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Monday, March 15, 2021

Erich Fromm

Erich Seligmann Fromm (/frɒm/; German: [fʁɔm]; March 23, 1900 – March 18, 1980) was a German social psychologist, psychoanalyst, sociologist, humanistic philosopher, and democratic socialist. He was a German Jew who fled the Nazi regime and settled in the US. He was one of the founders of The William Alanson White Institute of Psychiatry, Psychoanalysis and Psychology in New York City and was associated with the Frankfurt School of critical theory.

Life

Erich Fromm was born on March 23, 1900, at Frankfurt am Main, the only child of Orthodox Jewish parents, Rosa (Krause) and Naphtali Fromm. He started his academic studies in 1918 at the University of Frankfurt am Main with two semesters of jurisprudence. During the summer semester of 1919, Fromm studied at the University of Heidelberg, where he began studying sociology under Alfred Weber (brother of the better known sociologist Max Weber), psychiatrist-philosopher Karl Jaspers, and Heinrich Rickert. Fromm received his PhD in sociology from Heidelberg in 1922. During the mid-1920s, he trained to become a psychoanalyst through Frieda Reichmann's psychoanalytic sanatorium in Heidelberg. They married in 1926, but separated shortly after and divorced in 1942. He began his own clinical practice in 1927. In 1930 he joined the Frankfurt Institute for Social Research and completed his psychoanalytical training.

After the Nazi takeover of power in Germany, Fromm moved first to Geneva and then, in 1934, to Columbia University in New York. Together with Karen Horney and Harry Stack Sullivan, Fromm belongs to a Neo-Freudian school of psychoanalytical thought. Horney and Fromm each had a marked influence on the other's thought, with Horney illuminating some aspects of psychoanalysis for Fromm and the latter elucidating sociology for Horney. Their relationship ended in the late 1930s. After leaving Columbia, Fromm helped form the New York branch of the Washington School of Psychiatry in 1943, and in 1946 co-founded the William Alanson White Institute of Psychiatry, Psychoanalysis, and Psychology. He was on the faculty of Bennington College from 1941 to 1949, and taught courses at the New School for Social Research in New York from 1941 to 1959.

When Fromm moved to Mexico City in 1949, he became a professor at the National Autonomous University of Mexico (UNAM) and established a psychoanalytic section at the medical school there. Meanwhile, he taught as a professor of psychology at Michigan State University from 1957 to 1961 and as an adjunct professor of psychology at the graduate division of Arts and Sciences at New York University after 1962. He taught at UNAM until his retirement, in 1965, and at the Mexican Society of Psychoanalysis (SMP) until 1974. In 1974 he moved from Mexico City to Muralto, Switzerland, and died at his home in 1980, five days before his eightieth birthday. All the while, Fromm maintained his own clinical practice and published a series of books.

Fromm was reportedly an atheist but described his position as "nontheistic mysticism".

Psychological theory

Beginning with his first seminal work of 1941, Escape from Freedom (known in Britain as Fear of Freedom), Fromm's writings were notable as much for their social and political commentary as for their philosophical and psychological underpinnings. Indeed, Escape from Freedom is viewed as one of the founding works of political psychology. His second important work, Man for Himself: An Inquiry into the Psychology of Ethics, first published in 1947, continued and enriched the ideas of Escape from Freedom. Taken together, these books outlined Fromm's theory of human character, which was a natural outgrowth of Fromm's theory of human nature. Fromm's most popular book was The Art of Loving, an international bestseller first published in 1956, which recapitulated and complemented the theoretical principles of human nature found in Escape from Freedom and Man for Himself—principles which were revisited in many of Fromm's other major works.

Central to Fromm's world view was his interpretation of the Talmud and Hasidism. He began studying Talmud as a young man under Rabbi J. Horowitz and later under Rabbi Salman Baruch Rabinkow, a Chabad Hasid. While working towards his doctorate in sociology at the University of Heidelberg, Fromm studied the Tanya by the founder of Chabad, Rabbi Shneur Zalman of Liadi. Fromm also studied under Nehemia Nobel and Ludwig Krause while studying in Frankfurt. Fromm's grandfather and two great grandfathers on his father's side were rabbis, and a great uncle on his mother's side was a noted Talmudic scholar. However, Fromm turned away from orthodox Judaism in 1926, towards secular interpretations of scriptural ideals.

The cornerstone of Fromm's humanistic philosophy is his interpretation of the biblical story of Adam and Eve's exile from the Garden of Eden. Drawing on his knowledge of the Talmud, Fromm pointed out that being able to distinguish between good and evil is generally considered to be a virtue, but that biblical scholars generally consider Adam and Eve to have sinned by disobeying God and eating from the Tree of Knowledge. However, departing from traditional religious orthodoxy on this, Fromm extolled the virtues of humans taking independent action and using reason to establish moral values rather than adhering to authoritarian moral values.

