This article deals with a resonance of the concepts of legal-moral-law between two time periods.
The first time period is the 5th century BC in Athens, a century in which many famous thinkers came to Athens, contributing to a great exchange of ideas and thus laying the foundations of theoretical thought and hence of philosophy and science as they are known today. Among these thinkers were the Sophists, who developed rational thought and rhetoric, and questioned the establishment of the time. Among their disputes was the origin of laws.
The other time period is the present. At present time, the article will focus on the formulation of the DSM clinical criteria (an important clinical and scientific research tool) which are a type of modern psychiatric law and were created with the aim of facilitating a common language between psychiatrists, thus helping to improve therapeutic practice. However, these initially good intentions have also led to distortions, according to Allen Frances, author of the book “Saving Normal: DSM-5, Big Pharma and the Medicalization of Ordinary Life”. Correspondingly, distortions had also arisen from the (otherwise) revolutionary development of thought with the teachings of the Sophists.
Key-Words: Sophists, DSM, Allen Frances, over-diagnosis, medicalization
The Sophists were inspirational thinkers in ancient Athens in the 5th century BC, with great encyclopedic education and acute and restless spirits. They were regular teachers of the artful use of discourse, which is rhetoric, and linked rhetoric to political action and paid remuneration to young people who wanted to learn how to be able to think and speak well in court (a kind of higher education) and to be actively involved in political life. They were also curious to find answers to questions about various other aspects of life.
Therefore, the Sophists were teachers of all kinds of knowledge and in particular of knowledge of political matters, and held that virtue could be taught, contrary to the hitherto aristocratic conception. Various Sophists, Socrates and Plato included (427-347 BC), were not only accused of being paid for their teaching, but also for suggesting new ideas! As a result, their works almost disappeared, but their ideas were developed to be challenged by Plato in his dialogues and so, they became known to us.
The questions that the Sophists asked were:
-Should nature or law determine people’s relationships?
– Is justice a social contract? Who defines what is considered fair?
– Is virtue inherent or acquired?
-How is it expressed and seen?
-What is the importance of knowledge as opposed to faith?
-What about the power of proof and persuasion?
The Position of Protagoras
According to Plato, in the “Protagoras” dialogue, Zeus sent Hermes to bring two moral virtues to humans so that the human species would not be wiped out by civil strife and so that the development of political consciousness and bonds of friendship and union between humans could emerge. These virtues were “Diki” (sense of right and justice) and Aidos (modesty, shame and respect for others). Protagoras stresses the primacy of the “law” of the state over the “nature” of the state. The “legal” state is the result of progressive and changing cultural developments. The “law” man is superior to the natural man, who lives according to his instincts.
In Thrasimachos’ view, justice is “the interest of the strong”. He believed that justice is “the advantage of the strongest”, that is to say that the law is a weapon in the hands of the strongest and that law is the law of the strongest; therefore the governing body of each city enacts laws that are related to its own interests, according to the current system of government, and this is called justice. The laws, therefore, are first imposed on the people by the sovereign class for the sole purpose of its benefit. Injustice is therefore “the strongest, most free and most dominant of justice”. Thus, justice is a noble folly and injustice is virtue and wisdom, and ultimately the weak are compelled to serve the powerful by damaging themselves.
Other Sophists, such as Hippias and Antifontas, also believed that law violated the moral order of equality.
“Law” or “Nature”
According to the previous information, “Nature” is in conformity with the biological functions and needs of man, whatever man would spontaneously adopt if he were not bound by social contracts. Whereas ‘Law’ is anything but conventional, which is the result of common acceptance, direct or indirect (language, laws, moral values and rational categories). “Law” is also what we say in our words as opposed to the rules we can apply “acting”. Nevertheless, the law (as an expression of law and right) is determined either by the powerful/aristocrats or generally the ruling class and expresses their views, ambitions and interests. Ultimately, the concept of measure, balance and connection with the common good determines whether the law will benefit or harm.
The Psychiatrist Allen Frances
Allen Frances was Head of the Department of Psychiatry at Cornell University and served as Chair of the Department of Psychiatry at Duke University School of Medicine in 1991. He was born in 1942.
