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

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

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

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

"Prescriptions for Psychiatric Trouble"

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

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

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

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

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

Forensic applications: Disastrous unintended consequences

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

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

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

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

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

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

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

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

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

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

Special hat tip to the ever-helpful JANE

Forensic psychiatrist: Courts fostering "POLITICAL DIAGNOSIS"

After sex offenders, who will be next?

More leading experts are starting to notice and voice alarm over the pretextual use of psychiatric diagnoses in SVP civil commitment cases. In an editorial this week, a prominent forensic psychiatrist quotes the late Michael Crichton, calling it "bad science 'tricked out' for public policy ends."

Writing in the Psychiatric Times, James Knoll, psychiatry professor at SUNY-Syracuse and director of a forensic fellowship program, critiques both the questionable diagnoses and the shaky risk assessment techniques being used to civilly commit Sexually Violent Predators:

A variety of instruments have been developed (PCL-R, Static-99, Phallometry, Minnesota Sex Offender Screening Tool, etc.); however, these tests are often challenged in courts as not meeting legal standards for expert evidence and testimony. So while the research database has grown, the question remains: is it reliable enough to be proffered as expert testimony? Experts in the field continue to have serious reservations, and express caution about the (mis)use of these instruments for expert testimony.

Turning to the questionable diagnoses being used in SVP cases, Knoll puts the onus squarely on the U.S. Supreme Court for creating a tautological and "politico-legal" definition of "mental disorder or abnormality" for use in these civil commitment proceedings:

[T]he courts may use our diagnoses when they choose to, and they may ignore them and/or devise their own if it suits public policy…. Since it is forensic mental health professionals who are tasked with SVP evaluations, they have attempted to give this term meaning within the confines of their science. Have these attempts reached a consensus? It would appear that they have not. There continues to be substantial disagreement….

When psychiatric science becomes co-opted by a political agenda, an unhealthy alliance may be created. It is science that will always be the host organism, to be taken over by political viruses…. [P]sychiatry may come to resemble a new organism entirely -- one that serves the ends of the criminal justice system.

If we want to know where all this is headed if someone doesn't slam on the brakes, Knoll points us across the Atlantic to the United Kingdom, where offenders are indefinitely committed on the basis of a nebulous "Dangerous and Severe Personality Disorder" (DSPD):

Given the similarities between our SVP laws and the UK’s DSPD laws, is it too outrageous to speculate that a psychopathy (or DSPD-equivalent) commitment law might be on the U.S. horizon? Remember, the driving force behind such initiatives is usually only one highly publicized, egregious case away.

Related resource:

For an empirical study on the scientific problems with determining future violence under the UK's "Dangerous and Severe Personality Disorder" law, see: Ullrich, S., Yang, M., & Coid, J. (2009), "Dangerous and severe personality disorder: An investigation of the construct," International Journal of Law & Psychiatry (in press). The ultimate conclusions are strikingly similar to the issues posed by Knoll.

The study found a high rate of false positives -- that is, people categorized as DSPD and at high risk of serious reoffending when they actually did not reoffend when tracked in the community: 26 DSPD offenders would need to be civilly committed to prevent one major violent act.

When tracking sex crimes, which are of particular public concern, the researchers found that most new sex offenses were committed by offenders who were NOT categorized as DSPD, undermining the UK Home Office and Department of Health assumption that offenders at the highest risk for future sex offending would be categorized as DSPD.

After critiquing the accuracy of actuarial techniques, the article concludes:

"Bearing in mind the inaccuracy of DSPD criteria in identifying high risk individuals ... the construction of medico-legal terms, as in the case of DSPD, appears highly questionable.... [M]any determinants of violence are circumstantial and situational, and will invariably change over time, rather than related to some inherent characteristics of the perpetrator.... [F]ar more research is necessary ... before attempting to integrate a psychiatric condition into a legal system."

Heed these warnings, folks. The way things are headed in the U.S. criminal justice system, I expect to hear expansion of civil commitment to other groups -- violent offenders, juveniles, and others -- being proposed any minute now.

Photo credit: SUNY Office of Public Affairs

Oldest condemned man dies at 94

Elderly outlaw's competency remained at issue

Like so many Depression-era outlaws, the infamous Clyde Barrow and Bonnie Parker met early deaths, gunned down in a police ambush at the ages of 26 and 23. Among the few from that era to beat the hangman's noose was Viva Leroy Nash, the oldest death row prisoner in the United States, who died last week of natural causes.

