Undisclosed financial conflicts of interest in DSM-5 (2024)
bmj.com
bmj.com
While there has been a level of diagnostic expansion that I don’t think is helpful, it’s also important to consider:
What’s the psychiatric equivalent of a sprained ankle?
Does something have to be catastrophic to warrant a diagnosis?
Our physiological system does have that uniformity across the population but our psychological system does not seem to. Isn't it then misguided to try characterizing small deviations when we don't even have a uniform "background" to subtract?
Some people can’t get stranded ankles because they don’t have legs, so you don’t necessarily need a universal baseline across all of humanity when diagnosing conditions. Someone who is still within normal ranges but significantly doing worse than they where can quite reasonably seek treatment.
One of the biggest problems with psychiatry is that every diagnosis is a spectrum, and over time it's become more and more obvious that the boundaries for what is considered "neurotypical" are way too narrow.
Depression being a chemical imbalance was a complete lie to sell more medication, and how prolific this type of occurrence is within the industry is not hard to see.
At the very least, a plurality of phycological diagnoses are manifestations of physical behavior: diet, exercise, exposure to sunlight, etc
We're so overprescribed on medications to try to feel a certain way within far too narrow of a spectrum.
Why do you presume that there has to be an equivalent to a sprained ankle? Maybe the answer to your question is yes, only the catastrophic is worth addressing.
https://journals.plos.org/plosmedicine/article?id=10.1371/jo...
This is a very privileged view of the mind. I have ADHD (and autism). But I also have a quite high IQ, if one cares about such things. I'm pretty successful, professionally.
But it took until around 40yo to get the ADHD diagnosis and get a prescription for medication that has been life-altering. Was I suffering from catastrophic failures? Absolutely not: married, have kids, in the 1%, etc.
But have the meds had an incredibly positive influence on my life? Hell yes. I can do things that everyone else acted like was normal, but I straight up couldn't do it before. Housework is a prime example. It was like torture. Sitting around waiting for people to finish their sentences because they're "talking as slow as molasses" made for often unenjoyable social experiences.
But with the meds, this stuff is either tolerable or fun. My life is significantly better thanks to medical interventions. Instead of my wife blowing up because I didn't do something like mop the kitchen floor, I actually get it done (without meds I straight up cannot hold that kind of task in my mind if I'm not in the room looking at the mess; I will flit between ten other things in a different part of the house, then walk through the kitchen to get into my car to pick up the kids, see the kitchen, and think "ah, fuck me")
I'm happy that you're neurotypical and have a great life, but that's not true for a lot of us, and the idea that "only catastrophic mental issues should be dealt with by professionals" is you just telling on yourself and your ignorances.
There also is a good chance I don't have children because just being alive and by myself was super exhausting before I got diagnosed in my late 30. Having children was unthinkable until then.
But was it catastrophic? I don't know. I finished college except it took two times as long and got a job where I of course suffered pretty much the whole time.
But that was all very normal for me, just the way I was, at least that's what I used to believe.
For those with ADHD they turn on the prefrontal cortex which reduces or removes the feeling of utter torture and pain from doing chores.
It's sort of like taking a drug that takes away the fear and almost physical inability to to touch a hot stove most people have. Normally that'd be bad. Except here the hot stove is actually harmless and useful to touch.
Benzodiazepines, opioids, stimulants, opioid-like substances like carisoprodol (there is a reason why people call it Soma). these are the first that come to my mind. contrary to popular belief, downers often give you euphoria.
Edit: ok, that was vallium. ;)
I bet if you knew your house would burn down if you didn't do "normal" things you would have done them no problem.
Stimulants make otherwise unenjoyable things enjoyable? Who would have thought? Do you think people that do "normal" things enjoy them? Is it necessary to enjoy everything all the time?
Because you talk like one, with no apparent empathy for the neurodiverse, except perhaps people with profound issues. "We shouldn't treat any problems except the catastrophically bad." Gross.
> I bet if you knew your house would burn down if you didn't do "normal" things you would have done them no problem.
This is not arguing in favor of your stance, but rather in favor of mine. You're essentially saying "ADHDers can't get shit done without being in dangerous situations, and THAT IS ACCEPTABLE." And yet you think this supports your idea that non-catastrophic disorders shouldn't be treated.
Getting yourself to do things in a boring situation that you might only do in an exciting situation is a big challenge in ADHD management
If everything was a "house on fire" level emergency, many ADHDers would get more done but would eventually collapse from running around on adrenaline for days
These problems are not easily solved
To pretend that humans are hedonic beasts incapable of cognitive adaption is ridiculous. We do not operate purely on impulse save for pharmaceutical intervention. We can force ourselves to give things more or less importance regardless of the actual stakes.
