Are Psychiatrists Who Criticize New Proposals for the Diagnostic Manual Dangerous?

Allen Frances, MD

Psychiatrist Allen Francis was chairman of the task force that developed the last edition of diagnostic Bible in Psychiatry, the DSM.  It was the fourth edition and came out in 1994.  As someone intimately involved in the process of formulating changes in the diagnostic nomenclature, he became concerned when he began to notice that the changes he helped create in the DSM were beginning to lead to the "upcoding" or expanding of psychiatric diagnoses to include normal but problematic variants of human behavior.  

With widespread changes in insurance plans that paid far more to psychiatrists for medicating many so-called "biological" disorders than for providing psychotherapy for what used to be called "neuroses" or "acting out," along with major pushes by pharmaceutical companies to expand the indications of their lucrative new drugs to larger and larger numbers of people, more and more people were being medicated with potentially toxic drugs for what are, for all intents and purposes, disorders of behavior and relationships.  This has been a major theme of this blog.

[For clarification, I should note that diagnoses in psychiatry are not based on the causes of disorders (etiology), but on descriptions of the typical behavior, emotional and cognitive attributes that are seen in various syndromes. A syndrome is a group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition. These characteristics tend to cluster together and can be distinguished from one another using epidemiology (the study of the risk factors, distribution, and control of disease in populations) and the presence of similar descriptions throughout history, as well as through the combined presence of a group of particular symptoms with the absence of other co-occurring symptoms and attributes.

The classification of psychiatric disorders is not based on causes because, in many if not most cases, we have not been able to track down an exact cause (due to our limited understanding of the brain and its relationship to behavior and mentation), and also because almost all psychiatric disorders have multiple biological, psychological, and socio-cultural risk factors.  In fact, "risk factors" rather than "causes" is probably the preferred term that should be used in psychiatry, because there are no necessary or sufficient antecedents to the development of the various disorders.

Nonetheless, all psychiatric diagnoses are not created equally.  Some - like schizophrenia - have been well described, and consistently so, for hundreds of years in multiple cultures.  The defining characteristics of many other conditions, like ADHD for example, are sort of voted on by committees of "experts," many of who have conflicts of interest because they get money from the pharmaceutical companies.  In those cases, the decisions about diagnoses are sort of like the ones made by the Council of Nicaea, during which various Christian Bishops literally voted on which of the many Gospels were the word of God, and which were not].

Dr. Francis has become a leading critic of the plan to come out with a newer edition of the diagnostic manual, to be called the DSM-5 (I guess roman numerals have become passe).  He worries that upcoding will get even worse with many of the new proposals, and medications even more widely mis-prescribed.  And not just by psychiatrists.  80% of anti-depressants, for example, are prescribed by primary care  physicians, and most stimulants by pediatricians.  


And just wait and see what happens if psychologists ever get prescribing privileges, which they desperately seek!  Psychotherapy as we know it may disappear completely.

I also think that, since for most psychiatric conditions we do not know a whole lot more about the causes of the various psychiatric conditions than we did when the DSM-IV was published, coming out with a new diagnostic manual is premature to say the least. Also, since the current research base uses current definitions, changing all of the definitions can be very destructive to building on our scientific knowledge in the future.  


Some of the suggested changes seem to center around the idea of "spectrum" disorders, in which various disorders are grouped together because some of the symptoms sort of look alike.

Just recently, the American Psychiatric Association (APA) recruited a new public relations spokesman, formerly of the US Defense Department, who was quoted as saying that "Francis is a 'dangerous' man trying to undermine an earnest academic endeavor."  It sounds like, rather than address the well-thought-out criticisms of Dr. Francis, the APA has elected to circle the wagons defensively and engage in ad hominem attacks. 

In response, Dr. Francis posted a rebuttal in a psychiatric newspaper.  Allow me to quote his very cogent response:  

"The piece in Time Magazine manages to raise again the silly APA suggestion that my objections to DSM-5 are motivated by a feared loss of royalties. Let’s set the record straight—hopefully for the last time. The royalties on my DSM IV handbook are about $10,000 a year—not at all commensurate with all the time I have spent trying to protect DSM-5 from making all its repeated mistakes.

"My motivation for taking on this unpleasant task is simple—to prevent DSM-5 from promoting a general diagnostic inflation that will result in the mislabeling of millions of people as mentally disordered. Tagging  someone with an inaccurate mental disorder diagnosis often results in unnecessary treatment with medications that can have very harmful side effects. I entered the DSM-5 controversy only because I had learned painful lessons working on the previous three DSM’s, seeing how they can be misused with serious unintended consequences. It felt irresponsible to stay on the sidelines and not point out the obvious and substantial risks posed by the DSM-5 proposals.

