true. Talk about trying to close the barn door after the horses are long gone!
Meanwhile, on the other side of the fence, the Association for Women in Psychology is saying, "Who wants it?" The Association has launched a new web site devoted to concerns about bias in the DSM-V diagnostic system. The site features a veritable link fest of criticisms, with articles on specific areas of diagnostic bias that will inordinately affect women, including anorexia nervosa, borderline personality disorder, female sexual dysfunction, and gender identity disorder.
Of particular relevance to forensic practitioners is an article critiquing parental alienation syndrome, proposed for the DSM-V, as well as articles on racism and social class bias in the diagnostic system.
Check it all out, folks. And if you disagree with anything you see, be sure to speak up now, before it's too late. The new manual, originally slated for publication in 2012, has been pushed back to May 2013, which may seem far away. But you only have two short months -- until April 20, 2010 -- to view the draft and make comments; after that, the website "will be available for viewing only." So much pseudoscience, so little time.
It's easy to register and make your comments. Whether the psychiatric gurus will listen is another story. But if you don't try, you'll never know.
Related resources:
Peter Aldhous, the award-winning science reporter covering the DSM debacle for New Scientist magazine, will be following up on his widely disseminated article, Psychiatry's Civil War, with a critical report on the latest developments. He is the guest on Michael Krasny's Forum on KQED radio on Wednesday (February 10); you can download the audio of "Updating Psychiatry's Bible" HERE.
December 10, 2009
APA announces postponement of DSM-V
The final version of DSM-V is scheduled to be published in 2012, but given the level of controversy and the need to test whether psychiatrists can reliably use the proposed diagnoses, that date seems certain to slip.The full release from the American Psychiatric Association is HERE.
New Scientist expose of psychiatry’s "civil war"
On Saturday, the world's leading science and technology news weekly is publishing a scathing expose of the political and financial shenanigans underlying the DSM-V revision process. Accompanying the report in the New Scientist is an editorial calling for a halt to the print version of the American Psychiatric Association's money-making diagnostic bible:
The final wording of the new manual will have worldwide significance. DSM is considered the bible of psychiatry, and if the APA broadens the diagnostic criteria for conditions such as schizophrenia and depression, millions more people could be placed on powerful drugs, some of which have serious side effects. Similarly, newly defined mental illnesses that deem certain individuals a danger to society could be used to justify locking these people up for life."Psychiatry’s civil war" is the title of the hard-hitting expose by award-winning science writer Peter Aldhous, San Francisco bureau chief for New Scientist magazine.
Given such high stakes, we should all be worried by the controversy. Proponents of some of the changes are being accused of running ahead of the science, and there are warnings that the APA is risking "disastrous unintended consequences" if it goes ahead with plans to publish DSM-V, as the new manual will be known, in 2012.
As Aldhous reports, professional disputes over the form and content of the upcoming edition "are getting ugly." He notes that respected Duke University scholar Jane Costello has resigned from the work group on childhood and adolescence disorders, citing a lack of scientific rigor across the whole DSM revision. "I felt that there was not enough empirical work being achieved or planned," she says.
In a sidebar, Aldhous shines a spotlight on controversial proposals of pivotal importance to forensic psychology, including the pseudoscientific diagnosis of "hebephilia" that I have previously blogged about:
You may have never heard of "hebephilia", but this obscure diagnosis has huge significance in the courts. If it becomes accepted it could lead to hundreds of sex offenders who have served their jail time being locked up indefinitely - on grounds that some say are spurious.In a call to put the brakes on this speeding train, the New Scientist's accompanying editorial points out that this would hurt the coffers of the American Psychiatric Association, which has earned more than $40 million since 2000 from DSM sales. But, the editorial concludes, "it's hard to see who else stands to gain from the current exercise -- and if the critics' dire predictions come to pass, patients will be the biggest losers."
The proposed diagnosis has been condemned by critics as dangerously blurring the boundary between paedophilia and normal male attraction to teenage girls -- which isn't necessarily acted upon. Karen Franklin, a forensic psychologist in El Cerrito, California, argues that the diagnosis makes a disease out of preferences that have been shaped through human evolution. "People didn't used to live so long and mating started earlier," she says.
The work group is also considering whether some men are specifically turned on by rape -- a proposed condition termed paraphilic coercive disorder. Again, the evidence is based largely on measurements of penile blood flow in response to sexual images and stories, and the validity of the condition is hotly contested.
The rows over hebephilia and paraphilic coercive disorder aren't academic, because 20 US states have passed laws that allow sex offenders who have served their sentences to be detained indefinitely in a secure hospital if they are deemed "sexual predators." This can only be done if the offenders have a psychiatric disorder that increases their risk of reoffending -- which few do, according to DSM-IV.
Franklin says that if hebephilia and paraphilic coercive disorder make it into DSM-V, they will be seized upon to consign men to a lifetime of incarceration.
November 23, 2009
Asperger's ruling: Judge should have allowed experts
The 9th U.S. Circuit Court of Appeals overturned seven counts of arson against a California physicist who with his buddies had vandalized and torched more than 130 vehicles back in 2003.
William "Billy" Cottrell is described in news accounts as a talented young physicist who was diagnosed with Asperger's, a high-functioning form of autism, during his 2004 trial for arson and conspiracy.
In its ruling, the appellate court let stand a conviction for conspiracy. But the court held that aiding and abetting of arson requires a specific intent in that Cottrell must have knowingly participated in the crimes and tried through his actions to make them succeed. Thus, it was reversible error not to allow expert evidence of a mental condition that might have impacted the defendant's subjective judgments.
