More prominent voices join chorus of DSM5 critics

With the unveiling of the draft DSM5, the chorus of well-aimed criticisms flying in from all sides is becoming truly spectacular. The latest voices are prominent scholars writing in the eminently respectable Wall Street Journal, Los Angeles Times, and Washington Post.

All three focus on what most critics agree is an especially troubling aspect of the proposed manual -- the "wholesale medical imperialization" that eventually will label nearly every human being with one or more psychiatric pathologies. The authors of the DSM, critics assert, have appointed themselves as the arbiters of what is normal and what is not.

Wall Street Journal: Psychiatry in demise

Edward Shorter, a University of Toronto professor and preeminent scholar of the history of medicine, gives a historical overview of the DSM's development to support his verdict that the latest draft manual illustrates a discipline in demise.

To flip through the latest draft of the American Psychiatric Association's Diagnostic and Statistical Manual, in the works for seven years now, is to see the discipline's floundering writ large. Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.

Los Angeles Times: Overdiagnosis gone berserk

Allen Frances, chairman of the DSM-IV task force, has been sounding the alarm over this new manual far and wide of late. This latest essay is perhaps his most eloquent to date, and of direct relevance to forensic practice in that it focuses on the proposed sexual disorders that will be used pretextually in civil commitment proceedings:

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

The sexual disorders section is particularly adventurous. "Hypersexuality disorder" would bring great comfort to philanderers wishing to hide the motivation for their exploits behind a psychiatric excuse. "Paraphilic coercive disorder" introduces the novel and dangerous idea that rapists merit a diagnosis of mental disorder if they get special sexual excitement from raping….

Frances urges the public to pay attention and voice opposition to psychiatry's "recklessly expansive suggestions" before the juggernaut becomes unstoppable:

This is a societal issue that transcends psychiatry. It is not too late to save normality from DSM-V if the greater public interest is factored into the necessary risk/benefit analyses.

Washington Post: George Will weighs in

Finally, prominent political columnist George F. Will weighed in on the moral implications of the proposed diagnostic expansions. Will expressed worries about the legal consequences of excusing amoral conduct as a symptom of uncontrollable illness.

The 16 years since the last revision evidently were prolific in producing new afflictions. The revision may aggravate the confusion of moral categories.

Today's DSM defines "oppositional defiant disorder" as a pattern of "negativistic, defiant, disobedient and hostile behavior toward authority figures." Symptoms include "often loses temper," "often deliberately annoys people" or "is often touchy." DSM omits this symptom: "is a teenager." …

[C]onfusion can flow from the notion that normality is always obvious and normative, meaning preferable. And the notion that deviations from it should be considered "disorders" to be "cured" rather than stigmatized as offenses against valid moral norms.

Now that just about every major news outlet in the United States has run highly critical analyses, the question becomes: Will the American Psychiatric Association listen? Or, like an individual in the throes of a manic episode, will it continue its pell-mell rush to diagnose all human behaviors, creating an ever-broader assortment of bizarre pathologies?

Hat tip: Bruce

Breaking news: Mitchell labeled as malingerer, ruled competent

Checking for updates on the Elizabeth Smart case for tonight's lecture on competency restoration, I see that the judge ruled just moments ago that Brian David Mitchell is competent to stand trial.

In an opinion that went on for a hefty 149 pages, U.S. District Judge Dale Kimball agreed with prosecution psychiatrist Michael Welner that Mitchell is a psychopath who is faking mental illness to avoid criminal responsibility. The 56-year-old alleged kidnapper "does not presently suffer from a mental disease or defect that impedes his rational and factual understanding" of the proceedings against him, the judge ruled.

The decision came after a 10-day competency hearing at which Dr. Jennifer Skeem testified that Mitchell suffered from a delusional disorder and was incompetent.

Judge Kimball's 149-page ruling is online HERE.
Today's Associated Press coverage is online HERE.
My previous coverage of the case includes:

• "Legal pointillism": New approach to competency
• Epic competency hearing continues
• Record-breaking fee for competency report?
• Mitchell slated for epic competency hearing
• Utah court: OK to forcibly medicate accused kidnapper

DSM: Paraphilia controversy escalating

Brouhaha hits Land Down Under

Last week, I reported on a scathing denunciation by Allen Frances, MD, chair of the DSM-IV Task Force, of the draft proposal for the 5th edition of the diagnostic manual. Frances was particularly critical of the proposed sexual disorders, calling pedohebephilia "one of the most poorly written and unworkable" proposals to surface.