His successes include his participation in the preparation of the DSM-III Diagnostic and Statistical Manual of Mental Disorders (1980) and DSM-III-R (1987). In addition, he led the DSM-IV Working Group (1994), and subsequently criticized its successor, the DSM-5 (2013). He expresses personal views on US clinical practice and reality, but his skepticism has been accepted by a significant number of specialists and stakeholders.
Data about the DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the updated 2013 edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association (APA*). In the United States, DSM is the basis for psychiatric diagnoses. Treatment recommendations, as well as payments by healthcare providers, are primarily determined by DSM classifications and diagnoses.
-Various bodies have criticized the fifth edition, both before and after its publication. Critics claim, for example, that many revisions or additions to the DSM-5 lack empirical support, reliability is low for many disorders, many sections contain scribbled, confused or contradictory information and the psychiatric industry has unduly influenced the content of the manual.
-Many of the DSM-5 Working Group members had conflict of interest, including links with drug companies. Several scientists have argued that the DSM-5 forces clinicians to discriminate against unreliable evidence, discrimination that has a significant impact on treatment, including prescription medication and available health insurance coverage.
-The general criticism of the DSM-5 eventually resulted in a petition, signed by many mental health organizations, calling for the DSM-5 to be reviewed.
Allen Frances’ Objections to the DSM-5 Criteria
- The number of criteria, the duration and the total burden are three key factors where, should there be any reduction in the one, leads to over diagnosis.
- Non-connection with reason plus the recent past.
- Permanent or escalating diagnosis.
- Hippocrates: “It is more important to know the patient who is suffering from the disease, the human being himself, and not only the disease he has.”
- Possible omission of incident vs. over-diagnosis.
- Diagnosis links to chronic drug intake.
Objections to Reasoning and Priorities
– There was enthusiasm over the discovery of new clinical entities and definitions of new diagnoses, but without credible investigation and evaluation (literature reviews, data analyzes and field trials). The ambition of the editorial board was also to apply and transfer neuroscience data to clinical practice
– Diagnostic suggestions were adopted by specialists in individual clinical fields and specialized university clinics, where there were other data such as selectivity, time, specialized personnel, for instance, supporters of early intervention for psychosis, and therefore early diagnosis, such as the Australian psychiatrist Patrick McGorry. These frameworks, however, are far from everyday clinical practice, both in the subtle diagnostic methods and during the diagnostic phase, and in the availability of skilled and experienced staff.
– Finally, one last point was the close relationship of the last committee and the lack of transparency, unlike the previous committees, which prevented the filtering and processing of different opinions.
DSM-IV (Diagnosis 383) and DSM-5 (Diagnosis 541)
As Frances himself describes:
“We told people working at DSM-IV that they needed to prove with accurate literature and a lot of data analysis that any change would not be harmful but would prove positive. In the end, 2 of the 94 proposals were accepted”.
“My concern about the DSM-5 was that the leaders gave the exact opposite instructions: Start the diagnostic system from the beginning and be as creative as possible. After 40 years of working for DSM, I’ve realized that if something can be used in the wrong way, it will be, especially if there is financial benefit (to pharmaceutical companies).”
“… and stage 2 of quality control was never used…”
Correct Diagnosis of Few with Over – Diagnosis of Many = Diagnostic Inflation
The DSM-5 working group focused on early detection and treatment, broadening and generalizing the criteria, while Frances warned of diagnostic inflation, over diagnosis and reduction of the limits of regularity.
The reduction in thresholds for the diagnosis of existing disorders (ADHD disorder, autism, addictions, personality disorders, bipolar II disorder) was also disturbed by the addition of new (possibly commercial) disorders, such as impaired mood disorder or psychotic disorder, which were fortunately modified.
However, questions and concerns remain about criteria and diagnoses, such as: infant outbursts (dysregulated mood disorder), affective disorders (children / adolescents), ADHD, autistic spectrum disorders, mild neuropsychiatric disorders, physical disorder, behavioral addiction etc.
Formal Institutional Reactions
Noteworthy is the decision of the Belgian Superior Health Council (LANSET, September 2019) which advises against the use of DSM-5 classifications and proposes a more comprehensive 5-stage assessment. An important detail is the composition of the board, which consists of a variety of participants, not only mental health experts.