The defense had proposed a theory in which Asperger's prevented Cottrell from understanding what his friends were up to until it was too late; once he figured it out, he supposedly tried to stop them.
Local mental health professionals quoted in the Pasadena Star-News differed as to whether an Asperger's defense might have succeeded in mitigating Cottrell's culpability.
On the one hand, psychologist Bruce Hirsch said Asperger's could have reduced Cottrell's ability to understand the situation, as people with the condition often cannot tell when they are being lied to.
"What you're really talking about is a social naivete and, yes, people with Asperger's can be very socially naive," Hirsch is quoted as saying. "They are so bound to the truth that the concept of lying doesn't even exist in their mind. Somehow the social reasoning of people with Asperger's is very concrete, very black and white, and they don't get that people tell lies."
On the other hand, marriage and family therapist Amy Keller said the defense theory of Asperger's does not take into account the rigid morality of most Asperger's patients.
"I find that, after working with a lot of Asperger's patients, that they are so stubborn," Keller told the newspaper. "They're not that easily influenced. If anything, they're very clear about right and wrong."
Either way, the appellate reversal will not have a practical import on Cottrell. Prosecutors decided not to retry him, because it would not have impacted his 100-month federal prison term.
Cottrell will soon be taking the bus back to the Arizona federal prison where he teaches physics and cosmology classes to fellow prisoners.
Hat tip: Ken Pope
- Asperger’s: Here today, gone tomorrow: Would erasure from DSM impact forensic use? (Nov. 3, 2009 blog post)
- The short life of a diagnosis (Nov. 9, 2009 New York Times op-ed by Simon Baron-Cohen)
- Forensic aspects of Asperger's Syndrome, Barry-Walsh, J.B., & Mullen, P.E., Journal of Forensic Psychiatry, 2004, Volume 15, pages 96-107.
November 9, 2009
Paraphilic coercive disorder: Contagious virus?
Of the 198 students at St Paul's College at the University of Sydney, a large proportion were apparently infected with a highly contagious form of the virus. If Paraphilic Coercive Disorder makes it into the next Diagnostic and Statistical Manual of Mental Disorders, St. Paul's will be Ground Zero for the epidemic.
According to an article in today's Sydney Morning Herald, men at the elite, all-male college proudly set up a pro-rape Facebook group called "Define Statutory" that promoted sexual aggression against women. But the elite students did not stop with words. They fostered an alcohol-fueled climate in which rapes were common, most sexual assaults went unreported, and women students felt so unsafe that they quit school, the story reports.
Reporter Ruth Pollard documented a series of rapes and sexual assaults, including one incident in which about 30 drunk, naked men broke into a college and surrounded a young woman, touching and taunting her.
The good news is that, if it's a contagious illness, there could be an immunization like the one for the H1N1 virus. So, while the DSM developers are frenetically creating new diagnoses, let's not forget to work on finding some cures, too.
The Sydney Morning Herald article is HERE.
November 6, 2009
Scientist razes proposed "Paraphilic Coercive Disorder"
Government evaluators in Sexually Violent Predator cases must be thrilled with the possibilities being generated by the prolific paraphilias subworkgroup of the DSM-V Sexual Disorders Workgroup. If these proposed diagnoses make it into the psychiatric bible, the task of establishing that sex offenders have bona fide mental disorders meriting hospitalization will suddenly get a whole lot easier.
But this will only happen if good science is not allowed to interfere with pragmatism and pretextuality. After all, the empirical support for some of these pseudoscientific categories is weak at best.
Now issuing a strong call of alarm is perhaps the premiere scientific researcher into the etiology of rape, Raymond Knight, the Mortimer Gryzmish Professor of Human Relations at Brandeis University.
In a forthcoming article in the Archives of Sexual Behavior, the respected scholar cautions against adoption of Coercive Paraphilic Disorder, which he says is not supported by empirical data and has a vast potential for misuse by the civil commitment industry.
Currently, the propensity to rape is not considered a mental illness. Proponents of adding a rapist diagnosis to the Diagnostic and Statistical Manual of Mental Disorders (DSM) claim it was only excluded the last time around due to pesky feminists' objections that it would excuse rapists from criminal consequences. However, that turns out to be something of a myth. The main reason it was excluded, says psychologist and lawyer Thomas Zander, who conducted primary research into the history, was because it was not scientifically supportable. And, according to Knight's article, it is even less supportable now than it was back then.
The fact that rape propensity is not a bona fide mental illness has proved a hurdle for the civil commitment industry. To be hospitalized on the basis of possible future dangerousness, sex offenders must be found to suffer from a mental disorder that reduces their volitional control. To get around this legal barrier against unconstitutional preventive detention, government evaluators have taken to assigning a de facto label of "Paraphilia Not Otherwise Specified - Nonconsent."
As Knight points out, if Coercive Paraphilic Disorder is introduced into the DSM-V, it will provide tacit support for the legitimacy of the bogus "NOS" diagnosis. This, he says, would be a travesty:
"The inclusion of PCD [Paraphilic Coercive Disorder] would inappropriately legitimize this 'disorder' and grant it the imprimatur of the DSM, which is almost universally cited by expert witnesses in civil commitment proceedings…. The diagnosis has little empirical support, and it would be a travesty to grant it a status that would perpetuate its misuse."In his article, Knight discusses the evidence from a long line of research that suggests there is not a separate category of men with a propensity to rape. Rather than being a distinct "taxon," rape propensity exists along a continuum.
He also challenges the contention of a Canadian research group that rapists are sexually aroused by the coercive aspects of sexual assault. A more likely scientific explanation for why some men rape is that the coercive elements of the situation fail to inhibit their sexual arousal, he writes.
