I think it will be hard to expand psychiatry to that level while keeping it professional. The fundamental issue is that people ascribe personality flaws to others instinctually and also have strong feelings around being subjected to such treatment, in a way that they don’t have around sprained ankles. In everyday life it’s called badmouthing or trash-talking. It’s a part of human nature.
What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm…by Americans. The DSM in many ways represents the worst of so-called social science.
But conceptually in the DSM most disorders are defined by whether they cause hardship in the patient's life. Whether that means some disorders would not have to be considered disorders in an ideal society is irrelevant for this context, because people need help navigating the society we have.
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?
How else would you do it? Unlike an e.g. viral infection there is no positive test you can look at. Generally a disorder is considered something that significantly impacts someone's life, getting in the way of things like working, social life, life enjoyment. I don't think you can be totally objective about this, and you get into things like if i.e. autism is mild is it a disorder? It's pretty clear to me it should be considered as such after a certain level of severity, but maybe it shouldn't always be if it has minimal impact on the person
A "disorder" is just a collection of symptoms that have been empirically shown to benefit from certain treatments. If someone doesn't think they have those symptoms then they can just not seek a diagnosis or treatment. Nobody is forcing a diagnosis on somebody who doesn't want it.
If you look into the history of psychiatry I think you’ll find quite a lot of examples when diagnosis and treatment was forced on people who didn’t want it. It’s not hard to find contemporary such examples either.
Agreeing that social science is harder than most, I see these definitions as “circle around a set of presentations / symptoms / behaviours “. As somebody who has several circles around them, it doesn’t bother me overly. Historical enforced procedures / incarcerations did, but I understand value of “common language”. In a wildly different area that may or may not resonate with HN, I find similar value in PMP or ITIL - it’s not the One True Way, it is not necessarily a permanent scientific best approach… but it does give people of today a way to communicate with each other across domains, companies, cultures and experiences .
>What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm
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.
> The DSM in many ways represents the worst of so-called social science.
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.
But people do. Psychology courses do, with a similar "tool to help standardize communication" line recited robotically and then practically ignored. Most practicing psychologists do as well, to only a somewhat lesser degree.
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.
I wonder how much of the DSM is based on loose correlations, non-replicated or fraudulent research.
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...
The DSM isn't about understanding how the brain works, it's about correlating sets of symptoms to treatments. If your issues are characterized by this broad set of symptoms, then likely you'll benefit from these sorts of treatments, and etc. We don't have a good understanding of how the brain works, but we're pretty confident that people with schizophrenia often benefit from antipsychotic medications.
In some ways the financial conflicts of interest make sense, because the people that best understand a set of symptoms probably also are the ones in the best position to create new treatments. Being undisclosed makes it feel way more scummy than it might actually be.
That should be true across medicine. A biotech is best suited to invent new medications for existing diseases consulting with or acquiring in-house talent that knows the disease inside and out.
Experts generally benefit from their expertise. Nothing new, shouldn't be controversial.
The thing is, society doesn't have to worry that the guy selling crutches is going to reinvent the definition of a broken leg to increase crutch sales.
We should worry about the guy selling crutches. He could be lobbying against safety standards that would decrease the number of broken legs. We should assume he's acting in his own best interest, and carefully consider if his actions align with our collective best interest. Disclosure is critical.
It's hard to tell honestly. I studied psychology for two years in uni, and I dropped out rather disillusioned about the field. Some of my least favorite aspects included:
- 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.
The DSM-V is still incredibly hostile towards trans people through a game of internal power politics and cherry-picked research. It's really bad honestly.
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.
>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).
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?
> 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).
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.
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.
This is the wrong question… The DSM is just an ontology that aims to standardize communication of otherwise ill-defined or nebulous clinical entities. It provides language for medical professionals of various backgrounds to understand each other across cultures. That’s all it is.
