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.
There isn't one because a sprained ankle is a binary diagnosis.
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.
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.
They don't work for everybody though; I have ADHD and Ritalin/Focalin help just a little (and only if I take them to the point where I feel like pressed-meat in the mornings), while Adderall gives me hallucinations.
No, the drugs don't make doing chores fun or any of that.
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.
Why do you presume I'm neurotypical and undiagnosed with any psychiatric disorder? I'm formally diagnosed with severe OCD, depression, and ADHD. I was on SSRI, then SNRI and additionally methylphenidate for years. Eventually I got tired for feeling like a shell of a human being, and weaned off of the SNRI. It took a lot of effort to induce neuroplasticity and ease my OCD and depression, but I did it. Eventually, I weaned off the methylphenidate because I believed I could do it if I tried. Later in life, I also gained and eventually lost weight, which was a similar acceptance that "bad" things, like hunger, are ok and a symptom of something good, my body consuming fat. Then the same for sore muscles at the gym. Over time, I accepted discomfort and the fight or flight my brain was constantly trying to force onto me was a lie, and eventually my brain and nervous system caught up. My physical and mental health improved, my social life, my professional life, etc.
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?
>I bet if you knew your house would burn down if you didn't do "normal" things you would have done them no problem
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
The point is it's obviously a problem of perspective. Things are not important because they aren't considered important. If the stakes are higher they are elevated in importance and more demanding of attention.
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.
Exciting and even emergency situations don't cure ADHD or allow people with ADHD to magically function "normally" (or even effectively enough to avoid serious harm to themselves/others). The amount of importance a person with ADHD attributes to a task doesn't tell you if they'll be able to complete it as well as they would if they were being treated with medication or even if they will be able to complete it at all.
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.
You are forgetting what people did before psych meds were available. Almost everyone treated themselves with alcohol and tobacco. Coffee is up there, too. There is cognitive adaptation, not denying it, but only up to a point.
If I knew my house would burn down if I forgot where my keys where it wouldn't do much more than turn me into a paranoid barely functional mess. Higher stakes do not automatically help. Although ironically part of being ADHD is functioning well in high stakes situations, it's not healthy to create high stakes situations in order to function (although some people do this).
This is one of the most personally compelling reasons why I agree with my ADHD diagnosis - I've known for a long time that I work better in a state of chaos than not. I actually often enjoy it. And others have commented on that about me as well.
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.
A person's treatment doesn't depend on what's "normal" it depends on the level of impairment/improvement. Why do you even care if somebody takes medication for a condition they have and it makes their lives easier? Why should anyone avoid a "quick fix" to a major problem because you think they should suffer more discomfort?
> Why do you presume I'm neurotypical and undiagnosed with any psychiatric disorder?
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.
You are catastrophically incorrect and it's ironic that you would say I do not have empathy.
No I'm saying you lack the impulse control and self discipline to perform tasks unless the stakes are high. But you're not an animal, you can do something about that without medication. You can accept the discomfort and move through it just like you do when the stakes are actually high. Just like I do. The idea that everything in life should induce minimal discomfort or that "it's hard" is an excuse is a completely modern, first world problem, to speak of privilege.
Mindfulness and thinking about your thoughts are proven as effective or more effective than medication for a wide range of psychological disorders, including ADHD, or CBT if you want to formalize it.
Your story can be summarized as "I was bad at doing things that made me feel discomfort, but now I'm on stimulants and I don't feel discomfort anymore." What else did you try? What areas of life did you accept discomfort for the sake of long term growth? If there were any, what made them different?
> You can accept the discomfort and move through it just like you do when the stakes are actually high. Just like I do.
Have you ever considered that the things which you find doable or even trivial might be incomprehensibly more difficult for other people? You mentioned being diagnosed with ADHD higher up, but part of the diagnostic criteria for ADHD is quite literally about severity of the symptoms:
DSM-5: "There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning."