"I don’t consider myself a dangerous man except insofar as I am raising questions that seem dangerous to DSM-5 because there are no convincing answers. My often repeated challenge to APA—provide us with some straightforward answers to these twelve simple questions:

1.   Why insist on allowing the diagnosis of Major Depressive Disorder after only two weeks of symptoms that are completely compatible with normal grief?

2.   Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder when its rates have already tripled in just 15 years?

3.   Why include a psychosis risk diagnosis which has been rejected as premature by most leading researchers in the field because it risks exacerbating what is already the shameful off-label overuse of antipsychotic drugs in children?

4.   Why introduce Disruptive Mood Dysregulation Disorder when it has been studied by only one research team for only six years and risks encouraging the inappropriate antipsychotic drug prescription for kids with temper tantrums?

5.   Why sneak in Hebephilia under the banner of Pedophilia when this will create a nightmare in forensic psychiatry?

6.   Why lower the threshold for Generalized Anxiety Disorder and introduce Mixed Anxiety Depression when both of these changes will confound mental disorder with the anxieties and sadnesses of everyday life?

7.   Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?

8.   Why label as a mental disorder the experience of indulging in one binge eating episode a week for three months?

9.   Why introduce a system of personality diagnosis so complicated it will never be used and will give dimensional diagnosis an undeserved bad name?

10. Why not delay publication of DSM-5 to allow enough time to complete the previously planned and crucial second stage of field testing that was abruptly cancelled because of the constant administrative delays in completing the first stage?

11. Why should we accept ambiguously worded DSM-5 diagnoses whose reliability barely exceeds chance?

12. And most fundamental: Why not allow for an independent scientific review of all the controversial DSM-5 changes identified above—proposed by 47 mental health organizations as the only way to guarantee a credible DSM-5? What is there to hide and what harm is done by additional careful review?

"If I am a dangerous man, it is because I am exposing DSM-5’s carelessness and thus putting at risk APA’s substantial publishing profits. During the past 3 years, I have made numerous attempts, private and public, to warn the APA leadership of the troubles that lie ahead and to implore them to regain control of what was clearly a runaway DSM-5 process.

"This has had no real effect other than delaying publication of DSM-5 for a year and the appointment of an oversight committee that turned out to be toothless. I am reduced now to just one means of protecting patients, families, and the larger society from the recklessness of the DSM-5 proposals—repeatedly pointing out their risks in as many forums as possible."

Well said, my good man.  It seem to me that the APA is at risk of being dangerous, not Dr. Francis.

Well-Meaning Blacks and Whites Continue to Talk Past Each Other About Race

In dysfunctional families, one common attribute that most people have makes it difficult for them to resolve their differences in a constructive way in order to solve family problems. Each family member becomes so convinced, and can give a lot of evidence for, their own ideas about what is going on that they do not seem to listen at all to the other person’s point of view.  

When the other person gives his or her point of view, family members tend to invalidate the other by merely restating their own point of view, as if the other person had not said anything at all.  And rare is the dyad in a family that considers the idea that they may both be right and that their views are not really incompatible at all.

Another one of the major points in my ideas about dysfunctional families is that the problems commonly seen in these families often represent a sort of microcosm of the very same conflicts seen in larger groups within their particular society.

I saw an interesting example of this that stems from the discussions of racism that were triggered by the recent murder of Treyvon Martin.

There was an interesting posting of two “dueling” op-ed pieces in the Memphis newspaper on March 28, 2012: one by a Black columnist, Walter E. Williams, and one by a White columnist, Frank Cerabino.  Strangely, the Black columnist took the position that I have seen usually taken by Whites, and vice versa.

Frank Cerabino

The main point of Cerabino’s column was that if the roles were reversed – if a White man was killed by a Black person who was serving on a Neighborhood Watch, then the shooter would have been arrested immediately.  The columnist even had a real life example to give that illustrated his point.  Cerabino also thought that if the shooter Zimmerman had been Black and Martin White, that the shooter would have been held without bail. The obvious implication is that society is still far more racist than it often claims to be.

Walter E. Williams

Williams, taking the traditionally White argument, points out why in our society “Black and young” has become synonymous with “crime and suspicion.”  Furthermore, he believes that this equating these two is not always based on racism, but more often on our universal tendency to profile strangers on the bases of categories that represent higher versus lower risks to ourselves.  Even African-American cab drivers and pizza delivery men avoid certain Black neighborhoods, he points out, because of concerns about their safety. 

Most people are familiar with the statistics about young Black males that show that they represent a disproportionate share of all the people who commit violent crimes, and therefore such determinations are not actually racist but more statistical or something like that.  And parenthetically, most of their victims are other Black people, not Whites. “We humans are not Gods,” Williams says, “therefore, we must often base our decisions on guesses and hunches…based on easily observed physical characteristics…”

The justaposition of these two articles reminded me of a segment of the now defunct news magazine show Primetime Live that was broadcast twenty years ago.  It seems like the arguments have changed very little over that period of time.