The brain is certainly difficult to study, but does it not stand to reason that there should be a collection of the current understanding of how to treat things when they go wrong? No one is calling the DSM V the final, definitive, work, there's a reason it's numbered.
So these folks are implying that the rework of the DSM-4 into DSM-5 was tainted in some way by association of the authors with pharma or other industries? Do I understand that correctly?
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.)
> So these folks are implying that the rework of the DSM-4 into DSM-5 was tainted in some way by association of the authors with pharma or other industries?
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
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.
The OP did ask that first question, but to me it read as being more rhetorical so that we could maybe get specific answers about what in the DSM-5 would have been written differently otherwise.
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
I dunno that we disagree. My point was just that its easier to put a finger on the scale when any improvement, non-improvement, or even the existence of a disease itself is more subjective.
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?
That’s not accurate in the case of osteopenia. It’s defined by a T score. The quantile of the distribution of bone density measurements of young, healthy people that matched the bone density of this patient. Treatments for osteopenia are basically making sure you’re getting enough calcium, vitaD, and high impact exercise…if everyone did all those things (and they worked), the rate of osteopenia would drop to zero.
> The most common type of payment was for food and beverages (90.9%) followed by travel (69.1%).
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 food is specified as $89506.7 so, we're talking about less than two grand each.
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.
Sometime in the early 2000's we passed a point where more than 50% of the population had an AXIS 2 or higher chemical disorder[1]. It was around this point that I became skeptical of the DSM.
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.
What is an Axis II chemical disorder? I'm fairly certain that Axis II was personality disorders and intellectual disabilities in the DSM IV.
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.
>I'm fairly certain that Axis II was personality disorders and intellectual disabilities in the DSM IV.
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.
Ok, so we're on the same page as to what we're referring to, but, to be clear, that 50% claim is incorrect[1], it's much lower than that.
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?
I tried to correct myself above, and included the source this time.
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?
Most mental health diagnoses are transient. If half of people at some point experience diagnosable mental illness in their lives, that doesn't seem all that outlandish to me. Most of us will, at some point, have some kind of non-psychiatric illness, too.
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.
I don't think that it's incorrect at all to say that half of us will at some or multiple points in time suffer from some disorder, in fact I find it comforting to recognize that we will all go through this at some point.
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.
It helps to think of these as clusters of symptoms or personality traits anyone might have, which occasionally interfere on your life enough to need treatment. A lot of mental illnesses aren't like a class of person but something that's happening to a person for a while
Surely this is a mistake dang? It's prima facie absurd and if not that unnecessarily stifling. The thread is already talking about the statistics of America, it's not flamebait to bring that up. One may disagree with op, but who would actually complain about it being added to the discussion itself? Doesn't creating a situation where something like this can't even be said more contribute to an atmosphere of passive aggressiveness than not?
I don't think it's a mistake; the comment didn't add any information; it consisted of generic negative rhetoric plus markers of internet snark (leading "Eh", "actual").
This kind of thing just doesn't lead to good HN discussion. It's at best a generic tangent and more likely a generic flamewar tangent.
Nationalistic flamebait is when someone makes a pejorative generalization about a country, usually in the context of a comment which has little or no actual information, but only denunciatory rhetoric. Your GP comment clearly fits that description, as I read it. This is not a borderline call!
What happens when people post like that is that others, who have the opposite sympathies, get provoked and feel entitled to respond in kind. Of course, what they feel is "responding in kind" is usually much worse, and thus we end up in a downward spiral.
None of this is what HN is for. We want curious conversation here, and that doesn't consist of putting down entire countries, nor of grand generalizations (especially negative ones). Curiosity is much more inclined to look at some interesting or surprising specific about a situation. That's also what the site guidelines ask people to avoid generic tangents (https://hn.algolia.com/?dateRange=all&page=0&prefix=true&que...).
As someone who has been here many, many years - this is truly mystifying to me. And not just me, apparently. And also notably, no one responded that way to that comment.
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.