This dimensional model coincides with a large body of sociological and anthropological research, which suggests that men in certain environments -- most notably wars -- are much more likely to commit rape. Indeed, research has found that even on the same college campus, some fraternity environments promote a "rape culture" among men, whereas others do not. (I discuss this environmental aspect of rape in an article I wrote a few years back on the theatrical elements of group rape.)
Knight's scientifically grounded critique is a refreshing change from the pseudoscientific tenor of many of the DSM diagnostic proposals. More scientific rebuttals to some of the shaky studies in the sex offender field are currently in press, and I will try to stay attuned and alert you readers as soon as they become publicly available.
Further resources:
Knight, Raymond. (2009). Is a diagnostic category for Paraphilic Coercive Disorder defensible? Archives of Sexual Behavior. This article is online, but requires a subscription. The abstract is visible HERE, along with the email address of the author (from whom copies may be requested).
Zander, T. K. (2008). Commentary: Inventing Diagnosis for Civil Commitment of Rapists. Journal of the American Academy of Psychiatry & the Law , 36, 459-469.
Zander, T.K. (2005). Civil Commitment Without Psychosis: The Law’s Reliance on the Weakest Links in Psychodiagnosis. Journal of Sexual Offender Civil Commitment: Science and the Law, 1, pp.17-82.
Franklin, Karen. (2004). Enacting Masculinity: Antigay Violence and Group Rape as Participatory Theater. Sexuality Research and Social Policy, 1 (2), pp. 25–40.
November 3, 2009
Asperger’s: Here today, gone tomorrow?
It was just a few years ago that Asperger's Disorder exploded into the public consciousness. But just as suddenly, if the DSM-V authors have their way, it may disappear, absorbed back into the spectrum of autism disorders from whence it came.
An intriguing story in today's New York Times describes the controversy that is heating up as the DSM-V work groups prepare to issue their final diagnostic proposals in January.
As Times reporter Claudia Wallis notes, Asperger's is "one of the most intriguing labels" in the diagnostic book:
"Children with Asperger's syndrome, a mild form of autism, are socially awkward and often physically clumsy, but many are verbal prodigies, speaking in complex sentences at early ages, reading newspapers fluently by age 5 or 6 and acquiring expertise in some preferred topic -- stegosaurs, clipper ships, Interstate highways -- that will astonish adults and bore their playmates to tears."The sudden rise of this "once obscure diagnosis," diagnosed four times more often in boys than girls, accounts for much of the apparent rise in autism, which now has a prevalence rate of about 1 percent among U.S. children.
Although self-described "Aspies" and their families distinguish Asperger's from the more stigmatized label of autism, experts quoted by the Times say the distinctions are confusing and not scientifically based.
Asperger's in the forensic context
At the same time that it faces formal extinction, Asperger's is seeing ever-escalating use in the criminal courts, in cases ranging from violent crime to computer hacking and child pornography possession.
Typically, the diagnosis is proposed by defense attorneys seeking to mitigate the mental state required for a crime. A hallmark of the disorder is severe problems understanding social rules and nuances, and therefore navigating social situations. Sometimes, the profound deficit in social reasoning explains crimes that otherwise are simply bizarre, and lacking in rational motivation. Consider this scenario, adopted from a case I worked on:
You’re on an excursion with a recreational group, walking through a downtown area. The group encounters a red light. Seeing no traffic, everyone jaywalks. All except the young man with Asperger’s, whose can’t break a rule. No one notices as he gets left behind. When he finally finds the group again, he is furious, and punches the group leader in the face.In this case, the defendant had a particularly severe and clearcut case that had been diagnosed and treated at a specialty clinic from the time he was a toddler. Thus, it could not be argued that the diagnosis was being manufactured with a pretextual goal in the legal context.
In other cases, especially when an alternate and rational motivation is at least equally plausible, the defense has met with less success. For example, as I blogged about last year, it was unsuccessfully advanced in the case of Hans Reiser, the oddball computer programmer who killed his wife and buried her body in the hills of Oakland, California.
In an article on "the geek defense" in Slate magazine, science writer Erica Westly gives other examples of Asperger's recent deployment in court, some successful and some not.
- Astonishingly, a jury in Galveston, Texas acquitted billionaire real estate heir Robert Durst in the murder and dismemberment of his neighbor under the theory that Asperger's made him incapable of premeditating the crime.
- Lisa Brown of the United Kingdom was not so lucky. The 22-year-old woman was sentenced to life in prison in the murder of her mother after a judge ruled that her lack of empathy did not mitigate the gravity of the crime.
The compulsive behaviors and zealous collecting of many individuals with Asperger's is being invoked to explain certain types of criminal conduct, such as computer misconduct or child pornography collecting.
The Slate article features the high-profile case of Gary McKinnon, the British computer geek who hacked into U.S. military and NASA computers looking for proof that the U.S. government had covered up evidence of UFO landings. He claims Asperger's made him compulsively driven to search for evidence of alien spacecraft.
This type of defense is ready-made for compulsive collecting of child pornography images. In an Iowa case this year, a judge reduced a pornography possession sentence after concluding that Asperger's "might very well explain the number of images" the man had acquired. Similarly, across the Atlantic a 21-year-old student in the United Kingdom was sentenced to just four months in jail for possession of 922 pornographic images of children. Other courts have been less sympathetic to this version of a diminished capacity defense.
Anecdotally, I have heard of Asperger's arguments backfiring. Introduced as mitigation in cases of violent and/or sexual offending, Asperger's may become aggravating by increasing jurors' fear of a defendant because he is perceived as strange and therefore more unpredictable.