PrimeTime Live

The segment was entitled “True Colors” and was broadcast on ABC on September 26, 1991.  Documentary filmmakers had two men of the same age, one Black and one White, go out to society and apply for jobs, try to rent an apartment, and browse the aisles of different stores.  The two men had been trained to present themselves in an identical manner.  Both were equipped with similar histories (education, employment histories, credit scores, and so forth), and both appeared to be upper middle class.  They were dressed as one might expect the White man to be dressed, and both spoke English in the standard White dialect.

In some instances, they were reportedly treated the same by society, but many times this was not the case.  Jobs that were “open” to the White applicant suddenly became “filled” when the Black applicant showed up just a short time later.  The Black guy was followed around by the help in a variety of stores as if he might shoplift something at any moment – but this did not happen to the White guy when he came to the same store.  Potential landlords would lecture the Black man about such things as paying the rent on time, and did not appear particularly welcoming to him.  Again, the White man got a royal welcome and no lectures.

After the film was shown, members of a discussion group organized by the TV show began to express very similar points to those expressed by the two columnists in the Memphis newspaper.  

Tellingly, neither side (and the Whites and Blacks in this case took the expected sides) was willing to concede that the other side’s point had any validity at all.  Instead of a engaging in problem-solving about what to do about this dreadful state of affairs, the discussion just degenerated into an argument.

Now, in all of these cases, I believe that the discussants and writers involved were not overt racists, white supremacists, or black supremacists – remember the newspaper writers actually took the opposite positions from their television counterparts.  Even Jessie Jackson once said that if a young black male stranger were walking behind him in some circumstances, he would feel somewhat threatened.

So which side is right in this debate? 


Duh!!  Both are.  


Subliminal and not-so-subliminal racism is far more prevalent in White society than one side cares to admit.  And young Black males are on average more likely to be a significantly higher risk to a stranger than a young White counterpart.  On Primetime, the side arguing for the former proposition (and arguing as if the other side's argument could not possibly also be true) argued that the Black man in the film was nicely dressed, not speaking in Black slang, and very polite – and yet he was still treated as if he might be a member of the Crips or something.  


Quite true!

In fact, considering American history, it might seem that Blacks should be more threatened by Whites than the other way around.  In my lifetime, TV production codes prohibited the depiction of financially successful and well adjusted Black people.  

And then there was the terrifying documentary on PBS recently about the “felon leasing program” that took place in the South after Reconstruction and continued well into the twentieth century.  Black men were routinely arrested on trivial or flimsy charges, convicted by all-white jurors, and then leased out as slave labor for various businesses.  Victims were treated even worse than slaves because, in this situation, they did not represent valuable “property.”


Even today, being African American can lead you to get a longer sentence than for a White when being convicted of the same crime.  Until very recently, sentences for crack cocaine (used more often by Blacks) were far longer than sentences for powdered cocaine (used more often by Whites).

On the other hand, as I argued in my blog post The N-Word, a significant proportion of Blacks often do, in fact, act in accordance with old White stereotypes of Black people.  The reason is that doing so had survival value in more racist times – times that were not at all that long ago. For example, the Black comedian Chris Rock jokes about a Black motorist in the Old South who was shot to death at a stop sign by a White policeman - because he could read the sign.  Unfortunately, when Blacks of today act as if they do not want to be educated, it reinforces the Black stereotype for Whites.

In order to solve the problems of racism for both Blacks and Whites, we all need to start trying to be empathic to all of these points of view, and validate each other whenever we can.  We need to stop being so defensive and actually listen to each other.  Stop arguing and start putting our heads together!

What to Expect From Your Marriage

"In relationships, if you always do what you always did, you'll always get what you always got." ~ Amy Dickinson

A common complaint in letters to advice columns is that a spouse is chronically neglecting various needs of the complainer, or refuses to do something that the complainer fervently desires.  Sex may be the most common missing element described by people who write this type of letter – and women complain about the lack of it at least as often as do men – but it can be anything from refraining from cussing to refraining from describing embarrassing or quirky attributes of the complainer to outsiders.

To me, sexually frustrating one’s spouse seems to me to be the most strange of all such complaints, because it would be so easy and take so little effort to give the frustrated spouses what they say they want.  Do these spouses really care that little about keeping the other spouse happy?  That would seem really mean if not vicious.

After all, sex doesn’t take all that much effort, especially if you are not especially concerned about your own pleasure.  Why not make the other person happy occasionally even if you don’t enjoy it yourself?  A mere half hour every week or two might be just the ticket. 

