Three gems I got to from this week’s Spike Report: Emmanuelle Richard writes in Online Journalism Review that media coverage of the porn industry is rife with stereotype and inaccuracy. (Freelancer Richard’s weblog, by the way, is handsome and worth a visit if you read French.) A New York Times piece details the Chinese culinary practice of eating dogs. The article is not for the squeamish animal lover, but then, comments one Chinese interviewee, the same might be said of eating beef these days. Another New York Times selection describes the sensitive subject of interviewing subjects to gather data for their obituaries. Lots of witticism in the face of mortality.

One of my readers is the inspired artistic presence behind these sites. She writes:

*The Museum of Depressionist Art* specializes in the art of the

Depressionist school, which most other museums reject as being too

miserable, dejected and hopeless to warrant space on a wall. Depressionism,

according to the landmark Johnson & Jansen “Big Book o’ Art Stuff,” is not

limited to a single place or time. Instead it reflects the low point of an

otherwise highly regarded artist’s career.

*The Gallery of the Unidentifiable* is an independently operated wing of the

Museum of Depressionist Art. Its collection is famous for having not a

single identifiable artist (and in some cases, art form) in it, to

commemorate the uncertain origins of its benefactors, Gladys Dwindlebimmers

Ralston and her husband Abercrombie.

*Dear Aunt Nettie* is a daily advice column from the world’s oldest living

Internet guru. She lives and publishes her work from “Living Dead ‘R Us”

retirement home.

I heard Douglas Rushkoff mention this on NPR today. For rapidly-loading, graphics-free content surfing, MyMobileStuff: A Directory of Palm and Pocket PC Friendly Web Sites is a list of text-only web pages (business, entertainment, living, news and media, reference, sports and recreation, technology, travel) made for WAP devices but entirely suitable for desktop-based browsing. Almost makes it feel like the early days of the web again. Here, for example, is The New York Times’ top stories page in this format.

Addendum: Random Walks‘ Adam Rice writes to point out that “www.plinkit.com is another site full of links to lynx- and handheld- friendly

sites.”

Ex-Beatle Harrison: “I feel fine”; being treated for lung cancer. CNN [via nextdraft] And students sitting for their final-year exam in English at Cambridge University were asked, as part of a compulsory paper on tragedy, to analyze a Bee Gees lyric. Defensive, the chairman of the examination board says he saw references in the ‘text’ that the Bee Gees themselves hadn’t appreciated. “The line… where he sings ‘the feeling’s gone and you can’t go on’ is a fair

summary of the end of King Lear.”

The PerfectBook Machine. A $30,000 machine which prints, binds and spits out a book on order in minutes from a digital file, and can be run by “a distracted teenager”, may put everyone in the world within several miles of every book ever written. Boon or boondoggle?

More pithy eye-opening observations, this time on the seeming banality of an outdoor weekend, from NextDraft: “There has been a long tradition of public displays of

sportsmanship from Presidents. Golf seems to have

become the sport of choice. It makes sense. You don’t

want to see your President get smoked by someone else

over the weekend, and golf is always perceived more

as a match between the course and the person. The question

is usually ‘how’d you do’ and opposed to ‘who won?’. And

everyone who has hit the links (from beginners to pros)

has experienced golf’s wrath. Hit a golf ball into the trees

and feel our solidarity. Hit a tennis ball over the fence,

and hear our laughter.

During the Sunday morning talk shows, the pundits explained

that George W’s golf and fishing outings were part of an effort

to reconnect with the American people and pump up those poll

numbers. Does this stuff really work? “Oh my god,” the American

voter exclaims, “He holds his rod just like I do!” Want to connect

with the American people? Order way too much Chinese food, lay

on the couch in the Oval office, play video games and complain

about work all weekend.”

Witches Upset by Broomstick Style: “…Warner Bros has had a spell cast on it for showing

apprentice wizard Harry Potter riding his broomstick with the brush part at the

back.

A high priest of British White Witches said broomsticks should be ridden the other way round, and

has wished for the film to do badly at the box office until the studio admits it got it wrong.”

Sons and Lovers: a neo-Darwinian theory of the leisure class.

President George W. Bush has fathered two children, both of them daughters. Former president Bill Clinton has fathered a single child, also a daughter. That makes the forty-second and forty-third commanders in chief somewhat anomalous by historical standards. Of the 150 children sired by previous U.S. presidents, 90 were male and only 60 female. That’s three boys for every two girls. Now, this could be a statistical fluke, like flipping a coin 150 times and getting 90 or more heads. But such an outcome is observed very rarely, less than 1 percent of the time—unless, of course, the coin is biased.

American presidents are not the only elite group to produce

markedly more sons than daughters; the same goes for European

aristocracies and royal families. (Ditto, in the animal kingdom, for

socially dominant Peruvian spider monkeys and well-fed

opossums.) For oppressed groups, the situation is just the

opposite: In racist societies, the subject races tend to have slightly

more daughters than sons.