I hadn't noticed that, but they both look to be helping their members, at the cost of society in general. The American Psychological Association does have a good style guide though, so they have that going for them.
so ... apa ...the apa that writes the dsm-5, psychiatric disorders, the medical group, is the american PSYCHIATRIC assn.
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.
There used to be an American Philological Association, but they decided to change their name to the "Society for Classical Studies," because most people don't know the word "philology."
I’m a psychiatrist, so if you consider that a significant bias I’m disclosing it.
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?
I think it will be hard to expand psychiatry to that level while keeping it professional. The fundamental issue is that people ascribe personality flaws to others instinctually and also have strong feelings around being subjected to such treatment, in a way that they don’t have around sprained ankles. In everyday life it’s called badmouthing or trash-talking. It’s a part of human nature.
What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm…by Americans. The DSM in many ways represents the worst of so-called social science.
But conceptually in the DSM most disorders are defined by whether they cause hardship in the patient's life. Whether that means some disorders would not have to be considered disorders in an ideal society is irrelevant for this context, because people need help navigating the society we have.
Remember that in the US slaves wanting freedom was a mental disorder that made it past peer review: https://en.wikipedia.org/wiki/Drapetomania
What is your point?
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?
unfortunately, what seems to be driving modern disorder diagnosis is what gets issurance to pay. That's why autism is now a spectrum.
It’s the other way around AFAIK. Insurance pays for what’s categorized as a disorder by the DSM. Or did I misunderstand your statement?
And atoms used to be the smallest division of matter. Then we learned about smaller things.
Understanding changes as we do more research into a thing.
How else would you do it? Unlike an e.g. viral infection there is no positive test you can look at. Generally a disorder is considered something that significantly impacts someone's life, getting in the way of things like working, social life, life enjoyment. I don't think you can be totally objective about this, and you get into things like if i.e. autism is mild is it a disorder? It's pretty clear to me it should be considered as such after a certain level of severity, but maybe it shouldn't always be if it has minimal impact on the person
A "disorder" is just a collection of symptoms that have been empirically shown to benefit from certain treatments. If someone doesn't think they have those symptoms then they can just not seek a diagnosis or treatment. Nobody is forcing a diagnosis on somebody who doesn't want it.
If you look into the history of psychiatry I think you’ll find quite a lot of examples when diagnosis and treatment was forced on people who didn’t want it. It’s not hard to find contemporary such examples either.
Agreeing that social science is harder than most, I see these definitions as “circle around a set of presentations / symptoms / behaviours “. As somebody who has several circles around them, it doesn’t bother me overly. Historical enforced procedures / incarcerations did, but I understand value of “common language”. In a wildly different area that may or may not resonate with HN, I find similar value in PMP or ITIL - it’s not the One True Way, it is not necessarily a permanent scientific best approach… but it does give people of today a way to communicate with each other across domains, companies, cultures and experiences .
>What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm
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.
This is just false. By this criteria, you can then say many other conditions are not disorders.
Why do we have arbitrary cutoffs for cholesterol, blood sugar, blood pressure, etc?
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.
> The DSM in many ways represents the worst of so-called social science.
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.
But people do. Psychology courses do, with a similar "tool to help standardize communication" line recited robotically and then practically ignored. Most practicing psychologists do as well, to only a somewhat lesser degree.
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.
I’ve had a bunch of neuro/psycho classes and this was always well understood.
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.
I wonder how much of the DSM is based on loose correlations, non-replicated or fraudulent research.
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...
The DSM isn't about understanding how the brain works, it's about correlating sets of symptoms to treatments. If your issues are characterized by this broad set of symptoms, then likely you'll benefit from these sorts of treatments, and etc. We don't have a good understanding of how the brain works, but we're pretty confident that people with schizophrenia often benefit from antipsychotic medications.
In some ways the financial conflicts of interest make sense, because the people that best understand a set of symptoms probably also are the ones in the best position to create new treatments. Being undisclosed makes it feel way more scummy than it might actually be.