People with ADHD cannot all just "force themselves" to function. Novelty, excitement and interest can help, some of the time, but the rest of the time it's disaster. Depending on severity, the result of not getting the treatment they need can often include things like an inability to keep a job, homelessness, prison sentences, and accidents/injury. Those kinds of outcomes are pretty damn important to avoid, extremely stressful (exciting) to experience or be in imminent danger of, and certainly more than enough to motivate people to do the best that they can, but some percentage of people will never be able to avoid those outcomes by trying to will themselves into "cognitive adaption".
Others may be able to stave off the absolute worst outcomes without medication, but only through exhaustive efforts that prevent them from accomplishing the things they want in life. Why should someone constantly and needlessly push themselves to their absolute limit just to accomplish what comes easily for most people? For what? Bragging rights about how they reshaped their brains by sheer force of will? If medication for a mental condition can make people's lives better they should be free to take it.
To whatever extent you've been able to function without medication, that's great. Don't assume that what worked for you is applicable to everyone else, or even to most other people.
People were constantly bombarded with death, disease, things like starvation were near term risks, violence was everywhere, etc.
You're also overestimating the prevalence of alcoholism. Alcohol consumption was largely driven by safety and necessity, not abuse. Alcoholism was arguably more of a social stigma historically than it was today, certainly with harsher criminal penalties in many societies.
Edit: by chaos I mean things breaking down, going wrong, catching fire, etc. I accomplish things easily once I've taken so long to get to them, that they're seriously urgent.
Why do you think that is?
Asian Americans are so successful that they certainly must not have disproportionately higher rates of suicide right? That might be a sign of some "impairment" going unaddressed! Or maybe you see the rate at which they're killing themselves as yet another metric of success? Those scrappy East Asians are just so good at doing stuff!
They outperform by the metrics that matter for a clinical diagnosis and the West is so quick to jump to the conclusion that they're "under diagnosed", it's a uniquely Western and especially American conclusion.
Like many other biological systems, neurological wiring is multidimensional and not a natural fit into our arbitrary culturally defined abstractions, or even language. And the dimensions themselves are multifaceted expressions of multiple genes and environmental factors. I am happy to hear stories like yours, of people who can ultimately achieve "normal" functional parity without medication.
Have you considered if that would have been possible without the journey? Had you, on day 1, cancelled that first therapist appointment and decided to grit your teeth and "try" instead, could you have "accepted discomfort" on your own? Or is it possible that the methylphenidate created supportive conditions that improved your chances?
I ask because there is a body of well reproduced research demonstrating not only that ADHD patients have specific genetic and neurobiological differences from neurotypicals in areas associated with executive function, but that long term ADHD medication use can permanently bring the neurological differences into line with neurotypical controls. Something like 20% of medicated childhood ADHD patients can ultimately stop medication without losing points in functional testing or the associated brain structures. It's a lower percentage in adults and less well studied, but still exists. It's a big difference from the results of every non-chemical intervention we've studied, which have single digit efficacy percentages if they beat P at all.
I'm interested in your feelings about this because ADHD is by far the most-studied psychological disorder in the world, and ADHD medications as a group are not only equally well studied, but also the most successful and least harmful of any psychiatric drug. There are more safety and efficacy studies for ADHD medication than for ibuprofen.
So... if you feel your recovery was not helped by the neurogenetic compensations provided by methylphenidate, you should know that you are flying so far in the face of some of the best-validated medical science, that you imply invalidity of pharmaceutical or medical science as a whole.
... which is fine of course - it's your body and brain! But I bet it would help readers to know how you think this aligns with the science, or maybe what you think of medical science altogether. Questions like "Do you take ibuprofen?" And "Do you vaccinate?" Become relevant.
You're leaving out the part about being "well studied" paired with your conclusions is almost exclusively in American and Western European populations, things are significantly less clear in other populations and cultures.
You have inadvertently outed yourself as not having a clue by your reply. It’s nothing personal but you just clearly don’t have a clue and/or don’t have skin in the game.
It’s fine. I don’t know anything about professional juggling because I have zero skin in that game.
Paging Dr. Brochacho: fMRI and brain networks have been around for a while!
Your articles also say that:
- depression medication does appear to be effective in some cases regardless, indicating some other neurochemical mechanism at work.
- the existence of a "neurochemical imbalance myth" underpinning psychology as a whole is, itself, a myth.
- the idea that this mythical myth about neurochemical imbalance has been debunked, is also a myth.
- that the psychological scientific consensus has, since the first peer-reviewed mention of the word "neurochemical" in the 60s, quite consistently been aligned with the 1978 synthesis statement by the then president of the APA:
> "Psychiatric disorders result from the complex interaction of physical, psycho-logical, and social factors and treatment may be directed toward any or all three of these areas."
