The thesis of the article was simple: though the content of schizophrenic delusions changes wildly in different cultural contexts, there’s an underlying motivation for them that never varies and produces a fundamental sameness.
The simple, constant thing is that delusional schizophrenics lose the capability to identify all the thoughts in their head as belonging to themselves. In an effort to make sense of their experience, they invent elaborate theories which attribute their disconnected thoughts to external agencies. Gods, demons, orbital mind-control lasers — the content of such delusions varies wildly, but the function is always the same — to restore a sense of causal order to the schizophrenic’s universe, to impose a narrative on the eruptions that he or she can no longer recognize as “self”.
It’s a startling shift in perspective to realize that the construction of schizophrenic delusions arises from the same drive that yields scientific theory-building. Both are Heideggerian rearrangements of the cognitive toolkit, strategies driven by the necessity of coping with the experienced world. The schizophrenic’s tragedy is that the most important fact about his or her experiential world (how much of it is self looking at self) is inaccessible.
Eric S. Raymond, “Sometimes I hear voices”, Armed and Dangerous, 2013-10-06
March 2, 2014
QotD: The voices are coming from inside your head
January 4, 2014
By DSM-5 standards, most of us are suffering from personality disorders
From the last issue of the City Journal, Theodore Dalrymple‘s critique of the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes a rather wide-ranging diagnosis that applies to a huge number of people:
The overlap between straightforwardly pathological conditions (in Szasz’s sense) and those that result from social, psychological, or personal factors, or from bad moral choices, suggests that psychiatrists should show discretion in what they regard as genuine illness. The state of ignorance in which psychiatrists now practice, which will probably endure, ensures that they will often be wrong; but no one who has encountered, say, a manic in full flight is likely to doubt that he is in the presence of illness. But nor would it be easy, then, to see so-called factitious disorder, which consists of “falsification of physical or psychological signs and symptoms, or induction of injury or disease, associated with identified deception” in quite the same light: that is, to grant the same status to someone pretending to be ill as to someone genuinely ill.
Yet this is precisely what the DSM-5 does, establishing its authors’ lack of common sense, the quality that psychiatrists, perhaps more than any other kind of doctor, need. The manual’s lack of common sense would be amusing were it not destined to be taken with superstitious seriousness by psychiatrists around the world, as well as by insurers and lawyers.
The section of the volume devoted to personality disorders proves the point. Among the criteria for personality disorders in general are the following:
A: An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, in fields such as thought, emotion, interpersonal relations and impulse control . . .
B: The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C: The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning.
D: The pattern is stable and of long duration.
The DSM-5 then informs us that more than one in seven people have such a lifelong disorder — adding up to 45 million Americans and even more Europeans. These astonishing numbers give the authors not a moment’s pause (any more than does the fact that their own prevalence rates suggest that the average American suffers from more than two psychiatric disorders in any one year). Several undesirable characteristics must be present in an individual for a diagnosis of personality disorder to apply. Considering those characteristics, and that such a significant portion of the Western population supposedly exhibits many of them, either a mass outbreak of human nastiness and inability to deal with everyday life must have occurred, or the whole business of diagnosis must be dubious or even ridiculous.
Here is a random list of some of the characteristics that, in the DSM-5, make up personality disorders of various kinds:
Unjustified suspicions that others are harming, exploiting or deceiving.
Persistently grudge-bearing.
Detachment from social relations and limited expression of emotion.
Behavior or appearance that is odd, eccentric or peculiar.
Deceitfulness.
Persistent irresponsibility.
Indifference to risk to self or others.
Irritability and aggressiveness.
Lack of remorse.
Recurrent suicidal behavior, gestures or threats, or self-mutilation.
Inappropriately intense anger, frequent displays of temper.
Rapidly shifting and shallow expressions of emotion.
Use of physical appearance to draw attention to self.
Self-dramatization, theatricality.
Grandiosity.
Requirement for excessive admiration.
Sense of entitlement.
Interpersonal exploitativeness.
Lack of empathy.
Enviousness of others.
Arrogance and haughtiness.
Unwillingness to become involved with people.
Sense of social ineptitude and inferiority.
Avoidance of risk.
Difficulty in expressing disagreement with others because of fear of disapproval, i.e., pusillanimity.
Feeling of helplessness when alone.