You say it’s a chore?  So is going out and buying your spouse gifts on birthdays, Valentine's Day, and Christmas.  A lot of people seem willing to do those things.   How about meeting all of your other responsibilities at your job and at home?  Chores all, at least much of the time.  For most people, willing!

Even if the man is completely physically impotent and incurably so…and there's no G-rated way to say this... let’s just say his tongue probably works OK, doesn’t it?

Here is a typical example of a letter from a sex deprived wife, from the column Annie’s Mailbox from March 10, 2012.

"Dear Annie: "John" and I have been married for 15 years. He is a wonderful person and a great father...Our relationship is fine on the surface, but it's emotionally empty. There is little intimacy, which has been an issue throughout our marriage. It manifests itself periodically in arguments that never seem to get resolved… He wonders why I cannot "just be happy," because from his perspective, everything is fine. I have told him clearly that I need more attention and affection, but I have come to the realization that he is "just not that into me.

… Annie, I love my family. I am not asking for a magical romance. I don't think it's too much for a woman to need occasional loving physical gestures from her husband. I can't figure out why it's so hard for him to express his love if he cares for me as much as he says.


I don't want to leave, but things could be so much better if John would only put a little more effort into our marriage. Any suggestions on how to improve things? Or am I just destined to have an emotionless relationship?" 


The Annies answer: "There is a variety of reasons why a man may not show any interest in his wife: He could be gay, asexual, not attracted to you or having an affair. He could have low testosterone or other medical or emotional issues. The real problem is that he refuses to address it…"

Well those are all possibilities, but why would she have married someone like that in the first place if she craved affection so much?  It sounds from the letter like she just thinks hubby might just an A-hole, does it not?  I mean, she seems to think that he is someone who is depriving his dear wife of that which she craves, for no apparent reason.

But is that what is really happening?  Could be, but I have another, more likely explanation. The writer starts by saying that they have been married for fifteen years.  It doesn’t sound like this is a new problem, so what that probably means is that she has been putting up with this treatment for fifteen years.  And, after she mentions that, she praises the guy for being a “wonderful” person.  What, you may ask, is so wonderful about a guy who is more than willing to almost totally neglect your needs just because he can?

I find the husband’s response to be telling.   He asks her why she cannot "just be happy, because from his perspective, everything is fine.”  She also says that she has made it clear that the lack of intimacy bothers her a great deal.  So why would he think everything is just fine?  Why wouldn’t he already know the answer to the question of why she just “can’t be happy?”

Well, unless the guy has the IQ of a turnip, the only reasonable explanation for his apparent obtuseness and confusion is that he doesn’t believe her when she say she wants more intimacy.  Remember, she has been putting up with this for fifteen years.  In her letter she says he is wonderful and that she does not want to leave.   If we are hearing this in a letter she writes that may be up for public consumption, then the odds are extremely good that he has heard her say this stuff.  Many times.

The much less obvious explanation for this state of affairs – and so often the less obvious interpretation turns out to be the correct one for patients who I see in therapy - is that he takes her passive acquiescence of the state of affairs as a signal that she actually prefers it!  So, when she complains about it, he becomes confused and asks her why she is not happy, since he is doing exactly what he thinks she wants.  Maybe she really wants to avoid sex and affection, but also enjoys complaining!

He will never tell her about such thoughts because he knows that the thoughts will probably be greeted with great defensiveness, outright derision, or indignation from her that he is blaming her for his problem with intimacy.  That will get him exactly nothing but grief, so why bother?


More important, he is helping her to not face her issue with sex and affection, because he is volunteering to pretend to be the bad guy by denying her.

So could she really be covertly avoiding sex as much as he is?  And if so, why?  Well, the answer to the first question is a resounding, hell yes.  This does not mean that on some level she really does wish for more sex, but that for some reason she is more comfortable with the current state of affairs than with the “improved” version.  The answer as to why might be a one of many possible issues between her and her own family of origin, but she does not give us any clues in her letter about what those issues might be.

And what happened to his libido?  Again, we don’t know.  Maybe he has a whore/madonna conflict about his wife being a sexual being.  But it could also be many other things.

The point is, they are both avoiding sex, not just him. 

A different letter writer in the Dear Abby column of 3/15/12, says that she has been married for 32 years, and for all these years her husband has lied continually.  He fabricates the most outlandish stories, and the whole family knows it.  Furthermore, he is said to never own up to anything he has done wrong, but instead blames the letter writer for his actions. If she confronts or challenges him, he gets defensive and says she’s "always" belittling or challenging him in front of others. 

The probably translation, according to my scenario, is that she covertly thinks that he has a need for continuous humiliation - so she helps out by humiliating him -  and he thinks his wife needs to humiliate him - so he gives her plenty of opportunities.  After all, from the perspective of each, that is exactly what the other has always done.  For 32 years.