ICD-11: "Several symptoms of inattention/hyperactivity-impulsivity that are persistent, and sufficiently severe that they have a direct negative impact on academic, occupational, or social functioning"
Whether you're capable of pushing through it regardless of discomfort and difficulties, and failing to do so to the degree that it severely negatively affects your life is the defining line between "order" and "disorder".
> The idea that everything in life should induce minimal discomfort or that "it's hard" is an excuse is a completely modern, first world problem, to speak of privilege.
No, the idea is that people should receive help if we have a neurodevelopmental disorder that is severe enough to significantly impact our quality of life. Just like with any other medical condition.
> Mindfulness and thinking about your thoughts are proven as effective or more effective than medication for a wide range of psychological disorders, including ADHD, or CBT if you want to formalize it.
False:
> CBT is best used within a multi-modal treatment approach and as an adjunct to medication as current research does not fully support the efficacy of CBT as a sole treatment for adult ADHD [274,[316], [317], [318]]. Most controlled studies have been conducted in patients taking ADHD medication and demonstrate an additional significant treatment effect [313,[318], [319], [320], [321], [322]]. The largest controlled multi-center CBT-study to date has demonstrated that psychological interventions result in better outcomes when combined with MPH as compared to psychological interventions in unmedicated patients [228]. In a systematic review of 51 pharmacological and non-pharmacological interventions [316], the highest proportion of improved outcomes (83%) was for patients receiving combination treatment.
This sounds to me like getting into "You say you're depressed? Come on, snap out of it!" territory. I guess I consider psychological disorders to be a disorder when you aren't able to "snap out of it" or "just do things that are unpleasant".
Like yes, I do things that are unpleasant - ADHD doesn't mean I live a life of ease, avoiding unpleasantness all day long.
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!
Doesn't that presume that human psychology (cognitive functioning) is uniform at a level that would obviate the need even for personalities and styles?
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?
I think you’re overlooking the difference between diversity and changes to an individual.
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.
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.
> 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.
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.
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.
Reading your linked article, it's clear that this was viewed as absolute quackery even back then, and is about as conflict-of-interesty as you can get: commissioned by Louisiana at the height of the Civil War, and proposed by a doctor who served in the Confederate Army [1]. His suggested treatment for Drapetomania was "whipping the devil out of them".
This was proposed a decade before the war started and was reprinted widely in the Southern States. That the North found it ridiculous is a bit like saying that because the Chinese Academy of Sciences says there is no such thing as autism then it's obviously viewed as quackery in the West too.
Are you able to tell us a bit more about the Chinese Academy of Sciences saying there is no such thing as autism? I was curious but cannot find anything about this.
There's none lol. I may have participated in studies as a researcher partially funded by Chinese academy of sciences because we had Chinese collaboration, and some studies involved autism biomarker research.
> 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
Slaves wanting freedom is a mental disorder if it is maladaptive, debilitating, and infeasible in their circumstance, no? Being crazy doesn't mean you're wrong, it could mean you are right in a world where you must be wrong to survive.
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?
Hi, not the parent poster here. I believe the argument being made is that diagnostic criteria, and diagnoses themselves, can be shaped by cultural norms. As the Overton window shifts, so do the thoughts and behaviors that we deem pathological.
> 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.
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
> Generally a disorder is considered something that significantly impacts someone's life, getting in the way of things like working, social life, life enjoyment.
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.
These reductio ad absurdum arguments are wholly unpersuasive. The fact that there are some debatable gray areas in the DSMs seems like poor reasoning to throw the baby out with the bathwater. E.g. things like schizophrenia, OCD, major depressive disorder, etc. are so highly disruptive to the individuals involved that arguing that they shouldn't be disorders (or, contrary, that anything else is a disorder) feels like an unhelpful semantic game.
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.
Yes, that did unfortunately happen in the history of psychiatry. I am talking about modern American psychiatric practices (say, the last 10-20 years).
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.