Preoccupation with details, rules, lists, order, organization or schedules.
Excessive devotion to work.
Over-conscientiousness or scrupulousness.
Reluctance to delegate.
Rigidity and stubbornness.
The diagnoses for most of the disorders require at least four of the undesirable characteristics to be present, predominant, and persistent. One is reminded of the King of Brobdingnag’s view of Gulliver’s countrymen: “I cannot but conclude the bulk of your natives to be the most pernicious race of little odious vermin that nature ever suffered to crawl upon the surface of the earth.” Lest anyone object that “only” one in seven people suffers from personality disorders, and that therefore the King of Brobdingnag’s opinion of Western humanity — that it suffers from the “worst effects that avarice, faction, hypocrisy, perfidiousness, cruelty, rage, madness, hatred, envy, lust, malice, and ambition, could produce” — is not relevant, one must add that, for the DSM-5, people with personality disorders are merely the most extreme exemplars of their type. And if only the extremes have four or more undesirable and frequently horrible dominating characteristics, many individuals must have one, two, or even three such characteristics. If the DSM-5 reflects the American Psychiatric Association’s views, then that organization clearly views humanity with Swiftian distaste. Yet its distaste is not that of a disappointed lover (and certainly not expressed with Swift’s genius) but is motivated, one suspects, by the hope of an endless supply of patients. For those with psychiatric disorders need psychiatrists.
December 23, 2013
Psychiatry does not seek “to colonise everyday life – rather, everyday life now invites colonisation by psychiatry”
In Spiked, Sandy Starr reviews Gary Greenberg’s recently published The Book of Woe:
There is an inevitable contingency about diagnostic categories, particularly when it comes to psychiatry. Greenberg argues that for all the useful work that goes into constructing these categories, psychiatric diagnosis has a ‘self-validating nature…by which once you’ve created a diagnostic category, the fact that people fit into it becomes evidence that the disorder exists’. Greenberg reminds us that ‘while many diagnoses are made on clinical signs and symptoms rather than on lab tests or other external validators, only in psychiatry are all diagnoses made that way’.
It’s worth adding that this may be changing. As psychiatry seeks to predicate itself more and more upon genetics and neuroscience, there are expectations in some circles that biochemical diagnostic tests for psychiatric disorders will follow ineluctably. This prospect does not reassure me. Psychiatry is attempting the difficult feat of relocating its foundations without toppling its façade, and this involves elisions — several of which are discussed by Greenberg — that leave me feeling less persuaded of the profession’s credentials, not more.
[…]
That said, one can certainly appreciate the need for psychiatry to appear coherent and confident, given the far-reaching consequences of the DSM’s contents. Greenberg explains, for example, how the use of a single ‘and’ where an ‘or’ might have been used, in the definition of ‘paedophilia’ that made its way into the fourth edition, inadvertently made it far easier for US authorities to detain indefinitely (on psychiatric grounds) people who had been convicted of sexual offences against minors. In other words, a single use of the word ‘and’ in the DSM led to a complex domain of morality and law — the culpability (or otherwise) of people charged with sexual offences in various circumstances, and proportionate sentencing for their crimes — becoming subordinate to the considerations of psychiatry.
[…]
‘Once you start to think of your troubles as a disease, your idea of yourself, which is to say who you are, changes’, warns Greenberg. But while psychiatry gives a diagnostic imprimatur to our expectations of ourselves and of one another, psychiatry is not solely capable of bringing about a wholesale alteration of these expectations. To understand what else might account for a psychiatric turn in society, one needs to recognise that we live in a culture in which our adult capacities are constantly denigrated, in which victimhood has become one of the few widely recognised sources of authority, and in which we are constantly encouraged from all directions not only to put our problems on public display (rather than addressing them within the intimate confines of trusted friends, family or — in extremis — psychotherapists or even psychiatrists), but also to assume that our problems will most likely afflict us in perpetuity.
It’s not so much the case that psychiatry now seeks to colonise everyday life — rather, everyday life now invites colonisation by psychiatry. In circumstances such as these, even the most well-meaning and scrupulous psychiatrist might struggle to parse the suffering and idiosyncrasy they encounter, so as to partition it sensibly into the pathological and the normal. Greenberg’s barbs against psychiatry may be well deserved, and are certainly grounded in tantalising insider detail and no small amount of wit. But they represent an incomplete picture of the dynamics he sets out to get to grips with, which lie outside the institution of psychiatry as much as they lie within.
