Deceit and transparency in Placebo Research

Studies designed to elicit the full strength of the placebo effect differ from those in which the placebo effect represents a nuisance factor to be accounted for in order to establish the efficacy of a treatment. In the latter, informed consent is the rule; in the first, while consent may be informed in some narrow sense of the word, deception is common. However, the trickery of placebo experimentation goes beyond straightforward lies to include the use of crafty ambiguities, half-truths, and deliberate omissions in scripts read to the subjects of these studies. As words come to resemble therapeutic agents in their own right, it is only to be expected that researchers would methodically exploit verbal effects to evoke the responses they are looking for. Even experiments in which placebo is disclosed as placebo have used language in leading and misleading ways. Such studies are conducted in the hope of yielding results that might translate into clinical practice, but it should be noted that good clinical practice has a placebo value of its own — that is, confers a benefit over and beyond the specific effects of treatments — even if nothing like a sugar pill is administered

Buried in Silence: Homosexuality and the Feighner Criteria

The diagnostic revolution that culminated in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (1980) began with the publication in 1972 of the Feighner criteria, a set of rules for the identification of 16 disorders. While Feighner et al. claim that their diagnostic categories rest on solid data, the fact is that one was soon to be removed by the APA from its classification of mental disorders: homosexuality. However, the anomaly of an extinct category in a list of supposedly validated diagnostic criteria never became a point of discussion, quite as if the topic were unmentionable. It was in fact even more of an embarrassment than either side in the homosexuality debate seems to have realized at the time. Upon examination, the evidence offered by Feighner et al. in support of the diagnosis of homosexuality proves to be nil. Had there not been an informal embargo on discussion of the status of homosexuality in the Feighner document, the makers of DSM-III might have recognized that the diagnosis fails all Feighner tests of validity. Had they attached greater importance to these tests, the concept of a disorder that was built into DSM-III might have taken a different shape

In Defense of Frederick Crews

First paragraph: In her review of Frederick Crews’s Freud: The Making of an Illusion Lisa Appignanesi argues that Freud’s talking cures, while not working miracles, were innocuous compared to the harm done under the regime of the American Psychiatric Association’s Diagnostic and Statistical Manual even now. While I share Lisa Appignanesi’s concern over the misapplication of diagnostic labels and the over-prescription of psychoactive drugs, it should be noted that the interpretive liberties taken by the psychoanalysts who ruled American psychiatry as late as the 1970’s had much to do with the rise of the DSM diagnostic system as we know it. Instituted in DSM-III in 1980, this system proclaimed an “atheoretical” stance toward etiology, in direct reproach of the psychoanalytic practice of etiological speculation. As Nancy Andreasen, a member of the DSM-III Task Force and later the editor-in-chief of the American Journal of Psychiatry, wrote in retrospect, it was the recognition “that the psychodynamic emphasis had gone too far, leading to diagnostic imprecision,” that led to the making of DSM-III

James Lind and the Disclosure of Failure

The James Lind Library, an online repository of documents pertaining to the history and design of the clinical trial, records a number of cases in which a critic of the institution of medicine challenges the profession to a test of rival treatments. It was in this spirit that Bishop Berkeley (1685-1753) dared physicians to test their treatments for smallpox against his favored remedy, tar-water, under similar conditions. Like several other proposed trials of which we have a record, the tournament envisioned by Berkeley never took place. In the year of Berkeley’s death, however, the world learned of an actual test of rival treatments under controlled conditions that had gone unreported and therefore unnoticed for half a decade

Storm Clouds: The “Warning Signs” Fallacy

First paragraph: Soon after Maj. Nidal Malik Hasan shot to death 13 and injured many more at Fort Hood, Texas, on November 5, 2009, reporters and commentators began to wonder aloud whether warning signs of the homicidal outburst had been ignored. “Officials may not have heeded warning signs,” declared a headline in the Washington Post of Nov. 7. According to an article in the New York Times on Nov. 9, the FBI and the Army may be guilty of “missing possible warning signs that might have stopped a mass killing.” Whether or not such a massacre was predictable, the retrospective invocation of warning signs seems to take place regularly—predictably—in the aftermath of mass murder. Within a day of the massacre at Virginia Tech in April 2007, CBS News already had an article on its website headlined, “Warning Signs from Student Gunman.” Appended to the report of the Virginia Tech Review Panel, likewise, is “a list of red flags, warning signs and indicators.” It is as if the ritual repetition of a phrase served to buffer the shock of events. However, the notion that shocking events are preceded by legible warnings, and could therefore have been prevented if only the warnings were heeded, obscures the self-evident truth that it is easier to predict events after they have occurred