Your second article is particularly clear in explaining all this.
Exact quote from second article
"Furthermore, the SSRIs were accorded a rock-star status as effective antidepressants that they did not deserve. Most troubling from the standpoint of misleading the general public, pharmaceutical companies heavily promoted the “chemical imbalance” trope in their direct-to-consumer advertising."
There second article admits the overuse of the term while trying to defend psychiatry for never officially adopting it, but everyone who's been on them knows that's exactly what they were told about their effectiveness, so whether the trope originated with the pharmaceutical companies (my assertion) or not, they were still way over prescribed and there's no statistically significant evidence they actually work when controlling for confounders, as the first meta analysis clearly demonstrates.
Most people recognise a sprained ankle, at least mild ones, as a self limiting illness. An issue with psychiatric diagnoses is that they are often not taken to be self limiting and often become a large part of a patients self image. While sometimes this can be helpful and help inform treatment it can also be harmful and I have seen this harm first hand in patients I see.
And doctors only react when you can no longer use your legs for a year, otherwise they must be amputated.
Or would you rather have an earlier disgnostic with instructions to reduce extreme loads and try to take it easy. Let's check again in a week.
If someone smokes a lot of cigarettes and gets lung cancer, we don’t blame the doctor for the lung cancer. This shit is the patient’s responsibility.
Not sleeping a night.
A concussion? Obviously it’s not considered a psychiatric condition but concussions check a lot of the right boxes abstractly.
Instead, I would point to the physical trauma of a concussion as the differentiating factor.
https://pmc.ncbi.nlm.nih.gov/articles/PMC3480686/
> Fate, which takes away healthy, free, young people, never pardoned me once. It has let me live all this time, quite lucid, but closed up in here ... since I was ten years old .... eighty years in psychiatric hospital for a headache
Take modern medicine with a grain of salt.
Surely you’re not trying to draw some conclusion between an entire countries modern day medical field and a theory a person proposed in the 1800s, right?
That would depend on whether anything has changed since the 1800s. But that's very clearly not so -- consider that recovered memory therapy (https://en.wikipedia.org/wiki/Recovered-memory_therapy), based on as much science as drapetomania, was practiced in the 1990s, and still has adherents today.
Also, for human psychology to be regarded as a medical field, it would have to be based in science. But human psychology studies the mind, therefore by definition it's not based in science.
Understanding changes as we do more research into a thing.
Im not arguing people diagnosed with autism spectrum disorder shouldnt get benefits.
Its that the spectrum isnt as related enough that insividual disorders would make more sense. But that would require getting the health insurance industry to do more adjustments.
With the same argument, we could arguue that working and social life are getting in the way how I am, thus working and social life should be considered disorders.
I don't get this reference (that is likely rooted in US popular culture).
If the proposition here is that mental health disorders are fabricated maliciously in order to sell more medication or enforce some sort of social order, then I don't see how the very rare court-ordered enforcement of short-term stays at psychiatric institutions could be the mechanism for that.
The vast majority of people in the US who receive psychiatric care do so voluntarily, because they experience real symptoms that really affect their life, for which they need real treatment.
That's true, but that's not what the parent comment claimed. They didn't say a majority receive psychiatric care involuntarily, they said it's not hard to find examples who receive it involuntarily, and that's true. Lots of people are forced to take psychiatric medication right now, in developed countries including the US.
Just as an example, in the UK the verb "to section" is shorthand for "to commit to involuntary confinement in hospital under the legal authority of one or more sections of the Mental Health Act"
https://www.mind.org.uk/information-support/legal-rights/sec...
For example, you can be detained for up to 6 months under Section 3, if all four of these conditions are met:
1. you have a mental disorder
2. you need to be detained for your own health or safety or for the protection of other people
3. doctors agree that appropriate treatment is available for you
4. treatment can't be given unless you are detained in hospital
Ahh, you sweet summer child
Tell that to all multiple sclerosis patients that were tortured by psych departments of hospitals before (and after) the MRI machine was created.
Tell that to sleep apnea patients (especially the women, especially especially the younger thinner women in whom they say “it cannot happen to”) that are given a psych diagnoses for seeking treatment for symptoms before sleep disordered breathing issues are ever even brought into question.
The main problem is that DSM diagnoses are indeed forced on people. Usually highly incorrectly, too.
What's the alternative then? What would "empirically" determining what a "disorder" is look like?
>…by Americans
Most of the world outside of the US uses the ICD, not the DSM.
No. You need to read the thing.
The DSM only aims to be a tool to help standardize communication of often nebulous and otherwise ill-defined entities. It says so in the introductory pages.
