Where’s my DSM-5?
October 10th, 2013
Back in 2012, I participated in the field trials for the DSM-5. 5000 clinicians enrolled in the Routine Clinical Practice trial. It was a trial in a way that I don’t think the American Psychiatric Association intended, and only 700 of the enrolled persisted through the training, the paperwork, and the incredibly tedious interview process long enough to complete it. I am proud to say I was one of them. I wrote about this in The Book of Woe, so you can read about it there if you haven’t already.
The APA promised us collaborating investigators (a name whose VIchyesque overtones sort of creeped me out) a few goodies in return: Some continuing education credits, a frameable certificate, our names in the back of the book, and a free copy of the DSM-5. That’s a $200 value, which, after the eight hours of training and the six hours of running the trial, comes to about $15/hr., which is more than I would have made at McDonald’s.
I did get my certificate, which even came with a black mat. I got my CEUs. I got a nice letter thanking me for my service. And late in May, a week after the DSM-5 was released, I got this positively effusive email from Lisa Countis, the manager of field operations for the APA.
From: Lisa Countis <email@example.com>
To: ApaResearch <firstname.lastname@example.org>
Sent: Friday, May 24, 2013 5:18 PM
Subject: DSM-5 Field Trials Participants: Delivery of your DSM-5
Dear Collaborating Investigators,
The DSM-5 was released to the public on May 22nd. Your copy of the new DSM will ship from the publisher within the next few days and should arrive within 2-3 weeks. Thank you again for your support and participation in the Field Trials – your input played an important part in the refinement of the diagnostic criteria. Additionally, the input we received from you throughout the study recruitment, training, and implementation process has been invaluable in informing subsequent DSM-like studies. We have learned a lot from you!
Well, those 2 or 3 weeks have come and gone many times, and I still don’t have my DSM-5. It’s hard to imagine that, after all my support and participation and all the influence I have had on DSM-like studies and all they learned from me, they would stiff me. But I have emailed Lisa Countis a few times. I’ve been cordial and polite and she initially was cordial and polite back, promising to look into it that very day. But I never heard back. And now she’s not returning my emails.
I suppose it’s possible this is just an accident, but somehow I think this might reflect a certain, I don’t know, animosity on the APA’s part toward me. Now I can understand them being so sore with me that they wouldn’t want to send me a free copy of the DSM-5. But they should have thought of that before they promised me one, or, for that matter before they let me into their clinical trial. Not only that, but their book is #15 in the amazon rankings, better by an order of magnitude than mine, and the least they could do is be magnanimous in victory. Besides, a deal is a deal, right? And if they don’t make good on it, I’ll never know–unless I shell out the two hundred bucks (actually, it’s down to about a hundred on amazon, but that is still a hundred dollars more than it costs to download the ICD codes, which will suffice for my clinical purposes)–if my name is indeed in the back of the book.
So I’m asking for a little help here. I don’t want to flood Lisa Countis’s email box, but the APA’s research arm has a general mail box. It’s email@example.com. Perhaps you could drop them a line urging them to make good on their promise and liberate my copy of the DSM-5. Maybe tell them that it doesn’t look good when an organization so crucial to the social and moral life of our society doesn’t honor its promises. Or that it looks really menschy when you play nice with your critics. Anyone who can prove they were instrumental in getting me a copy will get a nice signed hardcover version of Manufacturing Depression (while supplies last) and my everlasting thanks. I promise!
September 20th, 2013
This will be the name of my next band. It’s also the name that the National CAncer Institute has suggested for certain “non-malignant conditions” that are currently called cancer, like ductal carcinoma in situ, a lesion that often shows up on mammograms and scares the bejesus out of women, not to mention leads to all sorts of treatments. “The word ‘cancer’ often invokes the specter of an inexorably lethal process,” an NCI panel wrote in JAMA. “However, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime.” And detection of these indolent lesions, they continue, can be dangerous because it leads to unnecessary procedures.
