Hired guns.” “Whores.” “Greedy, insensitive bastards. “ These are some of the more printable epithets used to describe psychiatric physicians who (allegedly) have “sold out to Big Pharma” ”—for example, by failing to disclose conflicts of interest, or to report large sums of money earned through their work with pharmaceutical companies. It may surprise some—but perhaps not many—that these terms of abuse were hurled not by members of some anti-psychiatry group, but by psychiatrists, writing on a well-known “watchdog” blog site. To be clear: I have no wish to excuse or rationalize the actions of some in our field who indeed have abused the public trust by engaging in any of the actions described. Anger—even outrage—is appropriate and healthy, with respect to their behavior. But must we also demonize these individuals, some of whom (notwithstanding their transgressions) have made important contributions to clinical care and scientific research?
The late Dr Albert Ellis—the psychologist who originated Rational Emotive Behavioral Therapy—always insisted that we distinguish between a person’s behavior, and the individual’s value as a human being. Writing in their classic 1961 book, A Guide to Rational Living, Ellis and his colleague, Robert Harper argued that, “…A person’s (good or bad) acts are the results of his being, but they are never that being itself.” (Ellis and Harper, 1961 p. 104, italics added).
We often tell our patients they should not condemn the totality of their being on the basis of a selfish or hurtful act they have committed—yet some of us seem all too ready to condemn a colleague in the most sweeping and dehumanizing terms, because he or she is guilty (or is believed guilty) of one or more ethical lapses. By all means, let us condemn the transgressions! But let’s also retain a scintilla of human sympathy and understanding for the flawed human beings who committed them.
The problem of “demonizing rhetoric” is obviously not confined to the field of psychiatry, where it seems to be the effluvium of a few particularly bilious individuals. The language of demonization is all too prevalent in the narratives of many political and religious groups, who attack their opponents as infidels, heretics, traitors, or even worse. Carried to an extreme, we find terms like “vermin” applied to ethnic or religious groups who are the objects of hatred or persecution—the Nazis were infamous in their use of this term. Yes, I know—there is a difference between calling someone a “drug company whore” and reducing the person to the status of vermin. But the distance between the terms is not as wide as some would persuade themselves. And when one moves from the psychiatry blog sites to the rabid anti-psychiatry websites (eg, http://outlawpsychiatry.blogspot.com/), one sees in no uncertain terms how easily an unflattering epithet can morph into a dehumanizing slur.
The divisions within psychiatry extend far beyond concerns over “conflicts of interest” and “Big Pharma”—where there are, at least, valid ethical issues to be raised. Unfortunately, the profession continues to be mired in the same fruitless arguments over “biology” versus “psychology” that anthropologist Tanya Luhrmann documented in her classic investigation, Of Two Minds: The Growing Disorder in American Psychiatry (2000). And, all too often, one hears proponents of the “biomedical” model disparaging advocates of the “psychodynamic” model—or vice verse. This sterile debate persists, despite the heroic efforts of “pluralistic unifiers”, such as my colleagues Nassir Ghaemi, Godehard Oepen, Glen Gabbard, Michael A. Schwartz, and Cynthia Geppert. These clinician-scholars have refused to buy into the Manichean world of the “splitters”; rather, they embrace a scientific-humanistic perspective that comprehends both molecules and motives. This broad-based, pluralistic model was the one I imbibed during my residency at Upstate Medical University, where a fledgling resident could —as my teachers, Robert Daly and Eugene Kaplan might put it—“do theology in the morning and biology in the afternoon.” Oh, yes—and engage in heated but respectful debate with gadfly Tom Szasz, during lunch!
Psychiatry as a profession faces many challenges, and no small number of genuine threats. From excessive involvement with “Big Pharma” to the diminished role of psychotherapy; from managed care’s fifteen minute “med checks” to controversies over DSM-V, psychiatry understandably feels besieged, these days. No doubt, we have contributed to many of these problems through our own missteps or inaction. Yet, for all its flaws, psychiatry remains the most comprehensive and humanistic of the medical specialties— and has a great deal to offer the suffering individuals who seek our help. In 1858, Abraham Lincoln—addressing the issue of slavery-- warned the nation that, “A house divided against itself cannot stand.” It would be a genuine tragedy if psychiatry becomes “a house divided” by the rancor of its own rhetoric.
Ronald Pies, MD
Editor-in-Chief
"Every kingdom divided against itself is brought to desolation; and every city or house divided against itself shall not stand."-- Matthew 12:25
“Judge the whole of the person charitably.”—Talmud (Pirke Avot, 1:6)
Read more!
