McMan's First Annual (Or Whenever) Psychiatric Exasperater Awards

One of the things I love about my job is the challenge of chasing a moving target. There are no certainties. Every idea is on the table. In place of what we now call psychiatry, a whole new science of the mind is beginning to emerge. A quick scroll through my blog pieces over the last year reveals just a small sample of highly dedicated scientists who are are changing the way we think:

Jill Bolte Taylor, Nora Volkow, Husseini Manji, Hagop Akiskal, Marsha Linehan, Fred Gage, David Braff, Nancy Andreasen ...

Likewise, hats off to the authors and commentators and film-makers who connect the dots and challenge us to connect our own: Robert Whitaker, Pete Earley, John Gartner, Jonah Lehrer, Katie Cadigan ...

Not to mention some of my favorite bloggers: Therese Borchard, Willa Goodfellow, Gina Pera ...

Plus no end of the unsung, those in the trenches, responding to the call, refusing to take no for an answer, rolling up their sleeves and doing - doing, doing ...

But scroll through my recent blog pieces and you will also encounter a number of individuals I have felt duty-bound to call out for their flagrant violation of the facts. Spirited and even heated discussion has a way of moving the conversation forward, but only when the facts are honored. In some strange and ineffable way, we move closer to an ever-elusive truth. Humanity is served.

The individuals I have singled only seem to serve themselves. Coincidentally, these individuals happen to be psychiatrists. So, without further ado, my first annual (or whenever) Psychiatric Exasperater Awards ...

Andrew Nierenberg

Earlier this year, Andrew Nierenberg, professor of psychiatry at Harvard and a prominent researcher into mood disorders, purported to “repudiate” and “refute” compelling evidence raised against indiscriminate use of antidepressants and antipsychotics by Robert Whitaker, author of “Anatomy of an Epidemic.”

Had Dr Nierenberg accomplished but one one-hundredth of his stated mission, I would have thanked him for profusely for adding his learned voice to a badly needed dialogue. Instead, Nierenberg - obviously without having even read Whitaker’s book - resorted to ad hominem attacks (comparing Whitaker, whom he referred to as “ignorant,” to Sarah Palin), faulty marshaling of facts (such as misrepresenting one key study as “retrospective” when it was in fact prospective), and a very sick attempt at humor (such as showing a slide with a fake insulting black box warning appended to Whitaker’s book).

In the end, the only thing that Nierenberg proved was his own intellectual bankruptcy. As for Whitaker, we are still awaiting a credible response from someone with an MD.

(See Whitaker vs Quack Psychiatry - Part II.)

Peter Kramer

Earlier this month, Peter Kramer, clinical professor of psychiatry and human behavior at Brown University, published an article in the NY Times, entitled “In Defense of Antidepressants.” Dr Kramer is author of the 1993 “Listening to Prozac,” the product of a far more credulous age when researchers and clinicians and patients alike believed in miracle treatments for illnesses we actually still know next to nothing about.

In his article, Dr Kramer presumed to respond to an uncontradicted scientific study with his own speculation. Just that - speculation, no facts, no science. Moreover, Dr Kramer willfully ignored both the leading real-world clinical trial that cast considerable doubt on treating depressed patients like guinea pigs, as well as very strong evidence of the very harmful effects of prescribing antidepressants to substantial portions of the population.

We would all benefit enormously from an intelligent discourse on when and when not to use antidepressants. On that vital point, Dr Kramer had nothing to contribute. Instead, in defiance of both reality and “first do no harm,” Dr Kramer would have the general public believe it is still 1993.

(See Peter Kramer and Antidepressants - Oy!)

Stuart Kaplan

The June 19 Newsweek contained an article by Stuart Kaplan, clinical professor of psychiatry at Penn State. The article - “Mommy, Am I Really Bipolar?” - is adapted from his new book, “Your Child Does Not Have Bipolar Disorder.” Asserted Kaplan: “There is no scientific evidence to support the belief that bipolar disorder surfaces in childhood.”

Except, of course, for a whole bunch of kids who cycle in and out of depression and mania.

Well, no, says Kaplan. These kids are really ADHD or oppositionally defiant. Or have something called “temper dysregulation disorder.” Anything but bipolar. The following flat-out misstatement screams for the return of the Star Chamber: “The description of childhood bipolar disorder by its advocates is dramatically different [from adult bipolar].”

No it’s not.

Had Dr Kaplan stuck to the facts, he could have assisted us in our understanding of how best to improve the lives of kids in obvious distress, not to mention their families. Instead, by dogmatically clinging to an absolutist position, Dr Kaplan came across as the head cheer-leader in an academic food fight. Unfortunately, this food fight involves the well-being of our children.

(See The Child Bipolar Diagnosis is Under Attack - Yet Again.)

Allen Frances

Reading Allen Frances on Psychology Today and the Psychiatric Times is as painful as viewing a painting by Thomas Kinkade. Dr Francis, professor emeritus at Duke University, headed up the DSM-IV of 1994. With the unveiling of the draft DSM-5 in Feb 2010, Dr Frances returned to the spotlight as its loudest and most inept critic.

Essentially, there are two Dr Frances - the one who fell in love with his 1994 opus and will brook no changes, and the one who feels he has sinned against humanity for his 1994 opus and likewise will brook no changes. In either case, his arguments come across as disordered and bizarre.

In citing numerous experts critical of DSM-5 changes, Dr Frances overlooks the obvious, namely that most of the problems faced by those working on the DSM-5 are the direct result of the Frances-led failures in bringing the DSM-IV into some kind of alignment with clinical reality back in 1994. The critics of the DSM-IV are justifiably legion. Not a peep from Dr Frances on this.

