February 26, 2010

DSM: Paraphilia controversy escalating

Brouhaha hits Land Down Under

Last week, I reported on a scathing denunciation by Allen Frances, MD, chair of the DSM-IV Task Force, of the draft proposal for the 5th edition of the diagnostic manual. Frances was particularly critical of the proposed sexual disorders, calling pedohebephilia "one of the most poorly written and unworkable" proposals to surface.

Now, Kenneth Zucker, chair of the DSM-V Sexual Disorders Work Group, has fired back in a letter to the Psychiatric Times. Defending not only pedohebephilia but also the other two controversial diagnoses of Hypersexual Disorder and Paraphilic Coercive Disorder, Zucker accused Frances of shooting from the hip, and "fir[ing] off criticisms as quickly as his grandchildren might tweet to their friends."

Frances fired right back, reiterating critics' central concern that these disorders lend themselves to "a grave misuse of psychiatry by the legal system in the handling of sexually violent predators”:
Every new diagnosis suggested for DSM5 requires (but has not yet received) a searching risk/benefit analysis and a thorough forensic review. I am confident that none of the suggestions for new diagnoses made by the Sexual Disorders Work Group would stand up to such scrutiny.
Today, experts in the Land Down Under chimed in with concern over Paraphilic Coercive Disorder. "Fears proposed new illness will be misused in court by rapists," reads the headline in the Sydney Morning Herald.

The reemergence of a proposal that was soundly rejected as a diagnosis in the 1980s "has come as a surprise to some psychologists," Nick Miller reports.

Lisa Phillips, a senior lecturer in psychological sciences at the University of Melbourne, echoes Frances' concerns over the potentially far-reaching legal implications of pathologizing rape as a mental disorder. Reiterating the concerns of feminists back in the 1980s, she said it could be used by rapists to avoid criminal responsibility for their acts.

This point fits with an intriguing insight by the brilliant legal scholar Eric Janus, who has written and lectured extensively on sex offender civil commitment and psychology-law topics more generally for the past couple of decades.

In Failure to Protect: America's Sexual Predator Laws and the Rise of the Preventive State (a book I highly recommend), Janus argues that the "tabloid model of gender violence" epitomized in sexually violent predator laws has -- perhaps accidentally -- become a powerful force for the politically conservative agenda of dismantling hard-fought feminist rape reforms. Like the newly proposed diagnoses, these laws favors biological and psychological explanations over sociocultural ones, and supports the patriarchal rape myth that rapists "lack control" over their sexual impulses.

Imagine the dustup if feminist psychiatrists and psychologists take note of these ersatz diagnoses and link up in opposition with legal scholars and psychologists concerned about their pretextual uses in civil commitment proceedings. And that's before transsexuals, furious over the Work Group's Gender Identity Disorder proposals, join the vocal chorus.

February 24, 2010

Napa Hospital chief arrested for sexual assault

Police marched into California's largest psychiatric hospital today and arrested its executive director on 35 felony charges stemming from the alleged molestation of a foster son for more than a decade. The alleged victim, who was 10 when the abuse allegedly began, came forward when he learned that Claude Edward Foulk Jr. was in charge of the hospital. Foulk is suspected of molesting at least four other boys going back to the 1970s.

Foulk was appointed to head the beleaguered hospital in 2007, shortly after the U.S. Attorney General's Office negotiated a consent decree mandating sweeping changes aimed at improving patient care and reducing suicides and assaults. The federal investigation had revealed widespread civil rights violations at Napa, including generic "treatment" and massive overuse of seclusion and restraints. Napa is the only state psychiatric hospital in Northern California, and houses defendants undergoing competency restoration treatment and those found not guilty by reason of insanity.

At the time of his appointment, Faulk was lauded for his lengthy career in mental health services in both the private and public sectors, according to news accounts.

The arrest, breaking news on television and in print media across the country and even internationally, will do nothing to boost staff morale, already abysmal at Napa and elsewhere in California's state hospital bureaucracy. It surely won't improve patient care, either.