Now, Kenneth Zucker, chair of the DSM-V Sexual Disorders Work Group, has fired back in a letter to the Psychiatric Times. Defending not only pedohebephilia but also the other two controversial diagnoses of Hypersexual Disorder and Paraphilic Coercive Disorder, Zucker accused Frances of shooting from the hip, and "fir[ing] off criticisms as quickly as his grandchildren might tweet to their friends."

Frances fired right back, reiterating critics' central concern that these disorders lend themselves to "a grave misuse of psychiatry by the legal system in the handling of sexually violent predators”:

Every new diagnosis suggested for DSM5 requires (but has not yet received) a searching risk/benefit analysis and a thorough forensic review. I am confident that none of the suggestions for new diagnoses made by the Sexual Disorders Work Group would stand up to such scrutiny.

Today, experts in the Land Down Under chimed in with concern over Paraphilic Coercive Disorder. "Fears proposed new illness will be misused in court by rapists," reads the headline in the Sydney Morning Herald.

The reemergence of a proposal that was soundly rejected as a diagnosis in the 1980s "has come as a surprise to some psychologists," Nick Miller reports.

Lisa Phillips, a senior lecturer in psychological sciences at the University of Melbourne, echoes Frances' concerns over the potentially far-reaching legal implications of pathologizing rape as a mental disorder. Reiterating the concerns of feminists back in the 1980s, she said it could be used by rapists to avoid criminal responsibility for their acts.

This point fits with an intriguing insight by the brilliant legal scholar Eric Janus, who has written and lectured extensively on sex offender civil commitment and psychology-law topics more generally for the past couple of decades.

In Failure to Protect: America's Sexual Predator Laws and the Rise of the Preventive State (a book I highly recommend), Janus argues that the "tabloid model of gender violence" epitomized in sexually violent predator laws has -- perhaps accidentally -- become a powerful force for the politically conservative agenda of dismantling hard-fought feminist rape reforms. Like the newly proposed diagnoses, these laws favors biological and psychological explanations over sociocultural ones, and supports the patriarchal rape myth that rapists "lack control" over their sexual impulses.

Imagine the dustup if feminist psychiatrists and psychologists take note of these ersatz diagnoses and link up in opposition with legal scholars and psychologists concerned about their pretextual uses in civil commitment proceedings. And that's before transsexuals, furious over the Work Group's Gender Identity Disorder proposals, join the vocal chorus.

Napa Hospital chief arrested for sexual assault

Police marched into California's largest psychiatric hospital today and arrested its executive director on 35 felony charges stemming from the alleged molestation of a foster son for more than a decade. The alleged victim, who was 10 when the abuse allegedly began, came forward when he learned that Claude Edward Foulk Jr. was in charge of the hospital. Foulk is suspected of molesting at least four other boys going back to the 1970s.

Foulk was appointed to head the beleaguered hospital in 2007, shortly after the U.S. Attorney General's Office negotiated a consent decree mandating sweeping changes aimed at improving patient care and reducing suicides and assaults. The federal investigation had revealed widespread civil rights violations at Napa, including generic "treatment" and massive overuse of seclusion and restraints. Napa is the only state psychiatric hospital in Northern California, and houses defendants undergoing competency restoration treatment and those found not guilty by reason of insanity.

At the time of his appointment, Faulk was lauded for his lengthy career in mental health services in both the private and public sectors, according to news accounts.

The arrest, breaking news on television and in print media across the country and even internationally, will do nothing to boost staff morale, already abysmal at Napa and elsewhere in California's state hospital bureaucracy. It surely won't improve patient care, either.

Blogosphere recommendations

Mind Hacks

I have been checking out Mind Hacks since it featured a really nice review of my blog. The blog evolved out of the 2004 book by the same name, in which authors Tom Stafford (a cognitive neuroscientist) and Matt Webb (an engineer and designer) provide 100 exercises that teach readers neuroscience theories through games and tricks.

Among the scientists who contributed "hacks" is Vaughan Bell, who seems largely responsible for keeping the blog alive through his quirky and eclectic posts. Dr. Bell is a psychologist currently working in Medellín, Colombia and also a visiting research fellow in the Department of Psychological Medicine and Psychiatry at the Institute of Psychiatry, King's College London.

Just to give you an idea of some of his near-daily offerings, he recently posted on everything from decorative skull shaping to dream smoking (that's when you dream about cigarettes after you quit smoking) to new research on cave paintings. I particularly enjoyed his link to an amazing Russian website that features historical art by and about the mad. It reminded me of when I was living in Paris at age 10 and was influenced by an exhibit of art by schizophrenics that my mother took me to at the Louvres museum. More somberly, the prolific Bell reported on a new study in the Journal of Adolescent Health finding that it's a myth that teens think they are invincibile; actually, they greatly overestimate their chances of dying soon. I found it interesting, because the behaviors that result from either thinking error could look very similar.