At risk in prison
In a final forensic angle, the extreme social awkwardness of Asperger's sufferers puts them at risk in prison, where social interactions are highly scripted and regulated. In one case I was involved in, a prisoner incurred new criminal charges stemming from a bizarre fight triggered by his misperception of social cues.
Indeed, computer hacker McKinnon is raising this issue in an attempt to avoid extradition to the United States. Given his condition, incarceration in a U.S. prison would amount to torture, he contends. As evidence, he cites a 2007 study by psychiatrist David Allen finding that imprisonment is extremely stressful and confusing for men with Asperger's, who find it hard to successfully interact with guards and other prisoners and thus spend much of their time hiding out in fear.
No one knows whether or how exclusion from the upcoming DSM-V, due to be published in 2012, might affect deployment of the diagnosis in court. After all, even if it is not a separate diagnosis, Asperger's will still presumably exist as a condition on the autism spectrum. And, as regular readers of this blog know, plenty of less valid diagnoses are invoked in court despite their absence from the DSM.
Although I understand the logic of the DSM-V work group, I cannot help but wonder -- given the massive influence of the pharmaceutical industry in shaping and perpetuating psychiatric diagnoses -- whether they would be proposing Asperger's for elimination if a money-making drug was available to treat it.
Somehow, I think not.
Further resource:
Barry-Walsh, J.B., & Mullen, P.E. (2004). Forensic aspects of Asperger's Syndrome. Journal of Forensic Psychiatry and Psychology, 15, 96-107.
October 11, 2009
Sex offender news roundup
After all, even those of you who work with sex offenders probably want a diversion sometimes. When you initially trained for your profession, I'll bet you weren't thinking, "This will be so fantastic! I'll get to spend lots of quality time with sex offenders, absorbing all of the intimate details of their warped atrocities against women and children!"
No? I didn't think so.
But, sigh, that's the reality these days. Rare monsters in the United States and elsewhere -- such as John Couey in New Jersey and Earl Shriner in Washington State -- drive social policy. Aggrieved family members fire up a local community, politicians jump on an easy bandwagon, and -- voila -- the rest is history. As New York Times reporter Michael Cieply perceptively noted, in reference to the Roman Polanski case, the landscape has changed dramatically in the last three decades:
Manners, mores and law enforcement have become far less forgiving of sex crimes involving minors in the 31 years since Mr. Polanski ... fled rather than face what was to have been a 48-day sentence after he pleaded guilty to unlawful sex with a minor. But if he is extradited from Switzerland, Mr. Polanski could face a more severe punishment than he did in the 1970s, as a vigorous victims' rights movement, a family-values revival and revelations of child abuse by clergy members have all helped change the moral and legal framework regarding sex with the young.Of course, we must guard against myopia. It is not just in the sex offender arena that we see zero tolerance policies gone wild. Look what is happening in the schools, for example. A 3rd-grade girl got expelled for a year because her grandmother sent a birthday cake to school for her. The problem wasn't the birthday cake, but the knife dear grandma sent to cut it with.
Anyway, on to this quick (I hope) roundup of sex offender-related developments.
Child victim decries conditions for sex offenders
Consequences of extreme social policies are so at odds with the original intents that even many who lobbied for the laws are having second thoughts. The Palm Beach (Florida) Post ran a remarkable story about a child sexual abuse victim whose victimization led to a legislative crusade against sex offenders. Lauren Book, whose child abuse saga began at age 11 at the hands of a caregiver, runs a nonprofit agency aimed at educating the public about child sexual abuse. Now, she is campaigning against the unintended consequences of the very residency restrictions that she helped inspire. Touring the sex offender encampment under the Julia Tuttle freeway in Florida, which I have previously blogged about, she said she has come to realize "that forcing predators to live in inhumane conditions will not protect children; in fact, she fears it may do the opposite":
"You can't really understand what it's like unless you go there. You can't capture it in words or pictures. Being there, hearing it, seeing it, smelling it - it's all part of understanding the situation…. It's a terrible situation under there, it is awful. I don't think them living under a bridge or absconding keeps children safe. I don't want them so desperate that they go out and find a child.''The perils of a naked pumpkin
Elsewhere, legislators and judges are taking small steps to limit the consequences to youth of overinclusive sex offender registration requirements.
I mean, how would you feel if your kid was branded for life as a registered sex offender just because he had participated in Boulder, Colorado's popular "Naked Pumpkin Run" or "World Naked Bike Ride"?
To circumvent this scenario, Boulder is drafting a public nudity ordinance that would exclude arrests for nudity-related pranks from the registration laws. Commenting over at Grits for Breakfast, Scott Henson hopes this signals a growing public awareness that sex offender registries are too broad. "But a better fix would be for the legislature to remove indecent exposure and other petty crimes from the registry list. IMO we don't need more laws on this issue so much as better ones."
And in Michigan, a judge just ruled that putting a juvenile on the state's sex offender registry would constitute cruel and unusual punishment, prohibited by the U.S. Constitution.
The case involved "T.D.," a 15-year-old boy who touched the breast of a 15-year-old classmate in school. His name would have appeared on the registry for 25 years, until he was 43 years old. That would be unfair, ruled Judge Darlene A. O'Brien, because T.D.'s offense was "more akin to a juvenile prank than predatory, perverted, criminally deviant sexual conduct likely to be repeated." In her well-reasoned ruling, she too addresses the unintended consequences of the laws:
Requiring this rehabilitated juvenile offender to register for a total of 25 years upon reaching adulthood is likely to become a self-fulfilling prophesy -- if TD cannot get through school or get jobs because of community notification and public shunning, he is likely to become marginalized and, in fact, more likely to commit crimes as a result.