December 10, 2013
Manufacturing crime
Charles Cooke on the ATF working hard to create new criminals through elaborate entrapment schemes:
The U.S. Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) is probably best known these days for the failure of its disastrous Fast and Furious scheme — a botched initiative that aimed to give American guns to Mexican cartels first and to ask questions later. Under pressure, the administration was quick to imply that the mistake was an aberration. But a watchdog report, published last week by the Milwaukee Journal Sentinel, suggests that the caprice, carelessness, and downright incompetence that marked the disaster was no accident. In fact, that it is endemic in the ATF.
After a bungled sting attracted the suspicion of the Milwaukee press earlier this year, reporters started to examine similar enterprises in the rest of the country. What they found astonished them. Among the tactics they discovered ATF agents employing were using mentally disabled Americans to help run unnecessary sting operations; establishing agency-run “fronts” in “safe zones” such as schools and churches; providing alcohol, drugs, and sexual invitations to minors; destroying property and then expecting the owners to pick up the tab; and hiring felons to sell guns to legal purchasers. Worse, perhaps, in a wide range of cases, undercover agents specifically instructed individuals to behave in a certain manner — and then arrested and imprisoned them for doing so. This is government at its worst. And it appears to be standard operating procedure.
As with Fast and Furious, the primary objective of the ATF’s stings seems not to be to fight a known threat but instead to manufacture crime. Across the country, the agency has set up shops in which it attempts to facilitate or to encourage illegal behavior, and it has drafted citizens into the scheme without telling them that they were involved. It is fishing — nonchalantly, haphazardly, even illegally. And the consequences can go hang.
[…]
At best the ATF’s new techniques constitute illegal entrapment. At worst, they are downright tyrannical. Entrapment is legally permitted if a suspect initiates a crime in the presence of an undercover agent or if he can reasonably be deemed to have been predisposed to commit the crime when offered an opportunity to do so. But it is difficult to see how either of these tests is being met in the Bruner case or in others. Indeed, cases using entrapment are often thrown out of court if the government is seen to have put too much pressure on a suspect or to have made breaking the law so easy or attractive as to render restraint impossible. Per the paper’s report, ATF tactics involved offering ridiculous prices for firearms to attract straw purchasers, requesting that suspects buy specific firearms that carry tougher sentences, or, as it did in one case, showing a known felon how to saw off a shotgun so that they could charge him with a more serious violation when he did it. Will anyone claim that these tactics are legal?
That they are immoral, too, needs less spelling out. Because no formal arrangements were made with the individuals whom the agency selected for involuntary cooperation, there were no means by which they could claim protection for their behavior after the fact. In other words: The federal government knowingly ruined their lives without telling them. And for what? Well, apparently to try to pick low-hanging fruit.
November 28, 2013
QotD: The gun-control debate
I begin rather skeptical of most gun-control proposals. The ones that are pitched in the aftermath of mass shootings are particularly cynical, as they often attempt to regulate circumstances unrelated to the shooting. I still grind my teeth at Mayors Against Illegal Guns running ads in my state citing the Virginia Tech shooting, and talking about the need to shut the “gun show loophole” — even though the shooter didn’t obtain his weapons at a gun show. These sorts of arguments strike me as one part craven opportunism, one part feel-good placebo. (I wanted to say “panacea,” but panacea actually means a genuine cure-all.)
If someone wants to propose a new restriction on gun ownership after a tragedy, and cites that tragedy as a reason to pass it, it’s necessary to show how that new restriction would have prevented, mitigated, or impacted that tragedy. For example, almost none of the gun laws proposed after Newtown would have changed much of anything in that awful shooting, as that disturbed young man stole his mother’s legally purchased guns.
I suppose there are two potential changes to the law that would have significantly altered events in Newtown. First, a total ban on private ownership of firearms, which our friends in the gun-control movement keep insisting isn’t their goal.
Second, a restriction on gun ownership by people who live under the same roof as a person who’s deemed mentally incompetent or a threat to himself or others. Of course, then you get into the questions of what constitutes, “mentally incompetent or a threat to himself or others,” what constitutes “under the same roof”, etc.