Beyond a simple condemnation of authoritarian value systems, Fromm used the story of Adam and Eve as an allegorical explanation for human biological evolution and existential angst, asserting that when Adam and Eve ate from the Tree of Knowledge, they became aware of themselves as being separate from nature while still being part of it. This is why they felt "naked" and "ashamed": they had evolved into human beings, conscious of themselves, their own mortality, and their powerlessness before the forces of nature and society, and no longer united with the universe as they were in their instinctive, pre-human existence as animals. According to Fromm, the awareness of a disunited human existence is a source of guilt and shame, and the solution to this existential dichotomy is found in the development of one's uniquely human powers of love and reason. However, Fromm distinguished his concept of love from unreflective popular notions as well as Freudian paradoxical love (see the criticism by Marcuse below).

Fromm considered love an interpersonal creative capacity rather than an emotion, and he distinguished this creative capacity from what he considered to be various forms of narcissistic neuroses and sado-masochistic tendencies that are commonly held out as proof of "true love". Indeed, Fromm viewed the experience of "falling in love" as evidence of one's failure to understand the true nature of love, which he believed always had the common elements of care, responsibility, respect, and knowledge. Drawing from his knowledge of the Torah, Fromm pointed to the story of Jonah, who did not wish to save the residents of Nineveh from the consequences of their sin, as demonstrative of his belief that the qualities of care and responsibility are generally absent from most human relationships. Fromm also asserted that few people in modern society had respect for the autonomy of their fellow human beings, much less the objective knowledge of what other people truly wanted and needed.

Fromm believed that freedom was an aspect of human nature that we either embrace or escape. He observed that embracing our freedom of will was healthy, whereas escaping freedom through the use of escape mechanisms was the root of psychological conflicts. Fromm outlined three of the most common escape mechanisms:

  • Automaton conformity: changing one's ideal self to conform to a perception of society's preferred type of personality, losing one's true self in the process; Automaton conformity displaces the burden of choice from self to society;
  • Authoritarianism: giving control of oneself to another. By submitting one's freedom to someone else, this act removes the freedom of choice almost entirely.
  • Destructiveness: any process which attempts to eliminate others or the world as a whole, all to escape freedom. Fromm said that "the destruction of the world is the last, almost desperate attempt to save myself from being crushed by it".

The word biophilia was frequently used by Fromm as a description of a productive psychological orientation and "state of being". For example, in an addendum to his book The Heart of Man: Its Genius For Good and Evil, Fromm wrote as part of his humanist credo:

"I believe that the man choosing progress can find a new unity through the development of all his human forces, which are produced in three orientations. These can be presented separately or together: biophilia, love for humanity and nature, and independence and freedom."

Erich Fromm postulated eight basic needs:


Need Description
Transcendence Being thrown into the world without their consent, humans have to transcend their nature by destroying or creating people or things. Humans can destroy through malignant aggression, or killing for reasons other than survival, but they can also create and care about their creations.
Rootedness Rootedness is the need to establish roots and to feel at home again in the world. Productively, rootedness enables us to grow beyond the security of our mother and establish ties with the outside world. With the nonproductive strategy, we become fixated and afraid to move beyond the security and safety of our mother or a mother substitute.
Sense of Identity The drive for a sense of identity is expressed nonproductively as conformity to a group and productively as individuality.
Frame of orientation Understanding the world and our place in it.
Excitation and Stimulation Actively striving for a goal rather than simply responding.
Unity A sense of oneness between one person and the "natural and human world outside."
Effectiveness The need to feel accomplished.

Fromm's thesis of the "escape from freedom" is epitomized in the following passage. The "individualized man" referenced by Fromm is man bereft of the "primary ties" of belonging (i.e. nature, family, etc.), also expressed as "freedom from":

There is only one possible, productive solution for the relationship of individualized man with the world: his active solidarity with all men and his spontaneous activity, love and work, which unite him again with the world, not by primary ties but as a free and independent individual.... However, if the economic, social and political conditions... do not offer a basis for the realization of individuality in the sense just mentioned, while at the same time people have lost those ties which gave them security, this lag makes freedom an unbearable burden. It then becomes identical with doubt, with a kind of life which lacks meaning and direction. Powerful tendencies arise to escape from this kind of freedom into submission or some kind of relationship to man and the world which promises relief from uncertainty, even if it deprives the individual of his freedom.

— Erich Fromm, Escape from Freedom [N.Y.: Rinehart, 1941], pp. 36–7. The point is repeated on pp. 31, 256–7.)