Tuesday, December 15, 2009
Monday, November 30, 2009
“Psychosurgery”: Promise, Perils, and Patients’ Protection
Psychosurgery. For some, the word connotes all the promising therapeutic applications of modern neuroscience; for others, it connotes all the baneful excesses of unregulated pseudoscience. In his recent front page story for the New York Times (Nov. 27), Benedict Carey presented a balanced and nuanced view of what is sometimes termed “psychiatric neurosurgery,” focusing mainly on cingulotomy, capsulotomy, and other neurosurgical approaches to refractory obsessive-compulsive disorder (OCD).
For one of the patients interviewed by Carey, neurosurgery to treat her intractable OCD was clearly very helpful; yet for other patients, neurosurgery for their OCD had adverse behavioral effects despite some improvement in their obsessive-compulsive symptoms. Thus, in one Swedish study by Ruck and colleagues, only 3 of 25 patients with OCD undergoing capsulotomy were in remission without adverse effects at long-term follow-up. Ten patients “were considered to have significant problems with executive functioning, apathy, or disinhibition” after their procedures.
Psychiatric Times has discussed both the medical and ethical issues surrounding psychosurgery, pointing out both the need for better understanding of the underlying brain circuits targeted by psychosurgery and the imperative of safe-guarding the rights of potential candidates for psychosurgery. One conundrum noted by Dr. Christian Ruck, and cited in the Times article, is that “innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid.” This is not to impugn the humanitarian motives that underlie most instances of psychosurgery; it is merely to say that institutions that perform psychosurgery may have a vested interest in seeing and presenting their outcome data in the best possible light.
In addition to the need for very strong informed consent procedures and intra-institutional review boards, there is also a case to be made for outside, independent review of an institution’s psychosurgery program. Indeed, in the U.N. General Assembly’s statement on the protection of persons with mental illness, we find the following injunction:
Given the rarity of psychiatric neurosurgery—the Times noted that about 500 such procedures have been carried out in the United States over the past decade—review of each case by an independent neuropsychiatric expert outside the “provider” institution seems feasible. There is no doubt that for some suffering patients who have not responded to standard treatment, psychosurgery may be the only viable option. But as Alan Stone, MD concluded in his article for Psychiatric Times, "Given the historical burden of the old psychosurgery, the new neurosurgeons have a special obligation to proceed with utmost scientific caution."
Ronald Pies, MD
Editor-in-Chief Read more!
For one of the patients interviewed by Carey, neurosurgery to treat her intractable OCD was clearly very helpful; yet for other patients, neurosurgery for their OCD had adverse behavioral effects despite some improvement in their obsessive-compulsive symptoms. Thus, in one Swedish study by Ruck and colleagues, only 3 of 25 patients with OCD undergoing capsulotomy were in remission without adverse effects at long-term follow-up. Ten patients “were considered to have significant problems with executive functioning, apathy, or disinhibition” after their procedures.
Psychiatric Times has discussed both the medical and ethical issues surrounding psychosurgery, pointing out both the need for better understanding of the underlying brain circuits targeted by psychosurgery and the imperative of safe-guarding the rights of potential candidates for psychosurgery. One conundrum noted by Dr. Christian Ruck, and cited in the Times article, is that “innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid.” This is not to impugn the humanitarian motives that underlie most instances of psychosurgery; it is merely to say that institutions that perform psychosurgery may have a vested interest in seeing and presenting their outcome data in the best possible light.
In addition to the need for very strong informed consent procedures and intra-institutional review boards, there is also a case to be made for outside, independent review of an institution’s psychosurgery program. Indeed, in the U.N. General Assembly’s statement on the protection of persons with mental illness, we find the following injunction:
“Psychosurgery and other intrusive and irreversible treatments for mental illness shall never be carried out on a patient who is an involuntary patient in a mental health facility and, to the extent that domestic law permits them to be carried out, they may be carried out on any other patient only where the patient has given informed consent and an independent external body has satisfied itself that there is genuine informed consent and that the treatment best serves the health needs of the patient."
Given the rarity of psychiatric neurosurgery—the Times noted that about 500 such procedures have been carried out in the United States over the past decade—review of each case by an independent neuropsychiatric expert outside the “provider” institution seems feasible. There is no doubt that for some suffering patients who have not responded to standard treatment, psychosurgery may be the only viable option. But as Alan Stone, MD concluded in his article for Psychiatric Times, "Given the historical burden of the old psychosurgery, the new neurosurgeons have a special obligation to proceed with utmost scientific caution."
