DSM-V Badly Off Track

According to Ken Pope, that’s the title of an interview with Allen Frances at Psychiatric Times. Dr. Frances was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke. I’m passing on the excerpts that Dr. Pope culled from the article:

Q: This is the first time you have commented on DSM-V. Why did you decide to speak up now?

A: We have already gone past the midway point of the time allotted for the preparation of DSM-V. I realized that not enough has been accomplished and that most of what is being suggested is headed in a very wrong direction. Particularly troubling is the almost total lack of recognition that changes in an official manual of diagnosis can have devastating unintended consequences. Before it is too late, I feel a responsibility to help DSM-V avoid mistakes by sharing the lessons learned during the past 30 years working on the 3 previous revisions of the DSM. Perhaps my comments may help the DSM-V Task Force avoid some of the hidden landmines I think they are dancing around.

Q: In your opinion, what has gone wrong in the DSM-V process?

A: The most fundamental errors have been its completely inexplicable secrecy and the lack of openness to outside influence and criticism. I simply can’t recall a single moment of work on the DSM-III, DSM-III-R, or DSM-IV when there was anything remotely worth keeping secret. Restricting the free flow of ideas creates enormous blind spots that greatly increase the risk of damaging unintended consequences. Specifically, it was a huge mistake to require that the DSM-V work group members sign a confidentiality agreement. It was also unwise to avoid having any institutional memory of how and why decisions were made in prior revisions. The advisory group is far too small and select to reduce, rather than encourage, heated debate. In producing a new edition of the DSM, your harshest critics eventually turn out to be your best friends because they are most likely to help you avoid pitfalls. My own highly critical comments on DSM-V are offered, and I hope will be taken, in this spirit.

Q: What are the risks you are so concerned about?

A: The work on DSM-V suffers from the unfortunate combination of being heavy on ambitious goals for change and light on the methodological rigor necessary to avoid the many problems that such change may cause once the system is in wide use. Unless DSM-V changes course dramatically, it will introduce numerous new, relatively untested categories that will greatly jack up the rates of mental disorders. Many people will be inappropriately identified as mentally ill and will receive excessive treatment. The pharmaceutical industry will have a field day. Two necessary forms of protection should have been established to prevent this: (1) a requirement that all changes be supported by a high threshold of systematically gathered empirical evidence, and (2) a careful risk-benefit analysis of the potential negative impact of each and every change.

DSM-V: A New Animal?

A few interesting tidbits I got from Ken Pope’s digest of a Los Angeles Times article on the current construction of the new Diagnostic and Statistical Manual:

But all agree that the so-called bible of psychiatry is expected to be considerably more nuanced and science-based than the last edition, DSM-IV, published in 1994.

Brain imaging and other technologies, plus new knowledge on biological and genetic causes of many disorders, have almost guaranteed significant alterations in how many mental afflictions are described.
….

The book will describe disorders in more detail, acknowledge variations that haven’t been viewed as part of “classic” illness and explain how conditions differ based on age, race, gender, culture and physical health, Kupfer said.

What that looks like in practice is anybody’s guess. But what seems clear is that DSM-V is going to be a different sort of animal. Ties to the pharmaceutical industry remains the biggest problem with the work. Here is another excerpt, again courtesy of Ken Pope, that typifies the justifiable concerns that have been raised many, many, many times:

Over the last two decades more medications have become available to treat mental disorders, and some doctors worry that the text may be written in a way that expands the market for drug therapies.

A study published online in the current issue of the journal Psychotherapy and Psychosomatics found that of 20 work group members writing clinical practice guidelines for the treatment of bipolar disorder, schizophrenia and major depression, 18 had at least one financial tie to industry.

A commentary in the May 7 New England Journal of Medicine said that 56% of DSM-V task force and committee members have industry ties.

DSM-V committee members have been asked to abide by conflict-of-interest rules, including agreeing to receive no more than $10,000 annually from industry sources during the period they serve on the committee.

But that isn’t going far enough, said Lisa Cosgrove, lead author of the Psychotherapy and Psychosomatics analysis and an associate professor and clinical psychologist at the University of Massachusetts.

“There are currently work groups where every single person has ties,” Cosgrove said. “It doesn’t seem like genuine progress has been made.”

Doubt Is Our Product

Here’s a brief quote from a Psychology Today interview with David Healy, author of Let Them Eat Prozac. I got wind of the interview from the ever vigilant Furious Seasons, and these are excerpts from that website:

“Well, I think what Donna’s story above illustrates is that pharmaceutical marketing departments are actually the postmodernists par excellence. They treat the human body (including its disorders and complaints) as texts to be interpreted one way this year and in just the opposite way a year or two later.