People shouldn’t treat it like a biology textbook, it’s a self-described ontology at most.
You cannot have an authoritative textbook proscribing definitions, and then expect people to treat them as just "a self-described ontology" with all the nuances and caveats around that just because it says so somewhere in the introduction. Psychology of all fields should know that.
This stuff is complicated. People are going to get it wrong. That sucks.
But if you’re going to judge the book, judge it by how it presents itself, don’t judge it by how a third party misrepresents it.
As long as the boards don't go after the shrinks who "misrepresent" the DSM, I would claim that this misrepresentation is systemic of (and possibly even intended by) the psycho-industrial complex.
I think this comment just reinforces a misunderstanding of what the DSM actually is.
> But if you’re going to judge the book, judge it by how it presents itself
Doctors (at least the good ones) aren't usually going in blind and just doing whatever the DSM tell them to as if they were following a flowchart or checklist. The DSM (which I'm not even fully defending here, I personally it feel has all kinds of problems) is just a guide. It's not the only tool in a doctor's arsenal and they aren't obligated to follow it.
> Why shouldn't it include a bunch of treatments if they've been shown to be beneficial?
There’s a well-known concept of “diagnosis by treatment” because unfortunately that’s often the best we can do in practice. It sounds backwards, and yeah, it is backwards, but oftentimes it’s the best we’ve got.
At the same time you want treatments and clinical presentations to be somewhat coherent, and you don’t want practitioners going totally rogue and deviating from the standard of care in a way that could harm people, so yeah the conditions and their potential treatments are associated.
Most discussion of treatments in the DSM are various forms of therapy. Most pharmaceutical treatments that are mentioned are about broad classes of medications, and they’re all old drugs with generics on the market. It’s not a book you consult for pharma info.
I've seen that used before to dismiss the severity of conditions like autism and especially ADHD. It's often coming from a well-meaning place, and sometimes it's just a comforting story people tell themselves in order to not feel as deficient ("The problem isn't me, it's the system!").
It's also absolutely true that the demands society places on all of us are unnatural and often excessive, but the fact is that even absent all external expectations some people with mental illness will be unable to accomplish what they themselves want and should be able to accomplish.
Even the most utopian, accepting, accommodating society it wouldn't be enough to make up for some people's inability to function.
I feel the same about a lot of the "super power" talk when it comes to mental illness. There are advantages and disadvantages to just about anything, but on the whole conditions like ADHD or autism tend to do way more harm than good.
The DSM only matters if somebody is actively seeking treatment for something that they have a problem with in their own situation. So what’s in there is totally irrelevant for the public at large. It’s only if somebody shows up and says there’s something going on that they don’t like. It’s really just billing codes, man. The reality is far different anyway, and it just gets distilled down to these primitive codes.
By this criteria, you can then say many other non-psych conditions are not disorders.
What classifies as a disorder other than making life worse for someone?
There is no universal book given by a holy entity that we can read to classify something as normal or a disorder.
Why do we have arbitrary cutoffs for cholesterol, blood sugar, blood pressure, etc?
I get the feeling that we understand how our brains work about as well as we understand how well mitochondria work - - and I see reports of new findings on mitochondria fairly regularly...
Experts generally benefit from their expertise. Nothing new, shouldn't be controversial.
- Acknowledgement by our professors that P-hacking (pruning datasets to get the desired results) was not just common, but rampant
- One of our classes being thrown in limbo for several months after we found out that a bunch of foundational research underpinning it was entirely made up (See: Diederik Stapel).
- Experiencing first-hand just how unreproducible most research in our faculty was (SPSS was the norm, R was the exception, Python was unused).
- Learning that most psychology research is conducted on white psychology students in their early/mid-twenties in the EU and US. But the findings are broadly generalized across populations and cultures.
- Learning that the DSM-IV classified homosexuality as a mental disorder. Though the DSM-V has since dropped this.
Though I do generally hold psychologists in high regard (therapy is good), I'm not particularly impressed by psychology as a science. And in turn don't necessarily trust the DSM all that much.
How did you experience this? Did you fail to reproduce the same results when doing the research again while using R? This is how I interpret your statement, but I think it's not what you mean.
If SPSS was the norm, R or SciPy shouldn't have made a difference in reproducibility as the statistics should be more or less the same. I did social science with SPSS fine; T-Tests, MANOVA, Cronbach's alpha, Kruskall-Wallis, it's all in there. It seems you suggest that using SPSS inherently makes for bad and irreproducible science, it's similar to saying using Word instead of an open source package like LaTeX makes research unreproducible even if the data, methodology and statistics are openly accessible. This is not the case. What i mean is that while I agree there can be friction between using Word and SPSS and Open Science and FAIR principles because of the proprietary formats, this isn't inherently a problem as people can use the dataset (csv or sqlite) and do the mentioned statistical tests outlined in the published pdf (or even an imported docx) in any statistical language.
https://www.go-fair.org/fair-principles/
For anyone looking for an easy to use alternative to R, Jamovi is a capable and easy to use open source alternative to SPSS and RStudio. https://medium.com/@Frank.M.LoSchiavo/jamovi-a-free-alternat...