Ronald Pies, MD
Editor-in-Chief Read more!
Thursday, October 29, 2009
Rape and the Heart of Darkness at Richmond High
The press reported it in various ways—either as a “brutal gang rape” or, more forensically, as a “2½-hour assault” on the Richmond High School campus. Anyway you look at it, the horrendous attack on a 15-year old girl raises troubling questions for theologians, criminologists, and, of course, psychiatrists. How do we understand an act as brutal as rape? What factors and forces in the rapist’s development can possibly account for such behavior? And how on earth do we explain the apparent indifference of the large crowd that watched the attack in Richmond, California, and allegedly did nothing to stop it—or even, to report it?
In a thoughtful analysis on CNN, Stephanie Chen provides a range of “expert opinions” on this last question. Essentially, the various hypotheses asserted that:
o Bystanders in large groups are unlikely to take appropriate action in such cases, because they assume others have already done so; or because “doing nothing becomes the norm” (the so-called bystander effect).
o Witnesses who otherwise might have phoned 911 may have feared retaliation from the perpetrators.
o Bystanders do not feel a “bond” with the victim, and may actually identify with the perpetrator, who is perceived as “more important” than the victim.
The CNN report speculated at length on the so-called “Genovese Syndrome,” named for the woman stabbed to death in Queens, NY in 1964, supposedly after 38 witnesses to the attack did nothing to help her. (The facts, however, are almost certainly otherwise, as an article in American Psychologist argues.)
Most of the forensic experts quoted in the CNN piece took a predictably “objective” point of view. None ventured the opinion that the crowd at Richmond High School failed to aid the rape victim because many human beings often act in a selfish, callous, and cowardly manner. Nobody put forth the view of rabbinical Judaism; namely, that we are all born with 2 primal inclinations, constantly at war with one another. The “good inclination” (yetzer hatov) is usually held to be a kind of late “add-on” to the more powerful “evil inclination” (yetzer hara), which often gains the upper hand. The yetzer hara seems to have been alive and well at Richmond High—and nobody lifted a finger to stop it. Rabbi Bruce Kadden, however, points out that the yetzer hara is not some “devil” external to our own selves; rather,
“…the yetzer hara is very much a part of us. We therefore cannot deny personal responsibility for what the yetzer hara causes us to do. It may explain our behavior, but it does not excuse it.”
Many psychiatrists, it seems to me, have been reluctant to venture into the obscure headwaters of evil—the territory explored so vividly in Josef Conrad’s 1902 novella, “The Heart of Darkness,” Many in our profession have taken the “scientific” view that matters of good and evil are best left to theologians and clergy; and that clinicians should limit themselves to analyzing and correcting the developmental, biological, and psychological precursors of “anti-social behavior.”
I disagree. Psychiatrists and other mental health professionals should not avoid the issue of evil, if only for the reason that good and evil are very real, and matter very deeply, to most of our patients. A woman who presents in therapy with a rape-related traumatic syndrome may be said to embody the problem of human evil: even her physiological responses to trauma-related stimuli have been altered by her experience. But more than that, the patient (male or female) who has suffered a brutal assault may need to explore the moral dimensions of the act and its consequences: “How could another human being do such a horrible thing? And - - why me, Doctor? Was I being punished by God? Am I somehow responsible for what happened? What should I do with all the hatred and rage I feel toward this monster? Is it right that I want him to suffer as much as I have?”
These understandable questions do not arise for all victims of trauma; but when they do, psychiatrists must be prepared to engage the patient in a serious, “I-Thou” dialogue, to use Martin Buber’s term. Similarly, philosopher and ethicist Margaret U. Walker has written of the need for “moral repair” after an act of wrongdoing. As therapists, we help effect such repair by establishing trust—the first step in mending the torn fabric of the traumatized patient’s moral universe. To gain the patient’s trust, however, we must be ready to talk frankly about good and evil. Sometimes, this means confronting the enormity of acts such as those that occurred at Richmond High.
[UPDATE 11/06/09]
It seems there may be a bright spot to this horrendous story, after all. ABC News is reporting that, while nearly all the bystanders did nothing,
"...one woman called police as soon as she heard what was happening. The 18-year-old mother and former Richmond High School student was at home watching a movie when her brother-in-law came home and said he had seen a girl getting raped.
