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.

Europeans first to shoot down controversial paraphilia

Resounding 100-to-1 vote against "pedohebephilia"

I was impressed by the unanimity of opposition to the sexual paraphilias among forensic psychiatrists at their annual conference last week in Tucson, Arizona.

But as it turns out, the sex experts of Europe had the Americans beat, both in numbers and timing.

At last month's meeting of the International Association for the Treatment of Sexual Offenders (IATSO) in Oslo, Norway, the vote was approximately 100 to 1 against the controversial diagnosis of "pedohebephilia," according to two reliable sources. The lone dissenting voice was a member of the DSM-5 committee.

I hope the DSM revisers are listening. If not, they are going to end up the laughingstock of the world.

Richard Green, MD: "Hebephilia is a Mental Disorder?"

The vote at the IATSO conference, where European psychiatry is strongly represented, came after a talk by Richard Green, a prominent psychiatrist, sexologist, and professor at the Imperial College of London. Green served on the Gender Identity Disorders subcommittee for DSM-IV, and was a leading advocate for removing homosexuality from the DSM back in the 1970s. In a published critique of the hebephilia proposal, he pointed out the parallels:

The parody of science masquerading as democracy made a laughing stock of psychiatry and the APA when it held a popular vote by its membership on whether homosexuality should remain a mental disorder. Decreeing in a few years time that 19-year-olds who prefer sex with 14-year-olds (5 years their junior) have a mental disorder … will not enhance psychiatry’s scientific credibility.

He has also pointed out that the age of legal consent in several European countries falls within the range that the proposed disorder would make pathological for the older participant.

A separate audience poll at the IATSO conference on the proposed diagnosis of hypersexuality was more mixed, with about a third favoring the diagnosis, a third opposing it, and a third undecided, according to one of my sources.

NPR report on AAPL debate

Meanwhile, National Public Radio has reported on Saturday's AAPL vote against the paraphilias. Reporter Alix Spiegel blogged about it on NPR's health blog, "SHOTS," under the heading "Forensic Psychiatrists Don't Favor Some Proposed Sexual Diagnoses."

These negative votes will have no a direct impact on the DSM-5, now due out in 2013. In the case of the controversial sexual paraphilias, one Canadian research group is dominating the process and most of the upcoming field trials will be done at government detention facilities where insular opinion runs heavily in favor of the diagnoses.

Proponents of the paraphilia revisions are urging supporters to lobby the DSM committee. It seems that, as we have seen in the past, lobbyists may have an inordinate impact, overshadowing valid science.

But if the American Psychiatric Association kowtows to this special interest niche and ignores the broader consensus of psychiatrists and other mental health professionals around the world, this will certainly reduce the credibility of the manual in years to come.

UPDATE: My Psychiatric Times coverage of the debate, "Forensic Psychiatrists Vote No on Proposed Paraphilias," is online HERE.

Wrangling over psychiatry's bible

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

Los Angeles Times
November 16, 2008

By Christopher Lane

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

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

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

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

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

The more you know about how psychiatrists defined dozens of disorders in the recent past, the more you can appreciate Spitzer's concern that the process should not be done in private. Although a new disorder is supposed to meet a host of criteria before being accepted into the manual, one consultant to the manual's third edition -- they're now working on the fifth -- explained to the New Yorker magazine that editorial meetings over the changes were often chaotic. "There was very little systematic research," he said, "and much of the research that existed was really a hodgepodge -- scattered, inconsistent and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest."

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

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

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

Lane's full opinion piece is online here.

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

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

Steffan's Alerts #3: Women, children, fire-setting and the public

Click on a title to read the article abstract; click on a highlighted author's name to request the full article.

JAAPL: Plethora of mental health and law offerings

As always, the new issue of the Journal of the American Academy of Psychiatry and Law is a goldmine for those interested in law and mental health matters. All articles may be accessed for free online. Topics include use of the DSM in litigation and legislative settings, rational understanding and competency to stand trial, treatment of sexual offenders, hebephilia and the DSM-5, competency of pregnant women with psychosis, diversion of women into substance abuse treatment, and analyses of several recent legal rulings, to name a few.