"In relationships, if you always do what you always did, you'll always get what you always got." 

Immaturity Officially a Disease: You Saw It Here First

The kid in red is in the same grade and classroom as the other four

In my post of September 20, 2010, Immaturity in YoungChildren: Officially a Disease, I described two studies published in a very obscure journal, the Journal of Health Economics, that both found nearly identical data about the diagnosis of ADHD in school children.  In the these articles, two different research groups (Evans, Morrill, &Parente, 29, 2010 657–673; Elder, 29 2010, 641–656) using four different data sets in different states came to the same conclusion. 

In one, roughly 8.4 percent of children born in the month prior to their state’s cutoff date for kindergarten eligibility – who typically become the youngest and most developmentally immature children within a grade – were diagnosed with ADHD, compared to 5.1 percent of children born in the month immediately afterward. The study also found that the youngest children in fifth and eighth grades were nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD!  The results of the second study were quite similar.

Translated into numbers nationwide, as Steindór summarized in his comment on my blog, this would mean that  between 900 thousand (Elder) and 1.1 million (Evans et al. 2010) of those children under age 18 in the US diagnosed with ADHD (at least 4.5 million) are misdiagnosed.  

Now, a year and a half later, another study, published in a more widely read journal and reported widely in the news, came up with the exact same conclusion.  (“Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children” by Richard L. Morrow, et. al., Canadian Medical Association Journal, published on line March 5, 2012). 

In a cohort study (a study of a group of individuals with something in common followed over time) of more than 900,000 Canadian children, researchers found that boys born in the month of December (the cutoff birth date for entry to school in British Columbia) were 30% more likely to be diagnosed with ADHD than boys in their grade who were born the previous January.

This number was even more dramatic in the girls, with those born in December 70% more likely to be diagnosed with ADHD than girls born in January.

In addition, both boys and girls were at a significantly higher risk of being prescribed an ADHD treatment medication if they were born in the later month than in the earlier one.

 "It could be that a lack of maturity in the youngest kids in the class is being misinterpreted as symptoms of a behavioral disorder," said lead author Richard L. Morrow.  


Could be?  About about “is?”

Some of these behaviors could include not being able to sit still, not being able to focus and listen to the teacher, or not following through on a task, he added.


"You wouldn't expect a 6- and 9-year-old to behave the same way, but we're often putting a 6- and 7-year-old in the same class. And we're learning that you can't expect the same behaviors from them," he added. "We would like to avoid medicalizing a normal range of childhood behaviors."  No sh*t!

This problem has been complicated recently by the fad of "redshirting" children for kindergarten: overachieving parents purposely starting them at age six rather than five in order to give them a competitive advantage academically over their classmates.  Now children in the same class may be as much as two years apart in age.

The study authors went on to  note that potential harms of overtreatment in children include increased risk for cardiovascular events, as well as effects on growth, sleep, and appetite.  There was no mention of the harm of making this diagnosis and using these potentially toxic medication instead of investigating and addressing possible psychosocial reasons for “hyperactivity” such as a chaotic family environment or abusive and/or inconsistent parenting practices.

This brings up the issue of the risk to the heart and the rest of the cardiovascular system posed by stimulant use.  There have been several studies recently published that have been reported in both the medical and lay media that claim that this risk is minimal.  


This is in an interesting contrast to the publicity about an article, published this week in BMJ Open (the online version of the British Medical Journal)  that purported to show that the use of sleeping pills increases the risk of dying from all causes by a factor of 4 over just two and a half years.  Sleeping pills are generally regarded as far less dangerous and less likely to be abused than stimulants.  The FDA categorizes benzos as "Schedule IV" (lower likelihood of abuse) and stimulants as "Schedule II" (most likely to be abused short of the illegal "Schedule I" drugs).

That study about sleeping pills seemed to me to be a bit hard to believe, especially since epidemiological studies are notoriously unreliable.  But even if the numbers are valid, the fact that the risk of death from all causes increases most likely means that there is  some other characteristic, or a bunch more characteristics, of the population of people who are prescribed sleepers that are not characteristic of other populations. Those additional factors might explain the findings.

As for stimulants, in the February, 2012 issue of the American Journal of Psychiatry, there is an article on methylphenidate (Ritalin and its variations) and risk of heart problems in adults. Using a large medication database, researchers matched about 44000 methylphenidate (MPH) users and about 176,000 controls. 


They looked at main the incidence of a cardiac event defined as a myocardial infarction, stroke, ventricular arrhythmia, or sudden death. They found a 117% increased risk - or over double the risk – in the Ritalin group. After adjustment for some potential confounding factors, the risk was still 84% higher.

The news stories about the study on the benzo’s seemed to be meant to scare people out of using them, while the stories about increased risk in stimulant users seemed to be meant to reassure people about using them.  Of course, both of these studies described relative risk and not absolute risk (See my post Stats.com from November 2, 2011).   