That's mild. In one of Chile's largest and most prestigious universities, Jodorowsky "psychomagic" is teached as a real therapeutic approach.
As someone with zero knowledge of psychology, I'm biased against it. Partly because of my vague impression that psychology tries to fit people to models, rather than viewing models as limited approximations.
For a while I've thought it would be nice to know what results the field of psychology actually has that are trusted. Was there anything at all in the taught content which you liked? I didn't realise the DSM-V was that bad. If research on trans people can be cherry-picked, then does that mean that some reliable research exists?
Then you are biased against "the science of mind and behavior"[0] by definition.
> For a while I've thought it would be nice to know what results the field of psychology actually has that are trusted.
Perhaps that people who seek out and engage in therapy with qualified professionals can (but not always) improve their lived experience?
Or that by studying the mind and human behavior, mental illness is now considered a medical condition, worthy of treatment, and has much less social stigma than years past?
I wonder if you can sue for fraud over this. The researcher knowingly deceived academia, and it's foreseeable that students would then pay to study the the false research.
give us your best academic hypothesis as to why p-hacking is rampant: I'll bet it will sound like psych analysis
Yes, that's the summary of the incentive system. It's not a highly remunerative profession although the rockstars can do quite well (usually through side gigs).
Practitioners of economics accept many types of scarcity and currency. Consider, for example, the marketplace of ideas paid for with attention, belief, energy spent spreading our favorites.
EDIT: missed Harry Potter reference
I must admit, it feels a bit strange. The truth is that I learned my first steps in programming by working through large, formidable books. In fact, my very first programming book was Assembly Language for Intel-Based Computers by Kip Irvine. After that, I read even larger books, many of them multiple times.
I have always been fond of reading well-written books by knowledgeable professionals. After reading such works, you come away with real understanding, greater clarity, and often new creativity. Books are valuable, and I have always respected a good one.
Yet the DSM-5-TR is quite the opposite. The Preface clearly states that the work is intended for everyone:
“The information is of value to all professionals associated with various aspects of mental health care, including psychiatrists, other physicians, psychologists, social workers, nurses, counselors, forensic and legal specialists, occupational and rehabilitation therapists, and other health professionals.”
I happen to be a social worker, and I have read a lot of books. I know how to study. I carefully looked up any words I might have misunderstood and used the dictionary freely.
But despite all my efforts, I often failed to make sense of what I was reading. One would expect a theory followed by a conclusion, or an observation leading to a conclusion, or a theorem that is then proven. Unfortunately, that structure is missing here.
A typical DSM entry begins with a statement presented as fact, only to be followed by other statements that seem to contradict it.
Take, for example:
“The prevalence of disinhibited social engagement disorder is unknown. Nevertheless, the disorder appears to be rare, occurring in a minority of children, even those who have experienced severe early deprivation. In low-income community populations in the United Kingdom, the prevalence is up to 2%.”
This kind of contradictory phrasing is standard in the DSM.
Again, the DSM is publicly available, and anyone can read it here: https://www.ifeet.org/files/DSM-5-TR.pdf
I would have expected more precision from a scientific book.
1. We don't know actual prevalence
2. But believe it is low
3. Upper bound in some community is 2%
I'm not sure I see what's contradictory in your example. Could you elaborate?
In fact, there is a way of doing that. And we, as programmers, have access to those methods. It's called Numerical Analisys. At times it's quite amazing to see how well mathematics can estimate data.
One of the examples, is German Tank Problem. https://www.numberphile.com/videos/clever-way-to-count-tanks
While being an extremely opaque problem we are able to handle it to an extremely precise numbers.
One does not have to be that acquainted with the ways of math to figure things out. One can just use some data source and point such data source out. I mean, any book, be that a book on financing or programming book would have a list of references under such statements.
And here we have it. An absolutely out-of-wack statement saying that the poorest regions of Britain are affected by this condition more than others. Who? Why? Where? How was this number obtained?
Probably "contradictory" is not a right word for such a claim. But I would love to see at least anything that would prove such a statement.
In fact, flip to the end of the DSM and look for the list of references. You'll find none. I kid you not, there is not a single reference to an outside source in this book. This means that my work on "Use of Dynamic Library Link to execute Assembly code in C#" that I've written in 2005 while in the university has 6 more references to outside sources than the DSM itself.
