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Dr. Allen Frances: July 2012 Archives

July 2012 Archives

Mass Murders, Madness and Gun Control

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The US has averaged two episodes of mass murder a year for the past 15 years. And the odds are good that we will carry this sorry record forward forever into the future. Each tragedy provokes a predictable round of shock, grieving, soul searching, and finger pointing. Why would someone do something so crazy? Who missed what warning signs? Why weren’t the victims better warned or better protected? What can we do to prevent this type of awful tragedy from constantly recurring?

Everyone is intensely interested in the psychology of the killer. There is a presumption that if we can understand the mind of the mass murderer, then perhaps we can prevent the mass murders. This is dead wrong. Psychiatry has no way of predicting or preventing rare and fairly random acts of senseless violence — it is simply impossible to find needles in haystacks. We must accept the fact that a small cohort of deranged and disaffected potential mass murderers will always exist undetected in our midst. The only questions are how often will these ticking time bombs go off and how much damage will they do when detonated.

The largely unnoticed elephant in the room is how astoundingly easy it always is for the killers to buy supercharged firearms and unlimited rounds of ammo. The ubiquity of powerful weaponry is what makes the US such a dangerous place to live. Guns do kill people and the number of people depends on the number of guns and the number of rounds they can fire in a given period of time. Successful political scare tactics have buried open discussion of the most obvious of simple truths — that the wide circulation of powerful semi-automatic weapons will inevitably result in a lot of preventable deaths. So don’t be at all surprised when there are a couple of mass murders every year — it is built into our current system. The US has the one of developed world’s worst statistics for mass murders and gun deaths because we have so many powerful guns floating around and gun laws that allow murderers easy access to them.

Add to the mix the egregiously vitriolic and verbally violent discourse of demagogic politicians and talk show hosts, egging on those vulnerable to physical violence and providing them with a seeming justification for their callous brutality. And I wonder about the collective conscience of those working in the video game and movie industry who have promoted a grotesque culture of violence. 

There is no psychiatric solution for mass murder. Armchair analyses of the individual culprits are interesting (but harmful) distractions. We really have only two choices: 1) accept mass murder as part of the American way of life, or 2) get in line with the rest of the civilized world and adopt sane gun control policies. The smart money is betting on the gun lobby and Hollywood — and betting against the future victims and their families. 

Two Who Resigned From DSM-5 Explain Why

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Roel Verheul and John Livesley both felt compelled to resign from the DSM-5 Personality Disorders Work Group. Here is an email from them describing what went wrong in the preparation of this section: 

"We resigned from the DSM-5 Personality and Personality Disorder Work Group in April 2012 with a mixture of sadness and regret. We believed that the construction of DSM-5 afforded an important opportunity to advance the study of personality disorder by developing an evidence-based classification with greater clinical utility than DSM-IV. T he data and conceptual tools for such an undertaking have been available for some time and the field seemed to recognize the need for change. Regrettably, the Work Group has been unable to capitalize on the opportunity and has advanced a proposal that is seriously flawed. It has also demonstrated an inability to respond to constructive feedback both from within the Work Group and from the many experts in the field who have communicated their concerns directly and indirectly. We also regret the need to resign because we were the only International members of the Work Group which is now without representation from outside the US.

“Early on in the DSM-5 process, we developed major concerns about the Work Group's mode of working and its emerging recommendations that we communicated to the Work Group and Task Force. We did not resign earlier because we continued to cherish the hope that eventually science and common sense would prevail and that there would be an opportunity to construct a coherent, evidence-based classification that would help to advance the field and facilitate patient care. In the spring of this year, it became apparent that is was not going to happen. We considered the current proposal to be fundamentally flawed and decided that it would be wrong of us to appear to collude with it any longer.

“As we see it, there are two major problems with the proposal. First, the proposed classification is unnecessarily complex, incoherent, and inconsistent. The obvious complexity and incoherence seriously interfere with clinical utility. Although the proposal is touted as an innovative and integrative hybrid system, this claim is spurious. In fact, it consists of the juxtaposition of two distinct classifications (typal and dimensional) based on incompatible models without any attempt to reconcile or integrate them into a coherent structure. This structure also creates confusion since it is not clear whether the clinician should u se one or both systems in routine clinical practice.

“Second, the proposal displays a truly stunning disregard for evidence. Important aspects of the proposal lack any reasonable evidential support of reliability and validity. For example, there is little evidence to justify which disorders to retain and which to eliminate. Even more concerning is the fact that a major component of proposal is inconsistent with extensive evidence. The latter point is especially troublesome because it was noted in publication from the Work Group that the evidence did not support the use of typal constructs of the kind recommended by the current proposal. This creates the untenable situation of the Work Group advancing a taxonomic model that it has acknowledged in a published article to be inconsistent with the evidence.

“For these and other reasons, we felt that the only honest course of action was to resign from the Work Group. The current proposal represents the worst possible outcome: it displays almost total discontinuity with DSM-IV while failing to improve the validity and clinical utility of the classification. Not surprisingly, the proposal has received widespread criticism to which the Work Group seems impervious."

As it stands now, the DSM-5 personality section is not readable, much less usable. It will be ignored by clinicians and will do grave harm to research. This is the sad product of small group of cloistered DSM-5 "experts" stubbornly ignoring the sharp criticism from within their own group and the near universal rejection of their proposals by everyone else in the field. Drs. Verheul and Livesley have performed a service in trying to stop this runaway train and in now explaining how it went off the tracks. 

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