A fascinating hypothesis; that the needs of social dominance can find a way to be biologically expressed in the alteration of the sex ratio. It deserves to be pondered carefully with our dawning ability to exert much more deliberate, and potentially insidious, control over the sex of our offspring. Lingua Franca

“The systems to take care of the most severely mentally ill kids are completely broken.”

Children Trapped by Gaps in Treatment of Mental Illness

The 16-year-old girl had needed help, no question. She was throwing chairs, she was taking rides from strangers, she was acting

suicidal. Finally, she ended up in a psychiatric hospital, where, her mother says, the staff effectively saved her life, stabilized her, worked on her bipolar

disorder.

But once in, the girl could not get out. Not for months after the staff thought she was ready to go. No matter how she cried. She had joined the ranks of

thousands of mentally ill children and teenagers in the country who, doctors, advocates and officials say, are trapped in psychiatric hospitals and in other

institutions for lack of treatment programs outside.

…There are the children who must wait for hours in emergency rooms while in full-blown psychiatric crises. There are the “boarder kids,” children stuck for

days or weeks — or in extreme cases, months — in pediatric wards because there is no place for them in a psychiatric ward or hospital.

There are the “wait-listed kids,” waiting months for outpatient therapy or case management. And there are the “stuck kids” themselves, usually about 100

of them at any time in the state, according to official figures, who are ready for discharge from psychiatric hospitals but cannot leave for lack of outside

treatment programs.

At the hospital I direct, here in Massachusetts, the state most well-endowed in the United States with mental health professionals per capita, we have “stuck kids”

occupying 10-15 of our 42 child and adolescent beds at any one time, waiting for a place to go long after stabilized, for as long as 18 months at the extreme.

2-3 months is not unusual. The problem grows faster than grandstanders like the state’s commissioner of mental health, quoted in this New York

Times article, can throw money at it, proclaiming “an overall crisis in mental health” and citing a shortage in psychiatric staffing and numbers of child and

adolescent psychiatric beds in the state. She dances neatly around one of the real issues, the impact of managed care, perhaps because of the need

to maintain good relations with the succession of draconian, for-profit contractors to which the state has sold out the management of the Medicaid benefits

that fund so much of child treatment. “Private managed care, experts say, tends to reduce coverage for mental health, and parents often wait too long before

seeking help. In some states, managed care programs for children covered by public money have so cut the amount of treatment received that state

governments have abandoned the programs.” The contraction in numbers of hospital beds is a direct result of the reductions in reimbursement levels, making

it impossible for hospitals to cover the expense of providing the care — whether for-profit or nonprofit. Paradoxically, length of stay increases and

quality of care decreases as inpatient mental health care becomes more severely managed; hospitals cutting staffing levels in the interests of

economizing and increasing workloads of professional staff such as social workers and psychiatrists translates directly into inefficiency of treatment. Direct

care staff are really the ‘stone from which no blood can be gotten.’

While the article also cites demographic shifts (the ‘boomlet’ in adolescent

population), it misses a more important change in societal attitude — a conceptual problem which, IMHO, is the most important sense in which “the

systems to take care of the most severely mentally ill kids are completely broken.” Child and adolescent mental health care resources are more and more

wasted — yes, I know, a stark word — on social control of behavior and conduct problems rather than ‘true’ mental illness, in what I feel is a displacement of

responsibility for the failures of other segments of society — social service agencies, the educational system, the legal-judicial system and, most important,

parental responsibility. The psychiatric profession, perhaps to protect and expand its market niche in the era of managed care. colludes and enables this

process willingly or inadvertently via the increasing medicalization of these problems. (now, as an aside, this, as detailed in the National Post, is not what I would propose as an alternative…) We ‘bless’ these conditions with diagnostic labels, thus making them

reimbursable. To wit:

the official codification of diagnoses such as “oppositional-defiant disorder” and “conduct disorder” for what are essentially bad

behavior;

the increasing treatment of adolescent substance abuse as a mental illness;

the overdiagnosis of ‘trauma’ and ‘post-traumatic stress’ in

the aftermath of virtually any disturbing childhood events;

the supposition that there is a mental illness whenever an adolescent has made a suicide

gesture, and the vastly broadened notion of what constitutes a suicide gesture;

the expansion of the diagnosis of ADHD (attention deficit hyperactivity

disorder) from a meaningful indicator of dysfunction in the machinery and physiology of directing and sustaining attention to a meaningless label for any

unruliness or distractibility; and

recent efforts to expand beyond anything reasonable the boundaries of the domain of adolescent bipolar disorder.