Sins of the father

In a new issue of the British Journal of Criminology, Sytske Besemer and colleagues examine whether children whose parents have been incarcerated are later involved in the criminal justice system at disproportionate rates compared to children whose parents have been convicted but never imprisoned in the Netherlands and England. After controlling for a number of possible intervening variables in their longitudinal study, the authors provide data showing that children in the latter--but not the former--country are adversely affected by their parents' incarceration.

Advancing understanding and predictive utility of childhood firesetting

Although mental health professionals have long held that deliberate fire setting by children is prognostic of future conduct problems, Ian Lambie and Isabel Randell review how science in this area has progressed -- or not progressed -- in a new issue of Clinical Psychology Review. They call for future research to address the relationship between youth firesetting and future antisocial behavior as well as to update best practices in assessing and intervening with children who set fires.

Factors involved in reporting rapes

Data from a national survey of 3,001 women in 2006 indicated that the rate of reporting rape has not significantly changed since the 1990s. In a new issue of Journal of Interpersonal Violence, lead author Kate Wolitzky-Taylor explores barriers and predictors of reporting sexual assaults to law enforcement.

Criminal justice response to female offenders

In a forthcoming issue of Psychology, Public Policy, and Law, Shabnam Javdani, Naomi Sadeh, and Edelyn Verona advance theory on the legal and social policy factors involved in the increasing arrest rates of girls and women.

Public's views on sentencing practices

Does the public really support tougher sentencing of offenders? Preliminary data suggests this is not the case in Australia when members of the public are provided details about the personal lives of offenders. In a new issue of Criminology and Criminal Justice, Austin Lovegrove sampled several hundred participants through their review and discussion of judges' sentences on six offenders in four actual cases.

Steffan's alerts are brought to you by Jarrod Steffan, Ph.D., a forensic and clinical psychologist based in Wichita, Kansas. For more information about Dr. Steffan, please visit his website.

Wallowa Lake diagnostic training

Sculpture on Main Street of Joseph, Oregon
with Eagle Cap Wilderness Area in background
(K Franklin)

On the day that the world didn't end, I found it fitting to be literally at the end of the road, giving a training on controversies in psychiatric diagnosis. The setting was Oregon’s picturesque Wallowa Lake, where for 26 years the Eastern Oregon Psychological Association has sponsored an annual retreat.


The mental health professionals at the retreat were a bright and independent bunch whose practices take them across scenic mountainous terrain to far-flung rural communities, Indian reservations, jails and psychiatric facilities in eastern Oregon, Washington and Idaho.


Since Oregon has avoided the Sexually Violent Predator quagmire, the practitioners – as well as the psychologists from Eastern Oregon University in La Grande in attendance -- were both amused and appalled to learn about the pseudoscientific constructs of hebephilia and paraphilic coercive disorder for which the sex offender industry is lobbying. Other controversial diagnoses and proposed diagnoses covered in the daylong workshop included:

• Posttraumatic Stress Disorder
• Antisocial Personality Disorder and Psychopathy
• Parental Alienation Syndrome
• Attenuated Psychosis Syndrome
• Mild Neurocognitive Disorder
• Disruptive Mood Dysregulation Disorder
• Premenstrual Dysphoric Disorder
• Traumatic Grief Disorder
• Gambling Disorder

Wallowa River as seen from Chief Joseph
Trail (K Franklin)

If you ever get a chance to attend this annual retreat, which is not well advertised but always takes place the weekend before Memorial Day Weekend, I recommend it highly. Not only is the crowd an enjoyable and intellectual one, but the setting is amazing. It's not for no reason that the Nez Perce consider sacred this valley butting up against the mountains of the Eagle Cap Wilderness Area.

The legendary Chief Joseph is buried on a glacial moraine overlooking the lake. The town named in his honor, Joseph, was a dying old ranching and mining community when it was discovered by artists who have reinvigorated the main drag, opening shuttered storefronts and installing amazing sculptures on every corner. Summer vacationers can now rub shoulders with cowboys and Indians in gourmet restaurants featuring local micro-brews and wines.

It's not an easy place to get to (one must catch a puddle jumper to Walla Walla, Washington or Pendleton, Oregon and then drive for several hours), but its breathtaking beauty and unique character make it well worth a visit.