"He was like, 'I'm scared,' and I'm like, 'Well, we should call the cops because that's the thing to do,'" Margarita Vargas said. "I didn't think about it twice, I just, I'm like, I immediately grabbed the phone and said, 'I'm gonna call the cops,' because that's something I wouldn't want anybody to go through or if I was in that situation, I would want someone to do the same for me."
Vargas said after making the call to police, she walked over to the school to make sure the police had arrived."
Ronald Pies, MD
Read more!
In a thoughtful analysis on CNN, Stephanie Chen provides a range of “expert opinions” on this last question. Essentially, the various hypotheses asserted that:
o Bystanders in large groups are unlikely to take appropriate action in such cases, because they assume others have already done so; or because “doing nothing becomes the norm” (the so-called bystander effect).
o Witnesses who otherwise might have phoned 911 may have feared retaliation from the perpetrators.
o Bystanders do not feel a “bond” with the victim, and may actually identify with the perpetrator, who is perceived as “more important” than the victim.
The CNN report speculated at length on the so-called “Genovese Syndrome,” named for the woman stabbed to death in Queens, NY in 1964, supposedly after 38 witnesses to the attack did nothing to help her. (The facts, however, are almost certainly otherwise, as an article in American Psychologist argues.)
Most of the forensic experts quoted in the CNN piece took a predictably “objective” point of view. None ventured the opinion that the crowd at Richmond High School failed to aid the rape victim because many human beings often act in a selfish, callous, and cowardly manner. Nobody put forth the view of rabbinical Judaism; namely, that we are all born with 2 primal inclinations, constantly at war with one another. The “good inclination” (yetzer hatov) is usually held to be a kind of late “add-on” to the more powerful “evil inclination” (yetzer hara), which often gains the upper hand. The yetzer hara seems to have been alive and well at Richmond High—and nobody lifted a finger to stop it. Rabbi Bruce Kadden, however, points out that the yetzer hara is not some “devil” external to our own selves; rather,
“…the yetzer hara is very much a part of us. We therefore cannot deny personal responsibility for what the yetzer hara causes us to do. It may explain our behavior, but it does not excuse it.”
Many psychiatrists, it seems to me, have been reluctant to venture into the obscure headwaters of evil—the territory explored so vividly in Josef Conrad’s 1902 novella, “The Heart of Darkness,” Many in our profession have taken the “scientific” view that matters of good and evil are best left to theologians and clergy; and that clinicians should limit themselves to analyzing and correcting the developmental, biological, and psychological precursors of “anti-social behavior.”
I disagree. Psychiatrists and other mental health professionals should not avoid the issue of evil, if only for the reason that good and evil are very real, and matter very deeply, to most of our patients. A woman who presents in therapy with a rape-related traumatic syndrome may be said to embody the problem of human evil: even her physiological responses to trauma-related stimuli have been altered by her experience. But more than that, the patient (male or female) who has suffered a brutal assault may need to explore the moral dimensions of the act and its consequences: “How could another human being do such a horrible thing? And - - why me, Doctor? Was I being punished by God? Am I somehow responsible for what happened? What should I do with all the hatred and rage I feel toward this monster? Is it right that I want him to suffer as much as I have?”
These understandable questions do not arise for all victims of trauma; but when they do, psychiatrists must be prepared to engage the patient in a serious, “I-Thou” dialogue, to use Martin Buber’s term. Similarly, philosopher and ethicist Margaret U. Walker has written of the need for “moral repair” after an act of wrongdoing. As therapists, we help effect such repair by establishing trust—the first step in mending the torn fabric of the traumatized patient’s moral universe. To gain the patient’s trust, however, we must be ready to talk frankly about good and evil. Sometimes, this means confronting the enormity of acts such as those that occurred at Richmond High.
[UPDATE 11/06/09]
It seems there may be a bright spot to this horrendous story, after all. ABC News is reporting that, while nearly all the bystanders did nothing,
"...one woman called police as soon as she heard what was happening. The 18-year-old mother and former Richmond High School student was at home watching a movie when her brother-in-law came home and said he had seen a girl getting raped.
"He was like, 'I'm scared,' and I'm like, 'Well, we should call the cops because that's the thing to do,'" Margarita Vargas said. "I didn't think about it twice, I just, I'm like, I immediately grabbed the phone and said, 'I'm gonna call the cops,' because that's something I wouldn't want anybody to go through or if I was in that situation, I would want someone to do the same for me."
Vargas said after making the call to police, she walked over to the school to make sure the police had arrived."
Ronald Pies, MD
Read more!