“In contrast, when it comes to the hazards of these drugs—just like the tobacco companies before them—the motto of Pharma has become ‘doubt is our product’-—they simply refuse to concede that their drugs are linked to any hazard at all . . . until the drug goes off patent. You cannot get a better definition of postmodernism than “doubt is our product.’”

Really, the interview is worth checking out. The headline starts: Bipolar disorder and it’s biomythology.

Lexapro For Teens

Here’s an excerpt from Furious Seasons on why not antidepressants for kids:

Because anti-depressants represent America’s quick fix culture: compare our approach with the UK’s, where anti-depressants are mostly banned for anyone under 18 and where its own health care agencies (ie, NICE) recommend approaching depression treatment by going through watchful waiting, making sure patients are eating properly and exercising, psychotherapy and, then and only then, moving to anti-depressants. Since making that shift a few years ago in the nation’s depression treatment policies, I’ve heard no reports of British teens going through a suicide epidemic. In fact, the suicide rate went down over there when most anti-depressants (except Prozac) were banned for under-18s.

ADHD: Medicate or Nature Walk?

From a New York Times article on the importance of recess, an interesting assertion regarding the effectiveness of medication v. nature  walks for ADHD:

A small study of children with attention deficit hyperactivity disorder last year found that walks outdoors appeared to improve scores on tests of attention and concentration. Notably, children who took walks in natural settings did better than those who walked in urban areas, according to the report, published online in August in The Journal of Attention Disorders. The researchers found that a dose of nature worked as well as a dose of medication to improve concentration, or even better.

When Testing is Damaging: “Stereotype Threat”

From a Washington Post article by Shankar Vedantam “How a Self-Fulfilling Stereotype Can Drag Down Performance” on some research that suggests that standardized tests themselves effect their outcome. Make sure to read the last two paragraphs. The story was brought to my attention by and excerpted by Ken Pope:

Sociologist Min-Hsuing Huang recently decided to ask whether the race of the person administering the survey mattered: He found that when black people and white people answered 10 vocabulary questions posed by a white interviewer, blacks on average answered 5.49 questions correctly and whites answered 6.33 correctly — a gap typical of the ones found on many standardized tests.

Huang then examined the performance of African Americans who interacted with black interviewers: He found that black respondents then answered 6.33 questions correctly — the same as white ones. The reason African Americans scored more poorly on tests administered by white interviewers, Huang theorized, is that these situations can make the issue of race salient and subtly remind the test-takers of the societal stereotype that blacks are intellectually inferior to whites.

Huang’s findings, recently published in the journal Social Science Research, are only the latest in a body of research that has gone largely unnoticed by policymakers, parents and managers: Dozens of field experiments have found that reminding African Americans and Latinos about their race before administering academic tests, or telling them that the tests are measures of innate intelligence, can hurt their performance compared with minorities who were not reminded about race and not told that the results reflect inherent ability.

Psychologists such as Claude Steele at Stanford University came up with the term “stereotype threat” for the phenomenon:  When people are threatened by a negative stereotype they think applies to them, they can be subtly biased to live out that stereotype.

The threats do not have to take place at a conscious level: When volunteers in experimental studies that have found huge stereotype-threat differences in performance are told about the phenomenon afterward, they invariably tell researchers that the theory is interesting but does not apply to them.

Nor are the findings limited to blacks and Latinos. The same phenomenon applies to women’s performance in mathematics.

<snip>

In a soon-to-be-published study, researchers Gregory M. Walton at Stanford and Steven J. Spencer at Waterloo University in Ontario explored a question with even thornier implications.  What does stereotype threat tell you if you are a college admissions officer debating between a man and a woman who both have an SAT score of 1200?

<snip>

But in two meta-analyses involving nearly 19,000 students, Walton and Spencer found that when schools and colleges go out of their way to ameliorate stereotype threats, the performance of women and minorities soars — it’s as if these students are athletes who have been running against a headwind.  Without the headwind, Walton and Spencer found that minorities, and women in math and science, do not just do as well as whites and men with the same SAT scores — they outperform them.

“We would argue if you simply use test scores, you are building in discrimination into a system,” Spencer said.  ”The test scores underrepresent what minorities, and women in math and science, can do.”

When Your Husband Has to Hide the Belts

If you had any doubt that having bipolar disorder (manic depression) is extremely difficult, check out this heartbreaking post from Marissa Miller at Depression Introspection.

New Office

I’ve just opened a new office. A fruitful and pleasant post-doc with Rose City Counseling Center has ended, and I’ve just completed my second week in private practice. The new office is in a beautiful old building near Old Town Pasadena, off Colorado, between the Paseo and Vroman’s. Here’s my new information:

Kalea Chapman, Psy.D.