Blogosphere recommendations

Mind Hacks

I have been checking out Mind Hacks since it featured a really nice review of my blog. The blog evolved out of the 2004 book by the same name, in which authors Tom Stafford (a cognitive neuroscientist) and Matt Webb (an engineer and designer) provide 100 exercises that teach readers neuroscience theories through games and tricks.

Among the scientists who contributed "hacks" is Vaughan Bell, who seems largely responsible for keeping the blog alive through his quirky and eclectic posts. Dr. Bell is a psychologist currently working in MedellĂ­n, Colombia and also a visiting research fellow in the Department of Psychological Medicine and Psychiatry at the Institute of Psychiatry, King's College London.

Just to give you an idea of some of his near-daily offerings, he recently posted on everything from decorative skull shaping to dream smoking (that's when you dream about cigarettes after you quit smoking) to new research on cave paintings. I particularly enjoyed his link to an amazing Russian website that features historical art by and about the mad. It reminded me of when I was living in Paris at age 10 and was influenced by an exhibit of art by schizophrenics that my mother took me to at the Louvres museum. More somberly, the prolific Bell reported on a new study in the Journal of Adolescent Health finding that it's a myth that teens think they are invincibile; actually, they greatly overestimate their chances of dying soon. I found it interesting, because the behaviors that result from either thinking error could look very similar.

The psychology of the angry American

Elsewhere in the blogosphere, my forensic psychology colleague Paul G. Mattiuzzi in Sacramento has an interesting analysis at his Everyday Psychology blog of the psychology of the pilot who intentionally crashed his plane into an IRS building in Austin, Texas on February 18.

Dr. Mattiuzzi based his analysis on the diatribes that Joe Stack wrote before taking his last flight. Although Mattiuzzi doesn't specifically reference the so-called Tea Party Movement, his comments on the "lunatic fringe" seem to apply to these disaffected white Americans:
There is in this country today, it seems to me, a gathering storm of mindlessly angry people who are "fed up" for reasons they can barely explain. There are people in the media who are telling them they should be angry, and perhaps more importantly, that they should be afraid….

[These] people have come to identify the government as an enemy of the people. They are grandiose in their belief that they understand it all better than anyone else. They are self-righteous in their indignation and in their resentment. They express a sense of entitlement, arguing that they have a right not just to their own opinions, but also to their own facts. They shout until no one can hear them and then complain that no one is listening. They expect their individual voice to prevail and then complain that they have been denied representation. They do not wish to contribute to the common good, but demand all the benefits they have been promised. Like Stack, they bemoan corporate greed while demanding that greed be unfettered.
Dr. Mattiuzzi hopes that acts like Joe Stack's do not inspire copycats. As he concludes (in my favorite lines from his essay):
Joe Stack wanted us to believe that in his abject failure, he had achieved success. It's as if he listened to only part of what Bob Dylan once sang ("there's no success like failure"), without bothering to stick around and hear the end of the lyric: "and failure's no success at all."
Mind Hacks is HERE. Everyday Psychology is HERE.

February 22, 2010

Calif.: Legal training on competency assessment

March 24-26 conference to offer MCLE credits

I've gotten a surge in queries from psychologists interested in being supervised as they embark into the tricky area of court-ordered competency-to-stand-trial assessments. With that need in mind, I'm excited that the Forensic Mental Health Association is featuring a special "legal track" on competency at next month's conference. It won't adequately train folks in the nuts and bolts, but they can get the lay of the land and become aware of some of the pitfalls and controversies.

One of the sessions that looks is especially interesting is on "Expert Qualifications and the Adequacy of Court-Ordered Evaluations." Having seen plenty of deficient, drive-by evaluations caused by a combination of the courts' low standards and low pay, I am happy to see this area getting some much-needed attention. The co-presenters are Judge Kurt Kumli of Santa Clara County, a nationally recognized expert in juvenile law and policy, and attorney David Meyer of USC's Institute of Psychiatry and Law.