Five basic orientations

In his book Man for Himself Fromm spoke of "orientation of character". He differentiates his theory of character from that of Freud by focusing on two ways an individual relates to the world. Freud analyzed character in terms of libido organization, whereas Fromm says that in the process of living, we relate to the world by: 1) acquiring and assimilating things—"Assimilation", and 2) reacting to people—"Socialization". Fromm asserted that these two ways of relating to the world were not instinctive, but an individual's response to the peculiar circumstances of his or her life; he also believed that people are never exclusively one type of orientation. These two ways of relating to life's circumstances lead to basic character-orientations.

Fromm lists four types of nonproductive character orientation, which he called receptive, exploitative, hoarding, and marketing, and one positive character orientation, which he called productive. Receptive and exploitative orientations are basically how an individual may relate to other people and are socialization attributes of character. A hoarding orientation is an acquiring and assimilating materials/valuables character trait. The marketing orientation arises in response to the human situation in the modern era. The current needs of the market determine value. It is a relativistic ethic. In contrast, the productive orientation is an objective ethic. Despite the existential struggles of humanity, each human has the potential for love, reason and productive work in life. Fromm writes, "It is the paradox of human existence that man must simultaneously seek for closeness and for independence; for oneness with others and at the same time for the preservation of his uniqueness and particularity. ...the answer to this paradox – and to the moral problems of man – is productiveness."

Fromm's influence on other notable psychologists

Fromm's four non-productive orientations were subject to validation through a psychometric test, The Person Relatedness Test by Elias H. Porter, PhD in collaboration with Carl Rogers, PhD at the University of Chicago's Counseling Center between 1953 and 1955. Fromm's four non-productive orientations also served as basis for the LIFO test, first published in 1967 by Stuart Atkins, Alan Katcher, PhD, and Elias Porter, PhD and the Strength Deployment Inventory, first published in 1971 by Elias H. Porter, PhD. Fromm also influenced his student Sally L. Smith who went on to become the founder of the Lab School of Washington and the Baltimore Lab School.

Critique of Freud

Fromm examined the life and work of Sigmund Freud at length. Fromm identified a discrepancy between early and later Freudian theory: namely that, prior to World War I, Freud had described human drives as a tension between desire and repression, but after the end of the war, began framing human drives as a struggle between biologically universal Life and Death (Eros and Thanatos) instincts. Fromm charged Freud and his followers with never acknowledging the contradictions between the two theories.

Fromm also criticized Freud's dualistic thinking. According to Fromm, Freudian descriptions of human consciousness as struggles between two poles were narrow and limiting. Fromm also condemned Freud as a misogynist unable to think outside the patriarchal milieu of early 20th century Vienna. However, in spite of these criticisms, Fromm nonetheless expressed a great respect for Freud and his accomplishments. Fromm contended that Freud was one of the "architects of the modern age", alongside Albert Einstein and Karl Marx, but emphasized that he considered Marx both far more historically important than Freud and a finer thinker.

Political ideas and activities

Fromm's best known work, Escape from Freedom, focuses on the human urge to seek a source of authority and control upon reaching a freedom that was thought to be an individual's true desire. Fromm's critique of the modern political order and capitalist system led him to seek insights from medieval feudalism. In Escape from Freedom, he found value in the lack of individual freedom, rigid structure, and obligations required on the members of medieval society:

What characterizes medieval in contrast to modern society is its lack of individual freedom…But altogether a person was not free in the modern sense, neither was he alone and isolated. In having a distinct, unchangeable, and unquestionable place in the social world from the moment of birth, man was rooted in a structuralized whole, and thus life had a meaning which left no place, and no need for doubt…There was comparatively little competition. One was born into a certain economic position which guaranteed a livelihood determined by tradition, just as it carried economic obligations to those higher in the social hierarchy.

Noam Chomsky discusses Erich Fromm's theory of alienation.

The culmination of Fromm's social and political philosophy was his book The Sane Society, published in 1955, which argued in favor of a humanistic and democratic socialism. Building primarily upon the early works of Karl Marx, Fromm sought to re-emphasise the ideal of freedom, missing from most Soviet Marxism and more frequently found in the writings of libertarian socialists and liberal theoreticians. Fromm's brand of socialism rejected both Western capitalism and Soviet communism, which he saw as dehumanizing, and which resulted in the virtually universal modern phenomenon of alienation. He became one of the founders of socialist humanism, promoting the early writings of Marx and his humanist messages to the US and Western European public.

In the early 1960s, Fromm published two books dealing with Marxist thought (Marx's Concept of Man and Beyond the Chains of Illusion: My Encounter with Marx and Freud). In 1965, working to stimulate the Western and Eastern cooperation between Marxist humanists, Fromm published a series of articles entitled Socialist Humanism: An International Symposium. In 1966, the American Humanist Association named him Humanist of the Year.

