Inside the Battle to Define Mental Illness
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By Gary Greenberg
- December 27, 2010 |
- 12:00 pm |
- Wired January 2011
Photo: Garry Mcleod; Origami: Robert Lang
Every so often Al Frances says something that seems to surprise even him. Just now, for instance, in the predawn darkness of his comfortable, rambling home in Carmel, California, he has broken off his exercise routine to declare that “there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.” Then an odd, reflective look crosses his face, as if he’s taking in the strangeness of this scene: Allen Frances, lead editor of the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (universally known as the DSM-IV), the guy who wrote the book on mental illness, confessing that “these concepts are virtually impossible to define precisely with bright lines at the boundaries.” For the first time in two days, the conversation comes to an awkward halt.
But he recovers quickly, and back in the living room he finishes explaining why he came out of a seemingly contented retirement to launch a bitter and protracted battle with the people, some of them friends, who are creating the next edition of the DSM. And to criticize them not just once, and not in professional mumbo jumbo that would keep the fight inside the professional family, but repeatedly and in plain English, in newspapers and magazines and blogs. And to accuse his colleagues not just of bad science but of bad faith, hubris, and blindness, of making diseases out of everyday suffering and, as a result, padding the bottom lines of drug companies. These aren’t new accusations to level at psychiatry, but Frances used to be their target, not their source. He’s hurling grenades into the bunker where he spent his entire career.
As a practicing psychotherapist myself, I can attest that this is a startling turn. But when Frances tries to explain it, he resists the kinds of reasons that mental health professionals usually give each other, the ones about character traits or personality quirks formed in childhood. He says he doesn’t want to give ammunition to his enemies, who have already shown their willingness to “shoot the messenger.” It’s not an unfounded concern. In its first official response to Frances, the APA diagnosed him with “pride of authorship” and pointed out that his royalty payments would end once the new edition was published—a fact that “should be considered when evaluating his critique and its timing.”
Frances, who claims he doesn’t care about the royalties (which amount, he says, to just 10 grand a year), also claims not to mind if the APA cites his faults. He just wishes they’d go after the right ones—the serious errors in the DSM-IV. “We made mistakes that had terrible consequences,” he says. Diagnoses of autism, attention-deficit hyperactivity disorder, and bipolar disorder skyrocketed, and Frances thinks his manual inadvertently facilitated these epidemics—and, in the bargain, fostered an increasing tendency to chalk up life’s difficulties to mental illness and then treat them with psychiatric drugs.
The insurgency against the DSM-5 (the APA has decided to shed the Roman numerals) has now spread far beyond just Allen Frances. Psychiatrists at the top of their specialties, clinicians at prominent hospitals, and even some contributors to the new edition have expressed deep reservations about it. Dissidents complain that the revision process is in disarray and that the preliminary results, made public for the first time in February 2010, are filled with potential clinical and public relations nightmares. Although most of the dissenters are squeamish about making their concerns public—especially because of a surprisingly restrictive nondisclosure agreement that all insiders were required to sign—they are becoming increasingly restive, and some are beginning to agree with Frances that public pressure may be the only way to derail a train that he fears will “take psychiatry off a cliff.”
At stake in the fight between Frances and the APA is more than professional turf, more than careers and reputations, more than the $6.5 million in sales that the DSM averages each year. The book is the basis of psychiatrists’ authority to pronounce upon our mental health, to command health care dollars from insurance companies for treatment and from government agencies for research. It is as important to psychiatrists as the Constitution is to the US government or the Bible is to Christians. Outside the profession, too, the DSM rules, serving as the authoritative text for psychologists, social workers, and other mental health workers; it is invoked by lawyers in arguing over the culpability of criminal defendants and by parents seeking school services for their children. If, as Frances warns, the new volume is an “absolute disaster,” it could cause a seismic shift in the way mental health care is practiced in this country. It could cause the APA to lose its franchise on our psychic suffering, the naming rights to our pain.
Allen Frances is worried that the DSM-5 will "take psychiatry off a cliff."
Photo: Susanna Howe; photographed at Café Sabarsky, Neue Galerie, NYC
This is hardly the first time that defining mental illness has led to rancor within the profession. It happened in 1993, when feminists denounced Frances for considering the inclusion of “late luteal phase dysphoric disorder” (formerly known as premenstrual syndrome) as a possible diagnosis for DSM-IV. It happened in 1980, when psychoanalysts objected to the removal of the word neurosis—their bread and butter—from the DSM-III. It happened in 1973, when gay psychiatrists, after years of loud protest, finally forced a reluctant APA to acknowledge that homosexuality was not and never had been an illness. Indeed, it’s been happening since at least 1922, when two prominent psychiatrists warned that a planned change to the nomenclature would be tantamount to declaring that “the whole world is, or has been, insane.”
Some of this disputatiousness is the hazard of any professional specialty. But when psychiatrists say, as they have during each of these fights, that the success or failure of their efforts could sink the whole profession, they aren’t just scoring rhetorical points. The authority of any doctor depends on their ability to name a patient’s suffering. For patients to accept a diagnosis, they must believe that doctors know—in the same way that physicists know about gravity or biologists about mitosis—that their disease exists and that they have it. But this kind of certainty has eluded psychiatry, and every fight over nomenclature threatens to undermine the legitimacy of the profession by revealing its dirty secret: that for all their confident pronouncements, psychiatrists can’t rigorously differentiate illness from everyday suffering. This is why, as one psychiatrist wrote after the APA voted homosexuality out of the DSM, “there is a terrible sense of shame among psychiatrists, always wanting to show that our diagnoses are as good as the scientific ones used in real medicine.”
Since 1980, when the DSM-III was published, psychiatrists have tried to solve this problem by using what is called descriptive diagnosis: a checklist approach, whereby illnesses are defined wholly by the symptoms patients present. The main virtue of descriptive psychiatry is that it doesn’t rely on unprovable notions about the nature and causes of mental illness, as the Freudian theories behind all those “neuroses” had done. Two doctors who observe a patient carefully and consult the DSM’s criteria lists usually won’t disagree on the diagnosis—something that was embarrassingly common before 1980. But descriptive psychiatry also has a major problem: Its diagnoses are nothing more than groupings of symptoms. If, during a two-week period, you have five of the nine symptoms of depression listed in the DSM, then you have “major depression,” no matter your circumstances or your own perception of your troubles. “No one should be proud that we have a descriptive system,” Frances tells me. “The fact that we do only reveals our limitations.” Instead of curing the profession’s own malady, descriptive psychiatry has just covered it up.