Special thanks to David Starr, Dwight Mowry, Marianne Weaver, Terry Templeman, Charles Lyons, and Stephen and Beth Condon for all of your work and your kindness in arranging and facilitating this event.

DSM makeover: What will they come up with next?

Overhaul of diagnostic bible shrouded in secrecy

It's a tried-and-true formula:

1. Do a quick-and-dirty study or two.

2. Find a huge, perhaps escalating, problem that has heretofore been overlooked.

3. Create a product label (aka diagnosis).

And, voila! The drug companies will take it from there. A diagnosis that was once just a twinkle in the eye of a creative researcher becomes reified as a concrete entity.

Over the past couple of decades, the DSM has risen from its humble origin to an object of worship, regarded as the absolute scientific truth. Privately, however, many mental health professionals refer to it as a "joke." That's partly because we are aware of studies showing the poor validity of many of its constructs. It's also because we know about some of the forces (in addition to scientific progress) that influence each new edition. These include internal turf wars (the DSM-III was developed in large part to decrease the power of the psychoanalytic wing of psychiatry), cultural fads, group-think, and outside lobbying. And leading the outside lobbying, of course, is the pharmaceutical industry.

An example of how this process works is the case of shyness. Christopher Lane, an English professor and Guggenheim fellow, shows in his book, Shyness: How Normal Behavior Became a Sickness, how psychiatrists transformed shyness from a normal personality trait into a pathological condition labeled Social Anxiety Disorder. As Lane points out, not only can diagnoses be manufactured out of whole cloth, but their prevalence can be made to rise and fall like the stock market through arbitrary adjustments of the threshold cutoffs. And the DSM has a very low bar for calling something a disorder.

In writing his book, Lane was able to get unprecedented access to internal memos and letters of the American Psychiatric Association's DSM-III task force. Based on these primary sources, he credits the rise of the DSM from an obscure tract used mainly by state hospital hacks to an international bible to one man - Robert Spitzer - who chaired the task force and handpicked its members from people he considered "kindred spirits." (Spitzer is perhaps better known among the general public for his controversial stance that gay people could be turned heterosexual through reparative therapy.)

Over the years, the DSM has expanded from just 106 pages to its current 886. (See chart.) The severe mental disorders that once formed the book's core are still in there. There's just so much fluff that it's harder to find them.

And now, the American Psychiatric Association is at it again, working on the fifth edition that is set to launch in May 2012. But this time, perhaps in response to exposes such as Lane's, there will be no telltale memos and letters to document the process. Task force members are sworn to complete secrecy; they must sign a "confidentiality agreement" prohibiting them from disclosing anything to anyone.

Petition drive against secrecy

Ironically, even DSM-III architect Robert Spitzer is being excluded this time around. Denied access to task force committee minutes and other information, an angry Spitzer wrote a protest editorial that was rejected for publication by the American Journal of Psychiatry, the official journal of the American Psychiatric Association. (The editorial, "Developing DSM-V in Secret," is online here). With psychologist Scott Lilienfeld and others, Spitzer last month called for a petition drive to force the APA to open up the DSM-V revision process to public observation.

No doubt hoping to forestall such a petition drive, the APA just announced that its Assembly of local branch representatives will vote November 18 on an "action paper" that would encourage less secrecy. The vaguely worded paper calls on the APA's Board of Trustees to "develop policies and processes that balance the need for openness and transparency and the need to protect its intellectual property." If approved by the Assembly, the action paper will go before the association's Board of Trustees in December.

The secrecy issue comes amid mounting controversy over psychiatrists' ties to the drug industry. The U.S. Senate Finance Committee has launched an investigation into whether drug money is compromising the integrity of medical science. Prominent psychiatrist Charles Nemeroff of Emory University, whom critics have nicknamed "Dr. Bling Bling," is at the center of the probe; he reportedly earned millions of dollars from pharmaceutical companies while promoting drugs to heal depression and other emotional problems. (See Sunday's Atlanta Journal-Constitution.)

Perhaps all of this hubbub will encourage the DSM developers to be a bit more circumspect with new diagnoses, realizing that a massively overmedicated and increasingly cynical public could get fed up.