This means that  “double the risk” means the risk might go from, say, a tenth of a percent to two tenths of percent.  Double a very small risk is still a very small risk.  The absolute risk in this example would have gone up just one tenth of one percent.  Still, if millions of people are getting the prescriptions, this increased risk can still turn out to apply to a sizeable number of people.

Physicians will not be able to see the increased risk in their clinical experience.  As Nassir Ghaemi says, “They don't happen in 10-20% of patients in our practice; they happen in 1-2% (or 0.1-0.2%), and so, the average clinician, faced with a welter of patients, doesn't make the causal connection.”

The question should be, what are the risks versus the benefits from taking the medication.  For sleeping pills, for instance, one might want to know if there is a much larger increased risk of death for people who are sleep deprived.  For example, before the practice was stopped, medical interns would routinely work 36 hour shifts.  Fatal accidents on the car trip from the hospital back home were not all that unusual.

Then there is the whole question of other, non-pharmacological treatments, which is relevant for both the use of sedatives and stimulants.  Of course, they do not work for everyone either.

An editorial in the same issue of the American Journal of Psychiatry as the study of Ritalin in adults sounded reassuring about stimulant use.  Based on that study, I’m not so reassured.  

Ve Have Vays of Making You Talk, Part VIII: Countering Logical Fallacies

In Part I of this post, I discussed why family members hate to discuss their chronic repetitive ongoing interpersonal difficulties with each other (metacommunication), and the problems that usually ensue whenever they try. 

I discussed the most common avoidance strategy - merely changing the subject (#1) - and suggested effective countermoves to keep a constructive conversation on track. In Part II, I discussed strategies #2 and #3, nitpicking and accusations of overgeneralizing respectively. In Part III, I discussed strategy #4, blame shifting. In Part IV, strategy #5, fatalism.

This post is the fourth in a series about strategy #6, the use of irrational arguments (previously: non sequiturs; post hoc reasoning; begging the question). Descriptions of this strategy have been subdivided into several posts because, in order to counter irrational arguments, one first has to recognize them.  Until this post, I have held off describing the basic strategy to counter irrational arguments until after I finished describing some of the most common types.  Today’s post will be the last concerning these irrational arguments, and will also describe the basic countermeasure.

Irrational arguments are used in metacommunication to throw other people. Listeners either become confused about, or unsure of the validity of, any point they are trying to make or question they are trying to ask.  Fallacious arguments are also frequently used to avoid divulging an individual's real motives for taking or having taken certain actions. 

Today’s post will describe arguing from worst case scenarios, and ad hominem or personal attacks.

An argument is often made that a particular course of action is ill-advised because of difficulties that might arise in a worst-case scenario. In other words, one asks the question, "If I did so and so, what would be the conse­quences if everything possible went wrong?"

Posing a worst-case scenario does not always mean that the poser is engaged in an illogical maneuver. Indeed, for certain questions, such as whether to build a nuclear reactor near an earthquake fault, looking at worst-case scenarios can be a matter of life and death. Residents of Fukushima, Japan, will know exactly what I am talking about.

The worst-case argument becomes logically suspect if it is being used as an excuse to avoid some action when either of two con­ditions is present. The first is when the worst case is so unlikely to occur as to be almost meaningless. The second is when the worst case is preventable.

The most common usage of the maneuver in psychother­apy cases occurs when patients attempt to suppress some ­aspect of themselves by frightening themselves with the thought of dreadful consequences should the characteristic of self ever be expressed. One of the most often seen examples of this involves the ques­tion of whether or not to express anger.  


I once was the therapist for a group where every single member was in complete agreement that anger should be kept to oneself. They all painted a most shocking picture of the dire results that might ensue if their anger were ever unleashed. The anger would be destructive to the nth degree.

Everyone present said they had so much anger inside that if some of it got out, a dam would burst and a flood of violent fury would come pouring out. They might murder all of their loved ones and bomb government buildings. They would all suddenly become completely crazed, and each might end up in a mental institution or worse. They might tear the objects of their rage limb from limb and end up on death row. 


If thoughts like that did not scare them into keeping their anger quiet, nothing would.

The worst-case scenario that was proposed by the group members is illogical for several reasons. First, it is based on the non sequitur "If I let out some of my anger, I'll let it all out." Forgetting for the moment the unlikelihood that the rage they fear is as extensive as they believe it to be, how did they come to the conclusion that they would have more difficulty restrain­ing themselves once some of the anger had emerged than before the process started? They were each masters at self-restraint.