The DSM-5 battle comes at a time when psychiatry’s authority seems more tenuous than ever. In terms of both research dollars and public attention, molecular biology—neuroscience and genetics—has come to dominate inquiries into what makes us tick. And indeed, a few tantalizing results from these disciplines have cast serious doubt on long-held psychiatric ideas. Take schizophrenia and bipolar disorder: For more than a century, those two illnesses have occupied separate branches of the psychiatric taxonomy. But research suggests that the same genetic factors predispose people to both illnesses, a discovery that casts doubt on whether this fundamental division exists in nature or only in the minds of psychiatrists. Other results suggest new diagnostic criteria for diseases: Depressed patients, for example, tend to have cell loss in the hippocampal regions, areas normally rich in serotonin. Certain mental illnesses are alleviated by brain therapies, such as transcranial magnetic stimulation, even as the reasons why are not entirely understood.
Some mental health researchers are convinced that the DSM might soon be completely revolutionized or even rendered obsolete. In recent years, the National Institute of Mental Health has launched an effort to transform psychiatry into what its director, Thomas Insel, calls clinical neuroscience. This project will focus on observable ways that brain circuitry affects the functional aspects of mental illness—symptoms, such as anger or anxiety or disordered thinking, that figure in our current diagnoses. The institute says it’s “agnostic” on the subject of whether, or how, this process would create new definitions of illnesses, but it seems poised to abandon the reigning DSM approach. “Our resources are more likely to be invested in a program to transform diagnosis by 2020,” Insel says, “rather than modifying the current paradigm.”
Although the APA doesn’t disagree that a revolution might be on the horizon, the organization doesn’t feel it can wait until 2020, or beyond, to revise the DSM-IV. Its categories line up poorly with the ways people actually suffer, leading to high rates of patients with multiple diagnoses. Neither does the manual help therapists draw on a body of knowledge, developed largely since DSM-IV, about how to match treatments to patients based on the specific features of their disorder. The profession cannot afford to wait for the science to catch up to its needs. Which means that the stakes are higher, the current crisis deeper, and the potential damage to psychiatry greater than ever before.
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Changing Our Minds |
From the DSM-I to the DSM-5, definitions of mental illness have evolved with the culture. Here’s a sample of the rewrites.
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Condition |
DSM-I (1952) |
DSM-II (1968) |
DSM-III (1980; revised 1987) |
DSM-IV (1994; revised 2000) |
DSM-5 (rough draft released 2010) |
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Autism |
Schizophrenic reaction, childhood type
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Schizophrenia, childhood type; schizoid personality
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Infantile autism
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Autistic disorder
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Autism spectrum disorder
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Depression |
Depressive reaction
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Depressive neurosis
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Major depression
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Major depressive episode
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Major depressive episode
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Hysteria |
Phobic reaction; conversion reaction
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Hysterical neurosis; hysterical personality
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Histrionic personality disorder
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Histrionic personality disorder
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Histrionic personality disorder is removed. |
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Sexual Interest/Arousal Disorder |
Not listed |
Not listed |
Not listed |
Not listed |
A new disorder for DSM-5, defined as an absent or reduced interest in sex. Diagnosed in men if their “excitement” lags during 75 percent of encounters; in women, if reduced during all encounters. |
Allen Frances’ revolt against the DSM-5 was spurred by another unlikely revolutionary: Robert Spitzer, lead editor of the DSM-III and a man believed by many to have saved the profession by spearheading the shift to descriptive psychiatry. As the DSM-5 task force began its work, Spitzer was “dumbfounded” when Darrel Regier, the APA’s director of research and vice chair of the task force, refused his request to see the minutes of its meetings. Soon thereafter, he was appalled, he says, to discover that the APA had required psychiatrists involved with the revision to sign a paper promising they would never talk about what they were doing, except when necessary for their jobs. “The intent seemed to be not to let anyone know what the hell was going on,” Spitzer says.
In July 2008, Spitzer wrote a letter to Psychiatric News, an APA newsletter, complaining that the secrecy was at odds with scientific process, which “benefits from the very exchange of information that is prohibited by the confidentiality agreement.” He asked Frances to sign onto his letter, but Frances declined; a decade into his retirement from Duke University Medical School, he had mostly stayed on the sidelines since planning for the DSM-5 began in 1999, and he intended to keep it that way. “I told him I completely agreed that this was a disastrous way for DSM-5 to start, but I didn’t want to get involved at all. I wished him luck and went back to the beach.”
But that was before Frances found out about a new illness proposed for the DSM-5. In May 2009, during a party at the APA’s annual convention in San Francisco, he struck up a conversation with Will Carpenter, a psychiatrist at the University of Maryland. Carpenter is chair of the Psychotic Disorders work group, one of 13 DSM-5 panels that have been holding meetings since 2008 to consider revisions. These panels, each comprising 10 or so psychiatrists and other mental health professionals, report to the supervising task force, which consists of the work-group chairs and a dozen other experts. The task force will turn the work groups’ proposals into a rough draft to be field-tested, revised, and then ratified—first by the APA’s trustees and then by its 39,000 members.
At the party, Frances and Carpenter began to talk about “psychosis risk syndrome,” a diagnosis that Carpenter’s group was considering for the new edition. It would apply mostly to adolescents who occasionally have jumbled thoughts, hear voices, or experience delusions. Since these kids never fully lose contact with reality, they don’t qualify for any of the existing psychotic disorders. But “throughout medicine, there’s a presumption that early identification and intervention is better than late,” Carpenter says, citing the monitoring of cholesterol as an example. If adolescents on the brink of psychosis can be treated before a full-blown psychosis develops, he adds, “it could make a huge difference in their life story.”
This new disease reminded Frances of one of his keenest regrets about the DSM-IV: its role, as he perceives it, in the epidemic of bipolar diagnoses in children over the past decade. Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold. Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes. In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose money he’d received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times reported that Biederman told the company his proposed trial of Risperdal in young children “will support the safety and effectiveness of risperidone in this age group.”) Frances believes this bipolar “fad” would not have occurred had the DSM-IV committee not rejected a move to limit the diagnosis to adults.
