Start with the well-known Creeley poem, ‘I Know a Man’:

As I sd to my
friend, because I am
always talking, – John, I

sd, which was not his
name, the darkness sur-
rounds us, what

can we do against
it, or else, shall we &
why not, buy a goddamn big car,

drive, he sd, for
christ’s sake, look
out where yr going.

A timeline of recent campus shootings and speculation about what it is about campuses and schools that attracts deranged shooters. (The Lede, The New York Times)

Herbert Spencer (1851): “As a corollary to the proposition that all institutions must be subordinated to the law of equal freedom, we cannot choose but admit the right of the citizen to adopt a condition of voluntary outlawry. If every man has freedom to do all that he wills, provided he infringes not the equal freedom of any other man, then he is free to drop connection with the state – to relinquish its protection and to refuse paying toward its support. It is self-evident that in so behaving he in no way trenches upon the liberty of others, for his position is a passive one, and while passive he cannot become an aggressor. It is equally self-evident that he cannot be compelled to continue one of a political corporation without a breach of the moral law, seeing that citizenship involves payment of taxes; and the taking away of a man’s property against his will is an infringement of his rights.”

Bertrand Russell (1943): “To avoid the various foolish opinions to which mankind are prone, no superhuman genius is required. A few simple rules will keep you, not from all error, but from silly error.”

In his book, Shepard takes issue with the experience of Barbara Ehrenreich, who in Nickeled and Dimed found she was not able to make ends meet or progress beyond a series of menial jobs when she tried self=imposed poverty as a social experiment. Could gender and age be making the difference? Or could it be preconceptions? I haven’t read the book (but I heard him interviewed on NPR) and he sounds vivacious and unjaded, in contrast to Ehrenreich’s well-worn and well-founded cynicism and rage against the machine.

A Guide to Using Caffeine Right. (Developing Intelligence)

…and its future in DSM-V. This editorial from the January 2008 British Journal of Psychiatry from Gerald Rosen, Robert Spitzer and Paul McHugh is music to my ears. It questions the validity and the future of the post-traumatic stress disorder (PTSD) diagnosis because the symptoms it describes are already covered by other depressive and anxiety disorder diagnoses. THe concept of PTSD emerged as a diagnosis with DSM-III in the context of the ’60’s feminist and antiwar movements. I believe it was an expression of the sentiment that victims of abuse and returning Vietnam veterans had experienced something more extraordinary than other sufferers, and therefore that the extremity of their reactions needed to be codified in a new diagnosis. Very quickly, then, insensitivity to the PTSD diagnosis came to seem like insensitivity to the plights of various classes of the downtrodden and oppressed. And, from the patients’ point of view, it has been a very appealing diagnosis to carry, given that it serves to remove the stigma of mental illness from the person and locate the defect in the horrendous external event that befell them.

So, since the inception of the diagnosis in the early 1980’s, there has been a momentum to apply it from both clinicians and patients. As FmH readers will be aware, this bandwagon effect is one of my pet peeves. I have opined that the diagnosis has come to be applied sloppily and indiscriminately whenever an inexperienced, earnest and naive clinician felt that something terrible, deserving of empathy, had happened to their patient. The orthodox adherents of PTSD have claimed that horrendous traumatic experience beyond the pale of what the human nervous system was designed to endure altered neurophysiological functioning in distinct and specific ways, accounting for the defining symptoms of PTSD and justifying the need for such a diagnosis. When the diagnosis was handed out nonchalantly to anyone who had suffered a stress or a loss, in contrast, it lost its specificity, as the sufferer really did not embody such a profound alteration in neurophysiological functioning. What was being described was more run-of-the-mill depression or anxiety in response to expectable stresses and losses. The indiscriminate use of the PTSD diagnosis has also reinforced rampant victim culture in our society.

But this new editorial may represent even a more profound objection to the diagnosis of PTSD than I have been making. It may not be invalidated by being applied too broadly; it may be entirely invalid in the first place. Whwere in the diagnostic pigeonholes were the PTSD sufferers before there was PTSD? They carried depression and/or anxiety diagnoses. Should they be there again? This makes sense to me for several reasons.

First, the description of PTSD involves three symptom clusters — intrusive recollections of the trauma, exaggerated emotional and physiological reactivity when triggered by memories or reminders of what has happened, and self-protective avoidance and constriction of emotion in reaction. In learning and teaching about this diagnosis, I have felt hardpressed to explain how these are different from anxiety, depression, and compensatory efforts. So, in terms of the severity of a trauma, exactly where are we to draw the line between those that merely bum one out, those that cause depression, and those that cause PTSD?

Secondly, it has long been known that resilient individuals do not necessarily develop PTSD symptoms in response to traumatic experiences similar to those that produce the syndrome in others. Since it is shaped by constitutional factors in the suffferer, the concept of a distinctive response to extreme trauma is further watered down.

Thirdly, some argue that there are depressive disorders, there are anxiety disorders, and there is the somewhat unusual fusion of the two symptom complexes in PTSD. But many psychiatrists, myself included, feel we have rarely seen a ‘pure’ depressive or anxiety disorder case, that patients always embody a combination of the two, and that the depressive and anxiety disorders are not as distinct as the diagnostic scheme would have use believe. Among other lines of evidence contributing to this impression is the fact of the overlap in efficacy of therapeutic agents for depression and anxiety. Antidepressants are good anxiolytics (perhaps better than Valium and its modern family of anti-anxiety derivatives, the benzodiazepines). Anti-anxiety medications have a venerable history for the treatment of depression. Treatment for PTSD, in any case, is little more than targeting some combination of anxiety and depressive symptoms, anyway.