Imprisoned for most of his adult life, Nash lived long enough to become both psychotic and demented, according to his lawyers; he was also deaf and almost blind. At the time of his death, his competency to participate in post-conviction habeas proceedings was on appeal to the U.S. Supreme Court.

Forensic psychiatrist Barry Morenz of the University of Arizona had evaluated Nash and opined that the old outlaw suffered from a delusional disorder. His symptoms included paranoid and grandiose delusions as well as auditory hallucinations. Dr. Morenz also noted worsening cognitive problems and memory impairment.

In the landmark case of Oscar Gates (formally known as the Rohan case), the 9th U.S. Circuit Court of Appeals ruled in 2003 that a death row prisoner has a right to be competent during post-conviction appeals, so that he may advise and consult with attorneys regarding issues that might arise. The standard is somewhere between the higher level of competency required to stand trial and the very low, so-called "Ford" competency standard required for execution.

In 2007, the appellate court applied this holding to Nash's case, granting a death penalty stay until Nash's ability to communicate rationally with his counsel could be evaluated and litigated. The government was appealing that ruling when Nash died.

A lengthy account in Phoenix' New Times last year was skeptical of Nash's incompetence claim. It described the self-educated convict as "intelligent and well read" and "a consummate jailhouse lawyer" who in the 1960s won "certain procedural safeguards for inmates" in a ruling that almost made it to the U.S. Supreme Court.

But then again, maybe advancing age and years of supermax confinement finally did him in. After all, more than one out of three people in their 90s has a dementia. And long confinement in solitary housing eventually drives even the strongest mind "stir crazy."

Life at Nash's final residence, the austere supermax Arizona State Prison Complex-Eyman, is an invisible form of torture. With Arizona "at the vanguard of the country's correctional zeitgeist in stripping away inmate privilege," according to a critical report in The Tucson Weekly, long-term lockdown in the unit is the state's "version of a straitjacket." Devoid of human connection, prisoners in such environments not uncommonly take to self-stimulating behaviors that is rare in other contexts -- sculpting figurines out of feces, masturbating in public view, or gouging their flesh and playing with it.

Craig Haney, an expert on the psychological effects of long-term solitary confinement, called the Arizona supermax one of the most severe. "Solitary confinement has been around for a long time," Haney told the Weekly. "What's different about these supermax units is that the technology of the modern correctional institution allows for a separation, almost a technological separation, of inmates from the social world around them in ways that really weren't possible in the past."

Under these conditions, if a condemned prisoner's appeals drag on long enough, it is almost inevitable that his mind will deteriorate to the point that he needs a forensic evaluation of his competency to rationally communicate with his attorney. So, if other Depression-era outlaws had survived long enough, we forensic practitioners may have gotten a chance to glimpse back into a bygone era through their eyes as well.

A wild and colorful life

It surely would have been interesting to interview this old man who talked like he had just stepped out of an Old West movie. Born in Salt Lake City's rural south side in 1915, during Prohibition, the "wild child" dropped out of school in the seventh grade and embarked on a life of crime.

During the Roaring Twenties he and a gang of other boys burglarized warehouses. In his mid-teens, armed with a gun, he caught an outbound boxcar and, like millions of other dispossessed young men during the Great Depression, set off "to seek his fortune," according to a laudatory 2005 account in the New Criminologist that referred to him as "a living legend." The account was based in part on more than 200 pages of handwritten memoirs.

By age 17, he was serving time at an industrial school for juveniles in Ohio for car theft. He escaped, did an armed robbery, and was sentenced to 30 months at Kansas' notorious Leavenworth Penitentiary, where he has said that a Mafia don tutored him in jewelry store heists.

Paroled in 1934, he fathered his only child (who died 21 years ago) and resumed his life of crime, with robbery sprees in Utah, Georgia, Alabama, and who knows where else. He was imprisoned in 1936 after a bungled robbery with his younger brother. Next arrested in 1946 in Alabama for check-kiting, he escaped from jail and reportedly fled to Mexico with a large sum of stolen money.