That should be true across medicine. A biotech is best suited to invent new medications for existing diseases consulting with or acquiring in-house talent that knows the disease inside and out.
Experts generally benefit from their expertise. Nothing new, shouldn't be controversial.
The thing is, society doesn't have to worry that the guy selling crutches is going to reinvent the definition of a broken leg to increase crutch sales.
We should worry about the guy selling crutches. He could be lobbying against safety standards that would decrease the number of broken legs. We should assume he's acting in his own best interest, and carefully consider if his actions align with our collective best interest. Disclosure is critical.
It's hard to tell honestly. I studied psychology for two years in uni, and I dropped out rather disillusioned about the field. Some of my least favorite aspects included:
The DSM-V is still incredibly hostile towards trans people through a game of internal power politics and cherry-picked research. It's really bad honestly.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.
>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).
That's mild. In one of Chile's largest and most prestigious universities, Jodorowsky "psychomagic" is teached as a real therapeutic approach.
At least you're working with Rust now.
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?
> 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).
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.
>P-hacking rampant
give us your best academic hypothesis as to why p-hacking is rampant: I'll bet it will sound like psych analysis
I took the liberty of indulging in some reading.
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.
Logically, your example is not contradictory.
It is not at all contradictory.> This kind of contradictory phrasing is standard in the DSM.
I'm not sure I see what's contradictory in your example. Could you elaborate?
This is the wrong question… The DSM is just an ontology that aims to standardize communication of otherwise ill-defined or nebulous clinical entities. It provides language for medical professionals of various backgrounds to understand each other across cultures. That’s all it is.
It's a sorting hat
Kind of like…labeling people by race? Surely there are misalignments.
The brain is certainly difficult to study, but does it not stand to reason that there should be a collection of the current understanding of how to treat things when they go wrong? No one is calling the DSM V the final, definitive, work, there's a reason it's numbered.
So these folks are implying that the rework of the DSM-4 into DSM-5 was tainted in some way by association of the authors with pharma or other industries? Do I understand that correctly?
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.)
> So these folks are implying that the rework of the DSM-4 into DSM-5 was tainted in some way by association of the authors with pharma or other industries?
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
>See "neglected tropical diseases"
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.
The OP did ask that first question, but to me it read as being more rhetorical so that we could maybe get specific answers about what in the DSM-5 would have been written differently otherwise.
> As true in psychiatry as anything else
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.
Not at all.
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
I dunno that we disagree. My point was just that its easier to put a finger on the scale when any improvement, non-improvement, or even the existence of a disease itself is more subjective.
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?
Next there will be a paper on the accountants that set accounting standards have a financial interest in accounting.
I'm pretty sure we have tablets from Babylon wherein homeowners are complaining that the building code was ghost written by the mud brick lobbyists.
I have particular issue with “diseases” defined as done for osteopenia.
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…
That’s not accurate in the case of osteopenia. It’s defined by a T score. The quantile of the distribution of bone density measurements of young, healthy people that matched the bone density of this patient. Treatments for osteopenia are basically making sure you’re getting enough calcium, vitaD, and high impact exercise…if everyone did all those things (and they worked), the rate of osteopenia would drop to zero.
> The most common type of payment was for food and beverages (90.9%) followed by travel (69.1%).
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.
It was 14 million for 55 people, wasn't it? That's a lot of coca cola cans.
The food is specified as $89506.7 so, we're talking about less than two grand each.
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.
Wally isn't the only one writing himself a new minivan this afternoon.
Sometime in the early 2000's we passed a point where more than 50% of the population had an AXIS 2 or higher chemical disorder[1]. It was around this point that I became skeptical of the DSM.
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.
What is an Axis II chemical disorder? I'm fairly certain that Axis II was personality disorders and intellectual disabilities in the DSM IV.
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.
[1] https://www.cdc.gov/nchs/products/databriefs/db511.htm
>I'm fairly certain that Axis II was personality disorders and intellectual disabilities in the DSM IV.