Tuesday, October 27, 2009
On Narcissism, the Internet, and Social Networking Sites
I read with interest the posts of Dr John Grohol, PsyD regarding my commentary, "Twitter and YouTube: Unanticipated Consequences of the Self-Esteem Movement.” I had hoped it would bring attention to this topic and am glad that this has opened up an important dialogue. However, the author has missed the point.
It was not my intention to blame the internet for creating more narcissists or for causing irreparable harm to our children. In fact, nowhere in my article do I “demonize” the internet as this post asserts. It is my contention that the internet is not, in and of itself, inherently evil. I do not blame social networking sites for the rise of narcissism in our culture. A more careful reading of the piece would reveal that I consider social networking sites a symptom of a narcissistic society rather than the cause of it.
My argument was not that the internet is to blame for the sad state of affairs in which we find ourselves. Rather, it is the philosophy that influenced the rearing of an entire generation, namely, the self-esteem movement. By shielding our youth from the dangers of criticism and disappointment, they have arrived at adulthood without having developed the coping skills they need to survive in the real world. No one succeeds at everything. This is a fact of life. But the millennial generation was not exposed to this reality. Not only do they shun criticism, they feel entitled to praise, even if undeserved.
The studies of Twenge and Campbell[1-3] have shown a steady rise in narcissism in the past several decades. While the author is quick to point to statements he believes are not backed by data, he fails to even take note of this study. This rise in narcissism was evident before the advent of social networking sites. And it is my contention that these sites would not have risen to such prominence but for the fact that a generation of narcissists needed an outlet. The millennial generation needed a way to assert their uniqueness, their specialness and garner the attention and praise of the masses. Facebook, MySpace, YouTube and Twitter filled the bill.
Communication has certainly changed throughout the last century. And with each successive change, the degree of face to face contact has decreased. From in person visits and hand written notes, we have progressed to phone calls and emails. Each time we remove ourselves from face-to-face contact with each other, the communication becomes eroded. When we can see each other, we can appreciate important non-verbal cues, absent if we just speak over the phone.
When we write or email, we lose the information that can be gleaned from pauses, prosody, and intonation of speech that are still available over the phone. When we text or blog, we have none of those things. The words must stand alone and they are condensed to their most basic and, in some cases, completely replaced by shorthand such as “lol”and “omg.”
Call me old-fashioned, but having a close friend with whom I have shared real experiences and confided real feelings to beats being anyone’s “bff.”
Lauren LaPorta, MD
Chairman, Department of Psychiatry
St Joseph's Regional Medical Center
Paterson, NJ
1. Twenge JM, Campbell WK. “Isn’t it fun to get the respect we’re going to deserve?” Narcissism, social rejection, and aggression. Pers Soc Psychol Bull. 2003;29:261-272.
2. Twenge JM, Konrath S, Foster JD, et al. Egos inflating over time: a cross-temporal meta-analysis of the Narcissistic Personality Inventory. J Pers. 2008;76:875-928.
3. Twenge J, Campbell K, Trzesniewski K, Donnellan B. Narcissism in Gen Y: is it increasing or not? Two opposing perspectives. Twenge J, Campbell WK. Generation Me in the jury box. The Jury Expert. May 2009;21(3). http://www.astcweb.org/public/publication/article.cfm/1/21/3/Narcissism-in-Generation-Y-and-Litigation-Advocacy. Accessed September 4, 2009.
Read more!
It was not my intention to blame the internet for creating more narcissists or for causing irreparable harm to our children. In fact, nowhere in my article do I “demonize” the internet as this post asserts. It is my contention that the internet is not, in and of itself, inherently evil. I do not blame social networking sites for the rise of narcissism in our culture. A more careful reading of the piece would reveal that I consider social networking sites a symptom of a narcissistic society rather than the cause of it.
My argument was not that the internet is to blame for the sad state of affairs in which we find ourselves. Rather, it is the philosophy that influenced the rearing of an entire generation, namely, the self-esteem movement. By shielding our youth from the dangers of criticism and disappointment, they have arrived at adulthood without having developed the coping skills they need to survive in the real world. No one succeeds at everything. This is a fact of life. But the millennial generation was not exposed to this reality. Not only do they shun criticism, they feel entitled to praise, even if undeserved.
The studies of Twenge and Campbell[1-3] have shown a steady rise in narcissism in the past several decades. While the author is quick to point to statements he believes are not backed by data, he fails to even take note of this study. This rise in narcissism was evident before the advent of social networking sites. And it is my contention that these sites would not have risen to such prominence but for the fact that a generation of narcissists needed an outlet. The millennial generation needed a way to assert their uniqueness, their specialness and garner the attention and praise of the masses. Facebook, MySpace, YouTube and Twitter filled the bill.