Prosecutors are appealing the decision, so an appellate court will get a chance to clarify whether juveniles must submit to public registration even when their offenses are mild and they present little risk of recidivism.
Challenges mounting on religious frontIn at least the second pending case, a convicted sex offender in North Carolina is challenging a law that restricts his ability to attend church services. Police arrested James Nichols after he attended a Sunday service at a church that offers day care. As reported in the New York Times, "many of the three dozen states that establish zones where sex offenders cannot live or visit do not provide exemptions for churches." A similar lawsuit is pending in federal court in Georgia. Also in the South, in the city of Louisville, Kentucky, a Pentecostal church has snubbed its nose at the punitive climate against sex offenders by unapologetically ordaining a convicted sex offender as a pastor.
Voice stress analysis upheld
At the same time that these types of fissures are developing in the larger systems, other agencies are imposing additional restrictions on sex offenders. For example, a federal judge has ruled that sex offenders can be required to submit to computerized voice stress analysis as part of their post-release supervision, just as many are already required to undergo testing with polygraphs and penile plethysmography under the "containment approach" to recidivism.
The federal judge in the Northern District of New York ruled that debates about the scientific reliability of the technique do not "bear much on the therapeutic value of the tool" as a lie-detection incentive.
The attorney for Ethan Gjurovich, who was convicted of child pornography charges, said this is the first case he knows of in which a federal court has endorsed voice stress analysis requirement on a parolee. He likened it to the psychological pressure of a "lie-detecting dog" -- "If you don't tell the truth, he's going to bite you."
Paraphilic coercive disorder proposal critiqued
On a parting note, I encourage you to check out an interesting critique of the Paraphilic Coercive Disorder diagnosis being proposed for the DSM-V, over at the Asexual Explorations blog. The blog -- as its title implies -- is devoted to the emerging issue of asexuality. But its author was so astounded upon learning about some of the wacky diagnoses being proposed for the upcoming Diagnostic and Statistical Manual of Mental Disorders that felt compelled to detour from his main topic.
BEWARE THE HALLOWEEN BOGEYMAN.
July 31, 2009
Lane on "diagnostic madness of DSM-V"
To linger anxiously, even bitterly, over job loss is all too human. To sigh with despair over precipitous declines in one's retirement account is also perfectly understandable. But if the APA includes post-traumatic embitterment disorder in the next edition of its diagnostic bible, it will be because a small group of mental-health professionals believes the public shouldn't dwell on such matters for too long.That's a snippet from Christopher Lane's latest essay on the upcoming DSM-V, in Slate magazine. Lane is an English professor and author of Shyness: How Normal Behavior Became a Sickness, a wonderful expose of how the DSM-III came to be.
That's a sobering thought -- enough, perhaps, to make you doubt the wisdom of those updating the new manual. The association has no clear definition of the cutoff between normal and pathological responses to life's letdowns. To those of us following the debates as closely as the association will allow, it's apparent that the DSM revisions have become a train wreck. The problem is, everyone involved has signed a contract promising not to share publicly what's going on.
Related article: Wrangling over psychiatry's bible, Los Angeles Times
June 30, 2009
DSM-V: Urgent warning and call to action
Allen Frances' strongly worded appeal in the Psychiatric Times predicts the DSM-V -- scheduled for publication in May 2012 - will usher in a flood of new mental disorders that will medicalize normality, producing "a bonanza for the pharmaceutical industry but at a huge cost to the new false-positive patients caught in the excessively wide DSM-V net."
"In my experience, experts on any given diagnosis always worry a great deal about missed cases but rarely consider the risks of creating a large pool of false positives—especially in primary care settings. The experts' motives are pure, but their awareness of risks is often naive. Psychiatry should not be in the business of inadvertently manufacturing mental disorders."Frances makes special note of the potential for "unpredictable and consequential" unintended consequences in forensic settings:
"Years after the DSM-IV was completed, we learned about the enormous unintended impact of a seemingly slight wording change we made only for technical reasons in the section on paraphilias. A misreading of our intentions in making the change had led to great confusion -- with forensic evaluators using the diagnosis of paraphilia not otherwise specified to justify the sometimes inappropriate lifetime psychiatric commitment of rapists who had no real mental disorder."This prediction is prophetic in light of current lobbying efforts by the paraphilias subworkgroup to create a new "pedohebephilic disorder" category that could vastly expand sex offender diagnosis, proving a bonanza for the sexual offender civil commitment industry.
Frances is highly critical of the "inexplicable secrecy and the lack of openness to outside influence and criticism" surrounding the DSM-V revision process.
"Restricting the free flow of ideas creates enormous blind spots that greatly increase the risk of damaging unintended consequences…. The advisory group is far too small and select to reduce, rather than encourage, heated debate. In producing a new edition of the DSM, your harshest critics eventually turn out to be your best friends because they are most likely to help you avoid pitfalls."He is urging the American Psychiatric Association to create an external committee to review what is going on with the DSM and make recommendations to avoid serious negative consequences in the future.
Frances' important article, A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences, is available HERE.
An accompanying Q&A, DSM-V Badly Off Track, is HERE.
Some of my related blog posts are HERE.
June 22, 2009
Despondex: Is psych mania overreaching?
First, click the image above to watch this ad for Despondex, the first-ever prescription depressant. It brilliantly captures how the pharmaceutical industry pathologizes human conditions, mints formal diagnoses to label them, and markets lucrative medications to treat them.