Dr Frances, by virtue of his elder statesman status, was in the enviable position of setting the tone for the debate, and thus informing us all on the challenges of taking diagnostic psychiatry into a new era. As it happened, intelligent expert commentary never materialized. Present and future generations of those seeking professional help will end up paying dearly.

(See The Dimensional Side to Personality.)

Final Word

With a major paradigm shift underway, we are living in an age of both inspiration and exasperation. The “inspirators,” though clearly the wave of the future, are by no means infallible - hence the need for spirited conversations. The “exasperaters” see themselves as guardians of the old paradigm and are often right a lot of the time, hence - again - the need for spirited conversations.

Unfortunately the exasperaters cited here add nothing to the conversation. To the contrary, they come across as authoritarian, anti-intellectual, and as maladaptive reactors to their changing environments. Hysterical reactionism is always a response to progress, which is good news. The bad news is that as the paradigm further shifts, we are likely to witness much more of this type of behavior.

Stay tuned for my next crop of annual awardees. I guarantee you won’t have to wait a year.

The Dimensional Side to Personality

We have been looking at Take Two (from June 21) in the DSM-5’s proposed update to personality disorders. In Take One (from Feb 2010), the DSM-5 attempted to combine categories (as in “which one?) with dimensions (as in “how much?”) into a hybrid system, using interchangeable parts that could best be described as modular. The concept was far-reaching. The catch was that it appeared to be very unwieldy in practice.

Yesterday, we looked at how the DSM-5’s Take Two tackled the categorical side of personality, using a dimensional twist. Today, we look at the DSM-5’s Take Two of the dimensional model, built on categorical pieces, but a different set of categorical pieces from Take One.

Take One, in essence, was based on a sort of reverse Five-Factor Model (such as “antagonism” in place of “agreeableness”) measuring 37 different trait facets on a four-point scale. Take Two is far more modest in scale, but may be much more useful.

Consider, for instance, the following four individuals:

Jane, 28, displays classic borderline symptoms - unstable self-image, trouble maintaining relationships, and so on. But she is working as a manager in a city government. Does the borderline label really apply?

Bill, in his 20s, flies off the handle, uses drugs, and has run-ins with the law, but does not meet the criteria for antisocial. But clearly, his behavior warrants clinical attention.

Sally, 14, is acting out like someone with borderline, but is her behavior more attributable to being a teen?

Joey, in his 50s, deals with major depression and diabetes, and has major issues getting along with his caregivers. Is there a diagnosis that doctors can apply to patients they don’t like?

Enter the Levels of Personality Functioning Scale. This employs the self and interpersonal functions from Criterion A used in all six categorical diagnoses and rates them in terms of severity from 0 to 4. Thus, in 0 (well-adjusted), we see these kind of qualities: “ongoing awareness of a unique self”, “sets and aspires to reasonable goals”, “capable of understanding others”, “maintains multiple, satisfying, and enduring relationships”, and so on.

Meanwhile, way over on 4, we see “boundaries with others are confused and lacking”, “poor differentiation of thoughts from actions” - well, you get the picture.

Then we’re asked to consider the six (mostly interchangeable) trait domains that form the basis of the six personality disorders: Negative Affectivity, Disinhibition, Antagonism, Psychoticism, and Compulsivity. Only this time we are viewing these domains as stand-alone entities rather than in the context of a full-blown personality disorder.

Let’s return to our individuals, who represent abbreviated versions of the examples served up by the DSM-5.

Jane, according to the DSM-5, would rate a diagnosis of borderline, “but her level of personality functioning might be rated as less impaired than that of the more typical borderline patient, with enhanced prospects for successful treatment.” In other words, Jane is a good prognosis patient.

Bill, under the old DSM, would probably sail under the diagnostic radar or fall through the cracks. Perhaps he would be diagnosed as Personality Disorder NOS (not otherwise specified), which tells us nothing. Under the DSM-5, we are told, Bill would be coded as “Personality Disorder Trait Specified,” emphasis on trait specified, such as hostility and impulsivity. These traits would then “serve as specific foci of clinical attention.”

Sally may show signs of emerging borderline, but the DSM-5 indicates the wise course is to hold off on this diagnosis, and instead note her as having a low level of personality functioning, with reference to specific traits such as emotional lability. These features can then be closely tracked as Sally matures.

Joey may not have a personality disorder, but he could be written up for “antagonism,” and impairment in interpersonal personality function. The DSM-5 doesn’t say this, but the best way of treating Joey’s depression and diabetes is to treat the personality issues that sabotage his being a successful patient.

***

Thus, in terms of functional impairment and various traits, in all four cases we are seeing evidence of “something” going on - from a personality disorder with a good prognosis to a clinical condition as serious as any personality disorder to a situation of wait-and-see to a pressing concern that merits some sort of intervention.

This may not be a perfect system, and already a predictably rotten tomato review has come in from Allen Frances, head of the criminally horrendous DSM-IV, who characterized Take Two as “an impossible mess to the rest of us.”

Dr Frances may well be right, but for all the wrong reasons. Dr Frances has indicated in all his DSM-5 writings to date that he sees himself as merely as the keeper of his precious DSM-IV, which is a very different proposition than lending his professional wisdom to improving the lives of those dealing with serious personality issues. In the final analysis, any attempt to pin down something as infinitely complex as personality is doomed to be flawed. Success, then, is modest, to be measured in terms of less flawed than the effort before.

Could the DSM-5 have done a better job? Of course it could have. Is the version it turned in way better than the sorry DSM-IV mess that Dr Frances is so in denial about? Don’t make me answer that.

Previous pieces:

Personality Disorders - The DSM-5 Has Another Go
Take Two on Personality Disorders