Perhaps the DSM's stranglehold on diagnosis would not be so serious if the book were only being used for its original and stated purpose, as a tool to help clinicians speak the same language in their efforts to understand and treat the mentally ill. But, increasingly, both medical and psychiatric disorders are being shaped by and for the pharmaceutical industry. (A good example of Big Pharma's influence over medical doctors is The rise of Viagra: How the little blue pill changed sex in America.) And in the forensic arena, the DSM is often employed pretextually, to accomplish various legal outcomes.

Proposed new diagnoses

So, what is in store this time around? Here's my sampling of some of the more controversial changes and new conditions being proposed, some with very specific relevance to forensic practice:

Parental Alienation Syndrome: This is by far the most controversial theory in high-conflict child custody litigation. And the battle lines are drawn primarily by gender: PAS is apt to be the first line of defense when a husband is accused in a custody battle of sexually abusing his children. Despite its lack of empirical support, a partisan lobby is pushing for its inclusion. (See my March 2008 blog post, "Showdown looming over controversial theory," for more background.)

Hebephilia: All psychodiagnoses, even those of psychotic disorders, have serious conceptual validity problems, but none are weaker than some of those being used to justify the civil commitment of sexually violent predators. The latest, and most farcical, is "hebephilia," or the sexual attraction to teens, which is being aggressively marketed by a small advocacy group. (I'll have more to say about this newly proposed diagnosis very soon; for now, you can check out my Halloween 2007 post, "Invasion of the hebephile hunters.")

Gender Identity Disorder: The proposed inclusion of this category has drawn the most fire, primarily from transgender activists, who have mounted a petition drive against Ken Zucker, chair of the sexual disorders task force. Information on this controversy can be found here, here, and here.

Among other novel constructs proposed for inclusion in the DSM-V are Internet Addiction and Relationship Disorder. If Big Pharma has its way, Female Sexual Dysfunction (FSD) could also be a contender (see my Amazon review of The Rise of Viagra). In addition, there are proposals to tweak the criteria for existing diagnoses relevant to forensic practice, including the sexual Paraphilias, Posttraumatic Stress Disorder, and Conduct Disorder.

For more information see:

Robert Spitzer’s documents criticizing the DSM-V secrecy (online here)

The APA’s official DSM-V website (here)

A critical analysis of psychodiagnosis more broadly (here)

My review of Christopher Lane's book, Shyness: How Normal Behavior Became a Sickness, is here. (As always, I encourage my readers and subscribers to click on the "yes" button if you find my Amazon reviews helpful; it helps get the word out.)

For further information on the pharmaceutical industry's role in the process, see my May 2008 blog post, "Who will write the next DSM?" and also check out my Amazon booklist, "Psychiatry and science: Critical perspectives."

Other academic articles on DSM diagnosis (not all of them available online, unfortunately) include:

Andreasen, N.C. (2007). DSM and the death of phenomenology in America: An example of unintended consequences. Schizophrenia Bulletin, 33, 108-112

Cunningham, M.D., & Reidy, T.J. (1998). Antisocial personality disorder and psychopathy: Diagnostic dilemmas in classifying patterns of antisocial behavior in sentencing evaluations. 16, 333-351.

Healy, D. Apr 15, 2006. The myth of 'mood stabilising' drugs. New Scientist (David Healy is a very controversial figure in this debate; Google his name for more on him)

Ruocco, A. (2005). Reevaluating the distinction between Axis I and Axis II disorders: The case of borderline personality disorder. Journal of Clinical Psychology, 61, 1509-1523

Stevens, G.F. (1993). Applying the Diagnosis Antisocial Personality to Imprisoned Offenders: Looking for Hay in a Haystack. Journal of Offender Rehabilitation, 19, 1-26

Tom Zander, Psy.D. (2005) Civil commitment without psychosis: The law's reliance on the weakest links in psychodiagnosis. Journal of Sex Offender Civil Commitment: Science and the Law (online here)

The photo of the DSM manuals is from the Bonkers Institute for Nearly Genuine Research, a very creative website.

Bipolar disorder by proxy proposed for DSM-5

New diagnosis to address "critical clinical need"

Although some scholars warn of dangers posed by the proposed expansions of psychiatric disorders, others say there remains a critical shortage of accurate diagnoses for those who need them. At a forensic psychiatry conference last month, for example, proponents said three new sexual disorders are needed to address an urgent clinical reality.