Communication has certainly changed throughout the last century. And with each successive change, the degree of face to face contact has decreased. From in person visits and hand written notes, we have progressed to phone calls and emails. Each time we remove ourselves from face-to-face contact with each other, the communication becomes eroded. When we can see each other, we can appreciate important non-verbal cues, absent if we just speak over the phone.
When we write or email, we lose the information that can be gleaned from pauses, prosody, and intonation of speech that are still available over the phone. When we text or blog, we have none of those things. The words must stand alone and they are condensed to their most basic and, in some cases, completely replaced by shorthand such as “lol”and “omg.”
Call me old-fashioned, but having a close friend with whom I have shared real experiences and confided real feelings to beats being anyone’s “bff.”
Lauren LaPorta, MD
Chairman, Department of Psychiatry
St Joseph's Regional Medical Center
Paterson, NJ
1. Twenge JM, Campbell WK. “Isn’t it fun to get the respect we’re going to deserve?” Narcissism, social rejection, and aggression. Pers Soc Psychol Bull. 2003;29:261-272.
2. Twenge JM, Konrath S, Foster JD, et al. Egos inflating over time: a cross-temporal meta-analysis of the Narcissistic Personality Inventory. J Pers. 2008;76:875-928.
3. Twenge J, Campbell K, Trzesniewski K, Donnellan B. Narcissism in Gen Y: is it increasing or not? Two opposing perspectives. Twenge J, Campbell WK. Generation Me in the jury box. The Jury Expert. May 2009;21(3). http://www.astcweb.org/public/publication/article.cfm/1/21/3/Narcissism-in-Generation-Y-and-Litigation-Advocacy. Accessed September 4, 2009.
Read more!
Thursday, October 22, 2009
A Citizen Above Suspicion
When I thought of writing this letter, I was put in mind of Jean-Jacques Dessalines (1758 – 1806), the Emperor of the tiny nation of Haiti, writing to the most powerful man of that time, Napoleon Bonaparte. Like Dessalines, I am a grain of sand standing next to the huge mountain of the psychiatric establishment. Fortunately, there is Psychiatric Times (PT), which allows a "half-island nation" like me, and many others, to reach a wide audience. Some publications welcome opinions only from the “Napoleons” of our profession!
I am trying to say that PT is "a citizen above suspicion." Its fairness is beyond question and the integrity of its editorial board, rock-solid. Still, your editorial, "Conflicts of Interest: Policies of Psychiatric Times" is the necessary spark that should ignite a long-awaited discussion. Given that PT's opinions are free of unethical influences from commercial sponsors, I want to ask Dr Pies and Ms Kweskin to explore the other side of the "coin" that they have just tossed: does the psychiatric establishment show fairness in its review of dissident opinions regarding non-pharmacological issues, such as psychiatric diagnosis?
My own experience says no. With the exception of PT and the Journal of Affective Disorders, few psychiatric journals will publish unorthodox opinions—for example, those questioning the validity of DSM diagnoses such as Borderline Personality Disorder, Oppositional-Defiant Disorder, or the widespread notion of “Treatment-resistant Depression.” By the same token, many in this specialty consider it heresy to suggest that ADHD is not as prevalent as the establishment wants us to believe. Similarly, the psychiatric establishment resists suggestions that many cases of "comorbid" anxiety and depression are neither, but are actually cases of sub-threshold bipolar spectrum disorder: the so-called "anxiety" is in fact agitation secondary to the bipolar mood disturbance.
I think there is real fear, within the psychiatric establishment, of opening a Pandora’s Box that could bring about a complete overhaul of the most revered diagnostic dogmas in this field. I very much appreciate the fact that PT allows dissident readers to raise their voices against such entrenched orthodoxy. Often, it is not a case of “crying wolf”-- but of the wolf actually scratching at the door.
Manuel Mota-Castillo MD
I am trying to say that PT is "a citizen above suspicion." Its fairness is beyond question and the integrity of its editorial board, rock-solid. Still, your editorial, "Conflicts of Interest: Policies of Psychiatric Times" is the necessary spark that should ignite a long-awaited discussion. Given that PT's opinions are free of unethical influences from commercial sponsors, I want to ask Dr Pies and Ms Kweskin to explore the other side of the "coin" that they have just tossed: does the psychiatric establishment show fairness in its review of dissident opinions regarding non-pharmacological issues, such as psychiatric diagnosis?