For a period, Fromm was also active in U.S. politics. He joined the Socialist Party of America in the mid-1950s, and did his best to help them provide an alternative viewpoint to McCarthyist trends in some US political thought. This alternative viewpoint was best expressed in his 1961 paper May Man Prevail? An Inquiry into the Facts and Fictions of Foreign Policy. However, as a co-founder of SANE, Fromm's strongest political activism was in the international peace movement, fighting against the nuclear arms race and U.S. involvement in the Vietnam War. After supporting Senator Eugene McCarthy's losing bid for the Democratic presidential nomination, Fromm more or less retreated from the American political scene, although he did write a paper in 1974 entitled Remarks on the Policy of Détente for a hearing held by the U.S. Senate Committee on Foreign Relations. Fromm was awarded Nelly Sachs Prize in 1979.

Criticism

In Eros and Civilization, Herbert Marcuse is critical of Fromm: In the beginning, he was a radical theorist, but later he turned to conformity. Marcuse also noted that Fromm, as well as his close colleagues Sullivan and Karen Horney, removed Freud's libido theory and other radical concepts, which thus reduced psychoanalysis to a set of idealist ethics, which only embrace the status quo. Fromm's response, in both The Sane Society and in The Anatomy of Human Destructiveness, argues that Freud indeed deserves substantial credit for recognizing the central importance of the unconscious, but also that he tended to rectify his own concepts that depicted the self as the passive outcome of instinct and social control, with minimal volition or variability. Fromm argues that later scholars such as Marcuse accepted these concepts as dogma, whereas social psychology requires a more dynamic theoretical and empirical approach. In reference to Fromm's leftist political activism as a public intellectual, Noam Chomsky said "I liked Fromm's attitudes but thought his work was pretty superficial".

Sunday, March 14, 2021

On Anti-Nuclear Bullshit

Founder and Executive Director

In his widely read essay, “On Bullshit,” the philosopher Harry Frankfurt famously distinguished between liars and bullshitters. Liars, counterintuitively, Frankfurt argued, actually care about the truth, and hence attempt to conceal or distort it. Bullshit, by contrast, serves a social function, not an epistemic one.

I was reminded of Frankfurt’s distinction recently, with the publication of a new paper by Harrison Fell, Alex Gilbert, Jesse Jenkins, and Matteo Mildenberger reanalyzing data from a study published last fall in Nature Energy by Benjamin Sovacool and colleagues at the University of Sussex Energy Group.

Sovacool and his coauthors claimed to demonstrate that deployment of nuclear energy around the world did not reduce carbon emissions. The reanalysis by Fell, et. al. is devastating, showing Sovacool’s data actually shows the opposite. From the abstract: “employing the same data sources and time periods, we find that nuclear power and renewable energy are both associated with lower per capita CO2 emissions with effects of similar magnitude and statistical significance.”

Of course, you don’t really need a complicated regression analysis to figure this out. France and Sweden boast the lowest per capita emissions among major advanced developed economies globally and get 80% and 50% of their electricity, respectively, from nuclear energy. When nations build nuclear plants, emissions reliably fall and when they shut them down, as we’ve witnessed over the last decade in Japan and California, they reliably rise.

But for decades, Sovacool and other prominent anti-nuclear academics have published a slew of dubious studies in peer-reviewed publications purporting to find that closing nuclear plants reduces emissions, that nuclear energy is fossil fuel intensive, uniquely dangerous, and inherently expensive, and that renewable energy alone can meet 100% of the world’s energy needs.

This is the sort of thing that many people would call bullshit. But in Frankfurt’s parlance, ideological academics like Sovacool are actually liars. By that, I am not suggesting that Sovacool and others are literally lying. Nor does any of it rise to the level of academic fraud.

But the history of anti-nuclear scholarship pretty strongly suggests that peer-review is no defense in the face of tenured academics with strong ideological commitments. Motivated cognition is a powerful thing and faced with an inconvenient truth, that nuclear energy, which environmentalists have long viewed as worse than fossil fuels, is actually one of the better options we have for cutting carbon emissions and addressing climate change, researchers like Sovacool are entirely capable of conjuring scholarly falsehoods via the magic of models, regression analyses, and highly selective data.

Bullshit, by contrast, is a different animal. It involves going along to get along, repeating claims that are prima facie ridiculous because everyone else appears to believe them too. If Sovacool and other anti-nuclear academics are liars in Frankfurt’s parlance, the peer reviewers and editors who went along with publishing the whole absurd exercise are bullshitters.