Then there are the proposals to limit how many rounds each gun can fire before reloading. Almost every spree shooter — we need a better term for this — has had more than one firearm when they’ve launched their attacks. Instituting 10-round limits would mean that future shooters would get off 20 shots before pausing to reload, presuming they only brought two guns. It’s reasonable to conclude future mass killers will just bring three or four guns when they begin their rampage. This strikes me as a quite modest mitigation in the danger of these shooters, too modest to seriously consider.
Jim Geraghty, “Why Post-Shooting Gun-Control Debates Are So Insufferable”, National Review Online, 2013-09-18
September 19, 2013
QotD: Guns and mental illness
There isn’t much of a culture-war component of discussing mental illness, other than a few folks on the Right who blame the Left for deinstitutionalizing the mentally ill in the 1960s. I suspect that there is no real constituency in favor of the Second Amendment rights of the mentally ill — provided, of course, the definition of “mentally ill” is clear, explicit, and taken seriously. (If you think there’s a stigma to admitting you’re seeing a therapist, a psychologist, or getting mental health treatment now, just wait until some of your legal rights can be restricted because of it.)
Thankfully, I’ve never known anyone who has had violent episodes or threatening mental illness. My sense of reading coverage and the literature is that people rarely “snap” and become dangerous killers overnight. As you’ve probably found in your research, there are certain common threads: withdrawal from others and lack of a support network; hostile behavior and temper control, outbursts, etc. It is maddeningly infuriating to hear friends and acquaintances of past shooters describe behavior that seems, in retrospect, to be a warning sign or red flag.
After Columbine, many school administrators tried to institute a new “If you see something, say something” approach to individuals behaving in a threatening manner. Then we saw in Virginia Tech that many, many students reported the gunman for strange and threatening behavior, including stalking. School administrators ultimately couldn’t do enough to stop him — either from fear of lawsuits or from overall bureaucratic inertia.
[…]
It’s not clear how effective a program like this would be; one would hope that people would already know to report strange, troubling, or threatening behavior to authorities. In past writings, I’ve emphasized that the only authority that can put someone on the federal firearms restriction list is a judge, and so that these sorts of concerns are best sent directly to the cops, not to a school administrator or company HR department.
However, a country where more Americans are trained to spot signs of serious, untreated and potentially dangerous mental illness strikes me as a better path than yet another effort to restrict the rights of 40 million gun owners because of the actions of a handful.
Jim Geraghty, “Why Post-Shooting Gun-Control Debates Are So Insufferable”, National Review Online, 2013-09-18
August 2, 2013
First it was bulemia, then anorexia, now it might be “orthorexia”
It’s nice to know that people in the richest culture in world history can still manage to make themselves utterly miserable by obsessing about things:
Picture this: After spending the summer indulging in ice cream and cocktails, you decide to embrace healthy eating. You cut out refined sugar and packaged food-the kind of nutrient-free junk on any doctor’s warning list. Wheat and dairy are the next to go.
People compliment you on your weight loss; your energy levels rival those of Jillian Michaels. But soon your innocent health kick takes a strange turn. Certain foods – even fruits and veggies – begin to seem dangerous, even unclean.
Within months, you’ve whittled your list of “acceptable” foods down to almost nothing.
This unhealthy fixation with eating healthfully is called “orthorexia nervosa,” a term coined by Dr. Steven Bratman, a Colorado-based physician, in 1997. Since then, orthorexia rates have spiralled in tandem with society’s insistence upon knowing every last detail about its food.
Orthorexia (derived from the Greek “ortho,” which means “correct”) often begins with a noble impulse – to get fit or eat organic – that grows into a self-destructive obsession where fewer and fewer foods meet the orthorexic’s increasingly high standards.
The result is everything from malnutrition to social anxiety as orthorexics avoid restaurants and their friends’ kitchens. At its most extreme, orthorexia can even act as a gateway to anorexia, says Merryl Bear, director of Toronto’s National Eating Disorder Information Centre.
“The gateway possibility is very real because the principles are so similar,” she explains. “Like anorexics, orthorexics prize being pure and in control above all else.” (Orthorexia is currently classified as a form of disordered eating, not a clinical eating disorder, in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.)