Incorporation of such broad-brush conditions as "psychosis risk syndrome," "temper dysregulation disorder," and "hebephilia" into the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due out in 2013, will help address the diagnostic shortfall, the clinical realists say. But more should be done.

To help meet the needs of those few who remain undiagnosed, California psychologist Michael Donner has proposed an umbrella disorder. To qualify for the newly minted Bipolar by Proxy (BPP), patients must meet at least one of the following criteria during the preceding two-year period:

1. A pervasive sense of well being
2. Repetitive episodes of sadness or pleasure while engaging in pleasant or unpleasant activities, typically lasting for the duration of the activity
3. A minimum of one episode of feeling extremely excited or irritated
4. Two or more episodes of crying, or three or more episodes of an urge to cry
5. Engaging in laughing behavior when confronted with something humorous
6. A general willingness to comply with a prescription medication regimen despite having no overt symptoms
7. One or more major medical health insurance reimbursement plans

As a rule-out, the disorder must not occur in the presence of any other previously undiagnosed mental illness. Nor can it be due to the direct physiological effects of exogenous substances (e.g., drugs of abuse or medications).

There may be no need to market a new drug for this condition. The prescription depressant Despondex (see below video) has been on the market for more than a year and targets annoying exuberance, a core symptom of Bipolar by Proxy that often alerts clinicians to conduct a more thorough diagnostic workup.

Although the reliability of the proposed diagnosis has not yet been established through clinical replication studies published in peer-reviewed journals, this should not be a barrier as field trials are being planned in time to make it into the manual just under the wire. The sites for the field trials will be strategically selected to maximize positive findings. Similarly, high inter-rater reliability will be assured through careful selection, training, and certification of raters by the Bipolar By Proxy Promulgation Association. The journal whose editorial board is dominated by that Association is expected to publish the positive findings. The larger question of validity is not thought to be a problem, as many other current and proposed diagnoses lack real-world validity.

Related post:

Despondex: Is psych mania overreaching? (June 22, 2009)

Photo credit: Eva Blue, Creative Commons License, Peaceful Heart Doctor, San Francisco Chinatown

Psychiatrists vote no on controversial paraphilias

By an overwhelming majority, a group of seasoned forensic psychiatrists who work with sex offenders voted last night against three controversial new sexual disorders being proposed for the DSM-5.

The votes were 31-2, 31-2, and 29-2, respectively, against Paraphilic Coercive Disorder, Pedohebephilia, and Hypersexual Disorder. The votes came at the end of a debate at the annual meeting of the American Association of Psychiatry and Law (AAPL) in Tucson, Arizona.

The rejection is symbolic, but sends a strong message to the DSM-5 developers. One of the six debate panelists, Richard Krueger, is a member of the Paraphilias SubWorking Group. Two other panelists serve as advisors to the committee. In the audience were prominent forensic psychiatrists who took stances regarding similar proposals during previous revisions of the DSM.

The American Psychiatric Association, to which most forensic psychiatrists belong, publishes the influential Diagnostic and Statistical Manual of Mental Disorders, now in its fourth edition. But psychiatrists have not played a central a role in the 20-year-old sex offender civil commitment industry, which is lobbying for these new diagnoses. Much of the planned field testing will be done at civil commitment sites.

The debaters

Arguing for and against Hypersexual Disorder were two prominent psychiatrists with decades of experience in assessing sexual disorders. Richard Krueger, on the "pro" team, is a Columbia University professor and medical director of the Sexual Behavior Clinic at the New York State Psychiatric Institute. John Bradford, an advisor to the DSM-IV and past president of AAPL, is a Distinguished Fellow of the APA, last year earning its prestigious Isaac Ray Award. The University of Ottawa professor is founder and clinical director of the Sexual Behaviors Clinic in Ottawa. He expressed concern about how clinicians would determine how much sexual preoccupation is excessive, and voiced worry that homosexual men might be disproportionately given the label.

