Tuesday, June 30, 2009

DSM-V The Twisted Perverse Myth that wants to Peek into your Bedroom

DSM5 - The Twisted Perverse Myth that wants to Peek into your Bedroom

When you think this comic book called the DSM-5 could not get any more ludicrous and strange; those egocentric APA psychiatrist take it to the OUTER LIMITS of complete audacity.

I have to give the Doug Bremner MD's Blog { Dr. Bremner works at EMORY UNIVERSITY} and
The Carlat Psychiatry Blog a hat tip and credit here {as a disclaimer I have to say I have disagreed with both these blogs before vehemently; but this information is just too good not to let bygones be bygones for now at least}.

I have re-posted their articles here; but you should visit their blogs to get involved in the comment section free for all that should be fairly entertaining on this topic no doubt.


Woman with Nice Ass

DSM Shadow Team: Female Sexual Dysfunction? (And Kupfer et al Strike Back)

I have been writing about the DSM process which isn’t always easy to do because the head of DSM-5, David Kupfer, MD, runs a pretty tight ship with his committee members, making them sign confidentiality agreements and not take any notes. Well since he said that there would be a “paradigm shift” and the sky is the limit for coming up with new diagnoses, there has been a lot of interest in the process.

I recently wrote about the editorial by Allen Frances MD, head of DSM-4, criticizing the current process of DSM-5, and now there is a nasty response from the DSM-5 group, authored by Alan Schatzberg MD, James Scully MD, David Kupfer MD, and David Regier MD, that psychiatry blogger Daniel Carlat MD offered to edit for them to make it more respectful. Lol. A blogger offering to help the leaders of academic psychiatry tone down their language. Lol again.

I mean the damn editorial hasn’t even been published yet.

In their response to Frances Kupfer et al make dubious claims that “attorneys” had advised them to have committee members sign confidentiality agreements to protect “intellectual property”. They also charge Frances (as well as Robert Spitzer MD, who founded DSM and has been making the email rounds with criticism of the current process) with greed in wanting to retain royalties from a book he wrote about DSM-4 which would become outdated after the release of DSM-5. I mean anyone in the business knows that book royalties pale in comparison to the hundreds of thousands of dollars to be had doing pharmaceutical industry consulting and speaking. In fact one could even argue that doing things like editing books (which have essentially no revenue, because hardly anyone buys them) is a feather in the cap that helps you get those more lucrative gigs.

One of the diagnoses on the table is Female Sexual Dysfunction (FSD), a “disease” that if accepted would surely drive the drug companies to “identify and treat” these poor lassies with drugs like the testosterone patch (see “Wow A Drug To Have Sex Once More a Month? Sign Me Up!“) or Viagra or whatever psychotropic they could drug out of the medicine cabinet.

Turns out the medicalizing women’s sexuality may not be such a good idea. There is a long and jaded history of evil meddling by medical doctors in this area. The publication of the book Feminine Forever, whose thesis was that post-menopausal women become shriveled asexual crones due to an estrogen deficiency led doctors to put an entire generation of post-menopausal women on hormone replacement therapy (HRT), which in turn was later found to have caused tens of thousands of deaths from heart attack and other problems.

Then there were Masters & Johnson, the famous sex research team who concluded that women had more frequent orgasms than men.

This “research” however was based on looking through peep holes at brothels, and later their “research sessions” they conducted with each other. Virginia Johnson was Dr. William Masters secretary, and they “partnered” to have sex on a nightly basis for “research” purposes for years. Their report on 67 patients with unwanted homosexuality showing a 70% conversion to heterosexuality using “conversion therapy” was later disclosed as a fraud when noone could find any evidence of the patients. This bizarre “research team” should hardly be taken seriously about women’s orgasms.

Turns out that the DSM-4 has ‘Female Hypoactive Sexual Desire Disorder’ and ‘Female Hypo Orgasmic Disorder’ (I mean did the guy try going down on her?) as well as Dyspaerunia (painful sex). As a recent editorial pointed out, maybe the 43% of women with some type of so-called sexual dysfunction are acting “appropriately”.

I mean, maybe they’re with jerks and don’t feel like doing it?

The American Journal of Psychiatry has been soliciting editorials on the DSM-5 process. Too bad they rejected the editorial by Robert Spitzer MD who founded the DSM, and for FSD they have only this lame piece by a trio of MDs whose pharma disclosures read like a phone book. Lol. Sort of.