Take bipolar disorder in children.
It has gone from a rare condition to a common diagnosis. In an 8-year period (1994-2002), the number of children diagnosed as bipolar increased by 4,000 percent. Yes, that's right. Four thousand percent. As with the ADHD craze a few years ago, with the diagnostic labeling has come medications for about two-thirds of the newly bipolar. Medications that cause severe long-term health consequences, such as obesity and diabetes.
Now, show me a child who doesn't have radical mood swings. As Christopher Lane describes in Shyness: How Normal Behavior Became a Sickness, the steps to creating a disorder are straightforward:
- Conduct a study.
- Discover a previously overlooked problem.
- Label it.
- Create a formal diagnosis.
- Promote a treatment.
- Marginalize the critics.
Indeed, we are witnessing this manufacturing process in the current effort to create a bizarre new diagnosis of "pedohebephilia" for the DSM-V, as I have blogged about more than once.
But has the psychiatric-pharmaceutical juggernaut gone too far? I am probably being overly optimistic, but I find this past week's developments mildly encouraging.
First came the research study published in the June 17 issue of the Journal of the American Medical Association, announcing flaws in the much-touted 'Depression Risk Gene' study upon which so much of our popular culture's notion of mental illness rests.
That followed exposes, such as one in the Miami Herald, of pharmaceutical drugmakers' use of ghostwriters to produce ''a huge body of medical literature that society can't trust.''
Just today came two more entries in the series of critical articles about psychiatric diagnosis and the pharmaceutical industry, in newspapers on separate continents -- the London Times and the San Francisco Chronicle.
The Chronicle's lead story focused on the diagnosis of bipolar disorder among children. The London Times article promotes a new book by the brilliant Richard Bentall (whose 1994 book, Madness Explained, deservedly won the British Psychological Book Of The Year award).
Doctoring the Mind: Is Our Current Treatment of Mental Illness Really Any Good? pulls no punches: It "paints a stark picture of a mental health system riddled with corruption and incompetence, in which shrinks live it up on pharmaceutical company cash while patients are disrespected, dehumanised and drugged to the eyeballs."
Bentall isn't some foaming-at-the-mouth anti-psychiatry extremist. He offers rational argument and scientific evidence to back up his claims about the ineffectiveness of modern psychiatric "treatment" and the weaknesses in its underlying biomedical model.
Bentall is not optimistic about change, though, because psychiatry and drug companies "have a vested interest in keeping things are they are."
I am afraid he may be right. Even in the midst of critiques pointing out the long-term harm, more people than ever are popping pills and allowing their children to pop them too. The latest rage, bipolar disorder, has so inundated popular and youth culture that it's even become an aggressive verb on the playground, as in:
"You don't watch out, man, I'm gonna go bipolar on you!"
If we don't watch out, that will be the newest mental defense to violent crime.
June 5, 2009
Hebephilia struck by third blow
It may be too soon to call it the death knell, but this week's ruling by a federal judge in Massachusetts certainly dealt a reeling blow to the highly contested pseudo-diagnosis of hebephilia and its ever-more-marginalized adherents.
In the third of three back-to-back decisions in federal court, U.S. District Judge Joseph Tauro said hebephilia just doesn't pass muster as a basis for civilly committing someone as a "sexually dangerous offender."
Hebephilia -- sexual attraction to adolescents -- certainly exists in nature, but the Government failed to meet is burden of establishing by clear and convincing evidence that it amounted to "a serious mental illness, abnormality, or disorder" as required for civil commitment, wrote the judge. Simply put, "hebephilia is not generally recognized as a serious mental illness by the psychological and psychiatric communities."
The case involved Todd Carta, who was due to be released from federal prison after serving time for computer-based child pornography. Carta has a lengthy history of sex with underage males, ages 13 on up, and has acknowledged an attraction to adolescent boys.
The Government's expert, psychologist Amy Phenix, diagnosed Carta with "Paraphilia Not Otherwise Specified: Hebephilia," which she defined as a sexual preference for "young teens . . . 'till about age seventeen."
Phenix's position was countered by psychologist Leonard Bard, who testified that Carta had no diagnosable mental disorder. Bard identified numerous problems with the diagnosis of hebephilia, including its absence from the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the prevalence of sexual attraction to adolescents among normal men.
The judge got it. In a thorough and well reasoned decision, he deconstructed the legal use of this nebulous diagnosis brick by brick. Perhaps most impressive was his clearly articulated understanding of the importance of adequate empirical research to support a diagnosis:
"Most importantly, the Government has failed to demonstrate that a diagnosis of hebephilia or paraphilia NOS: hebephilia is supported by research in the field of psychology…. Most of the articles put forward by the Government were published by coauthors Dr. Blanchard and Dr. Cantor. Dr. Bard criticized the work of Dr. Blanchard and Dr. Cantor, testifying that they are both on the editorial board of the journal that publishes their findings, which has at least the potential to damage the integrity of the peer-review process. Dr. Bard also criticized the research underlying their conclusions for failing to include a control group and for eliminating a large portion of the samples, among other problems. The five replies criticizing Dr. Blanchard's recent article proposing inclusion of hebephilia in the DSM-V suggest that Dr. Blanchard's work is not widely accepted. Dr. Bard testified that 'it’s the same group that is published over and over again trying to justify [a diagnosis of hebephilia], and they have failed.' "The judge acknowledged that by ordering Carta's release he was not suggesting the convicted sex offender is a model citizen, but just drawing a line in the sand between criminality and mental disorder: Absent a widely recognized mental disorder it is Unconstitutional to "order indefinite commitment on the basis of the offensiveness of Respondent's conduct alone."