Since orthorexics value purity, not weight loss, eating becomes a moral act. “A day filled with wheat grass juice, tofu and quinoa biscuits may come to feel as holy as one spent serving the destitute and homeless,” writes Bratman in his book Health Food Junkies: Overcoming the Obsession With Healthful Eating (2004).
H/T to Nicholas Packwood for the link.
Update: Colby Cosh was quick to send me a link to a piece he did on this topic more than a decade ago:
Since becoming a physician, Dr. Bratman has seen many people like his own young self — and some who are worse off — flirting with disaster by depriving their body of vital nutrients. The fads of his youth, far from disappearing, have survived and grown in number: there are even “Breatharians” who believe food to be wholly unnecessary. A few years ago Dr. Bratman coined the phrase “orthorexia” — merging Greek ortho-, meaning righteous, with the stem familiar from “anorexia” — to describe a pathological attachment to dietary theories.
“I never intended the term to be a serious diagnostic entity; you wouldn’t go to a hospital with ‘orthorexia,'” he says. “It’s informal, like ‘workaholic.'” The idea has nonetheless stirred controversy: a Yale University physician sniffed in one critique that “We’ve never had anybody come to our clinic with orthorexia.” Yet fanatical attachment to dietary theories can indeed be hazardous. Macrobiotic diets caused a string of deaths in the 1960s and had to be modified; “metabolic” treatments for cancer, usually involving fasting, occasionally turn disastrous; and vegetarians and vegans must monitor themselves for certain vitamin and mineral deficiencies. In September, an Armenian couple in Surrey, England, were convicted of starving their nine-month-old daughter to death on a “Fruitarian” fruit-only diet.
“People become orthorexic by falling in love with a dietary theory,” says Dr. Bratman. “They run across an idea like macrobiotics or raw-foodism, and embrace it like a religion. We’re not talking about common-sense rules of healthy eating, but theories which reject whole classes of foods and make spontaneous eating [impossible]…There’s a personality type, an obsessive type of person who is prone to embrace them in a quasi-religious way.” This can result in an enticing sense of moral superiority, sometimes coupled with the euphoria associated with partial starvation. But orthorexia also brings crippling feelings of unworthiness after the inevitable slip-ups, when the true believer succumbs to a cookie or a pizza. “There are similarities with anorexia,” he says. “An important one is that anorexics feel like they’ve done something evil when they gain weight, something morally wrong rather than merely unhealthy.” Similarly, the sure sign of an orthorexic is that he associates unhealthy eating with a sense of sin.
July 23, 2013
The rights of the mentally handicapped
In the Washington Post, Theresa Vargas covers the struggles of Margaret Jean “Jenny” Hatch, who is fighting a court case to be allowed to take greater control of her own fate.
It wasn’t her turn to talk, but early on during a hearing that will determine the limits of her independence, Margaret Jean Hatch stood up in a Newport News courtroom and cut the judge off in mid-sentence.
“I don’t need guardianship,” she declared. “I don’t want it.”
“Remove her from the courtroom,” the judge demanded.
“Judge, she’s very upset with this,” the woman’s attorney began.
“Don’t do it,” Hatch pleaded.
Hatch, a diminutive blonde known as “Jenny,” learned to read at the age of 6, has volunteered on political campaigns (always for Republicans) and once, after finding a job she wanted, showed up repeatedly until she got it. She also has Down syndrome, an IQ of 52 and tends to shower affection on strangers as well as friends.
The details of Jenny Hatch’s life have come under scrutiny in a complicated guardianship case that is pitting her wishes against those of her parents and testing the rights of adults with disabilities to choose how they live. The 29-year-old wants to move in with friends and continue the life she had, working at a thrift shop and riding her bike everywhere. Her parents want her to remain in a group home, supervised and protected.
H/T to Tyler Cowen, who writes:
On the basis of what I can glean from this article, I vote for Jenny […]
This is a much-neglected issue, and not just for Down Syndrome individuals. At a time when Edward Snowden, drones, and Gitmo are leading many people to reexamine many civil liberties issues, this one ought to be put on the table as well. It needs its Radley Balko. Ask yourself a simple question: if you don’t require guardianship, and yet have been placed under the legal guardianship of another, practically speaking how strong are your rights? What chances of amendment or redress do you really have and in the meantime how can you represent yourself?
Update, 6 August: The Washington Post reports on the outcome of the case.