The reason for my beef in here mainly that all the numbers are just stated, with no respect to what numbers are. And I would expect either an explanation of a numerical method to estimate this number, or a source as to where this number has been gotten from.
Also, I think its still helpful to define a disorder even if you haven't researched globally how many people have it.
> The reason for my beef in here mainly that all the numbers are just stated, with no respect to what numbers are. And I would expect either an explanation of a numerical method to estimate this number, or a source as to where this number has been gotten from. I agree that it would be nice have references. However, if you are just diagnosing an illness, it probably doesn't matter that much how many people in the world have this illness, just if the person in front of you has it or not. So the people that are actually using this text don't really need the sources.
It seems to me like the main purpose of DSM-5 is to define a bunch of disorders, so everyone has a common language to talk about the actually useful stuff like treatments. So even if it mistakenly says 2% instead of 0.2%, that doesn't really matter, I think.
Also, even if it is non-obvious to us, there might still be someplace where sources are listed. (IE maybe if you look at some meeting notes of the author committee)
A well written scientific book would never leave a reader in a state of “maybe”.
Also, if the numbers go down to 0.2% I can’t help but notice that this can’t be defined as a disorder. It is a statistical error.
There is a placebo effect. Furthermore any doctor knows the rule of self-diagnosis. “Any patient, given a chance, will self-diagnose anything”.
With no data on how the data about illness was obtained I can’t say if this is a statistical error or a fluke.
Also, as noted above, should there be a method of testing for such a condition that is objective, I would live with 2% or 0.2%. (For example, 0.001% of people are missing this and this chromosome, and we know that because we can do a DNA test.) But there is no way of saying something like this just cause you did a survey and ask people some vague questions about their mental state. There are people who would just fake answers in their responses for fun. And just cause of that I don’t trust numbers like 2% in this specific case.
When you do not have an objective metric to measure, prove, or hypothesize (as in physics, chemistry, etc), you're basically doing statistics on whatever arbitrary populations and bounds you choose with immeasurable confounders. That's why the replication crisis and p hacking are intrinsic properties of the social sciences
Is there an example that anyone has pointed to where DSM-5 could have been written differently, to the detriment of a commercial enterprise? (What little I've read in the DSM-5 is enough to leave one with glazed eyes.)
Yes
This has been known to economists for a long time
Medicine generally has had its progress (as a general good) held back by misaligned incentives for a long time
See "neglected tropical diseases"
As true in psychiatry as anything else
That seems totally different than what the OP is trying to imply, which seems to be that people who worked on the DSM added illnesses to it so they or their backers could financially benefit. If it's just a matter of "illness that can be better monetized have more financial backers, and therefore they get more attention", that seems... fine? In an ideal world I'd want malaria and whatever first world ailment (obesity?) to be treated equally on some objective factor like QALYs or whatever, but I don't see anything intrinsically wrong with private companies preferentially funding research that they stand to benefit from.
Wouldn't we expect it to be more true the fewer objective measures there are? Like if a treatment is supposed to improve blood sugar, and we can measure blood sugar cheaply in real time... we should expect misaligned incentives to have diminished effect compared to something where there is less ability to objectively measure, such as pretty much anything in psychiatry.
If there is money to be made the medical establishment will put much more effort into that area than if there is not
Bringing it back to the DSM: The more human states of mind that can be classified as a "psychiatric illness" the more money there is to be made in marketing various therapies
This is glaringly obvious in drug development but it applies to all forms of therapy that can be done in a way with a gate keeper who can charge a toll
Like, we can't sell treatment's for people's sixth thumbs because virtually no people have a sixth thumb and it's unambiguous that they don't-- and even among any who do it'll probably be clear if it needs treating or not. But I can sell a treatment for your hyper-meta-ego because who is to say if a person has one of those or not or if my treatment of it is successful or not?
In five or ten years, these categories will feel like missteps of the past (akin to calling all mental illness “hysteria”).
The Bereavement Exclusion Smoking Gun 100% of the DSM-IV mood disorders work group had financial ties to pharmaceutical companies Mad In America . This same group eliminated the bereavement exclusion in DSM-5, allowing normal grief to be diagnosed as major depression after just two weeks. Kenneth Kendler, speaking for the group, explicitly argued “Either the grief exclusion criterion needs to be eliminated or extended so that no depression that arises in the setting of adversity would be diagnosable” Mad In America - essentially arguing that context should be irrelevant to psychiatric diagnosis. This change was “perhaps the most controversial change from DSM-IV to DSM-5” PubMed Central and critics argued it would “result in an increasing number of persons with normal grief to be inappropriately diagnosed with MDD after only two weeks of depressive symptoms” American Academy of Family Physicians and lead to unnecessary antidepressant prescribing.