> The vast majority of people in the US who receive psychiatric care do so voluntarily
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.
>> Nobody is forcing a diagnosis on somebody who doesn't want it.
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.
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.
If the DSM merely described sets of symptoms and gave them names, I'd buy that. But by also mentioning (e.g. suggesting) specific treatments, the book is used as a prescription tool, not just a diagnostic tool.
> But if you’re going to judge the book, judge it by how it presents itself
Quite so. I just as we judge people by their actions, not their words, I judge the DSM by how it's actual content is structured, not by its introductory quip.
> 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.
The exercise and food science people are the worst of social science buddy. Or just “social” something, because it’s not science. “Science-based” always makes me laugh.
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.
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.
> Experiencing first-hand just how unreproducible most research in our faculty was (SPSS was the norm, R was the exception, Python was unused).
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.
>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?
> As someone with zero knowledge of psychology, I'm biased against it.
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?
> 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.
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.
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.
How can one identify an illness where one can't even tell who and how often have said illness?
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.
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.
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.
Nearly all of it, because that's the case for the overwhelming majority of the social sciences.
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
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?
The DSM is a bunch of nonsense. As long as they don’t provide physical mechanisms for disorders, it’s worthless. It clusters symptoms without knowing the underlying causes.
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.
" The FASB was conceived as a full-time body to insure that Board member deliberations encourage broad participation, objectively consider all stakeholder views, and are not influenced or directed by political/private interests "
The DSM diagnostic categories are glorified billing codes that everybody (who actually has real ground contact with mental health care for real for real) recognizes as primitive, Stone Age relics.
In five or ten years, these categories will feel like missteps of the past (akin to calling all mental illness “hysteria”).
> 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.
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.
Yeah, and the T score doesn’t seem to have any medical basis.
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.
The DSM has always rubbed me the wrong way as it seems like correlative pseudo science or at the least the worst possible use of statistics.
Most especially when it can be used as a method of you must have x because people who have these symptoms generally can fall into this category and because you have x you therefore must be crazy and insert ad hominem attack.
We're in an age where if these symptoms do exist in these categories they should be backed up with empirical brain science using imaging and neuro chemistry and correlative machine learning. There isn't a reason not to do it other than to protect incumbents. Psychiatry seems stuck in the age of "philosophy defines what physics is despite evidence or experimental design to the contrary".
EDIT - try reporting anything to the authorities about anything in any capacity whatsoever while being poor and have to answer the question "have you ever been diagnosed with a psychiatric disorder". It is most definitely used as a bludgeon of arbitrary authority against the poor which protects entrenched interests that would use the poor to leach money from the state.
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
Nationalistic flamebait is when someone makes a pejorative generalization about a country, usually in the context of a comment which has little 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.
You're right, but we have to moderate based on how these things work in the general case.
> this is truly mystifying to me
It's inevitable that there will be different interpretations of specific comments, so I hope you can at least 'upgrade' us to "wrong in this case" and hopefully we will make more sense in the future!
p.s. I know what you mean about "it's your show" but we really don't think of this as "our" show - the community is the only thing that's valuable about HN
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.
To diagnose 'narcissistic personality disorder (NPD)' you have to be an Olympic class athlete of the ice who skates effortlessly around and between the edges of frozen lakes of "people I just do not like".
In principle, those being accused of a conflict of interest in the creation of DSM-5 could argue that, because the DSM is science-based, it's open to impartial statistical analyses and comparison with established scientific theory that would render moot any such accusation.
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.
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.
Since we just asked you to stop breaking the site guidelines and you've continued to do it, I've banned this account.
If you don't want to be banned, you're welcome to email hn@ycombinator.com and give us reason to believe that you'll follow the rules in the future. They're here: https://news.ycombinator.com/newsguidelines.html.
Calling a comment "ridiculous" is against the guidelines?
Okay. Hopefully it isn't against the guidelines to say I think that's a silly guideline. Apparently saying "ridiculous" in response to a comment is very selectively enforced, must be my lucky day.