In a victory for the rights of adults with disabilities, a judge declared Friday that a 29-year-old woman with Down syndrome can live the life she wants, rejecting a guardianship request from her parents that would have allowed them to keep her in a group home against her will.
The ruling thrilled Jenny Hatch and her supporters, who included some of the country’s most prominent disability advocates.
“Oh my God,” Hatch said over and over again, shedding tears. “I’m so happy to go home today. I deserve it. It’s over. My God, it’s over.”
[…]
Legally, Hatch’s case came down to two questions: Was she an incapacitated adult in need of a guardian, and, if so, who would best serve in that role — her mother and stepfather, or Morris and Talbert?
But for national experts on the rights of people with disabilities, several of whom testified on Hatch’s behalf, the case was about much more. It was about an individual’s right to choose how to live and the government’s progress in providing the help needed to integrate even those with the most profound needs into the community.
In the end, Newport News Circuit Court Judge David F. Pugh said he believed that Hatch, who has an IQ of about 50, needed a guardian to help her make decisions but that he had also taken into account her preferences. He designated Morris and Talbert her temporary guardians for the next year, with the goal of ultimately helping her achieve more independence.
July 22, 2013
Examining post-traumatic stress disorder
In the New Yorker, David J. Morris looks at the psychological chameleon we call PTSD:
As it is understood today, post-traumatic stress disorder is a grab bag of symptoms that emerges after experiencing trauma, like nearly dying or having one’s bodily integrity violated. It includes a persistent sense of hypervigilance and recurrent, intrusive memories of past traumatic events. In the worst cases, veterans with P.T.S.D. may hallucinate the voices of dead comrades, enemy combatants, or their commanding officers. A 1995 study of combat veterans with P.T.S.D. published in Traumatology found that sixty-five per cent of subjects reported hearing voices, including command hallucinations that they felt compelled to obey. As the psychiatrist Jonathan Shay, the author of Achilles in Vietnam: Combat Trauma and the Undoing of Character, put it, “P.T.S.D. can unfortunately mimic virtually any condition in psychiatry.”
But there are a growing number of psychiatrists and researchers who are challenging our understanding of P.T.S.D. — even its very nature as an ailment. Modern psychiatry, they argue, is locked into a mindset that systematically overdiagnoses P.T.S.D. without nurturing veterans’ ability to heal themselves. American culture, meanwhile, vacillates between elevated ideas of hero worship and victimhood in its conception of veterans, which can be destructive to the veterans themselves. One of the chief proponents of this school of thought is Ben Shephard, a leading British historian of military psychiatry. In his provocative book, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century, he describes a historical cycle that governs the treatment of war stress: “the problem is at first denied, then exaggerated, then understood, and finally, forgotten.” Shephard claims that the West, and America in particular, are deeply mired in the exaggeration phase of that cycle. These skeptics of the prevailing model of P.T.S.D. were described in Scientific American as a “broad array of experts indeed, giants of psychology, psychiatry and epidemiology.” One of the major tenets of this argument is a fact that, on its face, suggests that P.T.S.D. is a culturally determined phenomenon as well as a medical one: American veterans are 2.5 to four times more likely to be diagnosed with P.T.S.D. than British veterans.
[…]
As Jonathan Shay, the author of Achilles in Vietnam, shows in his follow-up, Odysseus in America: Combat Trauma and the Trials of Homecoming, while the problem of returning from war is one of humanity’s oldest struggles, the use of P.T.S.D. to frame a wide variety of traumatic experiences is a relatively recent development. The growing criticism of our current understanding of P.T.S.D. suggests that what was once ignored or treated as a failure of character — the soldier’s weakness — has now been medicalized to the exclusion of discussing its moral and spiritual dimensions. “It feels to me as if the U.S. civilian population has pathologized the veteran experience,” Elliott Woods, an Iraq veteran-turned-reporter, told me not long ago. “One well-intentioned person said to me the other day, ‘I can’t see how anyone could go to Iraq and not come back with P.T.S.D.’
H/T to Tim Harford for the link.