The opening session of the legal track will address practical issues of enforcing court orders for competency restoration in state hospitals, jails, and conditional release programs. Again, this is a topic ripe for attention, as many competency restoration programs are sorely deficient.

Other sessions of the competency track will focus on juvenile competency, procedural changes in assessing trial competence in California, and the assessment of malingering. In addition to the usual continuing education credits for mental health practitioners, the track will offer MCLE credits to attorneys.

In addition to this special legal track on competency to stand trial, the March 24-26 conference features other high-caliber offerings:
  • Judge Stephen Manley of Santa Clara County will present a keynote address on collaborative courts in California
  • Stephen Behnke, JD, PhD and director of the APA Ethics Office, will review evolving conceptions of clinicians' duty to protect under Tarasoff
  • Stephen Miles, a professor of medicine at the University of Minnesota, will muse on lessons prison clinicians can learn from the involvement of psychologists and physicians in abusive interrogations in war-on-terror prisons
Your faithful blogger, Karen Franklin, is also presenting at the conference, on one of my favorite topics, "Ethical Considerations in Psychiatric Diagnoses in Forensic and Correctional Settings."

Finally, I just have to mention the most bizarre session I came across: "A psychiatric-legal analysis of a case of lycanthropy in a 19th-century serial killer" (presented by doctors J. Arturo Silva and Douglas Tucker). Yee-gads! With pop culture's current fascination with all things supernatural, that's one session I just must attend!

Registration is still open for the March 24-26 conference, although the "early-bird rate" ends March 1. Joining the FMHA earns you an additional $25 discount off the cost of registration. The conference is down in Seaside, California (by Monterey), so it's a scenic venue for those of you who might want to bring family. More information and the registration form are HERE.

Illustration: 18th century engraving, courtesy Wikipedia

February 20, 2010

DSM-V: Will shoddy manual implode years before launch date?

The DSM-V debacle continues to expand like a mushroom cloud following a nuclear explosion. Media pundits right and left are commenting critically on the draft manual, published online after years of cloak-and-dagger secrecy.

As most of you know by now, the American Psychiatric Association has granted the public a very brief window in which to comment online on the draft proposals. I haven't seen an explanation of how public input will be tallied or used. Will a popularity contest influence psychiatric diagnosis? We've seen how well citizen input works here in California, where the initiative process has brought government to a standstill. Can you imagine neurologists setting up a website to get lay input on a new diagnostic scheme for brain tumors? This debacle only underscores the point that the DSM is more politics than science.

Among the best commentaries I've seen this week are Sally Satel's op-ed in the Wall Street Journal and Allen Frances' piece in Psychiatric Times. Science magazine also has an interesting analysis of the proposed behavioral disorders, which would medicalize harmful habits like gambling, overeating, and down the line perhaps "Internet Addiction." All three articles touched on the negative forensic consequences of the radical proposed changes.

"Prescriptions for Psychiatric Trouble"

Psychiatrist Sally Satel, a resident scholar at the American Enterprise Institute, lecturer at Yale University School of Medicine, and a brilliant thinker, critiqued psychiatry's endless drive to expand mental disorder, placing ever-larger "swaths of the population under the umbrella of pathology." As Satel points out, the DSM-V continues the troubling tradition, launched 30 years ago with publication of the manual's third edition, of elevating reliability over validity:
[J]ust because two examiners concur that a person qualifies for a particular diagnosis does not mean that he has an authentic mental illness. How do we know, for example, that a person diagnosed with major depressive disorder (the formal designation for pathological depression) is not actually suffering from a bout of natural if intense sadness brought on by a shattering loss, a grave disappointment or a scathing betrayal?