While it is often true that people who have been stuffing their anger may suddenly explode when there is a "last straw," this usually occurs in the heat of the moment, not when one is planning how to bring up for discussion anger-provoking behavior.  For this reason, 

the situation is not really analogous to the Dutch boy with his finger in the dike. One can always catch oneself. 


Indeed, the extra guilt these people probably would feel for having exhib­ited angry feelings might make it even easier for them to re­strain themselves in the future. This worst case, in which all of a limitless amount of anger would come out in a deluge is a highly unlikely worst case. Furthermore, this worse case is preventable.

Acting out the anger is hardly the only way to express it. One can talk to the anger-provoking person in a constructive attempt to get them to knock off the provocations. 


The use of terrifying imagery to scare oneself out of a course of action  is a very clear example of what I mean by mortification. In this case, an aspect of self, the emotion of anger, is suppressed by frightening oneself with worries about horrific conse­quences.

One last fallacy that I would like to briefly mention is ad hominem. This translates from the Latin as "to the man." This fallacy is based on the non sequitur "if a person is reprehensible in some respect, then everything that person has to say is incor­rect." This fallacy is frequently encountered outside the metacommunicative realm in the area of politics. 

Politicians can have repulsive views on certain issues or may be self-serving liars. Nonetheless, any single assertion that they make might still be true or correct. One cannot reason logically that because their views are unpopular or because they have lied in the past, then any current assertion they make is false. 


From the standpoint of in­ductive reasoning, one can be highly suspicious of their state­ments because of their past behavior and motivation, but in order to actually disprove their thesis, one needs corroborating evidence. Just because Castro is a Communist autocrat, for example, one could not con­clude that he is always lying whenever he made accusations against the United States government.

In metacommunication, family members will frequently discount an idea because of the alleged motivation of the person making it, without addressing the actual merits of the idea.  The metacommunicator might be accused of being insincere or having some sort of ulterior motive for making an observation while the target completely ignores the merits of the observation itself.  

Invalidation is a form of an ad hominem attack.  The person bringing up a past event is accused of distorting it, or even making it up.  This situation usually leads to a fight or flight response on the part of the metacommunicator, which stops the effort to solve interpersonal problems in its tracks.

And now at long last, what does the metacommunicator do when faced with a person who uses illogical arguments to avoid dealing with an uncomfortable interpersonal issue.

The basic response is what many therapists refer to as the Columbo style of response. Columbo was a TV detective played by the actor Peter Falk who often got suspects to incriminate themselves by, in a sense, playing stupid.  He would point out discrepancies in the suspect’s story and kind of scratch his head, acting if he were the one who was not bright enough to figure out the explanation. 

Peter Falk as Columbo

He would never act as if he believed that the suspect were purposely misleading him, although he obviously knew that was really the case.  The suspect would then try to “help out” the hapless cop by clarifying the apparent discrepancy, much to his own detriment.

In metacommunication, the object of this strategy is of course not to make the other person incriminate himself or herself, but to get past the block to appropriate, metacommunicative problem solving.

In response to a logical fallacy, the metacommunicator tactfully expresses confusion about what the target is saying, or points out seeming contradictions. This is done in an almost apologetic fashion.  Rather than accusing the other of purposely being misleading or confusing, metacommuncators try to indicate that they themselves are taking responsibility for any lack of interpersonal understanding.

In addition to decreasing the target’s need to become defensive, with this strategy the target often feels obliged to clear up the patients’ confusion.  In order to do so, he or she must drop the logical fallacy.  When this happens, it is important that the metacommunicator seem grateful for the new clarity, and not have a kind of “I told you you were irrational” attitude.

Now maintaining this bemused, self-effacing sort of style is often particularly difficult to do if there is an ad hominem component to the target’s irrational argument.  


In that case, as mentioned above, it is the metacommunicator who usually becomes defensive, and who derails the effort for problem solving.  In this case, learning and practicing many of the strategies described in my series of posts on how to disarm a patient with borderline personality disorder, such as giving the other person the benefit of the doubt and acknowledging one’s own contribution to the problematic past interactions, come in very handy.

Re-labeling Depressive Symptoms as Manic Symptoms by Fiat

They look alike.  Madonna must really be a goat.

Another cartoonishly mischaracterized study described in a journal article was recently published in the Journal of Affective Disorders.  One of the editors of this journal is Hagop Akiskal  (I have discussed my opinion of Dr. Hagop Akiskal’s work in a previous blog post).  The article's title is Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes.  


The authors are Lewis L. Judd, Pamela J. Schettler, Hagop Akiskal [the very same], William Coryell, Jan Fawcett, Jess G. Fiedorowicz , David A. Solomon, and Martin B. Keller.

These authors suggest that the presence of something that they label as subsyndromal manic symptoms (that is, symptoms that they believe are the same as those that are usually seen in mania episodes but which are “below the threshold for mania" - whatever that means) are seen in the major depressive episodes (MDE’s) that are also characteristic of bipolar disorder.  