Anyways, this is probably the reminder I needed to stop commenting to HN. Some of the moderator decisions you guys are making lately are just.. way off base to me. Either you've changed or I have. Probably me.
"What an absolutely ridiculous comment. That is extremely obviously not what I said or implied." is obviously a flamewar reaction. This is not a borderline call!
If you had simply posted the last sentence, your comment would have been just fine.
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.
There isn't one because a sprained ankle is a binary diagnosis.
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...
> only the catastrophic is worth addressing
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.
Hold on.. did you just say there is a drug I can take that will making talking to people less boring and doing housework fun?
They don't work for everybody though; I have ADHD and Ritalin/Focalin help just a little (and only if I take them to the point where I feel like pressed-meat in the mornings), while Adderall gives me hallucinations.
No, the drugs don't make doing chores fun or any of that.
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.
Honestly, sounds like a plot out of futurama.
you clearly have not experienced any range of uppers
They didn’t call them mother’s little helpers for nothin’.
Edit: ok, that was vallium. ;)
Why do you presume I'm neurotypical and undiagnosed with any psychiatric disorder? I'm formally diagnosed with severe OCD, depression, and ADHD. I was on SSRI, then SNRI and additionally methylphenidate for years. Eventually I got tired for feeling like a shell of a human being, and weaned off of the SNRI. It took a lot of effort to induce neuroplasticity and ease my OCD and depression, but I did it. Eventually, I weaned off the methylphenidate because I believed I could do it if I tried. Later in life, I also gained and eventually lost weight, which was a similar acceptance that "bad" things, like hunger, are ok and a symptom of something good, my body consuming fat. Then the same for sore muscles at the gym. Over time, I accepted discomfort and the fight or flight my brain was constantly trying to force onto me was a lie, and eventually my brain and nervous system caught up. My physical and mental health improved, my social life, my professional life, etc.
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?
>I bet if you knew your house would burn down if you didn't do "normal" things you would have done them no problem
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
The point is it's obviously a problem of perspective. Things are not important because they aren't considered important. If the stakes are higher they are elevated in importance and more demanding of attention.
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.
Exciting and even emergency situations don't cure ADHD or allow people with ADHD to magically function "normally" (or even effectively enough to avoid serious harm to themselves/others). The amount of importance a person with ADHD attributes to a task doesn't tell you if they'll be able to complete it as well as they would if they were being treated with medication or even if they will be able to complete it at all.
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.
You are forgetting what people did before psych meds were available. Almost everyone treated themselves with alcohol and tobacco. Coffee is up there, too. There is cognitive adaptation, not denying it, but only up to a point.
And living, or rather surviving, on adrenaline fueled high stakes brinkmanship sucks. Especially if that's just to enable doing simple chores.
If I knew my house would burn down if I forgot where my keys where it wouldn't do much more than turn me into a paranoid barely functional mess. Higher stakes do not automatically help. Although ironically part of being ADHD is functioning well in high stakes situations, it's not healthy to create high stakes situations in order to function (although some people do this).
This is one of the most personally compelling reasons why I agree with my ADHD diagnosis - I've known for a long time that I work better in a state of chaos than not. I actually often enjoy it. And others have commented on that about me as well.
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.
Just because something works for you to lead a normal life doesn’t mean it works for everyone.
What the DSM defines as normal is far too narrow and we're too eager for quick fixes without discomfort or discipline.
A person's treatment doesn't depend on what's "normal" it depends on the level of impairment/improvement. Why do you even care if somebody takes medication for a condition they have and it makes their lives easier? Why should anyone avoid a "quick fix" to a major problem because you think they should suffer more discomfort?
> Why do you presume I'm neurotypical and undiagnosed with any psychiatric disorder?
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.
You are catastrophically incorrect and it's ironic that you would say I do not have empathy.