The manual will not help us here. In fact, a number of changes proposed for the DSM V (e.g., new diagnoses for binge eating, hoarding and hypersexuality) are likely to inadvertently place large swaths of normal human variation under the umbrella of pathology.
Both she and Allen Frances, former chair of both the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, believe that Psychosis Risk Syndrome may be the scariest example of overinclusion. Hundreds of thousands of young people, especially the poor and minorities, could be given this highly stigmatizing label and medicated with extremely dangerous drugs, even though these medications are not very effective and the broad majority of these youngsters would not go on to develop psychoses if left alone.

In his critique in Psychiatric Times, aptly titled "Opening Pandora's Box," Frances notes that the DSM-V "would create tens of millions of newly misidentified false positive 'patients.' " Not only could almost anyone qualify for at least one of the new diagnoses (which include such nebulous constructs as Mixed Anxiety Depressive Disorder, Minor Neurocognitive Disorder, Temper Dysfunctional Disorder with Dysphoria, and -- in a big nod to America's 12-Step religion -- Addiction Disorder), but thresholds are being lowered for many existing disorders as well.

Forensic applications: Disastrous unintended consequences

One of the DSM-V developers' most troubling weaknesses is their profound "insensitivity to possible misuse in forensic settings," Frances notes. As an example, he cites Pedohebephilia, "one of the most poorly written and unworkable" proposals in the draft:
Expanding the definition of pedophilia to include pubescent teenagers would medicalize criminal behavior and further the previously described misuse of psychiatry by the legal system. Certainly, sex with under-age victims should be discouraged as an important matter of public policy, but this should be accomplished by legal statute and appropriate sentencing, not by mental disorder fiat.
Two other potential "forensic disaster[s]" are Hypersexuality Disorder and Paraphilic Coercive Disorder, both of which will be used to expand the pool of sex offenders eligible for indefinite civil commitment on the basis of purported mental disorder.

In Frances' opinion, based on having worked on the three previous editions of the DSM and knowing many of the drafters of the current version, critics are missing the mark by focusing on alleged financial and/or professional conflicts of interest. Rather, the DSM-V work group members are sincere and well meaning, but have a natural, "and seemingly irresistible," tendency to expand the boundaries of diagnoses in order to identify and treat all potential sufferers. This "diagnostic imperialism" produces a fatal blind spot:
Unfortunately, Work Group members … [miss] the fact that every effort to reduce the rate of false negatives must inevitably raise the rate of false positives (often dramatically and with dire consequences). It is inherently difficult for experts, with their highly selected research and clinical experiences, to appreciate fully just how poorly their research findings may generalize to everyday practice -- especially as it is conducted by harried primary care clinicians in an environment heavily influenced by drug company marketing…. [T]he DSM5 suggestions display the peculiarly dangerous combination of nonspecific and inaccurate diagnosis leading to unproven and potentially quite harmful treatments.
Frances strongly argues that the time to weed out implausible and even "incoherent" proposals is now, not after the proposed field testing:
I feel it is my responsibility to raise clear alarms now because the past performance of the DSM5 leadership does not inspire confidence in its future ability to avoid serious mistakes.... Field trials are arduous and expensive and make sense only for testing the precise wording of criteria sets that have a real chance of making it into the manual -- not for the many poorly written and far out suggestions that have just been posted. It seems prudent to identify and root out problems now lest they sneak through in what will likely be an eventual mad rush to complete DSM5....

Because of the secretive and closed nature of the DSM5 process, the expectable enthusiasms of the experts who comprise the Work Groups have not been balanced, as they must always be, with real world practical clinical wisdom and a careful risk/benefit analysis of the possible unintended consequences of every suggestion.

It would be reckless now to rely on the complacent assumption that all these problems will eventually come out in the wash. By its previous actions and inactions, the DSM5 leadership has sacrificed any "benefit of the doubt" faith that their process will be self-correcting in a way that guarantees the eventual elimination all of the harmful options.
Note: If you want to read Sally Satel's op-ed, do it now; after seven days, Wall Street Journal articles are only available by subscription. I highly recommend that forensic experts and attorneys carefully review Frances' article, and note his recommendation for greater forensic oversight. At minimum, if new diagnoses without established validity are included in the manual, the DSM should add a caveat that they are never to be used as grounds for civil commitment.