This is the third federal ruling in a row against hebephilia. The only other federal courts to address its use both rejected it as a basis for civil commitment. Those cases were U.S. v. Shields and U.S. v. Abregana, both decided last year.
Normally, this might be a "Three Strikes and You're Out" situation. Put the tired old construct to bed.
But fans are frantically trying to rehabilitate and rejuvenate hebephilia by getting it added to the next edition of the DSM (DSM-V). This would get around at least one of the many concerns expressed by Judge Tauro and others, over "the lack of any clear criteria" for making the diagnosis. Spearheading the DSM-V effort is Raymond Blanchard of the Centre for Addiction and Mental Health in Canada, who not only sits on the editorial board of the journal that published his research (as Judge Tauro pointed out in his opinion), but also serves on the DSM-V Sexual and Gender Identity Disorders Work Group. From that influential position, he is lobbying for the addition of hebephilia or a newly minted term – pedohebephilic disorder (what a mouthful!) to the diagnostic bible.
With the DSM-V work groups stacked (see my related posts HERE), we may just have to wait and see. But in the meantime, All Hail to Massachusetts, for landing a solid blow against pseudoscience in the forensic arena.
Judge Tauro's decision is HERE. A list of articles on "Hebephilia and the DSM-V Controversy" is HERE; for more on hebephilia see my essay, "Invasion of the hebephile hunters: Or, the story of how an archaic word got a new lease on life."
Photo credit: Noel Kerns' "Closed," Creative Commons license (entrance to the defunct Mission Four Outdoor Theatre in San Antonio, Texas)
May 26, 2009
Embitterment disorder: The latest from DSM-V
But, really, folks. Post-traumatic embitterment disorder? Isn't that going a bit far?
The L.A. Times' Shari Roan has the story of how some psychiatrists want to create a formal label for embittered people bent on revenge. We all know them; now we'll have a handy-dandy acronym -- PTED -- by which to refer to them.
The article is part of Ms. Roan's ongoing coverage of the heated DSM debates at the American Psychiatric Convention in San Francisco. Today's coverage is here.
MORE DSM NEWS: A letter in the current New England Journal of Medicine on the pharmaceutical influence over the DSM-V development process, and the resultant "crisis of credibility" in psychiatry, is online HERE. The authors are Lisa Cosgrove, Ph.D., of the University of Massachusetts; Harold J. Bursztajn, M.D., of Harvard Medical School; and Sheldon Krimsky, Ph.D., of Tufts University.
November 28, 2008
Spitzer update on DSM-V transparency
Robert Spitzer, MD, chair of the DSM-III and DSM-III-R workgroups, has issued an update on efforts to reduce the secrecy surrounding the American Psychiatric Association's DSM-V revision process:
"As those of you who have followed this issue know, APA leadership has been resistant to improving the transparency of the revision process. At the outset, all DSM-V Task Force and Workgroup members were required to sign a confidentiality agreement that prohibited them from discussing anything about the DSM-V revision process.... Requests to APA leadership to see minutes of Task Force and Workgroup meetings were refused on the grounds that releasing minutes would compromise the revision process by inhibiting free discussions among Workgroup members. It also was argued that making minutes of meetings and conference calls would jeopardize APA's intellectual property rights. How this would happen has never been explained....The only Task Force report posted so far is here. Progress reports from the individual workgroups are posted here.
"Pressure on APA leadership to increase transparency culminated in the drafting of an Action Paper by some members of the APA Assembly. The paper called for the posting of the minutes to the DSM-V workgroup and task force meetings on the DSM-V web site....
"Although clearly a move in the right direction, I believe that these reports fall far short of providing the requisite transparency. The Workgroup reports are quite variable in terms of the amount of detail they provide regarding possible directions for change in the DSM-V....
"Full transparency of the process will only be satisfied by posting the minutes of all DSM-V conference calls and meetings so that the process of the deliberations is evident to all . Anything less is an invitation to critics of psychiatric diagnosis to raise questions about the scientific credibility of DSM-V. That is exactly what Christopher Lane, a harsh critic of the DSMs, did in an Op-Ed piece for the LA Times.
"One of the oft-repeated DSM-V talking points is that the process is 'open and transparent.' To be truly transparent, the nuts and bolts of the DSM-V process needs to be open for outside scrutiny. When it comes to the crucial issue of transparency, even the appearance of impropriety must be avoided. Rather than appearing open and transparent, current APA policy continues to give the appearance that APA has something to hide about how it is developing DSM-V. It remains likely that unwanted media attention will fall on the DSM process until full transparency is achieved."
My readers will be especially interested in the report from the Sexual and Gender Identity Disorders workgroup, which will make recommendations for the highly controversial Paraphilias section of the DSM. The brief report is very vague and really doesn't say much. Rumor has it that the workgroup may be considering adding a new diagnosis for nonsadistic rapists, a highly controversial proposal that was rejected the last time around but would help government experts at civil commitment proceedings. With the continuing secrecy surrounding the process there is no way to know for sure what the workgroup is up to; we'll just have to stay tuned.
November 26, 2008
Blogging jurors
Similarly, when jury consultant and trial lawyer Anne Reed started her excellent jury blog, Deliberations, she did not envision how many posts she would write about jurors who blog. But she has. And when she is quoted, interviewed, or asked to speak, social networking is the number one topic of interest.