No I'm saying you lack the impulse control and self discipline to perform tasks unless the stakes are high. But you're not an animal, you can do something about that without medication. You can accept the discomfort and move through it just like you do when the stakes are actually high. Just like I do. The idea that everything in life should induce minimal discomfort or that "it's hard" is an excuse is a completely modern, first world problem, to speak of privilege.
Mindfulness and thinking about your thoughts are proven as effective or more effective than medication for a wide range of psychological disorders, including ADHD, or CBT if you want to formalize it.
Your story can be summarized as "I was bad at doing things that made me feel discomfort, but now I'm on stimulants and I don't feel discomfort anymore." What else did you try? What areas of life did you accept discomfort for the sake of long term growth? If there were any, what made them different?
> You can accept the discomfort and move through it just like you do when the stakes are actually high. Just like I do.
Have you ever considered that the things which you find doable or even trivial might be incomprehensibly more difficult for other people? You mentioned being diagnosed with ADHD higher up, but part of the diagnostic criteria for ADHD is quite literally about severity of the symptoms:
DSM-5: "There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning."
ICD-11: "Several symptoms of inattention/hyperactivity-impulsivity that are persistent, and sufficiently severe that they have a direct negative impact on academic, occupational, or social functioning"
Whether you're capable of pushing through it regardless of discomfort and difficulties, and failing to do so to the degree that it severely negatively affects your life is the defining line between "order" and "disorder".
> The idea that everything in life should induce minimal discomfort or that "it's hard" is an excuse is a completely modern, first world problem, to speak of privilege.
No, the idea is that people should receive help if we have a neurodevelopmental disorder that is severe enough to significantly impact our quality of life. Just like with any other medical condition.
> Mindfulness and thinking about your thoughts are proven as effective or more effective than medication for a wide range of psychological disorders, including ADHD, or CBT if you want to formalize it.
False:
> CBT is best used within a multi-modal treatment approach and as an adjunct to medication as current research does not fully support the efficacy of CBT as a sole treatment for adult ADHD [274,[316], [317], [318]]. Most controlled studies have been conducted in patients taking ADHD medication and demonstrate an additional significant treatment effect [313,[318], [319], [320], [321], [322]]. The largest controlled multi-center CBT-study to date has demonstrated that psychological interventions result in better outcomes when combined with MPH as compared to psychological interventions in unmedicated patients [228]. In a systematic review of 51 pharmacological and non-pharmacological interventions [316], the highest proportion of improved outcomes (83%) was for patients receiving combination treatment.
https://www.sciencedirect.com/science/article/pii/S092493381...
This sounds to me like getting into "You say you're depressed? Come on, snap out of it!" territory. I guess I consider psychological disorders to be a disorder when you aren't able to "snap out of it" or "just do things that are unpleasant".
Like yes, I do things that are unpleasant - ADHD doesn't mean I live a life of ease, avoiding unpleasantness all day long.
“Chemical imbalance” lol.
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!
You're behind the times
https://www.nature.com/articles/s41380-022-01661-0
https://www.psychiatrictimes.com/view/debunking-two-chemical...
https://www.psychologytoday.com/us/blog/insight-therapy/2022...
Doesn't that presume that human psychology (cognitive functioning) is uniform at a level that would obviate the need even for personalities and styles?
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?
I think you’re overlooking the difference between diversity and changes to an individual.
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.
> What’s the psychiatric equivalent of a sprained ankle?
A concussion? Obviously it’s not considered a psychiatric condition but concussions check a lot of the right boxes abstractly.
What’s the right word to differentiate this from a psychiatric diagnosis? Neurological?
Not in my understanding. The line between neurological and psychiatric is more about history than about anatomy.
Instead, I would point to the physical trauma of a concussion as the differentiating factor.
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.
> 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.
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.
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
Reading your linked article, it's clear that this was viewed as absolute quackery even back then, and is about as conflict-of-interesty as you can get: commissioned by Louisiana at the height of the Civil War, and proposed by a doctor who served in the Confederate Army [1]. His suggested treatment for Drapetomania was "whipping the devil out of them".