16 S. Oakland Ave, Ste 216

Pasadena, CA 91101

Happy holidays.

Senior Care: Profit or Non-Profit?

Here’s an excerpt (courtesy of Ken Pope) from an article in U.S.A. Today. In brief, the finding is that for-profit elder care facilities deliver inferior care. The article includes a tool that enables you to find the specific rating of a given nursing home.

An analysis of nearly 16,000 nursing homes reveals for-profit homes are more likely to provide inferior care than their non-profit rivals, according to a USA TODAY examination of the federal government’s first ratings of the homes’ performance.

The new Zagat-like rating system, released today by the Centers for Medicare & Medicaid Services, assigns homes one to five stars for quality, staffing and health inspections, plus an overall score.

The scores reflect tens of thousands of inspection records, complaint investigations and quality measures, such as how many nursing staff hours were provided each day to patients, how many patients developed bedsores and how many were placed in restraints. Much of the data were collected in 2008.

Acting Medicare Administrator Kerry Weems says offering the data in a simple five-star format should prompt “a national conversation about nursing home quality” and spur homes to improve.

Strict, Lax, or Flexible Parenting Styles?

Popular, popular, popular. For some reason, this is consistently the most popular post on this blog.  I guess there are a lot of parents out there with questions. Perhaps it’s that parents, lacking a clear sense of what is the “right” way to parent, turn to books. Unfortunately parenting books so often tell you that there is only one way to parent — their way. So this kicks up a lot of anxiety. The truth is parents need to parent in the way that fits the best for their family, without heading toward the extremes. If you grew up in a lax household, you’re not likely to have much luck with being strict — you might — on the other hand, be able to set some boundaries…

With light edits, this is what was posted in July 2007 and May 2008.

(In terms of popularity the post on Bessel Van der Kolk and trauma comes a close second. And I would have thought the post on how to deal with a 3-year-old’s tantrum would have generated more interest.)

 

Strict, lax, and flexible.
In psychology, we say authoritarian, permissive, and authoritative. These terms based on the research of Baumrind (1971). Sharon Jablon, Ph.D., who runs a test prep workshop for the national licensing exam in psychology (EPPP), has a nice summary of these parenting styles, which I’m going to quote from:

Authoritarian parents expect unquestioned obedience, are demanding, controlling, threatening and punishing. [They] tend to be more detached and less warm than other parents. Children exposed to this parenting style are frequently moody, irritable, discontented, withdrawn, distrustful, and aggressive and tend to have more behavior disorders. …This parenting style was termed “conflicted-irritable” and led to children who were also termed “conflicted-irritable”.

Permissive parents value self-expression and self-regulation. [They] are either permissive-indifferent or permissive indulgent.

a) Permissive-indifferent parents set few limits, provide little monitoring, and are generally detached and uninvolved. Their children have poor self-control, are demanding, minimally compliant, and have poor interpersonal skills. [Apparently, Baumrind didn't have a label for this sub-type of permissive parenting.]

b) Permissive-indulgent parents are loving and emotionally available, yet set few limits, demands or controls. Their children tend to be impulsive, immature, and out of control. …The permissive-indulgent parenting style was termed “impulsive” and led to children who were termed “impulsive-aggressive”.

Authoritative parents (not authoritarian) are caring and emotionally available, yet firm, fair, and reasonable. They set appropriate limits, and provide structure and reasonable expectations. Children with authoritative parents are usually competent, confident, independent, cooperative, and at ease in social situations. …This parenting style was termed “energetic-friendly” and led to children who were termed “energetic-friendly-self-reliant”.

What have you observed?
Safe to say, you have observed or participated in parenting that resembles one of these categories more than the others. Reflect upon your own upbringing. Does one of these fit? Do the outcomes of these parenting styles described fit with your own experience?

Striving to be the parent you want to be.
If you are a parent, do you fall under one of the categories? Most of us would prefer to be to be in the “authoritative” camp. But most of us tend to veer into one of the other styles, if left to our own devices. In other words, some of us struggle with being lax, while others struggle with being strict. This has to do with how we were raised. By default, we raise our kids how we were raised; or, quite often, we raise our kids in reaction to how we were raised. Many of us struggle with being inconsistent, one of the most difficult battles of parenting.

Just another set of labels.
Remember, these are just labels. People love to categorize the world and say, “There, that’s how it is.” When we do this we blind ourselves to other possibilities. Reality is usually much more complicated. Perhaps this scheme does not fit with your own experience. As with any system of thought, take it with a grain of salt. These things have their day, are useful for a time, are often replaced by more useful ways of thinking. Take what you can use. If you’re interested in reading more about this scheme, click here.