Sure, peer-review is time-consuming and uncompensated. But that can’t remotely explain how Sovacool was able to take a study that he was forced to retract just three years ago, slap a fresh coat of paint on it, and republish it in a more prestigious journal. Or why Mark Jacobson’s now-debunked 100% renewable study was not only published by the Proceedings of the National Academy of Science but received an award as one of the best studies of the year, before its obvious flaws were exposed. Or, for that matter, why decades of coverage of nuclear energy in the mainstream media has so reliably diverged from the overwhelming evidence about nuclear’s remarkable record of safe operations and low emissions.

The actual technological pathways to deeply decarbonizing the entire global economy are few and far between. Nuclear is without question one of them.

Climate and energy bullshit proliferates not based on the strength of empirical claims upon which it is based but because it fits a social narrative that has been around for a very long time and that was mapped over, almost whole cloth, from earlier environmental claims about population, toxic chemicals, and limits to growth.

At bottom, almost all contemporary framings of the climate issue insist that addressing the problem will require a fundamental break from the past. Our actions, our choices, our determination to fundamentally remake the world, right now, shall determine whether we thrive or burn up in a runaway fossil-fueled cataclysm.

And so, in the popular climate discourse, we imagine more marching and protesting and clever climate communications might radically remake the political economy of carbon and energy on a planet with seven billion people, soon to be nine, that is still overwhelmingly dependent on fossil fuels. We argue that political will is all that stands in the way of an international treaty, a global carbon price, or a Green New Deal and that once the political breakthrough materializes, those measures will magically produce some unnamed and unobjectionable technology to do everything that wind and solar energy can’t.

Nuclear energy’s original sin was that it was plug and play with industrial modernity, promising limitless energy to support economic prosperity and a growing population. Even as most today acknowledge that any serious effort to address climate change will need to accommodate both, the popular climate discourse speaks of carbon budgets and temperature targets as if they were real things while barely mentioning nuclear, a real technology with documented success decarbonizing modern economies, because it doesn’t fit the narrative.

When nations build nuclear plants, emissions reliably fall and when they shut them down, as we’ve witnessed over the last decade in Japan and California, they reliably rise.

Instead, we talk of technologies that have never actually existed: gigantic machines that remove carbon directly from the atmosphere or hydrogen-powered aircraft or pumping sulfur particles into the stratosphere. The environmental movement and philanthropy have even been far more open to bolting costly carbon capture technology onto coal and gas plants than reconsidering nuclear energy, probably because the former is a pollution-control technology that would increase the cost of fossil energy and, not incidentally, is probably only feasible in the event that the world either regulates or taxes carbon dioxide.

Nuclear energy is no panacea either. And perhaps we will figure out how to entirely eliminate emissions with carbon capture or clean hydrogen or something else. But the actual technological pathways to deeply decarbonizing the entire global economy are few and far between. Nuclear is without question one of them. It can do things, like providing heat for industrial processes that renewables simply cannot easily, and is still the only low-carbon technology with a demonstrated track record of significantly decarbonizing a modern, industrialized economy.

As impressive as the falling costs of wind and solar energy have been, we aren’t going to power the entire global economy with variable sources of renewable energy alone. We have no experience or proven capability to operate an electrical grid entirely with wind and solar energy, much less the other 80% of the global energy economy that doesn’t run on electricity.

Most serious observers, in the news media, academia, government, and even environmental NGOs actually know this and most credible global decarbonization scenarios and energy systems models find a significant need for nuclear to deeply decarbonize modern economies. But you wouldn’t know that from our zombie climate discourse.

Successful climate action in the actual world won’t look anything like the heroic fantasias that so easily captivate the chattering classes. More likely, insofar as we succeed, we will do so via a series of partial, stumbling, and half-baked measures. Doing so will require things like nuclear energy, natural gas, carbon capture, and big agriculture that don’t, in the popular imagination, sit weightless on the land. It will require big government, big corporations and big infrastructure. It will accommodate itself to industrial modernity, consumption, and consumerism and will require a revolution in neither sentiment nor technology but rather the slow accumulation of knowledge, technological prowess, institutions, and practices.

In the end, everyone knows what Sovacool, Jacobson, and other anti-nuclear academics are up to. They are simply highly credentialed ideologues. It’s the bullshit that I worry more about, because, in its incoherence, overheated conspiracies, breezy utopias, and empty radicalism, it is far harder to interrogate

 

DSM-5

From Wikipedia, the free encyclopedia
 
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5)
DSM-5 Cover.png
AuthorAmerican Psychiatric Association
CountryUnited States
LanguageEnglish
SeriesDiagnostic and Statistical Manual of Mental Disorders
SubjectClassification and diagnosis of mental disorders
PublishedMay 18, 2013
Media typePrint (hardcover, softcover); e-book
Pages947
ISBN978-0-89042-554-1
OCLC830807378
616.89'075
LC ClassRC455.2.C4
Preceded byDSM-IV-TR 

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. The DSM-5 is the first DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the first "living document" version of a DSM.