The ADHD Expansion: DSM-5 systematically lowered ADHD diagnostic thresholds: - Reduced symptom threshold from 6 to 5 symptoms for adults/adolescents over 17 PubMed Central Neurodivergent Insights - Increased age of onset requirement from 7 to 12 years old Neurodivergent Insights - Lowered impairment criteria - now only need to “reduce quality of functioning” rather than be “clinically significant” PubMed Central Critics specifically identified ADHD expansion as worsening the “false positive problem” by “expanding diagnosis to adults before addressing its reliability in children”
It’s like going to the doctor with a runny nose, who the claims it’s influenza, due to the runny nose, without testing for Covid.
But we do know that certain symptoms tend to show up in clusters, and that patients in certain clusters tend to respond to certain drugs with an above-placebo level of effectiveness.
The same is true for a runny nose: It can be caused by any number of viruses (there is no such a thing as "the" influenza virus or "the" common cold virus), or allergies, or irritants like pepper spray, or a problem with the body's ability to regulate itself, or something else entirely – but going through the effort to test for every virus, allergen, irritant, and whatnot is wasteful, if all the patient needs at that moment is some nasal spray to breathe properly again. Incidentally, a runny nose is (or perhaps: was) not a common symptom of Covid, so unless other symptoms more indicative of it show, there may not a good reason to test for it, or prescribe medication specific to it.
If more symptoms accumulate over time, or the symptoms don't go away, you then probably can go back to your doctor, will get a different diagnosis and possibly a different prescription. The same is (or at least: should be) true for mental issues, where you might switch treatment over and over until something is found which actually helps your symptoms. Is this a flawed process? Frustrating? Absolutely. But is it "worthless"? I don't think so.
Hundreds of millions of people whose lives have been saved or improved thanks to broader recognition and treatment of their disorder would disagree.
Claiming that DSM-5 is "worthless" simply because it doesn't provide physical mechanisms that cause the disorders is an extraordinary claim that requires extraordinary evidence, not the other way around.
> how many have been ruined or ended in part due to the guidelines DSM
You tell us, how many have been ruined? What "guidelines" are you referring to?
Because they looked at clusters of symptoms, rather than actual causes.
Precisely my point.
As for ADHD etc; you do realise they changed the treatments and clustering precisely because of insight in physical processes?!
I stand by that. In fact, historically whenever they did this they caused a lot of harm.
I would beg to disagree: "The DSM is a bunch of nonsense. As long as [...], it’s worthless."
> DSM when not providing the underlying physical processes is worthless.
And when does the DSM ever provide the "underlying physical process"? It certainly doesn't for ADHD or any other chapters I happen to have read, which would make them worthless according to your criteria despite overwhelming evidence to the contrary.
And while I haven't read all 1000 pages of the DSM because it's not exactly my idea of a good time, I don't think it provides that kind of information in any chapter because we simply don't understand these disorders to that extent, as your original comment correctly observed.
> As long as they don’t provide physical mechanisms for disorders, it’s worthless
This reasoning will dismiss too many things.
We don't know the physics of almost anything, it's all progressive levels of approximation.
For the longest time we knew nothing about the physical mechanisms of anesthetics, or how a plane wing works.
Science doesn't need the mechanism. It needs predictive power. Observations, hypotheses, tests and thesis.
If I am a doctor on a task force, I'm not wasting my time doing that paperwork. Also, this essentially means that nearly every doctor would be in scope.
The "Compensation for services other than consulting" is way more dubious because it's a lot more money for fewer people and it's much greyer in terms of what they were getting for their money.
1) the support might be given for totally different purposes
2) how much directed material value can a _Diagnostic_ suggestion bring? Follow the editors of therapeutic protocols and you might find something
3) there are a dozen other more problematic arguments about DSM. Eg the choice of the panel comes before any support.
Rather than define an objective measure of the problem, they (by definition) effectively define the percentage of the population affected.
In other words, osteopenia is defined in such a way that it is not curable, preventable, etc.
What is the point saying, “disease X affects 5% of the population by definition”.
It’s like throwing away half the resumes for a job position and saying we don’t hire unlucky people…
Between 1.0 and 2.5 standard deviation is something like 15% of the population. “1.0” and “2.5” are ridiculously round number. What is the medical significance of such?
Sure, at some point, it will be correlated with fragile bones.
Adult male height is roughly 5’9” with standard deviation of 2.8”.
We DON’T say adult males under 5’2” are diagnosed as having medical disease.
If males under 5’2” were having clear difficulty functioning and outcomes were measurably worse for most of them and large numbers of them were seeking treatment and we actually had safe and effective treatments which measurably decreased or eliminated the problems caused by the fact that they are under 5’2” for most of them, then I'd expect that we would consider it a medical disease/disorder. Why shouldn't we?