The report has five key recommendations targeted at clinicians, policy makers, and the general public:
- Default non-problematizing and non-medicalizing approaches to mental complaints or crises because they may express existential and social problems.
- Careful attention paid to subjective experiences.
- Providing assistance and support for mental complaints or crises without a formal diagnosis as a precondition.
- Taking into account the perspective of people with mental complaints or crises and the way in which they give meaning as a central role to diagnosis and treatment.
- When formulating a case, paying close attention to the person-specific way in which, among other things, mental, existential (giving and losing meaning), biological, social, and cultural factors take shape.
The Role of Pharmaceutical Companies
The British doctor, Oxford academic and clinical researcher, GOLDACRE BEN in his book “BAD PHARMA, THE GAMES PLAYED BY PHARMACEUTICALS” refers to (besides many other “dark” issues connected to drugs) the term of ‘medicalization’, meaning the widening of the medical diagnostic categories, devising new diagnoses and converting normal expressions of the human experience into pathological ones so that they can be treated with pills.
Allen Frances also refers to the same phenomenon and the way that the pharmaceutical industry, through marketing, mentoring physicians, carriers, patient associations, and the public, used over-diagnosis to produce over-profit and was sometimes charged significant fines, which, of course it could easily afford to pay! It goes without saying that medicines are needed and used for cure and also that pharmaceutical companies are not charities, but there needs to be better state control, reliability, objectivity and limits.
Conclusions: Moderation and the Common Good
-The first Sophists were concerned about who set the laws (the powerful), but also about the value of laws for the smooth living of people. They also taught the meaning of virtue. Later Sophists, using rhetorical art, taught their students how to dominate and impose their ambitions and personal interests on others. That is, they used a revolutionary way of thinking, which opened new horizons of thought, for immoral and self-serving purposes with the aim of deceiving, and this is what today’s modern marketing is doing to sell its products.
-The DSM was organized to have a common language among experts and to improve credibility. This was mainly the case with the DSM-III which worked well. In the process, however, through personal ambitions, over-simplification and self-interest, it ended up threatening the notion of normal and saw “disturbances” everywhere, so it lost the plot. At the same time, the pharmaceutical industry earns significant profits. The result is that resources (benefits, medicines) are distributed to many who do not need them, while those who really need them do not receive them.
Allen Frances tried to strike a balance between reality, morality and objective data, so he asked for the truth, as the early Sophists and Plato did, and criticized the thinking behind, the power, the results and the general use of the newer tool (law) DSM-5 of the ruling class, that is ARA *.
The issue, ultimately, lies in the fine balance needed to make the clinical, institutional framework work both qualitatively and quantitatively. In other words, the difficult balancing of the two key pillars coupled with the need for regulatory policy decisions:
-Quality: principles / ethics / offer
-Quantity: new reliable data / financial / management
-“Beyond the DSM: The Perspectives of Psychiatry Approach to Patients” Matthew E. Peters, MD; Jacob Taylor, BA; Constantine G. Lyketsos, MD, MHS; and Margaret S. Chisolm, MD 2012 PHYSICIANS POSTGRADUATE PRESS
-“Η διάσωση του Φυσιολογικού. DSM-5 το δριμύ κατηγορώ ενός Ψυχιάτρου” or “Saving Normal: DSM-5, Big Pharma and the Medicalization of Ordinary Life ” ALLEN FRANCES MD, Εκδόσεις Τραυλός 2014
-“BAD PHARMA, Τα παιχνίδια που παίζει η φαρμακοβιομηχανία” Goldacre Ben, 2014, εκδόσεις Μεταίχμιο
-“Διαγνωστικά Κριτήρια από DSM-5” AMERICAN-PSYCHIATRIC-ASSOCIATION* , Ιατρικές εκδόσεις Λίτσας, 2015
-“Οι μεγάλοι σοφιστές στην Αθήνα του Περικλή” Romilly Jacqueline, 1994, Εκδόσεις Καρδαμίτσα
-“Οι Σοφιστές” W. Gurthie, 2003, Εκδόσεις ΜΙΕΤ