Wednesday, May 22, 2013

Arrival of the Deathstar

"I wouldn't be too proud of this technological terror you have constructed.  It's power is insignificant compared to that of the Force!"

Today, the American Psychiatric Association’s diagnostic Deathstar, the Diagnostic and Statistical Manual-5, arrived in the bookstores.  Clinicians everywhere will be taking a ball peen to their piggy banks to fork over the approximately $199.00 list price for the 947-page volume that describes the psychiatry association’s views of the mental health diagnoses they propose as the foundation for all clinical and research purposes.  Twelve years in the making, and proceeding from the work 13 work groups, 8 study groups and considerable APA administration, the tome could hardly be expected to arrive without some fanfare.  In the past 36 months, the primary note has been one of controversy.  How could so few contributors wield so much power in defining such an important document?  Is it fair?  Is it political?  Is it scientifically valid?  Treatment, insurance reimbursement, the outcome of divorces and civil suits, criminal prosecutions, mental hospitalizations, forced medication, even life and death itself may turn on the nuances on this crucial document.   As the demarcation of the no-man’s-land between the pathological and the merely unusual, it is important to the sexually variant, too.

A major project of this blog will be to trace the development of modern thinking about sexual variation. As the culmination of all of that work, the DSM-5 is indeed an important document.  It arrives just in time (or should I say, I finished the Michel Foucault entry just in time, because that entry was far more a consequence than cause of the manual’s release date) for us to recognize that for all its importance, the arrival of the manual is pretty much a non-event.  The rebel base on Yavin is in little more danger than it ever was, in part because of insights derived from Foucault.

Despite the controversy, the DSM-5 is a carefully worked, and fairly incremental change from its predecessor, DSM–IV.  The former volume was developed early in the age of selective serotonin reuptake inhibitors (SSRI’s)--Prozac is the first and best known example--and slightly revised in 2000.  So psychiatry has many more pharmacological tools than it did in 1994 when DSM-IV was issued.  Much of the revision centers on nuances of those conditions for which drugs are major form of treatment.  If there is a bright center of the psychiatric galaxy, paraphilias are the place that is farthest from it.
The central warfare over the DSM – 5 has centered on two kinds of arguments within psychiatry.  Is the diagnostic manual valid in its representation of its classification system relative to a cohesive theoretical system, and is it practical?  To guide research, it must be valid.  To be useful, fair, impartial and justify APA’s leadership in its construction, it must be practical.  There have been enough fireworks so that reasonable outsiders might have doubts on both these points.
DSM or not?
Much to the discomfiture of David J Kupfer, Chair of the APA’s DSM-5 Design Task Force, in the last 6 months, Thomas R Insel, Director of the National Institute of Mental Health, has publicly announced “as long as the research community takes DSM to be a bible, we’ll never make any progress” researching mental illness. As head of the US government's highest mental health research agency, those are commanding heights from which to be raining such powerful critical salvos against the DSM's research usefulness. Insel believes, quite correctly, that the diagnostic nosology, even though it purports to serve as a guide for research on all psychopathology, has no unifying underlying model of what causes the symptoms that comprise the diagnostic criteria.  That integral relation to theory is what good construct validity requires.

Long ago and in a galaxy rather close to home, psychiatry had such a DSM, then numbered ‘two.’  It was based on psychoanalytic theories about unconscious causes of symptoms that had been elaborated extensively by the intellectual descendents of Sigmund Freud.  In 1980, that system was overthrown because psychiatry became dissatisfied that the cohesive underlying explanations were built on shaky foundations since the practitioner community couldn’t agree on the diagnoses themselves.  For there to be any hope of validity, there needed to be reliability: different therapists need to be able to diagnose the same patient close to the same way.  So the DSM was redesigned to be so symptom-focused that different diagnosticians could agree on any given patient’s symptoms pretty well.  This was highly agreeable to consumers of psychiatry like courts, government, insurance companies, and patient’s themselves.  In the 1960s through the 1980s, psychoanalytic theory became so discredited that, with the adoption of DSM–III, graduate psychoanalytic training was largely driven from medical and psychological training at colleges and universities.  Since 1980, mental health diagnoses has been saying “look ma, no hands!” with respect to underlying theory.  If that doesn’t quite sound like the Holy Bible to you, it didn’t seem that way to most mental health workers either.
Which brings us back to NIMH Director Insel, who is advocating for underlying theory that is frankly, just not scientifically ready yet.  Insel is a neuroscientist by training, and he is looking to establish a diagnostic system based up neuroanatomy and pathways.  “Research domain criteria," Insel’s preferred classifications of symptoms based on neuroscientific causality, is still many years from realization.  President Obama’s initiative to map the human brain will be a very lengthy and ambitious project, an important step toward Insel’s vision, but probably will be far from sufficient.  Psychiatry has no choice but to proceed without construct validity in the interim. With respect to construct validity, the DSM-5 is about to function in the next 20 years pretty much as its last two predecessors did over the previous 30.  The book itself might be as bright and shinny as a new penny, but it will be used in the same old ways.