For those unfamiliar, patients with true bipolar disorder have both manic and major depressive episodes, obviously at different times, that are separated by relatively long periods of normal moods called euthymia.

They discuss how some other authors reported that “the most common manic symptom during bipolar MDEs was irritability (present in 73.1% of the sample), followed by distractibility (37.2%), psychomotor agitation (31.2%), flight of ideas or racing thoughts, (20.6%), and increased speech (11.0%). 

Now, of course, they do not mention that these very same symptoms are also seen in the major depressive episodes of people who never have had or will have a manic episode. And who respond to antidepressant medication and have no response at all to lithium (which is highly effective in bipolar disorder). Back in ancient history (the 70’s and 80’s) we labeled depressed patients who show such symptoms as having an agitated depression.  

Other patients with depression who are not agitated but are in fact extremely slowed down - as if on heavy sedatives - were said to have a retarded depression.  We stopped making this distinction between agitated and retarded major depressive episodes because we found that both types of depression usually respond to the same medications, (although agitated depressions seemed to have, on average, a somewhat worse prognosis for medication response).

This authors of this article state that irritable and agitated qualities of MDEs, defined in various ways, are prominent in the clinical and research literature on bipolar patients with yet another clinical entity called a mixed depressive state. In the opinion of a lot of psychiatrists like myself, a mixed state is something better characterized by the name dysphoric mania. The patient has all the symptoms of mania but, instead of the highly elevated, euphoric mood as most people in a manic state have, they feel awful.

I find I cannot use the definition of a "mixed state" that is used in the official diagnostic manual, the DSM, because it is actually impossible.  To have a mixed state according to DSM criteria, “The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day.”  This is impossible since many of the symptoms of mania and depression are polar opposites of one another, so that one cannot have both at the same time!

Anyway, the authors of the article under discussion described their study population thusly:

 “Subjects entered the NIMH CDS at five academic medical centers from 1978 to 1981, while seeking treatment for a major affective episode. Intake research diagnoses were made using Research Diagnostic Criteria (RDC) based on the Schedule for Affective Disorders and Schizophrenia (SADS) interviews ... as well as available medical and research records. Patients with bipolar disorder (type I or II) entering the CDS in a major depressive episode (MDE) were selected for these analyses. We excluded from the analysis all patients who were manic at intake (N=60), along with a small group of patients (N=5) who met DSM-IV-TR criteria for a mixed episode at intake (i.e., had full concurrent MDE plus mania).” 

Notice that they "found" and then excluded anyone that might possibly meet the contradictory DSM criteria for a “mixed state,” which is what they were talking about earlier as if it were the population of patients who were about to be described in their study, which in fact it was not.

52  of their patients were diagnosed as bipolar I and 90 were bipolar II.  As most of my readers know, I think bipolar II is a phony diagnosis in the first place. 

They go on: “Irritability and psychomotor agitation are included in the SADS interview not only as manic/hypomanic symptoms, but also in the depression section of the interview, as qualifiers for the MDE (i.e., specifically for periods of the intake MDE when the subject did not have evidence of a manic syndrome).”

“We have included these two characteristics of intake MDEs as subsyndromal manic symptoms because we believe they are clinically indistinguishable from criteria A-2 and B-6 for mania and may, therefore, represent a subtle and little recognized form of mixed bipolar MDE.”

The authors are subtly defining by fiat any depressed person with irritability as having a “subthreshold” manic symptom!  Sez who??  This is especially interesting considering that they used what is essentially a symptom checklist to make their diagnosis in the first place, and were not really using clinical judgment to tease out differences in the presentation, pervasiveness, and persistence of symptoms that may just look alike during evaluations done at one point in time.

The similar symptoms are, in fact, clinically distinguishable, precisely because the symptoms occur in different clinical states – that is, manic episodes and depressive episodes.  The authors use the word “may” in the sentence about the symptoms being a little recognized form of mixed bipolar, and then proceed entirely from the assumption that they are just that. 

To really sort this out, maybe they should have compared a sample of patients with bipolar depressive episodes to patients with unipolar depressive episodes (patients who get depressive episodes but not manic episodes).  But of course, if these authors found these symptoms in unipolar depressives, they could easily redefine the unipolars as bipolars because of the symptoms.  


Voila! Almost anyone who has a depressive episode is immediately re-categorized as bipolar!  Because they define it that way.

Actually, retarded depression is more common in bipolar patients than agitated depression.  

About the only valid conclusion one can draw from the data presented in the article is that bipolar patients who have an agitated depressive episode may have a somewhat worse prognosis, and may be more likely to experience a quick shift into a manic state, than bipolar patients who have retarded depressive episodes.


Of course, we knew that decades ago.