My own experience says no. With the exception of PT and the Journal of Affective Disorders, few psychiatric journals will publish unorthodox opinions—for example, those questioning the validity of DSM diagnoses such as Borderline Personality Disorder, Oppositional-Defiant Disorder, or the widespread notion of “Treatment-resistant Depression.” By the same token, many in this specialty consider it heresy to suggest that ADHD is not as prevalent as the establishment wants us to believe. Similarly, the psychiatric establishment resists suggestions that many cases of "comorbid" anxiety and depression are neither, but are actually cases of sub-threshold bipolar spectrum disorder: the so-called "anxiety" is in fact agitation secondary to the bipolar mood disturbance.
I think there is real fear, within the psychiatric establishment, of opening a Pandora’s Box that could bring about a complete overhaul of the most revered diagnostic dogmas in this field. I very much appreciate the fact that PT allows dissident readers to raise their voices against such entrenched orthodoxy. Often, it is not a case of “crying wolf”-- but of the wolf actually scratching at the door.
Manuel Mota-Castillo MD
I want to thank Dr Mota for his kind and appreciative remarks concerning Psychiatric Times. We have a long tradition of allowing "dissident" voices and controversial opinions to be heard in our pages (paper and now, electronic). Our founding Editor-in-Chief, John Schwartz, MD, never shied away from taking on "the powers that be," or in confronting the misbehavior of some groups opposed to the field of psychiatry.
I do suspect that there is resistance to change among some representatives of the psychiatric "establishment" (although, to be candid, some might place me in that camp). I think there are many reasons for this. One is that once a scientific (or not-so-scientific) "paradigm" has been established (to use historian Thomas Kuhn's term), it is hard to challenge it, even with persuasive data. The DSM framework is such a paradigm, and there is understandable reluctance to move away from it on the part of some who have labored mightily to create it. I suppose we should not completely discount the role of "Big Pharma" in promoting some diagnoses--perhaps including ADHD--for obvious reasons, though I do not take the view that all pharmaceutical companies are driven only by the profit motive. Still, the "direct to consumer" advertising so common these days may have the effect of reifying or expanding some diagnoses, even in the absence of convincing evidence. On the other hand, I do not agree with the camp that points to "disease mongering" as the source of, for example, the increased recognition of bipolar spectrum disorders.
I also think that some dubious diagnoses, such as "Conduct Disorder", simply reflect our over-reliance on a purely descriptive (symptom-based) diagnostic framework, rather than on one that seeks to establish common biogenetic and phenomenological (experiential) factors that may underlie several seemingly diverse conditions. Another good example, in my view, is the push to reify "Internet Addiction" as a full-fledged and discrete disorder, when it may represent merely one manifestation of an underlying aberration in the brain's reward system.
So, thanks, Dr Mota, for your voice of conscience and concern!
Ronald Pies, MD
Editor-in-Chief
Friday, October 16, 2009
Monitoring Pharmonitor
Congratulations to Dr Alan A. Stone for taking the time to nail the bias contained in the Supplement discussed in his piece, “Reality-Checking: Case In Point.” And congratulations to Psychiatric Times for printing Dr Stone’s article. Perhaps PT is ready to take further steps in separating itself from the "educational efforts" sponsored by pharmaceutical companies that have so deeply corrupted the practice of psychiatry, and medicine.
Chuck Joy, MD
Erie PA Read more!
Chuck Joy, MD
Erie PA Read more!
Thursday, September 17, 2009
On integrity and never ending diagnostic updates…
I read the article by Dr Frances and was impressed by its intelligence. I then read the response by the APA in the person of Dr Schatzberg et al. I was shocked by its sleazy attack on Dr Frances’ integrity. Dr Frances was accused of arguing because of anticipated personal financial gain. The accusation that Dr Frances was arguing ad hominem was the pot calling the kettle black.
The whole business of never-ending updates and changes to our diagnoses—whether paradigm-shifting or minor—should remind those of us who need reminding how primitive is our knowledge in our specialty.
Dr Frances seems more aware of this than Dr Schatzberg et al.
Arnold Knepfer, MD Read more!
The whole business of never-ending updates and changes to our diagnoses—whether paradigm-shifting or minor—should remind those of us who need reminding how primitive is our knowledge in our specialty.
Dr Frances seems more aware of this than Dr Schatzberg et al.
Arnold Knepfer, MD Read more!