Wouldn’t you assume, as does the author of this New York Times article unquestioningly, that this surely represents ‘true’ mental illness in need of

medical care? You’d be wrong. Adolescent psychiatric ‘experts’ are trying dogmatically to re- educate the rest of us to the fact that adolescent mania has

been underrecognized because it looks nothing like adult mania; with handwaving and smoke and mirrors, any mood instability or lability is now seen as

such.

I used to lecture medical students and psychiatric residents about the conceptual bases of psychiatry, flooring all but the most sophisticated with the assertion that

diagnostic categories, rather than being etched in stone, are built on shifting sands. There have been marked differences, both over time and from culture to culture or

even region to region, in the numbers of ‘official’ diagnoses, the extent of what is included in each. The flavor of the moment in categorization — whether you

want to be a ‘lumper’ or a ‘splitter’, to see similarities or differences, whether (to paraphrase Gregory Bateson) a given distinction makes a difference — changes over

time and place as well as with the individual predilection of the diagnostician. For something to shape up as a meaningful diagnostic category, it ought to have an accumulation of evidence along some or all of the following lines:

homogeneity of presentation;

consistent neuroanatomic or physiological alteration (as indicated by psychological test results, laboratory measures and/or

alterations in functional or structural imaging);

consistent longitudinal course over the affected individual’s life cycle;

consistent comorbidities, or associations with other conditions

heritable characteristics;

consistency of responses to therapeutic measures

Done properly, categorization based on such factors does not lead to circular definition. Done sloppily, it almost always does. The most profound example of that in

psychiatry is the way in which diagnostic categories tend to proliferate as new types of medications, or new applications for existing medications, are found. If you

define your disease states merely on the basis of what works to treat them, you’re in for conceptual trouble and confusion. The classic case was the vast expansion in

the numbers of people diagnosed with manic- depression (bipolar disorder) after the introduction of lithium in the late ’60’s. You might argue that this is innocent; all

of a sudden, because an effective treatment existed, it became useful and important to make the diagnosis (à la Gregory Bateson’s “distinction that makes a

difference” notion). I would argue that it’s often a far more malignant pathology in our reasoning, more akin to Molière’s pontificating physician in Le

Malade Imaginaire who thinks he’s explained something meaningful when he says that the opium poppy makes its user sleepy because it contains

(drumroll) ‘a dormative principle‘! And, while we’re at it, keep in mind the ‘use it or lose it’ phenomenon in medical care. Because of initial enthusiasm and

self-fulfilling prophecy, after a new therapeutic breakthrough is introduced, it quickly amasses an impressive track record. Its touted efficacy spreads by anecdote and

word of mouth. Later, when gold standard placebo-controlled double-blind studies with large enough numbers of subjects to be statistically significant are conducted,

results are never so impressive…

More recently, pharmaceutical-driven circularity in the definition of diagnostic categories has vastly expanded beyond the lithium example. Is it ADHD because it

‘responds’ to a psychostimulant? Nearly anyone will feel an enhanced sense of wellbeing and increased cognitive efficiency with this class of drugs. Is it a depressive

disorder because it ‘responds’ to an SSRI antidepressant? The quintessential ‘cosmetic psychopharmacology’ class of drugs, there are benefits to epiphenomena such

as emotional reactivity and irritability in most, even psychiatrically well, users. Is it an anxiety disorder because it ‘responds’ to an anxiolytic? By no means. And, back

to adolescent bipolar disorder, there is little or no evidence that patients so diagnosed will turn into adult bipolars; little or no evidence that adolescent mania and adult

mania are comingled in family trees; and little or no demonstrated consistent biochemical abnormality characterizing members of the class. Can you say they have a

disease because they seem to respond to the medications that are used to treat bipolar mood swings? No, because the ‘mood stabilizers’ — which by now have grown

beyond lithium to include a variety of anticonvulsant drugs — will dampen the intensity of most emotional turmoil and instability, nonspecifically!

Now, don’t misunderstand, I’m not trying to be a diagnostic nihilist here. No, wait, maybe I am; the more and more I pry up the rocks and peer underneath, the more

I see the bugs in the field… But, usually, I think there is a careful way to do diagnosing that remains meaningful and — this is the ultimate

point, isn’t it? — has therapeutic utility in helping our afflicted patients. Our truly afflicted patients.

Okay, I’ll get off my soapbox now… for the moment.

“There were two mysteries. The first was how he went on so long lying like this, and the second was why

people did not suspect anything.” Discovering the Facts of a Man Who Lived a Monstrous Fiction — The Adversary: A True Story of Monstrous

Deception reviewed:

On Jan. 9, 1993, in a small French

town, a respected doctor named

Jean-Claude Romand killed his wife and

their two children and then drove a few

miles to his parents’ home and killed them.

Tried and convicted by a French court, he

was given a life sentence.

Emmanuel Carrère, a French novelist and

screenwriter, was fascinated by the case,

not because of the murders but because Mr.

Romand was not a doctor and had invented

his entire life. It was a lie that he lived for

18 years. New York Times