I remember when my first wife got one of those phone calls about a funny mammogram, the kind that only come on a Thursday or Friday and leave you to worry all weekend. By the time we got to the follow-up visit early the next week, we were both nervous wrecks, she, understandably, more than I. As we were crossing the street to the hospital, she realized she had forgotten something in the car, which upset her even more. She spun around to return to the car. The pavement was a little wet from an earlier rain, and she slipped and fell. She was not injured, but it was the kind of accident that happens when you feel like your life is out of control, and seems to embody your situation. For a moment it seemed like misfortune would just cascade forever.
She turned out to be fine. Even better, the tests didn’t require all that much of her (aside from the time and worry)–no needle biopsies, no radiation-assisted scans, no knives. But that;s not always the case. Many of these screening tests–mammograms, pap tests, PSA assays–turn up “precancerous” or nonmalignant conditions on a frequent basis and lead to what the NCI panel calls overdiagnosis, which in turn leads to overtreatment. Between the stress of the diagnosis and the dangers of the follow-up tests and treatment the problem is a serious one. And much of it can be attributed to the effect on both doctor and patient of the word “cancer.” So, the panel reasonably concludes, the “the term “cancer” should be “reserved for describing lesions with a reasonable likelihood of lethal progression.” If it probably won’t kill you, in other words, it doesn’t deserve to be called cancer.
By recognizing the effect of nomenclature on people and on the society that pays for these treatments, these doctors are taking responsibility for unintended consequences of their profession’s actions. They’re implicitly acknowledging that some of those lopped off breasts and excised prostates have been sacrificed without cause, and that the harms suffered–pain, disfigurement, impotence, incontinence, surgical complications–have been unnecessary. They’re not hiding their proposal in a murky claim about the science demanding these changes, as if some new instrument had allowed them finally to map the boundaries of cancer, but rather acknowledging the contingency of those boundaries and suggesting that they be renegotiated for what amount to pragmatic and social reasons, not scientific ones.
Contrast this with the American Psychiatric Association’s studied avoidance of acknowledging the pragmatic and political motivations behind some of the changes they made in the DSM-5, especially the change in the ASperger’s diagnosis. The APA was surprised to hear that the diagnosis had bestowed an identity on people with Asperger’s–a naivete that seems nearly willful, given the high profile of the disorder and the idea of “neurotypicality” that is spawned. And they were adamant in denying that they were trying to rein in the diagnosis or do anything of the sort, resorting instead to scientific mumbo-jumbo that was embarrassingly ineffective and only highlighted even further the contingent nature of the category. Of course, they can’t exactly do that, because unlike oncology, psychiatry can never touch bottom; there is no end to the contingency and uncertainties of psychiatric diagnosis, whereas an oncologist can at least see a neoplasm, even if they have to struggle over what to name it. So psychiatrists have to avoid what the cancer docs can face head on. What is straightforward, even common sense, for cancer doctors is taboo for psychiatrists. This is probably why the APA hasn’t seized on the very public NCI statement and used it as an illustration of its claim that psychiatry just isn’t that much different from the rest of medicine.
But there’s something else about the NCI paper that should really grab attention. It;s right in the opening paragraph.
Over the past 30 years, awareness and screening have led to an emphasis on early diagnosis of cancer. Although the goals of these efforts were to reduce the rate of late-stage disease and decrease cancer mortality, secular trends and clinical trials suggest that these goals have not been met; national data demonstrate significant increases in early-stage disease, without a proportional decline in later-stage disease.
I think what they’re saying here is that they’ve managed to identify (and presumably treat) a lot more early-stage disease, but not to prevent late-stage disease, i.e., death from cancer. Early detection, in other words, doesn’t necessarily improve the picture for many cancers. What it does do is to identify and treat succesfully a lot of cancers that might not have gone on to kill people, or even harm them for that matter. So the claim that medicine has gotten better at treating cancer, the one you see in ads for cancer centers or hear about from proud oncologists, is not as true as we might like. The number of successfully treated cancers has certainly gone up, but so has the overall number of cancers, and many of those “successful” treatments were also unnecessary. I don’t think anyone has done this on purpose, but the overall effect here is disconcerting.
Mistakes Were Made
September 19th, 2013
First Richard Friedman admits that the neurochemical imbalance is a myth. Now Nancy Andreasen tells The New Yorker that the biological revolution was oversold. Is that the Four Horsemen I see coming around the corner?