Wednesday, September 16, 2009
Toward mental illness for all?
We were surprised to read of the open letter by Drs Frances and Spitzer regarding the creation of DSM-V. Over time we have been puzzled by a succession of Diagnostic and Statistical Manuals, and have been forced to conclude the long-term purpose of the DSM is to abolish mental illness from American society. Currently only half of all Americans fit the criteria in DSM-IV to be diagnosed with one kind of mental illness or another. 1 Surely the goal of DSM-V must be to increase the percentage of Americans eligible to be mentally ill. With the inclusion of sub-syndromal categories in DSM-V, the total percentage of mentally ill Americans should reach 75-80%. With a long-term commitment by the American Psychiatric Association to DSM-VI --or, if necessary, DSM-VII - - 100% of the American population can eventually be declared mentally ill. On that glorious day all mental health practitioners can take satisfaction in their decades long quest to abolish mental illness, because, as we all know, when everyone has something then no one has it.
1.“Mental Illness in U.S. Presidents Between 1776 and 1974,” J. R. T. Davidson, K. M. Connor, and M. Swartz, The Journal of Nervous and Mental Disease. Read more!
1.“Mental Illness in U.S. Presidents Between 1776 and 1974,” J. R. T. Davidson, K. M. Connor, and M. Swartz, The Journal of Nervous and Mental Disease. Read more!
Thursday, September 3, 2009
This Accusation Has No Logic. . .
The APA DSM-V Task Force’s response to Dr. Frances’s critique of DSM-V noted that his royalties for DSM-IV products would cease when DSM-V is published. However, Dr. Frances’ critique called for DSM-V developers to make fewer changes- - not more, and he made no call for longer DSM-V field trials; in fact he proposed additions such as prodromal and subthreshold syndromes to be put in an appendix that called for further research. His critique then would not extend his receipt of royalties, and perhaps even shorten them. Thus, the APA has no logic to accuse him of financial incentive unless they opine that his critique could significantly delay publication of DSM-V somehow, eg, by inciting turmoil within the working group which would mean that a critical mass of people would agree with his logic.
Doug Berger, M.D., Ph.D.
U.S. Board-Certified Psychiatrist
Tokyo, Japan Read more!
Doug Berger, M.D., Ph.D.
U.S. Board-Certified Psychiatrist
Tokyo, Japan Read more!
Preserving Irrelevance?
I agree with Drs Schatzberg, Scully, Kupfer and Regier. In my busy clinical practice, I do not see DSM-IV doing justice to clinical reality. Less than 25% of my patients have a genuinely good syndromatic fit with specific DSM diagnoses.
With diagnostic criteria strictly applied, I find myself with numerous NOS diagnoses with little in terms of treatment or prognosis utility. Preserving the current DSM structure would make it increasingly irrelevant to clinical practice.
DSM-IV seems to misconstrue how psychiatric diagnosis is made in real-world clinical situations which seem to parallel GK Chesterton’s famous quote “you can only find truth with logic if you have already found truth without it.” While a paradigm shift may be clearly disruptive, that is what psychiatry needs at this juncture to keep classification relevant to day today clinical practice.
While advances in neurobiology may help resolve some of our diagnostic stalemates, the complex sequential interaction between neurobiology, changing adaptive demands, and existential issues may continue to make psychiatric diagnosis a moving target.
Although a literature review seems to be an important avenue in the DSM revision, we must not overvalue it because we could easily get sidetracked by a circular situation in which literature is based on classification and vice versa.
Prevesh Rustagi, MD Read more!
With diagnostic criteria strictly applied, I find myself with numerous NOS diagnoses with little in terms of treatment or prognosis utility. Preserving the current DSM structure would make it increasingly irrelevant to clinical practice.
DSM-IV seems to misconstrue how psychiatric diagnosis is made in real-world clinical situations which seem to parallel GK Chesterton’s famous quote “you can only find truth with logic if you have already found truth without it.” While a paradigm shift may be clearly disruptive, that is what psychiatry needs at this juncture to keep classification relevant to day today clinical practice.
While advances in neurobiology may help resolve some of our diagnostic stalemates, the complex sequential interaction between neurobiology, changing adaptive demands, and existential issues may continue to make psychiatric diagnosis a moving target.
Although a literature review seems to be an important avenue in the DSM revision, we must not overvalue it because we could easily get sidetracked by a circular situation in which literature is based on classification and vice versa.
Prevesh Rustagi, MD Read more!
Subscribe to:
Posts (Atom)