Equally disturbing to the APA has been the criticism of DSM–5 from an unlikely source, the Director of the DSM–IV Task Force, Allen J Francis MD.  Francis has complained about secrecy in the development process, risks of over-medicalizing mental disorders, sub-standard inter-rater reliability for newly proposed diagnoses, and most seriously, that the manual represented huge power grab by psychiatry to shrink the boundaries of ‘normal’ behavior and generate the opportunity for immense new revenue for the companies that manufacture psychiatric medicines.  That Frances was chair of the previous task force was a major defection and embarrassment to APA, but his criticisms probably have scaled back parts of the plan to expand most areas of practice.  Two of the biggest controversies surround definitions of attention deficit disorder that might justify increasing prescriptions for stimulants, and the medicalization of bereavement, and opportunity for the prescription of anti-depressants.  If you were aggrieved by the loss of your life partner and you could take a drug to take the pain away, how many weeks after the loss would be too soon to pursue pharmaceutical relief?  In setting that time at 2 weeks, is the DSM-5 rendering a judgment on how long we should grieve, creating a boon for drug makers, or offering a service that suffering patients desire?  Without a system of construct validity, that is not really a scientific question, but one of social values ripe for further deconstruction.

Not analogous to depression or bereavement

The definitional problem of mental disorders defined by symptoms is a morass because of mufti-causality, because of multidimensionality, and because different interventions can cure the same ‘disease’.  We cannot cure bereavement by placing a cast on an unbroken leg that would have been perfectly effective for a leg that is actually fractured.  But a drug might very well decrease anguish that talk therapy, the passage of time, or religious faith might heal.  So is it a mental disorder, or just a problem we can fix, or a threat to our humanity, because we can make a bereavement disappear with medicine?

Michel Foucault "He's baack!"

This observation returns us to Michel Foucault, who would remind us that the power of the APA to mold our sense of what is normal and what is not is partially an emergent process for which we are all responsible.  That the DSM-5 has warts, frailties and defects is unarguable, but it is the DSM's role in the regulation and expression of social power that is suspect.  It is the uses our other institutions make of the DSM that are the principle source of the social troubles of which it is a part.  We have let business and government credence the volume, and allowed the APA to create it unilaterally.  Someday, that is going to change.  Until then, the Deathstar will go unfought, and very little will be different for the next 20 years than for the last twenty. The arrival of DSM-5 may not have altered the balance of power in the psychiatric galaxy, but it has preserved it. Incremental change sustains APA’s legitimacy and power, and keeps conflict manageable.
Perhaps in response to Dr Francis’s criticisms, and push back from consumer advocates like NCSF, very modest additional protections have been instituted against over-pathologizing kink in DSM-5.  The manual institutes a two step process for determining whether kinky behavior deserves a diagnosis.  If behavior is unusual, then it may well be a paraphilia, but absent coercive and nonconsensual behaviors and significant patient complaints about the adverse life consequence of kink, it is not a diagnosable Paraphila Disorder.  How much protection does this distinction afford if you ever wind up, say, in court?  Probably very little, since after all, there is evidence of adjustment problems and adverse consequences since your partner is leaving or your credit limit is exceeded, or your employer is firing you.  The manual does offer some protection by discouraging mental health professionals from diagnosing any identifiable variation as pathological if you come in to treatment for a condition that has nothing to do with your variation.  As far as Diagnostic and Statistical Manual-5 goes, the acceptance or social persecution of kink will unfold with incremental changes much like those in the immediate past.  I guess the struggle to restore freedom to the galaxy remains to be continued…

© Russell J Stambaugh, May 2013, Ann Arbor MI, All rights reserved 

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