People are, on average, fucking shitty people.
As a heuristic for identifying when something deserves attention?
If the majority of people are crazy, it's likely that our definition of "crazy" needs work.
That said, the situation isn't as dire as some folks with a vested interest would have you believe... If you're reading this and you're someone who needs to hear it: Keep taking your medicine! They'll work the kinks out eventually, and even if there is a conspiracy, it isn't against you personally.
[1] I meant personality disorder. Leaving the mistake to avoid making the thread confusing.
70% of people 60 years of age and older have high blood pressure[1], 50% of men regardless of age. Does this mean that our definition of high blood pressure needs work?
I'm not arguing that the DSM is perfect, but it's possible for something to be bad and also common. But I appreciate the "Keep taking your meds" sentiment as well, it has bigger problem overall, but it can still help people.
You are 100% correct, I thought personality disorders and typed chemical disorders for some reason. I'll leave the mistake so the thread makes sense.
> Does this mean that our definition of high blood pressure need work?
I think there's a difference between a disorder that is defined mechanistically and a disease that is only defined relatively. For example, if you're missing an arm, or at huge risk of stroke that's fairly obvious. However, if you are less happy than average, and more than 50% are also less happy then average... something is wrong with the math.
*EDIT* To make matters worse I should have said Axis 1 instead of 2. This is what I get for trying to remember a 20+ year old reference without citing it.
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/...
Who is claiming that more than 50% of people are "less happy than average"? That's not a disorder. I'm fairly certain that the DSM doesn't make a claim like that, does the APA? It feels straw-manish.
I know that it's hard to diagnose these more intangible issues, but they are still very important regardless. If more than 50% of people in a society were unhappy, isn't it possible that the society is making them that way and it's not something wrong with the scale?
The actual statistic I was misremembering says that 50.8% of people will meet the requirements for an Axis 1 or higher diagnoses before the age of 75. You're right that it's important to be accurate. Mea Culpa.
To the actual point of my wildly incorrect claim: If most people are judged to be mentally ill at some point in their life, and most of the diagnoses can only be made relative to some baseline that's deemed to be "normal", isn't that just a different way of saying that it's "normal" to be mentally ill?
I can't reply to Sketchy anymore (throttled maybe?), but I appreciate you both taking the time to have this conversation today. You've made me think a bit harder about something I've believed for 20+ years, and I think I agree now.
We all go through rough patches that can make our mental health slip, just like we go through rough patches where our physical health slips. What's important is that we recognize when something is wrong and get the help we need.
Just like my first point, it's normal to be older and have high blood pressure, but if that's the case, you should probably be taking medication.
you'd have to be crazy to not believe in demons
But the accused can't offer that defense, because the DSM is not based in science, and that in turn is because because human psychology isn't based in science.
The field of human psychology includes many scientific studies, some of them excellent, up to the point where a testable, falsifiable theory might be crafted based on those studies, but it stops there. Here's why:
For a study to be regarded as science, it must meet certain established standards, and many psychology studies meet or exceed those standards.
But for a field to be regarded as science, its practitioners must craft testable, falsifiable theories, based on natural phenomena, about their topic of study. Human psychology cannot do this, for the simple reason that human psychology studies the mind, and the mind is not part of nature.
In scientific fields, physics for example, a conflict-of-interest accusation is easily resolved: either a claim can be tested and potentially falsified by comparison with the field's defining theories, or it cannot (cold fusion comes to mind). But in psychology this doesn't work, because a claim cannot be compared to the field's testable, falsifiable scientific theories, theories that define the field, because ... wait for it ... such theories don't exist.
And how could such theories exist? Again, human psychology studies the mind, legitimate science must focus on natural (not supernatural) phenomena, and the mind doesn't meet that description -- it's not part of nature.
Neuroscience doesn't have these structural problems, it may someday replace psychology, but we're not there yet, and may not be for decades to come.
His whole career revelved around promoting strategies for policing and incarceration that clearly don't work, and the APA celebrated him for it. They have a huge bias toword the notion that everyone needs their help. Problems with the DSM wouldn't matter so much, if the APA hadn't shoehorned themselves, and their bible of the DSM, into countless aspects of government and healthcare.
Phillip Zimbardo, and the link you linked to, are the "American Psychological Association".
These are two different associations.
Theresa Miskimen is the president of the American Psychiatric Association, not Zimbardo.
the psychologists, they never went to medical school, so despite forming an organization and many publications, have little to do with diagnostic standards for medical doctors.
for clarity: THERE ARE TWO APA, the one written about in the article is not the same as the one in this comment.