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 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

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