Frances found psychosis risk syndrome particularly troubling in light of research suggesting that only about a quarter of its sufferers would go on to develop full-blown psychoses. He worried that those numbers would not stop drug companies from seizing on the new diagnosis and sparking a new treatment fad—a danger that Frances thought Carpenter was grievously underestimating. He already regretted having remained silent when, in the 1980s, he watched the pharmaceutical industry insinuate itself into the APA’s training programs. (Annual drug company contributions to those programs reached as much as $3 million before the organization decided, in 2008, to phase out industry-supported education.) Frances didn’t want to be “a crusader for the world,” he says. But the idea of more “kids getting unneeded antipsychotics that would make them gain 12 pounds in 12 weeks hit me in the gut. It was uniquely my job and my duty to protect them. If not me to correct it, who? I was stuck without an excuse to convince myself.”
At the party, he found Bob Spitzer’s wife and asked her to tell her husband (who had been prevented from traveling due to illness) that he was going to join him in protesting the DSM-5.
Throughout 2009, Spitzer and Frances carried out their assault. That June, Frances published a broadside on the website of Psychiatric Times, an independent industry newsletter. Among the numerous alarms the piece sounded, Frances warned that the new DSM, with its emphasis on early intervention, would cause a “wholesale imperial medicalization of normality” and “a bonanza for the pharmaceutical industry,” for which patients would pay the “high price [of] adverse effects, dollars, and stigma.” Two weeks later, the two men wrote a letter to the APA’s trustees, urging them to consider forming an oversight committee and postponing publication, in order to avoid an “embarrassing DSM-5.” Such a committee was convened, and it did recommend a delay, because—as its chair, a former APA president, later put it—”the revision process hadn’t begun to coalesce as much as it should have.” In December 2009, the APA announced a one-year postponement, pushing publication back to 2013. (The organization insists that Frances “did not have an impact” on the rescheduling of the revision.)
Illustration: Owen Gildersleeve
James Scully, medical director of the APA, fills the big leather chair in his office overlooking the Potomac River and the government buildings beyond. He’s a large, ruddy-faced man with a shock of white hair, and when he leans forward, his monogrammed cuffs perched on his knees, to deliver his assessment of Frances, even though it’s only two words—”he’s wrong”—you can hear his rising gorge and the sense of betrayal that seems to be swelling behind it.
Of all the things that Frances is wrong about—and there are many, Scully says, including his position on psychosis risk syndrome—the confidentiality agreement seems to be the one that really galls. First of all, it’s simply an intellectual property agreement “about who owns the product.” Second, he insists, this is the most open and transparent DSM revision ever, certainly more open than the process that produced Spitzer’s and Frances’ manuals, which were written in the pre-Internet era, before it was possible to field, as the task force has, 8,000 online comments on the proposed changes.
The agreement may well be mere intellectual property boilerplate. But, as I explain to Scully and later to APA research chief Darrel Regier, that hasn’t reassured all the psychiatrists who’ve had to sign it. They fret privately that the DSM-5 will create “monumental screwups” that will turn the field into a “laughingstock.” They accuse the task force of “not knowing where they’re going” and of “not having managed this right from the very beginning.” They worry that the “slipshod nature of the whole process” will lead to a “crappy product” that alienates clinicians even as it makes psychiatry “look capricious and silly.” None of them, however, are willing to go on record, for fear—unfounded or not—of “retaliation” and “reprisal.”
Regier wants to know who said these things.
Not all the dissidents are insisting on anonymity. E. Jane Costello, codirector of the Center for Developmental Epidemiology at Duke Medical School, says she doesn’t mind going on record because she’s “too small a fish” for them to bother with. Costello was one of two psychiatrists who resigned from the Childhood Disorders work group in spring 2009. In her resignation letter, which she subsequently made public, Costello excoriated the DSM committee for refusing to wait for the results of longitudinal studies she was planning and for failing to underwrite adequate research of its own. The proposed revisions, she wrote, “seem to have little basis in new scientific findings or organized clinical or epidemiological studies.” (In a response, the APA cited “several billions of dollars” already spent over the past 40 years on research the revision is drawing upon.)
To critics, the greatest liability of the DSM-5 process is precisely this disconnect between its ambition on one hand and the current state of the science on the other. Of particular concern is a proposal to institute “dimensional assessment” as part of all diagnostic evaluations. In this approach, clinicians would use standardized, diagnostic-specific tests to assign a severity rating to each patient’s illness. Regier hopes that these ratings, tallied against data about the course and outcome of illnesses, will eventually lead to psychiatry’s holy grail: “statistically valid cutpoints between normal and pathological.” Able to reliably rate the clinical significance of a disorder, doctors would finally have a scientific way to separate the sick from the merely suffering.
No one, not even Frances, thinks it’s a bad idea to augment the current binary approach to diagnosis, in which you either have the requisite symptoms or you don’t, with a method for quantifying gradations in illness. Dimensional assessment could provide what Frances calls a “governor” on absurdly high rates of diagnosis—by DSM criteria, epidemiologists have noted, a staggering 30 percent of Americans are mentally ill in any given year—and thereby solve both a public health problem and a public relations problem.
But Michael First, a Columbia University psychiatrist who headed up the DSM-5’s Prelude Project to solicit feedback before the revision, believes that implementing dimensional assessment right now is a tremendous mistake. The tests, he says, are nowhere near ready for use; while some of them have a long track record, “it seems that many of them were made up by the work groups” without any real-world validation. Bad tests could be disastrous not just for the profession, which would erect its diagnostic regime on a shaky foundation, but also for patients: If the tests have been sanctioned in the DSM, insurance companies could use them to cut off coverage for patients deemed not sick enough. “If they really want to do dimensional assessment,” First says, “they should wait the five or 10 years it would take for the scales to be ready.”
Regier won’t say how many of the tests are usable yet. “I don’t think it will be useful to get into this level of detail,” he emails. He acknowledges that dimensional assessment is still evolving, and he says the DSM-5 field trials—studies in which doctors will test the rough draft of the manual with patients—will help refine the tests. But the field trials, too, are bumping up against formidable deadlines. Although trials were scheduled to begin in May 2010, as of October only a pilot study was actually under way—and protocols for the rest of the trials couldn’t be finalized until that study was completed. Meanwhile, Regier has pegged May 2013 as a drop-dead date for publication of the new manual, which means that two sets of field trials and revisions must be completed by September 2012.