Andreasen isn’t just any psychiatrist. She has been one of the leading neuromantics of the past thirty years. She is the author of books like Brave New Brain, The Broken Brain, and The Creating Brain (detect a theme here?), and has made a career of breathless proclamations of psychiatry’s scientific triumph over the scourge of mental illness. In 1984 (!) she enthused that “The biological revolution in psychiatry has already occurred.” And in a way she was right. By then, psychiatrists and bureaucrats had already convinced each other that now that they had drugs that could treat serious mental illness, it would be a good idea to empty the psychiatric hospitals and scatter their patients to the streets of American cities to be treated as outpatients.
Four years later, fresh off that triumph, drug companies brought Prozac and then Paxil and Zoloft to market, and soon enough 20 percent of the American citizenry was taking psychiatric drugs to treat those biochemical imbalances that nearly all of us believed in. In the meantime, as Freudian theory was bashed by everyone from a retired Berkeley professor of English to the author of the DSM-III to Peter Kramer, the idea that psychological symptoms had actual meaning, that the things people thought and felt and said were something more than the random noise generated by the broken brain, and that people who treat the mentally ill should actually listen to what they have to say–that idea all but disappeared in favor of listening to the drugs and to the brains they theoretically treated.
Viva la revolucion.
All along, of course, people (including me) have been counseling restraint, wondering if it was really a good idea to deprive the mentally ill of their refuges, or to incorporate psychoactive drugs into our daily diet, or to tell the people over and over again about chemical imbalances that were invented in marketing departments rather than discovered in the lab (especially when the measured results of the treatments were equivocal at best) or to abandon the notion that what we think and feel and say is meaningful, and in so doing to undermine a notion of human agency that in its half millennium had brought us democracy, science, technology, and the notion of universal human rights. For their note of caution, these people were routinely diagnosed: as ignorant dead-enders, as Popes against Galileo, as guild members fighting for market share, as counter-revolutionaries standing in the way of progress.
And now, in a New Yorker piece about how the content of delusions seems to be changing with the times (and how could it not? Schizophrenic people in ancient times didn’t have a CIA to worry about, so they heard God’s voice instead) and therefore may indeed be of interest, Andreasen says the biological revolution went too far. “You can’t treat a person as a purely biological creature,” she says. Which is pretty obvious to you and me, but when you’ve made your living saying (and doing) (and encouraging your peers to do) the opposite, it can be an epiphany.
Now, it would be nice if Andreasen took a page out of Al Frances’s book and acknowledged her role in the overselling of biological psychiatry, or at least showed some understanding of the vast disaster it has caused in some people’s lives, and,. in a diffuse way, in society at large. Where is the remorse for having let herself get so carried away? Where is the acknowledgment of the effects of this mistake?
On the other hand, Antonio Egas Moniz didn’t return the Nobel he won in 1939 for inventing the transorbital lobotomy.
Maybe Andreasen did make a thorough account of herslef this and the New Yorker chose not to report it. But I sort of doubt it. Because listen to her explanation of why it might be a good idea to treat a person as, well, a person.
When you have a therapeutic relationship, you can manage the dosage better. You can talk to the patient about their side effects. Compliance goes up. The patient gets better more quickly.
It’s important to have a “therapeutic relationship,” in other words, so you can get better at prescribing drugs. Listening to the patient is just another way of listening to Prozac, which is just another way of listening to the brain, which, poor broken thing, is stuck trying to communicate with language. The rediscovery of the patient is only in service of making the revolution more efficient, or at least as efficient as it can be while we await the day we can cut out middleman completely.
And while I don’t want to bite the hand that feeds me occasionally too hard, I have to point out that the New Yorker, in turning to Andreasen and Ben Sadock and Joel Gold to enunciate the return of the repressed (not to mention in choosing such a fluffy example, the Truman Show syndrome) has sort of missed the boat here. Not that I have anything against them (and Sadock in particular has been very cordial in email with me), but they appear to be just discovering (or rediscovering) the idea that content has meaning and are hardly the most effective or knowledgeable advocates of that idea. Meanwhile, people like Gail Hornstein have been writing about the importance of the content of delusions for years–and not just to say that they draw from the well of popular culture or that they have value as therapeutic adjuncts, but that they can help us understand the delusional person and maybe even help him or her. Or Mary Olson and Jaakko Seikkula, who are old hands at taking the psychotic person as more than the unfortunate victim of a broken brain. Listening to them–now, that would be a revolution.
