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Psychiatry is to the Pharmaceutical Industry as Education Reform Is To . . . .

Posted: 2013-05-07

Publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013 promises to change the practice of modern psychiatry and psychology. Teachers will find something in common with physicians who question the direction and influence of this manual.


We don't care. We don't have to. We're the telephone company. Lily Tomlin as Ernestine



by Susan Ohanian



How did you complete that analogy in this essay title? The 'awareness and activism' revealed in your answer may define your career survival as well as children's well-being.



In his just-released The Book of Woe: The DSM and the Unmaking of Psychiatry, Gary Greenberg provides a history of the American Psychiatric Association's compendium of mental illness and the furor each revision provokes--and a clue to what I think the education reform folk are up to. Clearly, the release of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)($189), the so-called bible of psychiatry, invites experts in the field to question the "science" in psychiatry--and, for me, this leads directly to the huge problem of pseudo-science in education reform. One question must be part of all the discussion in both fields:



Who profits?



A number of critics have observed that doctors have to "diagnose" if they want to get paid and the DSM-5 is nothing but a billing device for doctors. In short, the medical solution becomes Take drugs and shut up. Think of the Common Core State [sic] Standards parallel. The CCSS is nothing but a device of the State for forcing teachers to march in line and train students into obedience. Write the Standard on the board and everybody shut up.



The very vocabulary of psychiatry is now defined at all levels by the pharmaceutical industry.



The very vocabulary of teaching is now defined by the Bill and Melinda Gates Foundation, with various professional organizations and schools of education traveling along as handmaidens while the testing and publishing industries collect the profits. For all the hoopla over Pearson raking in tons of money for their testing and their texts to prep students for tests, I don't blame the profiteers nearly so much as I blame the people who were in at the creation and who continue to support this monstrosity traveling as ed reform.



I also blame those who keep their silence. There is no way you can wash your hands of the fact that you are a huge part of the problem.



The majority of teachers keep silent, just waiting for the proverbial pendulum to swing. But look at what happened in psychiatry. In a New Yorker blog, Greenberg points out:



Since 1980, diagnoses have appeared and disappeared, and symptom lists have been tweaked and rejiggered with troubling regularity, generally after debate that seems more suited to the floors of Congress than the halls of science. The inevitable and public chaos--diagnostic epidemics, prescription-drug fads, patients labelled and relabelled--has only deepened psychiatry's inferiority complex.



We now have quiet chaos along with fads and teacher labeling-- while politicans and profiteers redefine education at all levels.



Gary Greenberg is also author of Manufacturing Depression (2010) and a contributor to Mother Jones and other magazines. His Book of Woe grew out of an article that he wrote for Wired magazine. Here's Greenberg describing the importance of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Think about education reform [sic] while you read it.



The D.S.M. and the Nature of Disease

by Gary Greenberg, New Yorker blog, April 9, 2013



When the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders hits the stores on May 22nd, it will signal the end of a fraught thirteen-year campaign. Every revision of the D.S.M. causes controversy; that's what happens when experts argue in public about the nature of human suffering. But never has the process provoked warfare so brutal, with attacks coming from within the profession as well from psychiatry's usual opponents. Indeed, it's possible that no book has ever been subject to such scrutiny in the course of being written. It is as if J. K. Rowling had produced her Harry Potter sequels in a glass studio with fans looking on and banging the windows whenever she typed something they didn't like.



All the critics seem to agree on one thing, which is that the D.S.M.-5 will "extend the reach of psychiatry" further into daily life. That complaint has even united the psychiatrist who ran the last revision with the Church of Scientology. The new book will make many more of us eligible for psychiatric diagnoses, they argue, and thus for even more drugs than we are already taking. ( More than ten per cent of American adults take antidepressants.)



But there is little reason to think that a new D.S.M. will increase the prevalence of mental-disorder diagnoses, and less to think that we will ever really know how many people are sick. Psychiatrists have never been able to establish the line between mental health and mental illness. As a result, ever since 1840, when the U.S. Census Office first asked states for an accounting of the mentally ill, doctors have been hard pressed to know how to supply it. Most counting methods have yielded suspicious results. The 1961 Midtown Manhattan Study, for instance, indicated that nearly eighty-five per cent of New Yorkers had some degree of mental disorder, a number that beggars common sense, unless perhaps you're a Woody Allen fan.



