Covid-19 Can Persist at Least Several Months

Interesting article by one of my favorite science writers, Ed Yong, in The Atlantic starts out as a review of the “long-haulers” whose Covid symptoms don’t get better as expected. As an aside keep in mind that this does not mean that symptomatic people are still contagious, i.e. shedding virus. One of the big things we still don’t know about this disease are which symptoms come directly from viral devastation of various organs and which from the resultant immune response from the body.

But the interesting part of the article for me is Yong’s mapping of long-haul Covid infection to so-called medical gaslighting — the profession’s downplaying of patients’ physical complaints as being “all in their head” or caused by stress, especially in women and, as Yong points out, in communities of color. There is a long history of mysterious illnesses — most notably chronic fatigue syndrome (myalgic encephalomyelitis in the UK) and fibromyalgia — of unclear causes, debilitating chronic symptoms, and no clear treatments.

Clusters of ME/CFS have followed many infectious outbreaks and even those medical professionals who take them seriously and do not dismiss them as purely psychiatric syndromes may be forgiven for failing to recognize that they probably cannot be reduced to being merely longterm or chronic variants of their mother diseases. Long ago I wrote a book chapter on controversial syndromes on the medical-psychiatric borderline. I focused on chronic fatigue syndrome and was guilty as charged myself, reviewing the data that it was essentially chronic Epstein-Barr virus infection. And in recent years I have lectured and taught about what some of us have described as chronic Lyme disease. Not that I am any kind of expert on these conditions. In fact, that is exactly the point — that this should be in the domain of the immunologists or infectious disease specialists rather than the psychiatrists. It is too soon to see if my non-psychiatric colleagues will begin sending post-Covid patients to us to treat postviral syndrome symptoms as if they are “just” emotional reactions.

Dealing with a novel medical condition which the world had never seen even six months ago should humble healthcare providers by highlighting how much we operate in the realms of mystery and ignorance. On the front lines, the dizzying pace of refining our approach in the face of such a moving target has been unprecedented. The unfortunate cases in which Covid infection appears to simply not go away may actually help us to finally realize that there may be a common syndrome affecting some with systemic infectious diseases. Much as we have stopped diagnosing or teaching about chronic Epstein-Barr, we should perhaps stop considering entites like “chronic Lyme” or “long-haul Covid” to be distinct entities and acknowledge the commonalities.

Several teams of investigators are already planning studies of Covid infection survivors to see if any become ME/CFS patients. A unifying conception would help stigmatized patients and might actually point the way to elucidating underlying mechanisms that might facilitate therapeutic interventions, And, established as having real, albeit complicated, causes, maybe psychiatrists like me should stop considering them to be in our province, the province of “all in the head”, at all? Mental health providers are going to have their hands full as it is helping with the devastating neuropsychiatric and emotional consequences of this pandemic.

As Yong concludes:

Perhaps COVID-19 will … galvanize an even larger survivor cohort. Perhaps, collectively, they can push for a better understanding of neglected chronic diseases, and an acceptance of truths that the existing disability community have long known. That health and sickness are not binary. That medicine is as much about listening to patients’ subjective experiences as it is about analyzing their organs. That being a survivor is something you must also survive.

Depression’s Upside

On the Threshold of Eternity

Wonderful behavioral science writer Jonah Lehrer (Proust Was a Neuroscientist) writes for the New York Times Magazine on the idea that depression may be adaptive. It is not a new idea; I have followed the intriguing literature about possible evolutionary reasons for the persistence of depression ever since I was a psychiatric resident troubled by how readily we in the field want to obliterate any signs of the condition whenever our patients present with it. Some theories have focused on the advantages of resource preservation, given the social isolation, decreased motivation and lessened self-indulgence the depressed person displays. It has also been suggested that the depressive alteration in cognition, in the direction of impaired self-esteem, decreased sense of efficacy and control over one’s circumstances, and pessimism , may actually be more realistic, at least in some circulstances, than the rose-colored glasses with which we usually walk around.

But recent research adds neuropsychological evidence of increased brain activity in depressed patient in regions of the prefrontal cortex associated with problem-solving, proportional to the degree of depression. It is certainly not the whole explanation, as critics counter, because some of the maladaptive impact of depression, including poor self-care, impairment in childrearing, increased susceptibility to other illness, and last but not least suicide, will outweigh the problem-solving advantages it might confer. Furthermore, there are many different kids of depression both in terms of precipitant and symptomatology. At one extreme, a person may become depressed in response to an acute recent loss (or even a future anticipated one); on the other hand, some people can develop either a dense acute depression or a smouldering chronic one without substantial stresses or losses. The imprecisions in both the lay person’s use of the term depression and its more technical clincal utilization muddy the waters in this regard.

Still, it is worth asking why a condition that is so painful and takes such a heavy toll would persist if it were not at least some of the time of some use… and whether, at least some of the time, we do more harm than good in leaping to treat it. Except, of course, the unequivocal good done to the pockets of the shareholders and executives of the pharmaceutical companies, reaping the profits from the explosive growth in antidepressant sales of the last few decades. (New York Times Magazine)

Revising Book on Disorders of the Mind

List of psychiatric medications

FmH readers know of my preoccupation with psychiatric diagnosis, its follies and abuses, about which I am more likely to rant here than any other topic (other than George W. bush and his administration). Today, the American Psychiatric Association posted on the web the details fo the next proposed revision, version V, to the DSM (the Diagnostic and Statistical Manual), which is the ‘bible’ of accepted psychiatric diagnoses and their criteria. DSM-V is currently scheduled to come out in 2013 after a period of public comment on the revisions and several years of field trials. The release date has already been pushed back because of controversy about the proposals and the revision process, some of which is pointed to in this NYTimes.com piece.Several different things happen in these revisions. First, the universe of existing mental illnesses is reparsed and some of the afflicted end up going into different pigeonholes. By and large, this is a trend I welcome, as the new distinctions made, and the old distinctions collapsed and erased, appear to be generally in line with the clinical experience of frontline practitioners like myself who spend all our time actually treating the mentally ill. Some of my pet peeves, like the overdiagnosis of attention deficit disorder, of childhood bipolar disorder, and of posttraumatic stress disorder, may be improved. As Gregory Bateson defined it, information is a “difference that makes a difference”, and some of the refined distinctions here will of course be more useful to psychiatric research than to practice, but by and large I find them meaningful.