I have a long list of topics that I never get around to, and blogging jurors is one that keeps going to the back burner. Since I haven't gotten around to writing about it yet, I've decided to point my readers to Anne Reed and let her tell you all about this interesting topic that trial lawyers in particular need to pay more attention to:
So here come two more online jurors this week, frightening lawyers everywhere. There's the Facebook juror in England who put a poll on Facebook to help her decide guilt or innocence. And there's the blogging juror here who knows she can't write about the case, but thinks that "doesn't mean I can't give people a a glimpse of the people I am dealing with," and so gives a great sketch of each person in the courtroom. ("The lead defense lawyer. When he is trying to make a point when questioning a witness he beats his hand on the jury box. "So you *wham* are telling me *wham* that blah blah blah blah blah BLAH! *WHAM*" ) The Facebook juror was dismissed; the word-sketch artist is still sitting, as far as we know.Reed's advice to attorneys?
This is going to happen to you. It's going to happen to you. It's going to happen to you.
Four things to add to your trial task list:
1. Ask. Ask jurors in voir dire whether they write on line and if so where. If you get a "yes" to that question, you have several tools: (1) the judge can strongly impress on that particular witness that she is to write nothing about the trial, not even character sketches; (2) the lawyers can keep an eye on the juror's site during the trial; and (3) if there's time, you can jump on the juror's site before the jury is chosen to see if it contains anything of concern.
2. Look. Simply running searches by jurors' names -- before the jury is seated if possible, after if not -- you can find non-anonymous blogs, of which there are many.
3. Watch. Even if you've asked and looked, you can still have jurors writing about your trial that you didn't know about, on anonymous sites they did not disclose. If you have enough people, assign someone to set up standing searches to try to catch these, using terms the juror might choose -- the location of the court, and the type of case it is. It also makes sense to check on-line comments to news stories about the case, where you have the staffing to do it.
4. Relax. It's possible that none of these techniques will find the Facebook juror or the sketch artist on your trial. Does that mean we're in a frightening new world with intolerable new rules? I don't think so. Remember that in the old days, both jurors probably would have had talked about the case in the same way, but in conversations with their friends, not on line -- and you wouldn't have found out about those either. If anything, it's easier, not harder, to find chatty jurors than it was when they simply talked.
Click here to see her full post, with links to an entire series on blogging jurors and to her very practical Trial Lawyer's Guide To Social Networking Sites, which does the work for you inquisitive types by linking to all of the major (and many of the minor) social networking sites.
I hope all of you have a nice Thanksgiving holiday!
November 25, 2008
More on the DSM-V controversy
Inspired by last week's op-ed in the L.A. Times, Atlanta Journal-Constitution staff writer Richard Halickshas has a new piece questioning some of the strange new diagnoses being proposed for the DSM-V:
Sex addiction. Internet addiction. Compulsive buying disorder. All of these and more could become officially recognized mental disorders in the next few years. The American Psychiatric Association is creating the fifth edition of its Diagnostic and Statistical Manual, or DSM-V, which defines mental disorders and adds new ones with each edition.As you see in the above coverage, the APA denies the charge by Lane and others, including none other than DSM-III Task Force Chairman Robert Spitzer, that the DSM-V revision process is occurring in secrecy.
Christopher Lane, author of the book "Shyness: How Normal Behavior Became an Illness," complained last week that the new DSM, due out in 2011, is being put together in secret, a charge that DSM's editors denied.
In "Wrangling Over Psychiatry’s Bible," published in the Los Angeles Times, Lane also warned that the creation of new disorders where none currently exists may be "little more than a pretext for prescribing profitable drugs."
Here's a look at selected new ailments under consideration by the committees of experts writing DSM-V.
Sex addiction
Real, says Dr. Patrick Carnes, a leading researcher in the field. It's a "compulsive behavior that completely dominates the addict's life. Sex becomes the organizing principle of addicts' lives."
Not real, says Seattle therapist Roger Libby. Slate.com quotes Libby: "You cannot be addicted to yourself. You have to have a substance external to yourself like alcohol or drugs to be addicted."
Caffeine withdrawal disorder
Real, say Johns Hopkins University researchers. Withdrawing from the world's most-used drug causes headache, fatigue, irritability, depression, difficulty concentrating, even flulike symptoms.
Not real? Few seem to argue against this. It's in DSM-IV as a trial diagnosis and is up for official diagnosis designation in DSM-V.
Parental Alienation Syndrome
Real, says paskids.com: [PAS] "arises primarily in the context of child-custody disputes. Its primary manifestation is the child’s campaign of denigration against a parent, a campaign that has no justification."
Not real, says the National Organization for Women: "Parental alienation really is a dangerous and cleverly marketed legal strategy that has caused much harm to victims of abuse, especially women and children during and post-divorce."
Internet addiction
Real, says Dr. Jerald Block, writing in the American Journal of Psychiatry: "Internet addiction appears to be a common disorder that merits inclusion in DSM-V… . [It] consists of at least three subtypes: excessive gaming, sexual preoccupations and email/text messaging."
Not real, argues thelastpsychiatrist.com. "Internet addiction belongs in DSM-V… . And then let's rename the DSM The Book of Fantastikal Magickal Pixies and incorporate it into the Monster Manual."
But, as Spitzer points out in a letter to Psychiatric News, the secrecy is spelled out quite clearly in the contract that all DSM-V task force members must sign:
"I will not, during the term of this appointment or after, divulge, furnish, or make accessible to anyone or use in any way... any Confidential Information. I understand that 'Confidential Information' includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other written or unwritten information, in any form, that emanates from or relates to my work with the APA task force or work group."The Atlanta Journal-Constitution article is online here. Spitzer's letter about the secrecy is here. My previous post on the DSM makeover controversy is here.