Finally, most of the neurobiological explanations for the etiology of PTSD emphasize the impact of activation of the fight-or-flight response, and the bathing of the brain in stress hormones, at the time the trauma is experienced. This supposedly damages the brain and changes its emotional reactivity, its memory processing, etc. thereafter. But, increasingly, depression too has come to be understood as a syndrome of altered brain function and tissue damage from the physiological effects of stress, in a similar way. One interesting trend throughout the mental health field, as it has emphasized biological factors more and more to the exclusion of psychological and emotional, is arguably the lessening separation of heretofore distinctive diagnoses. I have recently heard theoretical speculation that schizophrenic and bipolar (manic depressive) psychoses may not be separate entities either. Indeed, the central distinction in diagnostic psychiatry between disorders of mood and of thought makes less and less sense than we have thought.

In psychiatric epistemology, there has always been a tension between the ‘lumpers’ and the ‘splitters’. Modern developments in diagnostic nomelnclature embodied in recent editions of the Diagnostic and Statistical Manual (“DSM”) have clearly been in the hands of the splitters, to a sometimes baroque and ridiculous extent. Distinctions have proliferated, pigeonholes have multiplied. Interestingly, one of the co-authors of this editorial, Robert Spitzer, has been the maven of the DSM process for the past several decades. The reconsideration of PTSD signified by this editorial may represent a long-overdue resurgence of lumping. As a generalist and synthesist in the field, this is very appealing to me…

So, in a sense, it may not be that all or most post-traumatic stress is really depression and anxiety; it may be that all or most depression and anxiety disorders may really be post-traumatic. Much has been written about Freud’s betrayal of the trauma concept. In early vesions of psychoanalytic theory, he had recognized the impact of external events in the etiology of neuroses, but in revising his theory he increasingly focused on internal fantasies. Critics have suggested he was avoiding his own irresolvable conflicts about his relationships with the women in his life. In any case, this was the first of two major betrayals of the patient’s reality in mental health treatment which has shaped the conception of mental disorders and the approach to treatment for the ensuing century or more; the second has been the reductionistic biological focus of the last two decades, removing us even more from the core reality of the patient’s experience. Arguably, it has gotten to the point that third party payors, in a sense, only want to pay for “endogenous” disorders that do not arise from life events, relegating “reactive” syndromes to lesser diagnostic categories which are less reimbursable. In a way, I may have been dead wrong in complaining that PTSD was diagnosed too often and arguing for the more precise use of the concept. The impact of trauma may not be recognized or acknowledged nearly enough.

Reflections from Vaughan’s ever-excellent Mind Hacks:

*Dawdy:

“Yesterday, I wrote about the murder of a psychologist in New York City and wondered aloud and somewhat innocently at why this nonsense happens and continues to happen in our culture. I don’t hear too many stories of Brits hacking their psychiatrists or psychologists to death–OK, I know of zero cases like that in the UK. The post received several comments that I find disturbing and unacceptable, forcing me to ponder why I am even bothering to do this blog if the best I can get out of readers is a bunch of inhumane BS and tired anti-psychiatry polemics.”

As FmH readers know, I maintain an interest in privacy and its violations, although it has largely become a lost cause. In The Anonymity Experiment, a correspondent for Popular Science attempts to obscure her tracks for just a week, in accordance with the following directives:

I heard of this from kottke, and the foregone conclusion was that it would not be very successful. His teaser left me curious about how she would measure the results. The piece is well-documented and I learned a few things about how to cover my tracks better. But her conclusion? Predictably, that you can never know how successful you have been, and that there is more information out there about you than you can ever know.

Speaking of ingrained paranoia, I recently sent out Freedom of Information Act requests to ten government agencies I thought might have records on me from my prior activities. Most wrote back that they found nothing about me, a fact to which I had a complicated reaction. I was (a) relieved; (b) surprised that my lifelong countercultural activities had apparently not attracted the attention I had expected; (c) dismayed I was being thus denied an odd sort of badge of courage; (d) of course, mistrustful of the denials; and (e) mindful of the fact that submitting FOIA requests might per se place me on a watch list or two (which I had not worried about in writing the letters, expecting that I was already on file). The Dept of Homeland Security, by the way, did not answer in the negative, saying instead that it was a matter of national security whether I was being monitored for national security purposes, and therefore declining to answer my request. By the way, don’t we think Carnivore, or some sophisticated government data mining equivalent or improvement, whatever it might be called, is monitoring this post to the internet and flagging me for further concern?

What do FmHers think? Was the whole endeavor foolish on my part?

In his book, Shepard takes issue with the experience of Barbara Ehrenreich, who in Nickeled and Dimed found she was not able to make ends meet or progress beyond a series of menial jobs when she tried self=imposed poverty as a social experiment. Could gender and age be making the difference? Or could it be preconceptions? I haven’t read the book (but I heard him interviewed on NPR) and he sounds vivacious and unjaded, in contrast to Ehrenreich’s well-worn and well-founded cynicism and rage against the machine.