The DSM-5 is not a major revision of the DSM-IV-TR but there are significant differences. Changes in the DSM-5 include the reconceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder; the elimination of subtypes of schizophrenia; the deletion of the "bereavement exclusion" for depressive disorders; the renaming of gender identity disorder to gender dysphoria; the inclusion of binge eating disorder as a discrete eating disorder; the renaming and reconceptualization of paraphilias, now called paraphilic disorders; the removal of the five-axis system; and the splitting of disorders not otherwise specified into other specified disorders and unspecified disorders.

Some authorities criticized the fifth edition both before and after it was published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; inter-rater reliability is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry may have unduly influenced the manual's content (many DSM-5 workgroup participants had ties to pharmaceutical companies).

Changes from DSM-IV

The DSM-5 is divided into three Sections, using Roman numerals to designate each Section.

Section I

Section I describes DSM-5 chapter organization, its change from the multiaxial system, and Section III's dimensional assessments. The DSM-5 deleted the chapter that includes "disorders usually first diagnosed in infancy, childhood, or adolescence" opting to list them in other chapters. A note under Anxiety Disorders says that the "sequential order" of at least some DSM-5 chapters has significance that reflects the relationships between diagnoses.

The introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review. It states its goal is to harmonize with the ICD systems and share organizational structures as much as is feasible. Concern about the categorical system of diagnosis is expressed, but the conclusion is the reality that alternative definitions for most disorders are scientifically premature.

DSM-5 replaces the NOS (Not Otherwise Specified) categories with two options: other specified disorder and unspecified disorder to increase the utility to the clinician. The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification.

DSM-5 has discarded the multiaxial system of diagnosis (formerly Axis I, Axis II, Axis III), listing all disorders in Section II. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF). The World Health Organization's (WHO) Disability Assessment Schedule is added to Section III (Emerging measures and models) under Assessment Measures, as a suggested, but not required, method to assess functioning.

Section II: diagnostic criteria and codes

Neurodevelopmental disorders

Schizophrenia spectrum and other psychotic disorders

Bipolar and related disorders

Depressive disorders

Anxiety disorders

  • For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) "must recognize that their fear and anxiety are excessive or unreasonable". Also, the duration of at least 6 months now applies to everyone (not only to children).
  • Panic attack became a specifier for all DSM-5 disorders.
  • Panic disorder and agoraphobia became two separate disorders.
  • Specific types of phobias became specifiers but are otherwise unchanged.
  • The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier.
  • Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).

Obsessive-compulsive and related disorders

Trauma- and stressor-related disorders

  • Post traumatic stress disorder (PTSD) is now included in a new section titled "Trauma- and Stressor-Related Disorders."
  • The PTSD diagnostic clusters were reorganized and expanded from a total of three clusters to four based on the results of confirmatory factor analytic research conducted since the publication of DSM-IV.
  • Separate criteria were added for children six years old or younger.
  • For the diagnosis of acute stress disorder and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified to some extent. The requirement for specific subjective emotional reactions (Criterion A2 in DSM-IV) was eliminated because it lacked empirical support for its utility and predictive validity. Previously certain groups, such as military personnel involved in combat, law enforcement officers and other first responders, did not meet criterion A2 in DSM-IV because their training prepared them to not react emotionally to traumatic events.
  • Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder.
  • Adjustment disorders were moved to this new section and reconceptualized as stress-response syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and disturbed conduct are unchanged.

Dissociative disorders

Somatic symptom and related disorders

  • Somatoform disorders are now called somatic symptom and related disorders.
  • Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder.
  • Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.
  • Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy).
  • A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter "Other Conditions That May Be a Focus of Clinical Attention".
  • Criteria for conversion disorder (functional neurological symptom disorder) were changed.

Feeding and eating disorders

  • Criteria for pica and rumination disorder were changed and can now refer to people of any age.
  • Binge eating disorder graduated from DSM-IV's "Appendix B -- Criteria Sets and Axes Provided for Further Study" into a proper diagnosis.
  • Requirements for bulimia nervosa and binge eating disorder were changed from "at least twice weekly for 6 months to at least once weekly over the last 3 months".
  • The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea.
  • "Feeding disorder of infancy or early childhood", a rarely used diagnosis in DSM-IV, was renamed to avoidant/restrictive food intake disorder, and criteria were expanded.

Elimination disorders

  • No significant changes.
  • Disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV. Now it is an independent classification in DSM 5.