That reminds me
September 17th, 2013
My little aside about obesity as a disease reminded me of a story that illustrates just about everything that’s wrong with everything.
Back in the early aughts there was great hope for drugs called CB-1 receptor antagonists to treat obesity, notably one invented by Sanolfi-Aventis and called rimonabant. The idea was simple, or at least it was self-evident to anyone who might have smoked marijuana. The CB-1 receptor is stimulated by pot. (CB stands for cannabinoid; we have many different cannabinoid receptors in the brain, which is how pot does its thing.) Pot causes munchies. Therefore, if you block activity at the receptor, you can cause anti-munchies. Loss of appetite leads to less eating leads to weight loss, less diabetes and other metabolic diseases, and no more overflow on airplane seats. A win-win.
Except for one thing. On exactly the same logic, blocking cannabinoid receptors is going to cause anti-highness, or what the doctors like to call depression. I mean, it’s pretty obvious that a neural system that, when stimulated, makes you feel excellent is going to make you feel sort of lousy if it is suppressed. What were those scientists smoking when they forgot this?
And sure enough, although rimonabant was effective at making rats lose weight, and even some people, it also caused depressed mood with enough frequency and severity that the clinical trial was halted and the drug removed from the pipeline.
And here’s the funny part. In the wake of rimonabant’s demise there was a series of papers like this one offering solace to researchers by recounting what they had learned through the CB-1 antagonist adventure, and what other adventures lay in store. One of those suggested adventures was a foray into the world of depression treatment, once again on the same logic. As the scientists pointed out, “the reported clinical evidence that the CB1 antagonist rimonabant increases the risk of depression and anxiety, support the notion that the endocannabinoid system represents a novel target in the treatment of mood disorders.” Find a drug, in other words, that targets the cannabinoid receptors, and you might be onto something. You might discover a compound that makes people feel better, gives them pleasure even. I wonder what they’ll call it. Here’s my vote: marijuana.
In Other News
September 16th, 2013
The State of New Jersey has become the second state to outlaw reparative therapy for homosexuality. That’s what its advocates call it, at least they used to. Now they generally dare not speak its name, instead calling it “sexual orientation change effort.” I like the name some gay activists have invented for it: “pray the gay away.” Whatever you call it, it’s no longer legal in New Jersey, at least not when it’s practiced upon minors, and just ten days after the law passed, the Ninth Circuit Court of Appeals upheld a similar law passed in California a couple of years back. It was a bad end of August for the idiots out there who worry about who is sticking what into whom–a subject whose minute details they seem awfully intimate with and preoccupied by, especially when it concerns nubile youth.
In case it is not clear, I have no use for people who argue, from natural law or Biblical law or evolutionary doctrine, that homosexuality is a Bad Thing. Love is rare and life is hard and it is cruel to tell people who find themselves attracted to or in love with members of their own sex that they should stifle themselves. We’ll all be plenty stifled when we’re dead.
In the meantime, you could do a lot worse for a watchword than “only connect.” In fact, when I attended a conference run by the National Association for Research and Theapy of HOmosexuality a few years back in Orlando, I was pretty sure I was seeing a fair amount of connecting going on among the attendees, many of whom had supposedly been cured of their gayness–a fleeting glance in an elevator, hugs that went on just a tad long, the constant attention to the details of erotic life. Packed together into a windowless room across the road from the Magic Kingdom, their stifled desire seemed to be breaching its banks. I even got asked out on a date (or so I wanted to call it) by a tall dark man from Azerbaijan, an ex-gay, ex-Muslim, born again psychiatrist who wanted to go see Borat with me but at the last minute got a better offer. Too bad. I am sure we would have loved watching the wrestling scene together.