The psychology of the angry American

Elsewhere in the blogosphere, my forensic psychology colleague Paul G. Mattiuzzi in Sacramento has an interesting analysis at his Everyday Psychology blog of the psychology of the pilot who intentionally crashed his plane into an IRS building in Austin, Texas on February 18.

Dr. Mattiuzzi based his analysis on the diatribes that Joe Stack wrote before taking his last flight. Although Mattiuzzi doesn't specifically reference the so-called Tea Party Movement, his comments on the "lunatic fringe" seem to apply to these disaffected white Americans:

There is in this country today, it seems to me, a gathering storm of mindlessly angry people who are "fed up" for reasons they can barely explain. There are people in the media who are telling them they should be angry, and perhaps more importantly, that they should be afraid….

[These] people have come to identify the government as an enemy of the people. They are grandiose in their belief that they understand it all better than anyone else. They are self-righteous in their indignation and in their resentment. They express a sense of entitlement, arguing that they have a right not just to their own opinions, but also to their own facts. They shout until no one can hear them and then complain that no one is listening. They expect their individual voice to prevail and then complain that they have been denied representation. They do not wish to contribute to the common good, but demand all the benefits they have been promised. Like Stack, they bemoan corporate greed while demanding that greed be unfettered.

Dr. Mattiuzzi hopes that acts like Joe Stack's do not inspire copycats. As he concludes (in my favorite lines from his essay):

Joe Stack wanted us to believe that in his abject failure, he had achieved success. It's as if he listened to only part of what Bob Dylan once sang ("there's no success like failure"), without bothering to stick around and hear the end of the lyric: "and failure's no success at all."

Mind Hacks is HERE. Everyday Psychology is HERE.

Calif.: Legal training on competency assessment

March 24-26 conference to offer MCLE credits

I've gotten a surge in queries from psychologists interested in being supervised as they embark into the tricky area of court-ordered competency-to-stand-trial assessments. With that need in mind, I'm excited that the Forensic Mental Health Association is featuring a special "legal track" on competency at next month's conference. It won't adequately train folks in the nuts and bolts, but they can get the lay of the land and become aware of some of the pitfalls and controversies.

One of the sessions that looks is especially interesting is on "Expert Qualifications and the Adequacy of Court-Ordered Evaluations." Having seen plenty of deficient, drive-by evaluations caused by a combination of the courts' low standards and low pay, I am happy to see this area getting some much-needed attention. The co-presenters are Judge Kurt Kumli of Santa Clara County, a nationally recognized expert in juvenile law and policy, and attorney David Meyer of USC's Institute of Psychiatry and Law.

The opening session of the legal track will address practical issues of enforcing court orders for competency restoration in state hospitals, jails, and conditional release programs. Again, this is a topic ripe for attention, as many competency restoration programs are sorely deficient.

Other sessions of the competency track will focus on juvenile competency, procedural changes in assessing trial competence in California, and the assessment of malingering. In addition to the usual continuing education credits for mental health practitioners, the track will offer MCLE credits to attorneys.

In addition to this special legal track on competency to stand trial, the March 24-26 conference features other high-caliber offerings:

• Judge Stephen Manley of Santa Clara County will present a keynote address on collaborative courts in California

• Stephen Behnke, JD, PhD and director of the APA Ethics Office, will review evolving conceptions of clinicians' duty to protect under Tarasoff

• Stephen Miles, a professor of medicine at the University of Minnesota, will muse on lessons prison clinicians can learn from the involvement of psychologists and physicians in abusive interrogations in war-on-terror prisons

Your faithful blogger, Karen Franklin, is also presenting at the conference, on one of my favorite topics, "Ethical Considerations in Psychiatric Diagnoses in Forensic and Correctional Settings."

Finally, I just have to mention the most bizarre session I came across: "A psychiatric-legal analysis of a case of lycanthropy in a 19th-century serial killer" (presented by doctors J. Arturo Silva and Douglas Tucker). Yee-gads! With pop culture's current fascination with all things supernatural, that's one session I just must attend!

Registration is still open for the March 24-26 conference, although the "early-bird rate" ends March 1. Joining the FMHA earns you an additional $25 discount off the cost of registration. The conference is down in Seaside, California (by Monterey), so it's a scenic venue for those of you who might want to bring family. More information and the registration form are HERE.

Illustration: 18th century engraving, courtesy Wikipedia