The time crunch only gives critics more fuel. Frances, on hearing of the trials’ delay, BlackBerried out a communiqué about the task force’s “Keystone Kops” missteps—the “Rube Goldberg design,” the “numerous measures signifying nothing,” the “criteria sets that are unusable because so poorly written.” All of which, he wrote, will lead to “a mad dash to dreck at the end.”
When the rough draft of the DSM-5 was released, in February 2010, the diagnosis that had galvanized Frances—psychosis risk syndrome—wasn’t included. But another new proposed illness had taken its place: “attenuated psychotic symptoms syndrome,” which has essentially the same symptoms but with a name that no longer implies the patient will eventually develop a psychosis. In principle, Carpenter says, that change “eliminates the false-positive problem.” This is not as cynical as it might sound: Carpenter points out that a kid having even occasional hallucinations, especially one distressed enough to land in a psychiatrist’s office, is probably not entirely well, even if he doesn’t end up psychotic. Currently, a doctor confronted with such a patient has to resort to a diagnosis that doesn’t quite fit, often an anxiety or mood disorder.
But attenuated psychotic symptoms syndrome still creates a mental illness where there previously was none, giving drugmakers a new target for their hard sell and doctors, most of whom see it as part of their job to write prescriptions, more reason to medicate. Even Carpenter worries about this. “I wouldn’t bet a lot of money that clinicians will hold off on antipsychotics until there’s evidence of more severe symptoms,” he says. Nonetheless, he adds, “a diagnostic manual shouldn’t be organized to try to adjust to society’s problems.”
His implication is that the rest of medicine, in all its scientific rigor, doesn’t work that way. But in fact, medicine makes adjustments all the time. As obesity has become more of a social problem, for instance, doctors have created a new disease called metabolic syndrome, and they’re still arguing over the checklist of its definition: the blood pressure required for diagnosis, for example, and whether waist circumference should be a criterion. As Darrel Regier points out, diabetes is defined by a blood-glucose threshold, one that has changed over time. Whether physical or mental, a disease is really a statistical construct, a group of symptoms that afflicts a group of people similarly. We may think our doctors are like Gregory House, relentlessly stalking the biochemical culprits of our suffering, but in real medicine they are more like Darrel Regier, trying to discern the patterns in our distress and quantify them.
The fact that diseases can be invented (or, as with homosexuality, uninvented) and their criteria tweaked in response to social conditions is exactly what worries critics like Frances about some of the disorders proposed for the DSM-5—not only attenuated psychotic symptoms syndrome but also binge eating disorder, temper dysregulation disorder, and other “sub-threshold” diagnoses. To harness the power of medicine in service of kids with hallucinations, or compulsive overeaters, or 8-year-olds who throw frequent tantrums, is to command attention and resources for suffering that is undeniable. But it is also to increase psychiatry’s intrusion into everyday life, even as it gives us tidy names for our eternally messy problems.
I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.
“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.
“No.”
“So what would you say was the value of the diagnosis?”
“I got paid.”
As scientific understanding of the brain advances, the APA has found itself caught between paradigms, forced to revise a manual that everyone agrees needs to be fixed but with no obvious way forward. Regier says he’s hopeful that “full understanding of the underlying pathophysiology of mental disorders” will someday establish an “absolute threshold between normality and psychopathology.” Realistically, though, a new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. As Frances points out, a complete elucidation of the complexities of the brain has so far proven to be an “ever-receding target.”
What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench. Regier and Scully are more than willing to acknowledge this. As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are psychiatrists ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.
It’s a problem that bothers Frances, and it even makes him wonder about the wisdom of his crusade against the DSM-5. Diagnosis, he says, is “part of the magic,” part of the power to heal patients—and to convince them to endure the difficulties of treatment. The sun is up now, and Frances is working on his first Diet Coke of the day. “You know those medieval maps?” he says. “In the places where they didn’t know what was going on, they wrote ‘Dragons live here.’”
He went on: “We have a dragon’s world here. But you wouldn’t want to be without that map.”
Gary Greenberg (garygreenbergonline.com) is the author of Manufacturing Depression: The Secret History of a Modern Disease.
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The author is unclear on the distinction between Clinical Psychology and Psychiatry and seems to give primacy to pill pushers (psychiatrists) rather than clinicians who are actually extensively psychologically trained (clinical psychologists). It is inexcusable and idiotic to call psychologists “outside the profession”, particularly if one can read. The sponsoring body of the DSMs, APA stands for the American PSYCHOLOGICAL Association, not the American Psychiatric Association.
Further, Insel’s naive but faddish Neuroscience Jihad at the NIMH is ridiculous. It appears that these idiots hallucinate that Radiology has rendered all other branches of medicine obsolete and have faith that FMRI will explain all human behavior, just as computerized tomography has produced unequivocal accuracy in the explanation of all human physical illness.
Exceptionally well written article. I perceive some bias against the APA, but Greenberg seems to have presented a fair account of the APA and DSM-5 position. He also isn’t really advocating specific changes to the development of the DSM-5, which I consider a key indication that he is trying to be fair.
Some things were a bit subtle or needed further investigation – when he learned “Regier wants to know who said these things,” Greenberg really needed to press Regier on whether that indicated Regier did not intend to answer “these things” on their own merit. If I were an APA member, I would hear a clear threat in Regier’s question.
Maybe this is a long-used psychiatry phrase, but I was astounded by Greenberg’s perceptivity and penetrating insight when he warned a DSM-5 failure “could cause the APA to lose its franchise on our psychic suffering, the naming rights to our pain.”
As a practicing Roman Catholic, I have long questioned why I should accept the APA’s “franchise.” Much “psychological expertise” seems to come at the cost of sacrificing 2000 (actually 3500+) years of hard-won wisdom about human nature – sin, guilt, freedom, compulsion.
Greenberg’s piece is absolutely terrific: informative, investigative, and exceptionally well-written.