Two Wisconsin psychologists debated "Paraphilic Coercive Disorder," which would apply to rapists. Thomas Zander took the "con" position while David Thornton of the Sand Ridge Secure Detention Center for sexually violent predators was "pro." This is the third time that the American Psychiatric Association has considered such a diagnosis.

Tackling Pedohebephilia were two Northern Californians, forensic psychiatrist Douglas Tucker ("pro") and your faithful blogger ("con"). The controversial proposal would expand pedophilia from its current definition, in which the target of sexual attraction must be prepubescent, to young pubescents as old as 14.

The debate was organized by forensic psychiatrist Lynn Maskel, a clinical professor at the University of California-San Diego.

Clinical versus forensic utility?

The three-member "con" team focused on two main themes:

• All three proposed diagnoses lack a sufficient scientific basis.

• They are highly likely to be misused in the forensic context, the primary site for their application.

The "pro" debate team repeatedly insisted that these diagnoses are being proposed based on their scientific merit, not their utility to government evaluators in civil commitment cases. They said these new diagnoses are needed so people suffering with these conditions can get adequate treatment.

The clinical needs argument is a red herring. Clinicians are not turning away patients with problematic sexual behaviors because the proper billing code is missing from the Diagnostic and Statistical Manual of Mental Disorders. Rapists will not flock in for needed treatment when they hear that a Paraphilic Coercive Disorder label is now available for them.

The audience of forensic psychiatrists clearly did not buy the clinical justification. As more than one audience member asked the panel, If the rationale is strictly clinical, why are attorneys serving as advisors to the work group?

Back in 1986, the last time Paraphilic Coercive Disorder was proposed for the DSM, it was defeated in large part due to the opposition of forensic psychiatrists (not pesky feminists, as the historical revisionists would have it). Hopefully, history will repeat itself with respect to all three of these poorly conceptualized and dangerous proposals.

The debate was audiotaped, and will be available for purchase from AAPL. The texts of the proposed diagnoses can be viewed at the DSM-5 website. My resource page on Hebephilia is HERE. Thomas Zander’s article, Inventing Diagnosis for Civil Commitment of Rapists, is online HERE.

Photo: (L to R) John Bradford, Karen Franklin, Thomas Zander, David Thornton, Douglas Tucker, Richard Krueger. Photo credit: Luis Rosell.

UPDATE: My Psychiatric Times coverage of the debate, "Forensic Psychiatrists Vote No on Proposed Paraphilias," is online HERE.

Leading psychiatrists critique proposed sexual disorders

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

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

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

Pandering to legal pressure 

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

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

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

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

Loosening categories will reduce accuracy

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

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

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

Hypersexuality: Pathologizing young adults

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

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

Pedohebephilia: Confusing illegality with disorder

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

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

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

Federoff agreed:

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

Critical voices encouraged

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

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

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

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

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

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

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

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

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

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

Paint brushes and soap: The slippery slope of unfettered power

Courts rebuke detention centers for arbitrary and pretextual practices 

The case of the killer paint brush

When the government filed a petition seeking to civilly commit M.F. for sex crimes he might commit in the future, the elderly artist decided to go quietly. He gave up his right to a trial, in exchange for a legal order that he be allowed to do his art in his remaining years.

But officials at Missouri’s detention center resisted being told how to operate. M.F.’s security level was changed from green (low risk) to red (high risk), and his art supplies were taken away. When he challenged this in court, a government psychologist testified that the art supplies posed a threat to the institution’s security: Another patient could use them to hurt someone, or they might even block an evacuation route in the event of an emergency.

Calling the invocation of security “pretextual,”* a judge ordered the institution to return the paint brushes.

No soap unless we say so

In detention sites across the United States, objects far more innocuous than paint brushes are being wielded as weapons against captive sex offenders who -- like M.F. -- decline to enroll in proffered treatment.

In New Jersey, “A.J.,” a sex offender who declined treatment (insisting he is innocent) was denied basic hygiene items such as toilet paper, soap, shampoo, toothpaste, shaving cream and laundry detergent unless he could pay for them. The items were given free as prizes to sex offenders who enrolled in treatment. After a 3-day hearing, a judge ruled that the jailers were being “arbitrary and capricious”:

“Like food and clothing, personal hygiene items are central and core requirements of civilized existence. The refusal of the department of corrections to provide personal hygiene items to inmates at regular intervals is unreasonable. I also find that in this particular case the department of corrections sometimes observes its own rule and sometimes it doesn’t. So it’s capriciously applied as well.”

