I think psychiatry is among the noblest of professions, but I think that it has drifted astray from best practice. It is heartbreaking to me that 600,000 of our most severely ill patients are either in jail or homeless and that we have done so little to advocate for the community mental health centers and affordable housing that would have freed them from confinement and ended the shameless neglect (View Highlight)
Robert Spitzer, MD1 was an Umpire 1 and, until recently, so were most biological psychiatrists. The credibility of this model has been destroyed as we have learned more about the unfathomable complexity of the human brain and the complete failure of genetics and neuroscience to provide useful answers about what causes psychiatric problems. (View Highlight)
I am most fearful of the risks of over-diagnosis and have argued strongly for a narrower system with higher diagnostic thresholds. Experts in each area always want to expand their pet diagnoses and worry much more about missed patients than mislabeled patients. We contained the experts in preparing DSM IV; they were given a free rein in DSM 5, leading to a much more inclusive system. (View Highlight)
Going overboard in the other direction, the diagnostic exuberance of DSM 5 confuses mental disorder with the everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition. DSM 5 ambitiously mislabels normal diversity and childhood immaturity as disorder, creating stigma and promoting the excess use of medications (View Highlight)
With all its flaws and lack of empirical base, I think the field would have been better off sticking with DSM III. Changes since that edition have been consistently exploited to increase diagnostic inflation. If anything in DSM can be misused, it will be misused (View Highlight)
Freud is punished now for being unduly worshipped during his heyday 100 years ago; he gets far too little credit for presciently anticipating much of modern cognitive theory, neuroscience, and psychotherapy technique. Freud’s emphasis on the power of instinct and unconscious mental functioning successfully applied Darwinian psychology to a wide variety of clinical problems. But psychoanalysis was too important to be left in the hands of the antiquated psychoanalytic institutes that adhere religiously to old ideas that Freud himself would have surely abandoned as modern science made them obsolete and quaintly silly. It is tragic that many residents now get so little psychotherapy training; it explains why some psychiatrists become mindless pill-pushers. (View Highlight)
If I were in control of psychiatric diagnosis now, I would recommend a reduction in diagnostic inflation through a risk/benefit analysis. We need an evaluation of which diagnoses and what diagnostic thresholds do more harm than good. (View Highlight)
Never believe the extremely high rates of mental disorders routinely reported by epidemiological studies in psychiatry-usually labelling about 25% of the general population as mentally ill in the past year, about 50% lifetime. This entire literature has a systematic, but unacknowledged, methodological bias that inherently results in over-reporting. Because epidemiology requires such huge samples-in the tens of thousands-it is prohibitively expensive to conduct clinical interviews. Instead phone surveys are done by non-clinicians following a highly structured format that allows no clinical judgment whether the symptoms reported cause sufficient clinically significant distress and impairment to qualify as a mental disorder. Since there is no sharp boundary between normal distress and mental disorder, not assessing for clinical significance includes among those labelled mentally ill many who are merely distressed. The rates reported in studies are really only upper limits, not accurate approximations of true rates. They should be, but never are, reported as such (View Highlight)