But I digress. Much as I don’t like these people, I think you have to admit they have a point in their opposition to these laws. Not on the mindless libertarian principle they cite–that these laws infringe on the therapist’s right to choose the proper treatment, the patient’s right to choose to change something about him or herself, and parent’s rights to look after their children as they see fit. I mean, all of that is true, the laws do this. That is their explicit point, and explicitly because they hold that sexual orientation is not in the domain of things that can be chosen. Therefore, they say, reparative therapy is not the upholding of freedom, but rather a way to oppress people. Outlawing it is no worse than outlawing bloodletting or trepanation or, for that matter, slavery.
In real life, I am sure this is exactly how reparative therapy works. Parents scared to death that their children will grow up to be gay, and encouraged by their pastor or someone’s aunt, haul the kid they just discovered in an illicit embrace with one of their same-sex schoolmates to the nearest therapist who the pastor or aunt knows to have helped someone go straight. The point of the therapy is to change the child’s desire such that he wants what he is supposed to want, and what his parents (and probably at least sometimes the kid himself) wishes he wanted. It is inherently oppressive, in other words.
Now it turns out that sexual desire is pretty obdurate. You can shock and threaten and torture people. You can show them same-sex porn, tell them to masturbate to it, and then, right before they come, switch the to the opposite-sex channel. You can pay sex surrogates to copulate with them in hopes that a little professional swiving will show them the light. None of that seems to work very well. People want what they want.
But that’s not to say that sexual orientation never changes. It’s not even to say that sexual orientation exists, at least not in the same way that lefthandedness or eye color exist. The idea that we have to be one way or the other is a relatively recent one, maybe 150 years old, and it’s all caught up in Victorian Europe and its ideas about taking the measure of the species and cultivating it like some kind of fine garden. And there are notable exceptions, especially among women, at least some of whom seem to be relatively fluid in their sexuality. The problem here is most likely in the notion of a fixed orientation, which fits many different political agendas, but does not seem to fit us very well. Unfortunately, the notion of a fixed orientation is also the key to many of the advances gay people have made in the last half century, starting with the deletion of homosexuality from the DSM. If gay people were indeed born that way, then it is foolish as well as inhumane to try to change them.
So here we have another one of those myths, or noble lies, or whatever you want to call them–this time, that sexual orientation can’t change. If this is what it takes for your average state legislator to pass laws ending discrimination or allowing gay marriage or even outlawing conversion therapy, then I say let’s not worry too much that it is bullshit. But just as “born that way” can become a burden when events prove it incorrect, so too outlawing therapy based on the notion that people can’t change might also prove to be a bad move. After all, it seems like every day neuroscientists are telling us about some other capacity or tendency that is beyond our control. Just today, in fact, NPR reported on the American Medical Association’s decision to make obesity an official disease. “We’re all wired in slightly different ways,” a doctor told the reporter. Which means, says another doc, “if you have that genetic susceptibility to gain weight, you will gain weight easily, no matter what.” Fat people were born that way, in other words.
But that doesn’t mean they can’t be cured. As the NPR story makes clear, the disease designation will make it easier for patients to get treatment; that. as I’ve said millions of times, is exactly what it means to call something a disease. It will also make gastric reduction surgery and/or anti-obesity drugs more attractive to more people. “Born that way” is increasingly not so much a justification for not changing something as it is a way to put that change into the hands of medical science, whose unacknowledged ability to reach deep into our persons, into our sense of agency, into our ways of experiencing the world, also seems to be increasing. It’s an invitation to the geneticists and the brain docs and their drug company patrons to figure out how to intervene, and I guarantee you that somewhere some scientist is slaving away at the question of how to change sexual orientation. It’s as if the category itself had been invented so that it could be eradicated.
I suppose if this happens, at least some of us will be glad for those laws, although once a “cure” for homosexuality is discovered, the laws will be seen as outdated and scientifically unsound. In the meantime, I for one am glad that the born that way myth reigns. This is an extremely stupid society living through what is perhaps one of its stupidest eras, and I’ll take any glimmer of light. Surely the idea that people should be free to love whom they love is way too radical for us. But mark my words. Live by the lancet, die by the lancet.
And in the meantime, if state legislators really want to protect children from oppression masquerading as mental health treatment , maybe they ought to turn their attention to the unfolding atrocity of children on antipsychotic drugs. Or maybe to the fact that 14 percent of American families are living in poverty, and 20 percent of American children. But that’s for a different day.