June 27, 2013
Progress and regress in the pursuit of care for the mentally ill
In City Journal, James Panero looks at the history of treatment of the mentally ill in America:
If it’s true that “men moralise among ruins,” as Benjamin Disraeli wrote, the ruins of America’s nineteenth-century mental institutions should invite some serious reflection. Built between 1850 and 1900, these crumbling edifices speak to our onetime dedication to caring for the mentally ill. Almost all were designed on the Kirkbride Plan, named for Pennsylvania physician Thomas Story Kirkbride, author of an influential treatise on the role of architecture and landscape in treating mental disorders. Even in their dilapidated state, it’s possible to see how the buildings, which followed a method of care called the “moral treatment,” gave the mentally ill a calming refuge from the gutters, jails, and almshouses that had been the default custodians of society’s “lunatics.”
Unfortunately, in the middle of the twentieth century, as asylums became grossly overcrowded and invasive treatments aroused public concern, the moral treatment came to seem immoral. The eventual result was the process known as deinstitutionalization, which steadily ejected patients from the asylums. Instead of liberating the mentally ill, however, deinstitutionalization left them — like the asylums that once sheltered them — in ruins. Many of today’s mentally ill have returned to pre-Kirkbride conditions and live on society’s margins, either sleeping on the streets or drifting among prisons, jails, welfare hotels, and outpatient facilities. As their diseases go untreated, they do significant harm to themselves and their families. Some go further, terrorizing communities with disorder and violence. Our failure to care for them recalls the inhumane era that preceded the rise of the state institutions. The time has come for new facilities and a new moral treatment.
[. . .]
At a time when the medical science of mental illness was in its infancy, the Kirkbride Plan created alternative, protected worlds for patients. It echoed many of today’s more holistic approaches to treatment by encouraging patients to participate in social activities, games, and crafts. Kirkbride institutions often sported their own baseball diamonds, golf courses, bakeries, bowling alleys, ice cream shops, dairy farms, gardens, and stages for plays and other performances.
But in the twentieth century, a shadow fell over the Kirkbride asylums, as doctors there began using more invasive procedures. The Austrian psychiatrist Manfred Sakel introduced insulin shock therapy, now known as insulin coma therapy, in the 1930s. Electroshock therapy arrived from Italy soon after. Both treatments induced seizures to alter brain chemistry in patients with depression and schizophrenia. In 1949, the Portuguese neuropsychiatrist Egas Moniz won a Nobel Prize for developing the frontal lobotomy, which he had invented in 1935. Walter Freeman, a clinical neurologist in Washington, D.C., further popularized the treatment through his own outpatient procedure, which came to be known as the transorbital, or “ice-pick,” lobotomy.
May 22, 2013
The controversy over the DSM-V
The science writers at The Economist discuss the American Psychiatric Association’s new Diagnostic and Statistical Manual (below the fold because it auto-plays when you load the page):
May 12, 2013
Thomas Szasz was no conservative
In Reason, Jacob Sullum looks at an essay on the late Thomas Szasz that puzzlingly attempts to portray him as a staunch conservative:
In an interesting but puzzling Aeon essay, Cornell historian Holly Case notes the resemblance between contemporary doubts about the scientific foundation of psychiatry and the critique first laid out by Thomas Szasz half a century ago. “It might be that the world has only recently come around to his way of thinking,” Case suggests. Yet she misconstrues an important aspect of Szasz’s thinking by portraying him as “a staunch Republican” and a “conservative,” apparently unaware of his self-proclaimed libertarianism. Szasz, who died last year at the age of 92, was a Reason contributing editor for decades. He described the main motivation for his intellectual career as “my passion against coercion,” which he opposed (outside of situations involving the defense of rights) no matter who was advocating it, left, right, or center. Hence he opposed forced psychiatric treatment, but he also opposed interference in consensual transactions between psychiatrists and voluntary patients. Here he parted company with some left-wing critics of psychiatry.
[. . .]
But Case focuses mainly on common ground between what she views as right-wing and left-wing critics of psychiatry. Beginning in the 1960s, she writes, “Right and left sought to eliminate insanity in order to lionise dissent, legitimise the marginal and condemn the new normal. Few other issues show a convergence of right and left so far-reaching, while still allowing both sides to adhere to their politics and maintain a sense of total opposition.” At the same time, she says “Szasz was conspicuously alone in mounting the barricades from the right,” so she really needs him to be a right-winger. Bending the facts to fit her thesis, she ascribes to Szasz a “distinctively conservative perspective.” That label does not jibe with his opposition to drug prohibition and his forthright defense of the right to suicide, two major themes of his career that Case tellingly ignores. Szasz’s position on physician-assisted suicide combined both of these themes and demonstrated that his perspective was in fact distinctively libertarian. He opposed Oregon’s Death With Dignity Act (later imitated by Washington) because it medicalized a moral decision and required people to meet government-dictated criteria before they could legally end their lives. If the drug laws did not make it difficult for people to obtain substances useful for suicide (such as barbiturates), he said, there would be no need for physician-assisted suicide.