But his outlaw ways were catching up to him, and he spent most of his ensuing years in prison. He did a 25-year stretch for the 1947 shooting of a Connecticut police officer (who lived). In 1977, he was sentenced to two life terms for a robbery-murder. Somehow, he was placed on a prison work crew from which he escaped in 1982. Just three weeks later, he did the crime for which he was sentenced to die in 1983 -- a robbery-murder at a Phoenix coin shop.

Although his appeals have focused on his poor legal representation at his 1983 trial, given his litany of crime and the callous way that he executed his final victim it is doubtful than any jury would have voted to spare his life. Yet he managed to outlive men who were sent to death row long after he arrived, and ultimately he managed to die of natural causes.

Some have intimated that the state itself was dragging its heels, to avoid the spectacle of killing a dottering old man. With California and Alabama getting flak for recent executions of a 76-year-old and 74-year-old, respectively, just think of the clamor over the killing of a blind, deaf, crippled, demented and mentally ill 94-year-old.

So ends another chapter in America's love-hate relationship with capital punishment.

Hat tip: Kathleen

Photos: Bonnie Parker, circa 1932, credit Wikipedia Commons; Nash about 20 years ago, credit Arizona Department of Corrections; Arizona State Prison at Eyman, courtesy Department of Corrections

Skeem to give psychopathy training in Oregon

Save the date: Friday, April 9

On the heels of a hugely successful training featuring Stephen Hart of Simon Fraser University on sex offender risk assessment, Alexander Millkey and Michelle Guyton at Northwest Forensic Institute in Portland are doing it again. This time, they've scored Jennifer Skeem of the University of California at Irvine, who will provide advanced training on the controversial construct of psychopathy.

As many of you know, Dr. Skeem is an eminent scholar who has received the prestigious Saleem Shah Award for Early Career Excellence from the American Psychology-Law Society (APA Div 41) and the Distinguished Assistant Professor Award for Research at UC Irvine. She has published more than 70 scientific articles, chapters, and books, and is co-editor and an author of the excellent new book, Psychological Science in the Courtroom: Consensus and Controversy. Her research areas include psychopathy, violence risk assessment, and effective supervision strategies for individuals mandated for psychiatric care.

In this training, she will challenge prevailing assumptions that psychopathy is a unitary and homogeneous construct or something that can be reduced to a score on the Psychopathy Checklist-Revised (PCL-R). She will also present data challenging the deeply entrenched idea that people with psychopathic traits are incurable cases that should be diverted from treatment settings to environments where their behavior can merely be monitored and controlled.

The all-day training is on Friday, April 9 at Portland State University, and is followed by a networking reception with Dr. Skeem. Registrants will receive six hours of continuing education credits. The cost is only $175, or $75 for students.

For more information and to register, go to the Institute's website.

DSM-V: Get ready, get set . . . here it comes!

The American Psychiatric Association plans to launch its new DSM-V website tomorrow, February 10, publicly airing the long-anticipated diagnostic revision proposals and their criteria. I understand that two of the controversial forensic-related diagnoses I have blogged about extensively -- paraphilic coercive disorder and pedohebephilia -- are among those that made the draft manual.

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.

What is a gang?

A group of violent thugs? A social club? Troubled, homeless losers who are "hard to love"?

And what is gang membership? Is it a fixed identity, or something fluid, which urban youngsters claim or don't claim according to external circumstances and the flow of their lives?

How can we explain why, even in the roughest neighborhoods, at most 10 percent of youths belong to street gangs? Who are the other nine out of ten, and how do they negotiate survival without affiliation?

For answers to these complex questions, and more, I recommend a new book from New York University Press, Who You Claim, written by John Jay College of Criminal Justice sociology professor Robert Garot based on ethnographic researcher at a continuation school in Southern Calfornia.

Garot's nuanced analysis is a refreshing antidote to the kind of simplistic categorization that we see in corrections and in forensic practice, where young people being processed through the system are treated as if the label of gang member explains everything that we need to know about them.

His bottom-line message: Beware reifying gangs as fixed and essential components of identity, when even their members do not see them as such. As urban centers create increasingly fluid possibilities for identity -- exemplified by Polish-Brazilian and Mexican-Korean cuisines -- identity is becoming much more malleable and flexible than such a narrow and pejorative focus would lead us to believe.

My complete review, at Amazon, is HERE.