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/...
Ok, so we're on the same page as to what we're referring to, but, to be clear, that 50% claim is incorrect[1], it's much lower than that.
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?
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC3105841/
I tried to correct myself above, and included the source this time.
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?
Most mental health diagnoses are transient. If half of people at some point experience diagnosable mental illness in their lives, that doesn't seem all that outlandish to me. Most of us will, at some point, have some kind of non-psychiatric illness, too.
You, and SketchySeaBeast, both make a good point.
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.
I don't think that it's incorrect at all to say that half of us will at some or multiple points in time suffer from some disorder, in fact I find it comforting to recognize that we will all go through this at some point.
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.
It helps to think of these as clusters of symptoms or personality traits anyone might have, which occasionally interfere on your life enough to need treatment. A lot of mental illnesses aren't like a class of person but something that's happening to a person for a while
> If the majority of people are crazy, it's likely that our definition of "crazy" needs work.
you'd have to be crazy to not believe in demons
a personality disorder does not imply crazy as it is generally apathological, merely a malformed person.
[flagged]
Please keep nationalistic flamebait off this site. It leads to nationalistic flamewars, which we want to avoid here.
https://news.ycombinator.com/newsguidelines.html
Surely this is a mistake dang? It's prima facie absurd and if not that unnecessarily stifling. The thread is already talking about the statistics of America, it's not flamebait to bring that up. One may disagree with op, but who would actually complain about it being added to the discussion itself? Doesn't creating a situation where something like this can't even be said more contribute to an atmosphere of passive aggressiveness than not?
I don't think it's a mistake; the comment didn't add any information; it consisted of generic negative rhetoric plus markers of internet snark (leading "Eh", "actual").
This kind of thing just doesn't lead to good HN discussion. It's at best a generic tangent and more likely a generic flamewar tangent.
Huh? And what is nationalistic flame bait about it? Speaking as someone living it.
There is a reason why depression, anxiety, and a host of other issues have escalated for decades, and nationalism has nothing to do with it.
Nationalistic flamebait is when someone makes a pejorative generalization about a country, usually in the context of a comment which has little or no actual information, but only denunciatory rhetoric. Your GP comment clearly fits that description, as I read it. This is not a borderline call!
What happens when people post like that is that others, who have the opposite sympathies, get provoked and feel entitled to respond in kind. Of course, what they feel is "responding in kind" is usually much worse, and thus we end up in a downward spiral.
None of this is what HN is for. We want curious conversation here, and that doesn't consist of putting down entire countries, nor of grand generalizations (especially negative ones). Curiosity is much more inclined to look at some interesting or surprising specific about a situation. That's also what the site guidelines ask people to avoid generic tangents (https://hn.algolia.com/?dateRange=all&page=0&prefix=true&que...).
As someone who has been here many, many years - this is truly mystifying to me. And not just me, apparently. And also notably, no one responded that way to that comment.
But sure, it’s your show.
(2024)
Added. Thanks!
When the APA elected Philip Zimbardo, creator of the infamous Stanford Prison Experiment (https://en.wikipedia.org/wiki/Stanford_prison_experiment#Cri...), as their president (https://www.apa.org/about/governance/president/bio-philip-zi...) they lost my trust. He came up with a hypothesis on human behavior, then did everything he could to force the data to reflect that, including coercing volunteers into torturing each other.
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.
The DSM-5 is from the "American Psychiatric Association".
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.
I hadn't noticed that, but they both look to be helping their members, at the cost of society in general. The American Psychological Association does have a good style guide though, so they have that going for them.
so ... apa ...the apa that writes the dsm-5, psychiatric disorders, the medical group, is the american PSYCHIATRIC assn.
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.
There's also the American Philosophical Association.
There used to be an American Philological Association, but they decided to change their name to the "Society for Classical Studies," because most people don't know the word "philology."
What a surprise.