Andrew Wolfe
The problems psychiatry has with defining mental illness stem from a long-standing inability to do anything in the field other than prescribe drugs or commit atrocities such as shock “therapy” or the like. A study of psychiatric malpractice (aided willingly and profitably by BigPharma) is available at http://cchr.org.
stsk, while I agree with you about psychiatry’s unfortunate overreliance on imaging technology, questionable “somatic therapies” like TMS, and the misplaced emphasis on pharmaceuticals, you are patently wrong about the APA. The DSM is published by the American Psychiatric Association.
http://bit.ly/eVrSdA
Imagine if there was a single dictionary for words. Decisions about any chances to the language would be extremely controversial and conflictual.
Now, the definitions in the DSM have far reaching implications, and it is an instrument of control of a semi-governmental institution (institutions which also control the licensing for that profession). What could go wrong?
Government monopolies and their licensing arms make for unhealthy industries.
Unfortunately, too many people see the lunatic fringe (I’m looking at you, Church of Scientology) or new-agey types as the only opposition to conventional psychiatry. This article reflects an important and very serious set of concerns about the creation and use of knowledge about mental disorders in the United States today. I find it heartening to see members of psychiatry’s old guard trying to right the boat; however, they still seem motivated mostly by preservation of their field, if not their selves.
Unfortunately, it looks like the APA house is built on epistemological sand and that constructs, symptoms, and drugs deployed by psychiatry mostly just reify each other. That this is what the crux of a minority report to the DSM-5 might say well damns the medical model of human anguish. Who then, if the mental health professions lose it, will hold the “franchise on our psychic suffering, the naming rights to our pain”?
Meh. The DSM is a way to get paid by the system, as the APA doc said. Other than that, it’s a worthless thing. This is not news. This is the oldest news out there, at least to anyone with any functioning neurons at all. Hard to get that excited all of a sudden. DSM IV was as much a waste of good trees as the upcoming version.
Of *course* this name calling, aka ‘diagnosing’, is for the most part ridiculous. Of *course* defining people in such a narrow and rigid way is ludicrous. It’s all about drugs. And money. And a culture that promotes conformity above all else. But money for Pharma, that is the real bottom line here.
Daria Inbar, M.D.
http://www.pacificpsych.com
@ pj1280 You are, of course, correct about the sponsorship of the DSMs. If you follow the link to the APA in the article (until they fix it) it takes you to the APA (American Psychological Association) website…
Dear Dr. Frances, I read with great interest your commentary on DSM-5. I hope you might also enter the dialogue on http://www.bpdforum.com where researchers and clinicians have posted their thoughts on the issues. The site, with partial funding from NIMH, is under the editorship of Ken Silk, MD with John Gunderson, MD and John Oldham, MD, Co-Chairmen of the web site.
Perry Hoffman, Ph.D. President-National Education Alliance for Borderline Personality Disorder (NEA-BPD)
How simple, just let “U.S.” use some more drugs and than have a gander.
It’s important to recognize the problem is not so much the CONTENT of the DSM. The problem is the POWER behind it. Essentially, the DSM is a quasi-legal document, created in private by a few hundred squabbling powerful and well-off psychiatrists, who literally vote on what is ‘proper’ thought and behavior. It’s time for democracy to get more hands on with issues involving mental and emotional well being. I hope readers check out the international social change movement led by mental health consumers, psychiatric survivors, and dissident mental health professionals. You can start by googling our group, MindFreedom International. We’re entering our 25th year, and by the way we’re one of the TOTALLY INDEPENDENT groups in mental health field — with absolutely zero funding from governments, taxpayers, drug companies, mental health system, etc. For 40 years, in the grassroots, people questioning the dominance and bullying by the mental health industry have been creating alternatives, campaigning for human rights. It’s a diverse movement, but at least folks are speaking out. I hope everyone reading this also speaks up, in their own way. Bullying by DSM thrives on silence. (Too often, some folks think the only critics of psychiatry are the Scientologists, and their group CCHR. Not to criticize them, but the truth is our group MindFreedom and many groups in our field have zero connection to Scientology or CCHR. In fact, as I pointed out, we are totally independent. The hoax that criticism of psychiatry is ‘all Scientology’ has held back honest and open discussion of the psychiatric industry’s problems.) Thanks for speaking out, David Oaks, Director, MindFreedom International.
The most shocking thing about this article is that few are shocked by it. Those of us who were thrown off a cliff by being diagnosed with schizophrenia and heaved into a State Hospital, given powerful drugs that really messed with the biology of our brains, and essentially left for dead, we know how insane the traditional medical model psychiatry is. But no one listened to us, and it seems no one is listening to those who wrote the previous version of the DSM. I had to learn on my own that what was tormenting me was a learned dysfunction, a form of PTSD.
The horror of being hauled to a hospital (prison), hearing that enormous door close behind one, being tied down and forcibly injected, told that one would never leave though one had committed no crime…
And still there is no dialogue between those of us who try to force psychiatry to admit its Big Pharma induced psychosis.
Hugh Massengill, former mental patient
MindFreedom, Hearing Voices Networks, Mental Health Associations, and probably other groups now offer perspectives other than that which has been conventional for so many years now. Unstuck, The Biochemistry or Joy, and even some fitness curricula now provide ways to deal with emotional challenge by figuring out how to trigger endogenous chemicals of health. Coaches are even preparing injured athletes for the possible withdrawal from endogenous opiates and other exercise-generated chemicals when they are side-lined from the vigorous work-outs they have become accustomed (addicted?) to. We will see great change in the near future no matter what the industries decide about the codes they will use when seeking payment. At least during these trying economic times, gym memberships have gone up as unemployment has gone up. Perhaps this explains why crime has not gone up as was expected. Maybe some psychiatrists will switch to becoming personal trainers. Few in that trade earn as much, but at least you get to work out in community.
Thanks fellow psychiatric survivors for commenting…I’m actually heartened to hear from people in the field that the new DSM could spell the end of psychiatry as a profession. It’s about time! When people go to jail it’s after a jury trial of their peers and for committing a crime, yet psychiatrists regularly lock people up and force drugs on them based on “disorders” they can’t even provide a scientific rationale for. And then kids are put on these drugs, which are in fact neurotoxins, as a substitute for human care. The truth is that there is no real line between those who have “disorders” and those who are just suffering; it’s all suffering, in different degrees, and should be “treated” through community involvement: see survivor support and advocacy groups like Icarus Project, Freedom Center and Hearing Voices Network for ways it can be done.