The first edition of the D.S.M., published in 1952, was in effect at the time of the Midtown Manhattan study, but the researchers did not use it. They weren't as interested in counting the mentally ill as they were in how many people suffered psychological distress of any kind or degree, and even if they had been, the disorders it listed did not have criteria that could easily be turned into survey questions. But the D.S.M.-III, issued in 1980, provided a set of criteria for each disorder (as has every D.S.M. since then), and epidemiologists almost immediately created test instruments keyed to the new manual. In 1992, they concluded that about twenty-two per cent of Americans would qualify for a D.S.M.-III diagnosis in any given year, and thirty-three per cent of us in our lifetimes. By that time, however, the D.S.M.-IIIR ("R" for "revision") had been published, and, in 1994, a different research group, using the newer manual and an entirely different survey, turned up a one-year prevalence of 29.5 per cent and a lifetime prevalence of forty-eight per cent. That study came out just in time for the A.P.A. to release yet another manual, the D.S.M.-IV. And in 2005, researchers using the D.S.M.-IV found rates of twenty-six per cent in a year and forty-six per cent lifetime.



No one knows exactly what effect, if any, revisions to the D.S.M. have on these numbers. According to Ronald Kessler, the Harvard epidemiologist who ran the 1994 and 2005 projects, this "wasn't a question we set out to answer." Questioning all patients with both sets of criteria and then analyzing the results was an undertaking that would have distracted from other efforts, and, he adds, D.S.M.-related overdiagnosis just wasn't a "burning issue" at the time. It is now, of course, but the A.P.A. didn't directly address the question as it field-tested the D.S.M.-5.



Still, some tentative conclusions can be drawn. Michael First, a psychiatrist at Columbia and leading D.S.M. researcher, thinks the sharp increase between the D.S.M.-III and the D.S.M.-IIIR results has little to do with changes to the manual. "The prevalence appears to have changed," he told me, "but this is most likely due to the differences between the instruments used to conduct the study." N.Y.U.'s Jerome Wakefield, who has closely compared the two studies, explained that the earlier study "seemed to have a glitch. Subjects realized that if they answered yes to a general question they would then be asked a lot of detailed questions on the same subject, so they tended to say no as the interview wore on." In the D.S.M.-IIIR study, researchers asked all the general questions up front and then moved on to specifics. Researchers used the same approach in the D.S.M.-IV study, and although the manual had added such popular diagnoses as Asperger's syndrome and relaxed criteria for bipolar disorder and A.D.H.D., the overall prevalence barely budged. How many of us qualify as mentally ill appears to have more to do with how you count than with how many diagnoses are available.



The D.S.M.-5 is not likely to change that. Nor will it necessarily lead to more drugging of the populace. Drug companies are sure to seize on new diagnostic labels to get lucrative indications for their drugs, which they will then advertise to consumers who will in turn request the drugs from their doctors. But that won't necessarily translate into an increase in diagnoses. Doctors don't have to render diagnoses when they reach for the prescription pad. Seventy-two per cent of antidepressant prescriptions, for instance, are written in the absence of a psychiatric diagnosis. Indeed, disregarding the D.S.M.'s particulars may be the industry standard. As one D.S.M.-5 committee member told her colleagues at the A.P.A.'s annual meeting in May, "If the clinician's gut feeling is that the patient has the disorder, it's appropriate for them to get it [the diagnosis]." The D.S.M.-5 may only provide doctors with a new manual to ignore.



What will change with a revision is the prevalence of specific diagnoses. Come May 22nd, there will surely be more children diagnosed with disruptive mood dysregulation disorder, since that is a category new to the D.S.M.-5. And the prevalence of Asperger's syndrome will certainly drop to zero, as the diagnosis is being eliminated. But the D.M.D.D. kids are probably already diagnosed with bipolar disorder or some other mental illness, and many of the displaced Aspies may end up on the autism spectrum created for the D.S.M.-5. Adding or subtracting a diagnostic label won't necessarily change the overall prevalence of mental disorders any more than putting out a new Chevrolet model or eliminating the Oldsmobile badge would change the number of drivers.