[1]: https://en.wikipedia.org/wiki/Samuel_A._Cartwright
This was proposed a decade before the war started and was reprinted widely in the Southern States. That the North found it ridiculous is a bit like saying that because the Chinese Academy of Sciences says there is no such thing as autism then it's obviously viewed as quackery in the West too.
Are you able to tell us a bit more about the Chinese Academy of Sciences saying there is no such thing as autism? I was curious but cannot find anything about this.
https://en.wikipedia.org/wiki/Autism_in_China
There's none lol. I may have participated in studies as a researcher partially funded by Chinese academy of sciences because we had Chinese collaboration, and some studies involved autism biomarker research.
I member! Remember when dissatisfied women needing an orgasm was a mental disorder?
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.
Slaves wanting freedom is a mental disorder if it is maladaptive, debilitating, and infeasible in their circumstance, no? Being crazy doesn't mean you're wrong, it could mean you are right in a world where you must be wrong to survive.
“It is no measure of health to be well adjusted to a profoundly sick society.”
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?
Hi, not the parent poster here. I believe the argument being made is that diagnostic criteria, and diagnoses themselves, can be shaped by cultural norms. As the Overton window shifts, so do the thoughts and behaviors that we deem pathological.
> 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.
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?
[flagged]
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
> Generally a disorder is considered something that significantly impacts someone's life, getting in the way of things like working, social life, life enjoyment.
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.
These reductio ad absurdum arguments are wholly unpersuasive. The fact that there are some debatable gray areas in the DSMs seems like poor reasoning to throw the baby out with the bathwater. E.g. things like schizophrenia, OCD, major depressive disorder, etc. are so highly disruptive to the individuals involved that arguing that they shouldn't be disorders (or, contrary, that anything else is a disorder) feels like an unhelpful semantic game.
Sounds like you need to read better books Bromaster General!
> Sounds like you need to read better books Bromaster General!
I don't get this reference (that is likely rooted in US popular culture).
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.
Yes, that did unfortunately happen in the history of psychiatry. I am talking about modern American psychiatric practices (say, the last 10-20 years).
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.
> The vast majority of people in the US who receive psychiatric care do so voluntarily
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.
>> Nobody is forcing a diagnosis on somebody who doesn't want it.
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.
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’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.
If the DSM merely described sets of symptoms and gave them names, I'd buy that. But by also mentioning (e.g. suggesting) specific treatments, the book is used as a prescription tool, not just a diagnostic tool.
Quite so. I just as we judge people by their actions, not their words, I judge the DSM by how it's actual content is structured, not by its introductory quip.> 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.
“Empirical evidence” and “what is determined as undesirable, maladaptive, or outside the social norm” are not mutually exclusive.
Without a clear and agreed behavioral model, I don’t see how disorders can be properly defined.
The exercise and food science people are the worst of social science buddy. Or just “social” something, because it’s not science. “Science-based” always makes me laugh.
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.
I think this is not a valid criticism.
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 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.
> Experiencing first-hand just how unreproducible most research in our faculty was (SPSS was the norm, R was the exception, Python was unused).
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...
obviously p-hacking wouldnt be as prevalent if we just re-wrote DSM in rust
there'd be way too many personality traits included tho
>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?
> As someone with zero knowledge of psychology, I'm biased against it.
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?
0 - https://www.merriam-webster.com/dictionary/psychology
> 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
Incentives. Straight outta the dismal science.
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
So not a tinfoil sieve?
EDIT: missed Harry Potter reference
Kind of like…labeling people by race? Surely there are misalignments.
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?
How can one identify an illness where one can't even tell who and how often have said illness?
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.
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.
Nearly all of it, because that's the case for the overwhelming majority of the social sciences.
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
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?