The proposed DSM-5 definition for Borderline Personality Disorder (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=17) is a perfect example of the kind of messed-up thinking these mental health professionals have. It says: “They may also become angry or hostile, and feel misunderstood, mistreated, or victimized.” Well, that’s an awfully convenient sentence for those who are mistreating and victimizing a mental patient (through locking them up, forcible injecting them with tranquilizers, etc.) to have–of course they “feel” that way, it’s a symptom of their disorder! I myself was once diagnosed with BPD in a hospital setting–I was angry at a so-called friend for calling the police on me and having me locked up, so naturally that was interpreted as a symptom. The DSM-5 definition also says “They may engage in verbal or physical acts of aggression when angry. Emotional reactions are typically in response to negative interpersonal events involving loss or disappointment,” which as far as I can tell describes everybody. You can just imagine the possibilities, drug-company-profit-wise.
Like I said, I want to see the whole concept of “normal” vs. “pathological” emotion thrown out. But under the current system, my first hope it that the new DSM will eliminate more disorders than it creates. Given the influence of Big Pharma, that probably won’t happen. What probably will happen is that as more and more kids have labels and drugs shoved at them, and ever-higher portions of the population are determined “disordered” by psychiatrists, more and more people will ignore the DSM entirely and start to realize that diagnosis and drugging are not the answer.
A psychiatrist I knew as a friend described himself as “an agent of the culture”. What is an “agent of the culture”? He explained that you look for anyone who does not fit in – someone acting “differrent” – and those people may need to be put away even though they broke no law. Since cultures change from place to place and country to country, so does the defination of mental illness. As cultures evolve, the definations change. Gay people, for example, who were previously called “sexual psychopaths”, are now considered perfectly normal.
I’m very confused here. James Scully calls this “intellectual property.” However, I believe every Supreme Court case on the books says that basic scientific principles can’t be patented. I mean, this is science we’re talking about here, right?
Full disclosure, I’m in no way a Scientologist, but I am a survivor of coercive psychiatric practices, practices which this article points to as arbitrary at best, capricious at worst.
At last- some sanity in the whole “psychiatricc diagnosis” debate. Frances is spot on – the way we have reified the categories in DSM and conflated them with medical diagnoses is of real concern. More than anything else it is the level of woolly thinking amongst people who are supposed to be providing care to us that frightens me.
This is not to say I am against using the labels in DSM. I was personally diagnosed with ADHD only 2 years ago (at age 47), and have flourished since I recognised and understood my problem. Medication was a useful, short term boost, but is no longer necessary. The thing is I never saw myself as having a “lifelong neurobiological disorder” to borrow from the insightless and destructive orthodox view of ADHD. Instead the diagnosis told me that all my problems boiled down to inattention. The funny thing is that is exactly what my religion (Buddhism) says. It is ironic that it took a “medical diagnosis” to push me to actually becoming a practicing Buddhist rather than a procrastinating one. It is my meditation practice that has cured my ADHD- but I would have struggled to establish this without medication.
The comment in the body of the article about “naming rights to our pain” is apt, and very profound. These diagnoses have been around for a very long time under different religious descriptors.
For instance- it is well known that advanced meditators experience all sorts of anomalous visual and auditory experiences that would be labeled by psychiatrists as hallucinations. However if a person that advanced were to be so foolish as to report those kind of experiences to a psychiatrist, there would probably be some justification in calling him crazy!
While the posting to the cchr link is quite appropriate in the context of this debate- I do think that we need to be clear that the Church of Scientology and The CCHR are at risk of throwing the baby out with the bathwater in their opposition to the use of psychiatric medication. In my earlier post I mentioned that I had been formally diagnosed with ADHD at age 47. I should be more specific her, because my problems were perfectly described by the model of ADHD. I placed my life at great risk on many occasions through my inattention. It is a miracle that I survived to age 47 without having a fatal accident, not to mention the terrible stress of not knowing what consequences of what as yet unknown inattentive act were waiting around the corner. That does not even touch on the great difficulty of maintaining friendships and a positive self image when inattentive, impulsive, and continually losing the thread of conversations.
While I am against reifying ADHD as a “disease” it most certainly did involve disorder and suffering for myself, and those who shared my life.I can say with complete confidence that medication was life saving for myself, and very likely my being medicated may have been life saving for my long suffering family.
What is needed in dealing with these problems is the flexibility to avoid being bound up by limiting concepts such as the current psychiatric orthodoxy, or the equally limiting concept of blanket opposition to medication. We are talking about difficult problems here, and intellectual skill,and flexibility are both essential elements of an effective approach to managing them.
THe introduction of
Medical model psychiatry is already a laughing stock. Or at least it WOULD be worth laughing at if it wasn’t such a threat to our liberty. I want everyone to ask themselves how ethical they feel that they vote for governments that force psychiatry on people. Psychiatry is quackery, slapping labels on unwanted behavior and thoughts, and doling out tranquilizer drugs and electroshock, nothing more. There are millions of people who have had their lives shortened by decades or died, just because they ended up forced into psychiatry.
Human suffering, confusion, inattention, fixation, overwhelm, emotional pain, trauma, are real, it is just that they are NOT ‘medical’ problems, they are human problems. The quacks in the Church of Psychiatry come along and reify their labels and indoctrinate people to believe they have brain diseases despite the fact psychiatrists don’t examine anyone’s biology before smearing them with a label.
It is high time that freethinking skeptical individuals were given the human right to not live in fear of ever being forced into this reductionistic paradigm of quackery psychiatry reserves the right to force on all citizens by force of law. Since when is psychiatry the monopoly state religion on our pain, when did it earn the ‘naming rights’ as so aptly described in this article?