The market for mental disorders is already enormous, thanks in part to the relentless effort of the A.P.A. to use the D.S.M. to convince us that our psychological suffering is best understood as diseases that should be treated by doctors. Psychiatrists don't need any more disorders to expand the market; they only need franchise that allows them to dole out the diagnoses. Doctor or patient, we can all browse the updated catalog just as easily as we could the previous one--and as easily as we can browse Amazon for a book or video.



Of course, there are a couple of differences between G.M. or Amazon and the A.P.A. Cars and books are real, physical things; even by the A.P.A.'s own account, the D.S.M.'s categories are only useful constructs, the best psychiatrists can do until they figure out how to identify and classify mental illnesses in the same way other specialists now identify physical diseases. And the A.P.A., unlike those companies, has a monopoly on its market.



The D.S.M. has enormous impact on the public health. It determines which conditions insurers will cover, which drugs regulators will approve, which children will receive special-education services, and which criminal defendants will be able to stand trial and, in some cases, how they will be sentenced. Psychiatry has already reached far into our daily lives, and it's not by virtue of the particulars of any given D.S.M. It's because the A.P.A., a private guild, one with extensive ties to the drug industry, owns the naming rights to our pain. That so significant a public trust is in private hands, and on such questionable grounds, is what we ought to worry about.



I suggest that you read that final paragraph again. Think of the enormous market for what travels as education reform. Think about how the Bill and Melinda Gates Foundation, very much a private guild, has, with the help of the National Governors Association and the Council of Chief State School Officers, and schools of education and professional organizations Gates paid off, reached into the daily lives of public school teachers and their students. The public trust of public education is in private hands. . . and on very questionable grounds.



When Orwell published Nineteen Eighty-Four, Aldous Huxley wrote to him with a prediction:



Within the next generation I believe that the world's leaders will discover that infant conditioning and narco-hypnosis are more efficient, as instruments of government, than clubs and prisons, and that the lust for power can be just as completely satisfied by suggesting people into loving their servitude as by flogging them and kicking them into obedience.



In other words, I feel that the nightmare of Nineteen Eighty-Four is destined to modulate into the nightmare of a world having more resemblance to that which I imagined in Brave New World. The change will be brought about as a result of a felt need for increased efficiency. [emphasis added]





With regard current education reform, I suggest substituting rigor for efficiency. The provoked need for increased rigor.



The Massachusetts General Hospital Psychiatry Academy and MyCME partnered to conduct an attitudinal a survey of clinicians--about their perceptions and attitudes about the release of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as well as their concerns about changing diagnostic criteria, insights on how they think it affects their clinical practice, and thoughts on what the biggest challenges are.





  • 42% of clinicians indicate they have a high level of anticipation about the release of DSM-5


  • 2/3 of clinicians have some level of concern about understanding changes in diagnostic criteria


  • 40% of clinicians indicate some level of concern that it will take time to understand changes in DSM-5 and incorporate them into practice




  • A notably higher percentage of physicians says they're very concerned (15%), compared with non-physicians (2%).





    That last figure seems disappointingly similar to the number of educators who are "very concerned" about the Common Core.



    On April 23, 2013, Gary Greenberg wrote Does Psychiatry Need Science? at the New Yorker blog. It provoked impassioned comment.





    In 1886, Pliny Earle, then the superintendent of the state hospital for the insane in Northampton, Massachusetts, complained to his fellow psychiatrists that “in the present state of our knowledge, no classification of insanity can be erected upon a pathological basis.” Doctors in other specialties were using microscopes and chemical assays to discern the material causes of illness and to classify diseases accordingly. But psychiatrists, confronted with the impenetrable complexities of the brain, were "forced to fall back upon the symptomatology of the disease--the apparent mental condition, as judged from the outward manifestations." The rest of medicine may have been galloping into modernity on the back of science, but Earle and his colleagues were being left in the dust.