Special hat tip to the ever-helpful JANE

February 17, 2010

Forensic psychiatrist: Courts fostering "POLITICAL DIAGNOSIS"

After sex offenders, who will be next?

More leading experts are starting to notice and voice alarm over the pretextual use of psychiatric diagnoses in SVP civil commitment cases. In an editorial this week, a prominent forensic psychiatrist quotes the late Michael Crichton, calling it "bad science 'tricked out' for public policy ends."

Writing in the Psychiatric Times, James Knoll, psychiatry professor at SUNY-Syracuse and director of a forensic fellowship program, critiques both the questionable diagnoses and the shaky risk assessment techniques being used to civilly commit Sexually Violent Predators:
A variety of instruments have been developed (PCL-R, Static-99, Phallometry, Minnesota Sex Offender Screening Tool, etc.); however, these tests are often challenged in courts as not meeting legal standards for expert evidence and testimony. So while the research database has grown, the question remains: is it reliable enough to be proffered as expert testimony? Experts in the field continue to have serious reservations, and express caution about the (mis)use of these instruments for expert testimony.
Turning to the questionable diagnoses being used in SVP cases, Knoll puts the onus squarely on the U.S. Supreme Court for creating a tautological and "politico-legal" definition of "mental disorder or abnormality" for use in these civil commitment proceedings:
[T]he courts may use our diagnoses when they choose to, and they may ignore them and/or devise their own if it suits public policy…. Since it is forensic mental health professionals who are tasked with SVP evaluations, they have attempted to give this term meaning within the confines of their science. Have these attempts reached a consensus? It would appear that they have not. There continues to be substantial disagreement….

When psychiatric science becomes co-opted by a political agenda, an unhealthy alliance may be created. It is science that will always be the host organism, to be taken over by political viruses…. [P]sychiatry may come to resemble a new organism entirely -- one that serves the ends of the criminal justice system.
If we want to know where all this is headed if someone doesn't slam on the brakes, Knoll points us across the Atlantic to the United Kingdom, where offenders are indefinitely committed on the basis of a nebulous "Dangerous and Severe Personality Disorder" (DSPD):
Given the similarities between our SVP laws and the UK’s DSPD laws, is it too outrageous to speculate that a psychopathy (or DSPD-equivalent) commitment law might be on the U.S. horizon? Remember, the driving force behind such initiatives is usually only one highly publicized, egregious case away.
Related resource:

For an empirical study on the scientific problems with determining future violence under the UK's "Dangerous and Severe Personality Disorder" law, see: Ullrich, S., Yang, M., & Coid, J. (2009), "Dangerous and severe personality disorder: An investigation of the construct," International Journal of Law & Psychiatry (in press). The ultimate conclusions are strikingly similar to the issues posed by Knoll.

The study found a high rate of false positives -- that is, people categorized as DSPD and at high risk of serious reoffending when they actually did not reoffend when tracked in the community: 26 DSPD offenders would need to be civilly committed to prevent one major violent act.

When tracking sex crimes, which are of particular public concern, the researchers found that most new sex offenses were committed by offenders who were NOT categorized as DSPD, undermining the UK Home Office and Department of Health assumption that offenders at the highest risk for future sex offending would be categorized as DSPD.

After critiquing the accuracy of actuarial techniques, the article concludes:
"Bearing in mind the inaccuracy of DSPD criteria in identifying high risk individuals ... the construction of medico-legal terms, as in the case of DSPD, appears highly questionable.... [M]any determinants of violence are circumstantial and situational, and will invariably change over time, rather than related to some inherent characteristics of the perpetrator.... [F]ar more research is necessary ... before attempting to integrate a psychiatric condition into a legal system."
Heed these warnings, folks. The way things are headed in the U.S. criminal justice system, I expect to hear expansion of civil commitment to other groups -- violent offenders, juveniles, and others -- being proposed any minute now.