Ray Moynihan had a good piece in bmj on FSD (“FSD: The Making of a Disease”) in which he outlines how industry has moved in a serious way to pour cash in the “research and education” of this newly minted disorder, the rife conflicts of interest in the field, and the attempt by drug companies to medicalize female sexuality.



Psychiatry's DSM-V Process Now a Bar Room Brawl

Psychiatry’s diagnostic manual is due for a revision. But what began as a group of top scientists reviewing the research literature has degenerated into a dispute that puts the Hatfield-McCoy feud to shame.

The latest installment in this remarkable episode of American psychiatry involves an editorial by Dr. Allen Frances, the chairman of the committee that created the current version of the the DSM, the DSM-IV. The editorial has not even been officially published (it is in press at Psychiatric Times) but already it has made the rounds of the blogs and is being read and debated widely. Now, the APA has just released this rather stunning response.

Those who are not in psychiatric circles might find their eyes glazing over a bit as they read these articles. But we are witnessing here something dramatic and important. Psychiatry is wrestling with its identity, and in the process is creating the next set of ideas that will guide how real people are diagnosed and treated for years to come. The stakes for everybody are high.

In his editorial, Dr. Frances criticizes the evolving DSM-V on multiple levels, and makes the following claims:

--The process of writing the manual is less transparent and less inclusive than the process he oversaw when he chaired the DSM-IV committee

"The simple truth is that descriptive psychiatric diagnosis does not need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM-5."

--The main change being proposed—the official inclusion of a series of rating scales into the diagnostic criteria—is poorly conceived because busy clinicians will reject this extra paper-work.

--Other proposed changes in DSM-V will make it too easy to over-diagnose a range of conditions:

“The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatment--a bonanza for the pharmaceutical industry but at a huge cost to the new false positive "patients" caught in the excessively wide DSM-V net. They will pay a high price in side effects, dollars, and stigma, not to mentions the unpredictable impact on insurability, disability, and forensics.”

Frances’ article is compelling, not only because of the substance of his arguments but because of his clear and forceful writing style. With each sentence, you get a sense that this man has carefully thought through all of these issues and is passionately concerned about the future of his field.

The APA’s response, on the other hand, is a weird mixture of bureaucratese and mean-spiritedness. The bureaucratese I can understand—after all, this is a letter crafted by committee. But the nasty tone of the response is astonishing and undignified.

The APA gets off to cringing start by calling Frances and his colleagues liars:

“The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., submitted to Psychiatric Times contains factual errors and assumptions about the development of DSM-V that cannot go unchallenged. Frances now joins a group of individuals, many involved in development of previous editions of DSM, who repeat the same accusations about DSM-V with disregard for the facts.”

Wow. Can’t grown men have disagreements with one another without resorting to this kind of language? I might have started with something more like, “The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., is a thought-provoking critique of the DSM-5 process. While we respect and appreciate Dr. Frances’ leadership in American psychiatry over the years, we disagree with several of his points.” (Note to APA--send me all future "defense letters" for editing, at no charge).

After this, there are six paragraphs addressing some of Frances’ specific points. We hear that the DSM-V process has actually been “the most open and inclusive ever” and that the much villified “confidentiality agreement” was created to protect intellectual property rather than to keep proceedings secret. There is a defense of the usefulness of symptom rating scales: “Recent studies underscore the readiness of clinicians in both primary care and specialty mental health settings to adopt dimensional instruments on a routine basis.”

And there is a reasonable reminder of why some changes in the criteria are needed: “Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism.”

But after a brief, not terribly convincing rebuttal of the merits of Frances' argument, the writers decide to conclude by getting mean and personal again. This time, they accuse Dr. Frances of being deceptive in not disclosing his financial interests in DSM-IV (he is co-author of one book that teaches doctors how to use the manual). Then, they opine that Frances’ real motive in criticizing DSM-V is not a desire to improve diagnosis, but simply greed.

“Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.”

In other words, Dr. Frances wrote his editorial because he was just informed that once DSM-V is published, the APA will no longer publish new editions of books introducing psychiatrists to the outdated DSM-IV. Somehow, I doubt that this was exactly a news flash to Dr. Frances.

It is disturbing that the APA and DSM leadership would accuse Dr. Frances and his colleagues of being greedy, deceptive, and dumb. Who do they think they are--bloggers?

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