    Thirty years later, they had not caught up. In 1917, Thomas Salmon, another leading psychiatrist, echoed Earle's worry in an address to his colleagues, drawing their attention to the way that their reliance on appearances had resulted in a "chaotic" diagnostic system, which, he said, "discredits the science of psychiatry and reflects unfavorably upon our association." Psychiatry, Salmon continued, needed a nosology that would "meet the scientific demands of the day" if it was to command public trust.



    In the century that has passed since Salmon's lament, doctors in most medical specialties have only gotten better at sorting our suffering according to its biochemical causes. They have learned how to turn symptom into clues, and, like Sherlock Holmes stalking a criminal, to follow the evidence to the culprit. With a blood test or tissue culture, they can determine whether a skin rash is poison ivy or syphilis, or whether a cough is a symptom of a cold or of lung cancer. Sure-footed diagnosis is what we have come to expect from our physicians. It gives us some comfort, and the confidence to submit to their treatments.



    But psychiatrists still cannot meet this demand. A detailed understanding of the brain, with its hundred billion neurons and trillions of synapses, remains elusive, leaving psychiatry dependent on outward manifestations for its taxonomy of mental illnesses. Indeed, it has been doubling down on appearances since 1980, which is when the American Psychiatric Association created a Diagnostic and Statistical Manual of Mental Disorders (D.S.M.) that intentionally did not strive to go beyond the symptom. In place of biochemistry, the D.S.M. offers expert consensus about which clusters of symptoms constitute particular mental illnesses, and about which mental illnesses are real, or at least real enough to warrant a name and a place in the medical lexicon. But this approach hasn't really worked to establish the profession's credibility. In the four revisions of the D.S.M. since 1980, diagnoses have appeared and disappeared, and symptom lists have been tweaked and rejiggered with troubling regularity, generally after debate that seems more suited to the floors of Congress than the halls of science. The inevitable and public chaos--diagnostic epidemics, prescription-drug fads, patients labelled and relabelled--has only deepened psychiatry's inferiority complex.



    But it's not entirely clear that psychiatrists want a solution to the problem, at least not to judge from what happened when the experts conducting the most recent revision of the manual, the D.S.M.-5, were offered one. A group of seventeen prominent doctors—biological psychiatrists, experts in diagnostics, subspecialists in the field of depression, and even a historian—petitioned the D.S.M.-5's mood-disorders committee to add a diagnosis they named melancholia.



    The proposal was not so much an innovation as a retrieval of an old idea. Melancholia is one of the most venerable of psychiatric disorders, noted by doctors at least as far back as Hippocrates, who attributed its characteristic dejection and unresponsiveness to external events to an excess of black bile. But melancholia lost its place in psychiatric nosology in 1980, when all forms of depression were consolidated under a single diagnostic label—"major depressive disorder"--of which melancholia was only a variant. It was the D.S.M. equivalent of calling Pluto just another ice dwarf in the Kuiper Belt.



    The group argued that this was a grievous scientific error and cited evidence that melancholia was qualitatively different from other forms of depression. Some of the evidence was derived from the same kind of clinical observation that is the backbone of the D.S.M. For instance, people who showed the characteristic clinical symptoms--an unshakeable despondency and sense of guilt that arises from nowhere, responds to nothing, and dissipates for no apparent reason—also displayed some distinctive physical signs: hand-wringing, for instance, and psychomotor retardation, an easily perceived slowing down of movement, thought, and speech. But some of the group's proof was of precisely the kind that psychiatrists had been looking for since the nineteenth century. Thirty years of replicated studies had shown that patients with those signs and symptoms had a sleep architecture and cortisone metabolism that was distinct from that of other people, both normal and depressed. A night in a sleep lab could detect the reduced deep sleep and increased REM time characteristic of melancholics, and a dexamethasone suppression test (D.S.T.) could determine whether or not a patient’s stress hormones were in overdrive, as is generally the case among melancholic patients. And melancholia responded better than other kinds of depression to two treatments: tricyclic antidepressants (the first generation of the drugs) and electroconvulsive therapy (E.C.T., better known as shock therapy). Treatment success rates with this population reached as high as seventy per cent, much more robust than the anemic results found in trials that mixed melancholic and non-melancholic depression, and melancholics were less likely to respond to placebos.