Tip of the iceberg

Arbitrary, vindictive, petty and sometimes just plain silly practices like these are not rare. Rather, they are commonplace experiences in the state hospitals where thousands of U.S. sex offenders are detained indefinitely based on future risk, after having finished their prison sentences.

The organizational culture is a setup for petty tyranny to run amok.

Unlike in a real hospital, there is an inherent tension between detainees and staff. Under the civil commitment laws, detention sites are supposed to provide treatment to reduce the sex offenders' future risk. But most of the residents decline to engage in treatment. They are resentful about being detained, and see the generic group therapy as a humiliating sham. For staff, in turn, the impossibility of their task lowers morale and can spawn resentment of offenders.

It is hard not to feel morally superior to the offenders. Many are not sympathetic characters. They have assaulted their way through life, leaving behind a swath of psychic destruction to children and women. Their mistreatment is easy to justify as deserved, or in service to the greater good of public safety.

Add to this incendiary mix the few bad apples in any organizational barrel. Literary trickster Carlos Castaneda called them little petty tyrants, who persecute and inflict misery without causing death. If you have ever worked in a prison or mental hospital, you know that such environments provide fertile soil for pinches tiranitos.

As we saw at Abu Ghraib, a frustrated work force with unfettered power over a maligned and powerless population is a recipe for abuse. Indigent prisoners don’t exactly have a voice to complain about abuses of authority. This is especially true for sex offenders. No one wants to hear a victimizer whining about being a victim. 

Alienation and despair

When Martin Seligman played mind games on dogs, giving punishments arbitrarily and not allowing escape, the dogs became apathetic and depressed. "Learned helplessness" resulted from their absolute lack of control or agency. The same thing happens with humans.

The arbitrary and capricious treatment that sex offenders are subjected to creates a vicious cycle. It ramps up alienation, despair, and bitterness. And this mindset is not exactly conducive to the types of prosocial change that we want to see in offenders.

Conditions are so unbearable in these facilities ostensibly designed for care and treatment that three offenders are using “necessity” as a defense for an attempted escape. The three tried to escape from Minnesota’s Moose Lake facility, which was the subject of an ACLU complaint over alleged violations of patients’ rights.

Last week, the would-be escapers unsuccessfully pleaded with a judge to let them stay in the county jail rather than returning them to the hospital, where they said conditions were intolerable:

“Please don’t subject me to any more mental and physical abuse without recourse. Please don’t send me back. I’d rather be euthanized.”

The judge nonetheless ordered the man sent back:

“I don’t have the jurisdiction to address the conditions [at the detention site] or the circumstances of your placement there.”

And therein lies the rub. Legislatures enact civil detention laws and set their parameters. But once the massive and costly facilities are up and running, it is easy for administrators and staff to forget that they are just functionaries, beholden to higher authorities for guidance. When this happens, the courts should step up. They hold ultimate responsibility for making sure that government operations are legal and fair.

A.J. and M.F. were lucky to have tenacious lawyers protecting their rights. Even then, their victories were tiny -- the right to soap and paint brushes. More typically, detainees are out of sight and out of mind. No one is watching, and no one cares.

Back in the day, Russian writer Fyodor Dostoyevsky mused that the degree of civilization in a society could be judged by entering its prisons. I wonder what his verdict would be if he could travel through time and visit a modern civil detention facility.

Related posts:

• "Treatment": Backwards and upside down? Don't focus on "denial" or "lack of empathy," warn sex offender treatment experts

• "Consumed With Sex": Sex offender treatment in risk society

*In the context of mental health law, legal scholar Michael Perlin defines pretexuality as “the ways in which courts accept—either implicitly or explicitly—testimonial dishonesty and engage similarly in dishonest and frequently meretricious decision-making, specifically where witnesses, especially expert witnesses, show a high propensity to purposely distort their testimony in order to achieve desired ends.” I used the term in the title of my just-published historical review of the term “hebephilia,” citing its use in court as a pretextual mental disorder.