Psychiatry is an ideology, not a science, it is a mistaken belief system, doing harm on a massive scale, like a religion, and people are indoctrinated and duped into it, and most of the practitioners are arrogant enough to believe that their assertions are truth, and this extends to them sleeping at night while people’s bodies are altered by violent forced drugging, any ideology where the ideologues are prepared to initiate violence in the name of their beliefs, violence against innocent nonconsenting people, is truly the mark of fundamentalism. I too am a survivor of forced psychiatry, I live in constant fear of being forcibly tranquilized again, my biology raped by these violent thugs, they have zero conscience, absolute fanatical faith that they are right, and they have absolute power to have me kidnapped off the street and shot up with drugs. It is truly a profession of quacks that strikes mortal terror into every fiber of my being. They are agents of normality enforcement and social control, as well as hopeless pitiless indoctrinators pushing their vile dehumanizing labels and drugs. My problems were never ‘medical’ and I will hate until the day I die the human rights criminals who dared rape my biology and fill my head with lies. Consent is a human right, psychiatry is happy to use violence and force, and feels it has a right to our bodies. They are the rapists of the self, the mutilators of brain function, the destroyers and diminishers of social identities and equality. They are beginning to be exposed for the rapacious life destroying, brain maiming, child disabling pseudo medical criminals that they always have been.
And on a brighter note, alternatives and more human and humane non-medical assistance with life problems is more and more available if you get off the beaten track and look around.
If you know anything about scientific process or just logic, you would know that you can’t cure something you can’t even define. For a long time mental health folks used “competence” as the definition. In other words, if the patient was able to get through the day without a drool bucket he was more or less sane.
Of course, that would make Hitler a sane man.
Doesn’t work.
Psychiatry MUST clean itself up as a profession or it WILL (someday) be cleaned up by someone outside the field. That someone may easily “throw the baby out with the bathwater” which would be a grave mistake.
Psychiatry – practiced correctly is a needed field. But practiced correctly needs doctors who aren’t tainted by ethical or professional issues of any sort – AT ALL LEVELS. That means starting at the top where the DSM is developed and going all the way to the lowest psychiatrist on the payroll at the smallest public mental health facility. In my lifetime, I’ve seen where good mental health care has saved lives and helped those around the person with psychiatric problems and I’ve seen where it was allowed to abuse people – or even to be used by abusers to abuse another family member. One of my psychiatrists wouldn’t listen to a word I said – even when I had proof of what I was saying – but he took everything my then spouse said as if it were gospel truth. Because of my then spouse’s tales and descriptions my diagnosis went from PTSD to Bipolar Type 1 with psychotic features. Since I had psychotic features, NO ONE listened to a word I said – not about what went on at home, not about side effect, not about my physical health or anything else. Well, not until he slipped up and did in public what he’d denied to my doctors for all those years. Meanwhile, my Mom getting my Dad forcibly treated finally got HIS paranoia under control and my family back on speaking terms before my father’s death. I’m seeing a good psychiatrist now – and sure enough, my diagnosis is NOT bipolar. That psychiatrist who diagnosed the bipolar made a laundry list of ethics violations and the diagnosis never should have been made.
BTW the story of the doc asking his secretary for a diagnosis for a patient points to yet another common problem in psychiatry. Many psychiatrists use the DSM for what I can only call “inspiration”. They don’t really care if the patient’s symptoms fit the criteria of an illness, they’ll diagnosis it if a major symptom sort of fits (like if a patient mentions “mood swings” then a psychiatrist may automatically diagnose “bipolar” even though there are many other things that can cause that symptom and the “mood swings” may not fit the criteria for “bipolar”). The DSM isn’t just “inspiration” it’s supposed to be the CRITERIA for diagnosing. So it should at least be a good, close fit rather than well, you sorta have a symptom of it”. These are strong medications you’re giving people, doc, and NO ONE knows the long term effects. Make SURE they’re needed them before you go making us take them. Also, just because we do (or might) have an illness out of your “guidebook” doesn’t mean you can blow off our side effects – some of them are pretty serious. Like seizures and diabetes.
Greenberg’s article is just another reason I fear for my future children and their generation. The fine line between what is a “diagnosis for medical sake” and “diagnosis to ‘Get paid’” is what will bring our society down. We are already a society of undisciplined, overspending fatties that have to many problems for the Internet to contain. Why can’t problems be problems and not have to have a “name” for everything?
If a child acts out in public it doesn’t mean that have an “attention disorder”, it just probably stems from the parents not wanting to interact with their children but rather their TV and now Iphone. If someone is “depressed” because they have a crappy car, crappy job, and can’t find a mate, well they just need to have someone tell them to “Suck it up and change your life” instead of being handed a pill that will mask the reality.
A book such as the DSM that tries to identify “diseases” that psychiatrists and others think we have will bring about a loss of innocence and a society afraid to express themselves for fear of being labeled.
Neuropsychological evaluation with a QEEG Brain Mapping can identify areas of the brain that are effected and therapy, methods and technology that include things like Transcranial Electrotherapy, Cognitive rehabilitation therapy and Neurofeedback therapy that are known to correct brain dysfunctions can be used instead of drugs. Problem is insurance won’t pay because it does not help drug company profits.
An interesting conference? “Genetic, cellular, and cognitive approaches to understanding social behavior” – June 2011: http://tinyurl.com/2f9mbkx
Erin Biba may have demonstrated why use of DSM should be restricted to psychiatrists: Hysteria became Conversion Disorder, not Histrionic Personality disorder as the table suggests. And what is a “bipolar drug?” You shouldn’t make up terms of art as you go along. Risperdal (risperidone) is used to treat patients with bipolar disorder, but has never been called a bipolar drug to my knowledge. Finally, Dr. Frances makes it sound as though the explosion of over-diagnosis of Bipolar and other disorders resulted from overly broad criteria in his DSM. I blame the psychiatrists for misinterpreting the criteria. And remember that the patients probably had real problems with real suffering. The DSM just classifies them. It doesn’t force them to accept a particular treatment. As for the connection between DSM criteria and big pharma, I blame our inept FDA as much as the drug companies. As for the psychiatrist who “got paid” by finally selecting a diagnosis, he should have said “got paid by the insurance company.” None of my patients has ever refused to pay me until I gave them a diagnosis. Does this doc really expect an insurance company to send him money no questions asked? He probably also forgot to tell you that many if not most insurers require ICD (International Classification of Disease) diagnosis and will not accept DSM diagnoses anyway.
Actually, just about every atypical antypsychotic has won approval (meaning proof via clinical trials) in one nation or another (if not many nations) that it works as a mood stabilizer (meaning “bipolar drug”). Risperdal is an atypical antipsychotic. The only exceptions that come to mind are the cutting edge newest atypical antipsychotics and perhaps also Clozaril(but why anyone would use that by choice, doc or patient considering the risks, is beyond me).
of course, the point made at the end – that a psychiatrist needs to come up with a diagnosis in order to get paid – is not unique to psychiatry or to mental health. my internist needed to do the same thing to justify the blood tests he asked me to get at my yearly checkup a couple of weeks ago…he used the term “what diagnosis should I make up for you?”