    Distinctive signs, symptoms, lab studies, course, and outcome--if melancholia wasn't the Holy Grail, it was at least a sip from the chalice of science, one disorder that could go beyond appearances. You would think that the committee would at least have been eager to consider it as a partial remedy for ongoing concerns about the profession's lack of scientific rigor. But the panel barely gave melancholia the time of day, let alone a full-on floor debate, relegating it to the same slush pile as the proposed Parental Alienation Syndrome and Male-to-Eunuch Gender Identity Disorder. And the main obstacle was exactly what you would think was melancholia's main strength: the biological tests, especially the D.S.T. "I believe you and your colleagues are fundamentally correct," committee member William Coryell wrote to the melancholia advocates, by way of explaining his panel's inaction. But "the inclusion of a biological measure would be very hard to sell to the mood group." Coryell explained that the problem wasn’t the test's reliability, which he thought was better than anything else in psychiatry. Rather, it was that the D.S.T. would be "the only biological test for any diagnosis being considered." A single disorder that met the scientific demands of the day, in other words, would only make the failure to meet them in the rest of the D.S.M. that much more glaring.



    Coryell also noted that the melancholia proposal represented a departure from the notion, central to the D.S.M.'s descriptive method, that that the criteria for depression constitute a single disorder that every patient who matches the description has. "Depression is depression is depression," another mood-disorders specialist has said, and so, Coryell counselled, evidence for such a "sweeping change" in paradigm would have to be "extensive and compelling." (Coryell declined to comment for this article.)



    This notion--that the apparent mental condition is all that can matter--underlies not only the depression diagnosis but all of the D.S.M.'s categories. It may have been conceived as a stopgap, a way to bide time until the brain's role in psychological suffering has been elucidated, but in the meantime, expert consensus about appearances has become the cornerstone of the profession, one that psychiatrists are reluctant to yank out, lest the entire edifice collapse.



    Gary Greenberg's new book, The Book of Woe: The DSM and the Unmaking of Psychiatry, will be published in May.



    Here are some blurbs for Gary Greenberg's new book:



  • Gary Greenberg has become the Dante of our psychiatric age, and the DSM-5 is his Inferno. He guides us through the not-so-divine comedy that results when psychiatrists attempt to reduce our hopelessly complex inner worlds to an arbitrary taxonomy that provides a disorder for everybody. Greenberg leads us into depths that Dante never dreamed of. The Book of Woe is a mad chronicle of so-called madness."

    —Errol Morris, Academy Award–winning director, and author of A Wilderness of Error


  • Gary Greenberg's The Book of Woe is about the DSM in the way that Moby-Dick is about a whale--big-time, but only in part. An engaging history of a profession’s virtual bible, The Book of Woe is also a probing consideration of those psychic depths we cannot know and those social realities we pretend not to know, memorably rendered by a seasoned journalist who parses the complexities with a pickpocket's eye and a mensch's heart. If I wanted a therapist, and especially if I wanted to clear my mind of cant, I'd make an appointment with Dr. Greenberg as soon as he could fit me in."

    —Garret Keizer, author of Privacy and The Unwanted Sound of Everything We Want: A Book About Noise


  • Gary Greenberg is a thoughtful comedian and a cranky philosopher and a humble pest of a reporter, equal parts Woody Allen, Kierkegaard, and Columbo. The Book of Woe is a profound, and profoundly entertaining, riff on malady, power, and truth. This book is for those of us (i.e., all of us) who've ever wondered what it means, and what's at stake, when we try to distinguish the suffering of the ill from the suffering of the human.

    —Gideon Lewis-Kraus, author of A Sense of Direction




  • Gary Greenberg seems to take some solace in the possibility that the D.S.M.-5 may only provide doctors with a new manual to ignore. We can hope the same is true for the Common Core State [sic] Standards but as publishers and the AFT deluge materials, as Gates-funded cameras keep an eye on what teachers do in the classroom, this possibility of ignoring the mandates is increasingly unlikely.

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