Sleep–wake disorders

Sexual dysfunctions

  • DSM-5 has sex-specific sexual dysfunctions.
  • For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder.
  • Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a duration of approximately 6 months and more exact severity criteria.
  • A new diagnosis is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV.
  • Sexual aversion disorder was deleted.
  • Subtypes for all disorders include only "lifelong versus acquired" and "generalized versus situational" (one subtype was deleted from DSM-IV).
  • Two subtypes were deleted: "sexual dysfunction due to a general medical condition" and "due to psychological versus combined factors".

Gender dysphoria

  • DSM-IV gender identity disorder is similar to, but not the same as, gender dysphoria in DSM-5. Separate criteria for children, adolescents and adults that are appropriate for varying developmental states are added.
  • Subtypes of gender identity disorder based on sexual orientation were deleted.
  • Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one's gender) were combined. Along with these changes comes the creation of a separate gender dysphoria in children as well as one for adults and adolescents. The grouping has been moved out of the sexual disorders category and into its own. The name change was made in part due to stigmatization of the term "disorder" and the relatively common use of "gender dysphoria" in the GID literature and among specialists in the area. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.

Disruptive, impulse-control, and conduct disorders

Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders. Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter "Impulse-Control Disorders Not Otherwise Specified".

  • Antisocial personality disorder is listed here and in the chapter on personality disorders (but ADHD is listed under neurodevelopmental disorders).
  • Symptoms for oppositional defiant disorder are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The conduct disorder exclusion is deleted. The criteria were also changed with a note on frequency requirements and a measure of severity.
  • Criteria for conduct disorder are unchanged for the most part from DSM-IV. A specifier was added for people with limited "prosocial emotion", showing callous and unemotional traits.
  • People over the disorder's minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression. Criteria were added for frequency and to specify "impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences".

Substance-related and addictive disorders

  • Gambling disorder and tobacco use disorder are new.
  • Substance abuse and substance dependence from DSM-IV-TR have been combined into single substance use disorders specific to each substance of abuse within a new "addictions and related disorders" category. "Recurrent legal problems" was deleted and "craving or a strong desire or urge to use a substance" was added to the criteria. The threshold of the number of criteria that must be met was changed and severity from mild to severe is based on the number of criteria endorsed. Criteria for cannabis and caffeine withdrawal were added. New specifiers were added for early and sustained remission along with new specifiers for "in a controlled environment" and "on maintenance therapy".

There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified.

Neurocognitive disorders

Personality disorders

  • Personality disorder (PD) previously belonged to a different axis than almost all other disorders, but is now in one axis with all mental and other medical diagnoses. However, the same ten types of personality disorder are retained.
  • There is a call for the DSM-5 to provide relevant clinical information that is empirically based to conceptualize personality as well as psychopathology in personalities. The issue(s) of heterogeneity of a PD is problematic as well. For example, when determining the criteria for a PD it is possible for two individuals with the same diagnosis to have completely different symptoms that would not necessarily overlap. There is also concern as to which model is better for the DSM - the diagnostic model favored by psychiatrists or the dimensional model that is favored by psychologists. The diagnostic approach/model is one that follows the diagnostic approach of traditional medicine, is more convenient to use in clinical settings, however, it does not capture the intricacies of normal or abnormal personality. The dimensional approach/model is better at showing varied degrees of personality; it places emphasis on the continuum between normal and abnormal, and abnormal as something beyond a threshold whether in unipolar or bipolar cases.

Paraphilic disorders

  • New specifiers "in a controlled environment" and "in remission" were added to criteria for all paraphilic disorders.
  • A distinction is made between paraphilic behaviors, or paraphilias, and paraphilic disorders. All criteria sets were changed to add the word disorder to all of the paraphilias, for example, pedophilic disorder is listed instead of pedophilia. There is no change in the basic diagnostic structure since DSM-III-R; however, people now must meet both qualitative (criterion A) and negative consequences (criterion B) criteria to be diagnosed with a paraphilic disorder. Otherwise they have a paraphilia (and no diagnosis).

Section III: emerging measures and models

Alternative DSM-5 model for personality disorders

An alternative hybrid dimensional-categorical model for personality disorders is included to stimulate further research on this modified classification system.

Conditions for further study

These conditions and criteria are set forth to encourage future research and are not meant for clinical use.

Development

In 1999, a DSM-5 Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-5 and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.

On July 23, 2007, the APA announced the task force that would oversee the development of DSM-5. The DSM-5 Task Force consisted of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM had a broad range of experience and interests. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests.

The DSM-5 field trials included test-retest reliability which involved different clinicians doing independent evaluations of the same patient—a common approach to the study of diagnostic reliability.