The DSM is a bunch of nonsense. As long as they don’t provide physical mechanisms for disorders, it’s worthless. It clusters symptoms without knowing the underlying causes.
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.
While I agree that DSM is likely a bunch of nonsense:
> 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.
Ahahah I know what you did here.
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.
" The FASB was conceived as a full-time body to insure that Board member deliberations encourage broad participation, objectively consider all stakeholder views, and are not influenced or directed by political/private interests "
The DSM diagnostic categories are glorified billing codes that everybody (who actually has real ground contact with mental health care for real for real) recognizes as primitive, Stone Age relics.
In five or ten years, these categories will feel like missteps of the past (akin to calling all mental illness “hysteria”).
> 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.
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…
> What is the point saying, “disease X affects 5% of the population by definition”.
As a heuristic for identifying when something deserves attention?
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.
Yeah, and the T score doesn’t seem to have any medical basis.
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.
We don't, but TikTok and other pro-Russian/pro-Chinese/anti-West propaganda platforms sure as hell do. They made up a word for it, "manlet".
People are, on average, fucking shitty people.
The DSM has always rubbed me the wrong way as it seems like correlative pseudo science or at the least the worst possible use of statistics.
Most especially when it can be used as a method of you must have x because people who have these symptoms generally can fall into this category and because you have x you therefore must be crazy and insert ad hominem attack.
We're in an age where if these symptoms do exist in these categories they should be backed up with empirical brain science using imaging and neuro chemistry and correlative machine learning. There isn't a reason not to do it other than to protect incumbents. Psychiatry seems stuck in the age of "philosophy defines what physics is despite evidence or experimental design to the contrary".
EDIT - try reporting anything to the authorities about anything in any capacity whatsoever while being poor and have to answer the question "have you ever been diagnosed with a psychiatric disorder". It is most definitely used as a bludgeon of arbitrary authority against the poor which protects entrenched interests that would use the poor to leach money from the state.
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.
> 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
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
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
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 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.
> no one responded that way to that comment
You're right, but we have to moderate based on how these things work in the general case.
> this is truly mystifying to me
It's inevitable that there will be different interpretations of specific comments, so I hope you can at least 'upgrade' us to "wrong in this case" and hopefully we will make more sense in the future!
p.s. I know what you mean about "it's your show" but we really don't think of this as "our" show - the community is the only thing that's valuable about HN
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.
Wally isn't the only one writing himself a new minivan this afternoon.
To diagnose 'narcissistic personality disorder (NPD)' you have to be an Olympic class athlete of the ice who skates effortlessly around and between the edges of frozen lakes of "people I just do not like".
In principle, those being accused of a conflict of interest in the creation of DSM-5 could argue that, because the DSM is science-based, it's open to impartial statistical analyses and comparison with established scientific theory that would render moot any such accusation.
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.
(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.
[flagged]
Since we just asked you to stop breaking the site guidelines and you've continued to do it, I've banned this account.
If you don't want to be banned, you're welcome to email hn@ycombinator.com and give us reason to believe that you'll follow the rules in the future. They're here: https://news.ycombinator.com/newsguidelines.html.
[flagged]
Please don't respond to a bad comment by breaking the site guidelines yourself. That only makes things worse.
https://news.ycombinator.com/newsguidelines.html
Calling a comment "ridiculous" is against the guidelines?
Okay. Hopefully it isn't against the guidelines to say I think that's a silly guideline. Apparently saying "ridiculous" in response to a comment is very selectively enforced, must be my lucky day.
Anyways, this is probably the reminder I needed to stop commenting to HN. Some of the moderator decisions you guys are making lately are just.. way off base to me. Either you've changed or I have. Probably me.
Time to randomize the password. Cheers.
"What an absolutely ridiculous comment. That is extremely obviously not what I said or implied." is obviously a flamewar reaction. This is not a borderline call!
If you had simply posted the last sentence, your comment would have been just fine.
lol
[flagged]
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."
[flagged]
What a surprise.