May 6, 2013
QotD: This seems like a bad idea
A Florida county sheriff is being given a million dollars to violate the rights of the people who were stupid enough to put him in office.
According to an article by Palm Beach Post staff writers Dara Kam and Stacey Singer, posted Monday, April 29, Palm Beach County Sheriff Ric Bradshaw has been awarded $1 million by Florida House and Senate budget leaders for a new “violence prevention unit aimed at preventing tragedies like those in Newtown, Connecticut and Aurora, Colorado.
It would be bad enough if this particular jackbooted thug planned only to use this ill-gotten tax money for the usual militarized toys — machineguns or armored personnel carriers — the cops are so crazy about today, but Bradshaw reportedly wants to create “prevention intervention units” consisting of “specially trained deputies, mental health professionals, and caseworkers”. which “will respond to citizen calls to a 24-hour hotline with a knock on the door and a referral to services”.
“We want people to call us if the guy down the street says he hates the government…” the Big-Brotherly Bradshaw bloviated. “What does it hurt to have somebody knock on a door and ask, ‘Hey, is everything OK?'” Since the cops these days do their knocking with a three-foot concrete-filled section of four-inch diameter steel pipe, with welded rebar handles, Bradshaw’s stupid question tends to answer itelf.
L. Neil Smith, “Cutting the Root of Tyranny”, Libertarian Enterprise, 2013-05-06
April 26, 2013
Minnesota introduces new policy for dealing with veterans
You may not hear about this in the mainstream press, but The Duffel Blog digs for the real story:
Officials from the Minnesota Department of Motor Vehicles have confirmed approval of a new policy making it mandatory for all active-duty and military veterans to register their status with the agency. The move will require all veterans to have a special “Vet” designation on their drivers’ licenses and state identification cards.
The Minn. DMV, which hopes to have the policy implemented by 2015, cites an inherent mental health threat by veterans as their main reason for devising the plan.
“We’ve seen what these savages are capable of all over CNN and MSNBC,” says DMV director, Greg Olson. “Out of all the millions of men and women who have deployed to combat zones this past decade, there are literally a dozen, perhaps even two, who have come home and committed atrocious acts. That’s way too big a chance. We can’t risk having these people hidden in our community and will be making sure they’re easily identifiable to law enforcement personnel and citizens in general.”
The new strategy will most likely result in changed police escalation-of-force procedure when dealing with veterans during routine traffic stops.
According to Olson, law enforcement officers will be given more opportunity to defend themselves against a perceived threat.
“Phase One will consist of the officer identifying an individual’s vet status on his or her driver’s license,” he says. “Once the officer realizes what he or she is dealing with, Phase Two will kick in and they will immediately unsheathe their pistol and drawdown on the potential psychopath. Then, at Phase Three, the officer will be given free reign to search the individual’s vehicle for weapons and dead bodies. If, and only if, the officer doesn’t find anything, then he will subsequently release the veteran and thank them for their service.”
April 24, 2013
QotD: Welcoming the DSM-V appropriately
The much-awaited arrival of DSM-5 (the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders) should ensure that every human being is classed as insane. At this point we might be able to start again and consider what psychiatry is for. Genomics is keen to help in the effort by finding the loci that are associated with all sorts of mental disorders. Enter a huge population based study funded by the National Institute of Mental Health: “Our findings show that specific SNPs are associated with a range of psychiatric disorders of childhood onset or adult onset. In particular, variation in calcium-channel activity genes seems to have pleiotropic effects on psychopathology. These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.” Hmm. I think that when authors have to use words like “pleiotropic” and “nosology” there is a high chance that they do not know what they are talking about. So before welcoming the marriage of genomics and psychiatry, let us remember that there is a strong history of madness on both sides.
Richard Lehman, “Richard Lehman’s journal review—22 April 2013”, BMJ Group blogs, 2013-04-22