About 68% of DSM-5 task-force members and 56% of panel members reported having ties to the pharmaceutical industry, such as holding stock in pharmaceutical companies, serving as consultants to industry, or serving on company boards.

Revisions and updates

Beginning with the fifth edition, it is intended that diagnostic guideline revisions will be added incrementally. The DSM-5 is identified with Arabic rather than Roman numerals, marking a change in how future updates will be created. Incremental updates will be identified with decimals (DSM-5.1, DSM-5.2, etc.), until a new edition is written. The change reflects the intent of the APA to respond more quickly when a preponderance of research supports a specific change in the manual. The research base of mental disorders is evolving at different rates for different disorders.

Criticism

General

Robert Spitzer, the head of the DSM-III task force, publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: "When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you're going to have people complaining all over the place that they didn't have the opportunity to challenge anything." Allen Frances, chair of the DSM-IV task force, expressed a similar concern.

Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a 2009 Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed".

David Kupfer, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, vice chair of the task force, whose industry ties are disclosed with those of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders". They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM". The developments to this new version can be viewed on the APA website. Public input was requested for the first time in the history of the manual. During periods of public comment, members of the public could sign up at the DSM-5 website and provide feedback on the various proposed changes.

In June 2009, Allen Frances issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, (...) ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy." According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that brought thousands into the public debate about the DSM. Approximately 13,000 individuals and mental health professionals signed a petition in support of the letter. Thirteen other American Psychological Association divisions endorsed the petition. In a November 2011 article about the debate in the San Francisco Chronicle, Robbins notes that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences. In 2012, a footnote was added to the draft text which explains the distinction between grief and depression.

The DSM-5 has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders. A book-long appraisal of the DSM-5, with contributions from philosophers, historians and anthropologists, was published in 2015.

The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest. Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry, an increase from the 57% of DSM-IV task force members.

A 2015 essay from an Australian university criticized the DSM-5 for having poor cultural diversity, stating that recent work done in cognitive sciences and cognitive anthropology is still only accepting western psychology as the norm.

However, DSM-5 does now include a section on how to conduct a ‘cultural formulation interview’. Published in 2013, the cultural formulation interview gives information. about how a persons cultural identity may be affecting expression of signs and symptoms. This helps clinicians to make a much more valid diagnosis for disorders subject to significant cultural variation.

Borderline personality disorder controversy

In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of borderline personality disorder in DSM-5. The paper How Advocacy is Bringing BPD into the Light reported that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma." Instead, it proposed the name "emotional regulation disorder" or "emotional dysregulation disorder." There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).

The TARA-APD recommendations do not appear to have affected the American Psychiatric Association, the publisher of the DSM. As noted above, the DSM-5 does not employ a multi-axial diagnostic scheme, therefore the distinction between Axis I and II disorders no longer exists in the DSM nosology. The name, the diagnostic criteria for, and description of, borderline personality disorder remain largely unchanged from DSM-IV-TR.

British Psychological Society response

The British Psychological Society stated in its June 2011 response to DSM-5 draft versions, that it had "more concerns than plaudits". It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflect[ing] current normative social expectations", noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.

It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".

The Society suggested as its primary specific recommendation, a change from using "diagnostic frameworks" to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality:

[We recommend] a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or 'symptoms' or 'complaints'... We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc.)? These would be more helpful too in terms of epidemiology. While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of 'schizophrenia' or 'personality disorder' may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person's real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person's problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives. - British Psychological Society June 2011 response

National Institute of Mental Health

National Institute of Mental Health director Thomas R. Insel, MD, wrote in an April 29, 2013 blog post about the DSM-5:

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a "Bible" for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been "reliability" – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity ... Patients with mental disorders deserve better.

Insel also discussed an NIMH effort to develop a new classification system, Research Domain Criteria (RDoC), currently for research purposes only. Insel's post sparked a flurry of reaction, some of which might be termed sensationalistic, with headlines such as "Goodbye to the DSM-V", "Federal institute for mental health abandons controversial 'bible' of psychiatry", "National Institute of Mental Health abandoning the DSM", and "Psychiatry divided as mental health 'bible' denounced". Other responses provided a more nuanced analysis of the NIMH Director's post.

In May 2013, Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, MD, president of the American Psychiatric Association, that emphasized that DSM-5 "... represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5." Insel and Lieberman say that DSM-5 and RDoC "represent complementary, not competing, frameworks" for characterizing diseases and disorders. However, epistemologists of psychiatry tend to see the RDoC project as a putative revolutionary system that in the long run will try to replace the DSM, its expected early effect being a liberalization of the research criteria, with an increasing number of research centers adopting the RDoC definitions.

Inequality (mathematics)

From Wikipedia, the free encyclopedia https://en.wikipedia.org/wiki/Inequality...