I think one of the issues is that this is a multidimensional problem. We are trying to use one set of codes, whichever version we are talking about, for multiple purposes:
- Insurance companies expect an axis 1 diagnosis before reimbursing the patient or mental health practitioner. They also use the diagnosis when evaluating the appropriate level of care, I believe.
- Psychiatrists use diagnoses to get reimbursed for prescribing medication, other mental health practitioners (and some psychiatrists) use the same set of codes to get reimbursed for providing psychotherapy.
- Researchers use diagnoses to try to clarify what they are researching
- At least some mental health practitioners try to balance the desire for reimbursement with the potential implications of giving a specific diagnosis, when multiple diagnoses might apply
A broader set of criteria for a diagnosis may suggest that it will be easier for psychiatrists to prescribe medication and for pharmaceutical companies to sell their products, but it can also mean that it is easier to justify reimbursement for psychotherapy.
If psychotherapy helps (it often does) and doesn’t have negative side effects (it usually doesn’t), then being able to get reimbursed is a good thing – especially if having a valid diagnosis is the only way for the client to avoid paying for a useful treatment out of pocket.
Ideally, when evaluating a set of diagnostic criteria, we should try to keep in mind the pros and cons taking into account all of these issues and constituencies.
Ya era hora que una voz en español comentara acerca del tema; y aún más si viene, nada menos, que de Kraepelin (que por cierto visitó España y las islas Canarias).
El artículo es equilibrado y certero. Está bien escrito y refleja el cansancio y la irritación de los psicoterapeutas y los psiquiatras cuando tienen que enfrentarse con la “reificación”del sistema diagnóstico. Es triste que esto lo haya mencionado el finado George Winokur y en Archives of General Psychiatry, y que nos hayamos olvidado de ello: Cause the Bible told me so! creo que es el titulo del artículo. La intención original del DWSM después del experimento de Rosehan publicado en Science, era buena: reorganizaba el diagnóstico psiquiátrico e introducía el problema de la validez (pero a expensas del de la fiabilidad).
Como dicen los anglosajones, no se puede tirar el bebe con el agua sucia. Hay críticos serios del DSM – un desastre – como por ejemplo Nassir Ghaemi, o Allan Horwitz o Jerome Wakefield, pesos pesados, que tienen poco que ver con las estridencias de algunos (tanto los que proceden de la “derecha” – ¿Cientología? – como de la “izquierda” – ¿aquí a quién pondríamos? -). Gracias a ellos se podrían compensar los peores excesos del DSM5.
¡Un saludo hispano!
In terms of overlapping symptoms in different disorders (such as schizophrenia and bipolar), I’m surprised that there’s no mention of cluster analysis. I can’t remember the authors but I read a paper from 10-15 years ago that ran series of tests on different symptoms and found high overlap on traits like depression and anxiety, which is consistent with the DSM-IV-TR and diagnoses of comorbid depression and anxiety. I think that the genetic research on bipolar and schizophrenia is certainly vital for understanding etiology and the trajectories of illnesses but it shouldn’t ignore the fact that specific environmental factors are more likely to trigger one set of symptoms (like depression and anxiety) than others.
http://mindinquirer.wordpress.com
Well written article. I’ve often called the DSM “The bird watcher’s guide to psychiatry.” The psychiatrist observes what the symptoms are and looks it up in their DSM to identify it… more for billing purposes than anything else. This makes identifying a diagnosis very subjective, and many times not accurate. The article identifies a third of the population having a mental illness which would by any other standards be called an epidemic.
Over the past 35 years I’ve know and have walked with many people who have a mental illness. A DSM diagnosis is more often than not, a problem. On one hand people want to know what they have, so the diagnosis can be comforting and give a sense that help is possible. On the other hand many go through life with their diagnosis being changed several times. This makes many wonder how accurate a diagnosis really is. Symptoms one experiences and effective help to eliminate those symptoms are much more important than an actual diagnosis. We really do need a new more effective way to identify mental illnesses. When it comes to actual treatment and interventions, the DSM should be scrapped for something better. My bet is that the pharmaceutical companies would likely never let that happen.
Great article, great information. Thank you for putting this out there. It needs to be talked about more. Check out this video, it’s called Legal Drug Addict and talks about how we’ve been too quick to turn to medication for our kids and ourselves. http://www.youtube.com/watch?v=D1xgRIj8afA
Thanks again.
jp
There’s a factual inaccuracy in this story. You write, “It happened in 1973, when gay psychiatrists, after years of loud protest, finally forced a reluctant APA to acknowledge that homosexuality was not and never had been an illness.” Actually, the “years of loud protest” were the result of the efforts of gay activists from outside the APA. They started when the APA made the mistake of holding its 1970 convention in San Francisco, where the gay liberation movement was at its peak after the Stonewall Riots. Gay liberationists stormed the conference and shouted down speakers in order to make their voice heard. There was a small, secret group of gay psychiatrists within the APA, but they were too afraid of losing their jobs to speak out. In 1972, after much pressure from gay liberation activists, one psychiatrist named John Fryer agreed to speak at the convention only if he was disguised. He gave his speech as “Dr. H Anonymous,” wearing a wig, a nixon mask, a tuxedo, and speaking through a voice distorting microphone. Anyway, you can read all about it in the best historical source, “Homosexuality and American Psychiatry” by Ronald Bayer, but the fact remains that the gay activists were the only ones doing the “loud protesting.”
Thomas Szasz, MD, author of The Myth of Mental Illness (1960) and The Manufacture of Madness (1970)must be getting a well deserved chuckle out of this great article. Granted, he is far left on many matters, but we certainly need his wisdom to stave off the over diagnosing so prevalent today. I just love his quote: “Since theocracy is the rule of God or its priests, and democracy the rule of the people or of the majority, pharmacracy is therefore the rule of medicine or of doctors”. Statistically, can there actually be this many BiPolar people in our midst? Psychiatry is a machine that sustains itself with q3 month med reviews. What ever happened to the art of therapy, now it just seems to be calligraphy on a Rx pad. Sad.