However, the other thing that goes on from revision to revision of the DSM is a proliferation of diagnoses, leading to a relentless expansion of the scope and incidence of mental disorders among the population. This is what has been referred to as the medicalization of ‘normal’ human variability and of personality differences. If a broader net is cast and more people are diagnosable with mental disorders, you can imagine some of the consequences, which include the increasing use of medications for more and more benign variations; changes in social stigmatization; insurance reimbursement for various states of distress; and various diminished responsibility defenses in criminal proceedings. More profoundly, we are rewriting the concepts of personal responsibility and autonomy and the balance between free will and determinism.

I already have far too much work to do to welcome such a broader net, but then again I don’t make a fortune on the basis of how many prescriptions are written. (Estimates are that anywhere from 50-70% of those working on the revisions derive substantial income or research funding from the pharmaceutical industry.)

Tonight, because one of their reporters has been a reader of FmH, I was interviewed by the BBC about my impressions about the DSM-V proposals. It remains to be seen whether I gave them any juicy quotes they can use.

The Americanization of Mental Illness

On the Threshold of Eternity

“For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures. Indeed, a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.” (New York Times Magazine)

Placebo Response Under Genetic Control

Prozac, a selective serotonin reuptake inhibit...

Monoamine Oxidase A and Catechol-O-Methyltransferase Functional Polymorphisms and the Placebo Response in Major Depressive Disorder: “The placebo response shows pronounced interindividual variability. Placebos are postulated to act through central reward pathways that are modulated by monoamines. Because monoaminergic signaling is under strong genetic control, we hypothesized that common functional polymorphisms modulating monoaminergic tone would be related to degree of improvement during placebo treatment of subjects with major depressive disorder. We examined polymorphisms in genes encoding the catabolic enzymes catechol-O-methyltransferase and monoamine oxidase A. Subjects with monoamine oxidase A G/T polymorphisms (rs6323) coding for the highest activity form of the enzyme (G or G/G) had a significantly lower magnitude of placebo response than those with other genotypes. Subjects with Val158Met catechol-O-methyltransferase polymorphisms coding for a lower-activity form of the enzyme (2 Met alleles) showed a statistical trend toward a lower magnitude of placebo response. These findings support the hypothesis that genetic polymorphisms modulating monoaminergic tone are related to degree of placebo responsiveness in major depressive disorder.” (Journal of Clinical Psychopharmacology)

Some behavioral scientists consider the placebo response to be a nuisance that confounds psychopharmacological research; patients get better even when they do not get the active drug. Some of us, however, feel that the placebo response is a good friend of clinical psychiatry. Some meta-analyses of antidepressant efficacy studies suggest that the medications may not be that effective and that much of the therapeutic response to antidepressants may in fact be ascribable to the placebo response. (The psychiatrist’s role, as a corollary, may be not the art of picking a drug to prescribe but enlisting the individual into a mindset that mobilizes their self-healing capacities.) We already know that depression is related to the reward circuitry in the brain and that genetic susceptibility to depressive disorders relates to polymorphism in the catecholamine system. If the placebo response as well varies with differences in that circuitry, could it be that those patients with lower capacity for the placebo response could also be those patients prone to become depressed int he first place? If we cannot as effectively mobilize their placebo response when they are in the placebo wing of a drug study, perhaps they cannot as effectively bring self-suggestion, affirmation and other coping strategies to bear on the distressing situations in their lives?

Related:

Bipolar disorder and its biomythology: An interview with David Healy

Cover of "Mania: A Short History of Bipol...

Q: Part of what you describe in your new book Mania: A Short History of Bipolar Disorder is a fair amount of “biomythology” about the illness. What aspects in particular do you have in mind?

A: Biomythology links to biobabble, a term I coined in 1999 to correspond to the widely-used expression psychobabble. Biobabble refers to things like the supposed lowering of serotonin levels and the chemical imbalance that are said to lie at the heart of mood disorders, ADHD, and anxiety disorders. This is as mythical as the supposed alterations of libido that Freudian theory says are at the heart of psychodynamic disorders.

While libido and serotonin are real things, the way these terms were once used by psychoanalysts and by psychopharmacologists now—especially in the way they have seeped into popular culture—bears no relationship to any underlying serotonin level or measurable chemical imbalance or disorder of libido. What’s astonishing is how quickly these terms were taken up by popular culture, and how widely, with so many people now routinely referring their serotonin levels being out of whack when they are feeling wrong or unwell.

structure of serotoninStructure of serotonin

In the case of bipolar disorder the biomyths center on ideas of mood stabilization. But there is no evidence that the drugs stabilize moods. In fact, it is not even clear that it makes sense to talk about a mood center in the brain. A further piece of mythology aimed at keeping people on the drugs is that these are supposedly neuroprotective—but there’s no evidence that this is the case and in fact these drugs can lead to brain damage.

via Psychology Today Blogs.

Oh, I wish I had time right now to comment on this at length. Some great points here, but I think he is throwing babies out with bathwater, Read the entire piece. ..

I find, increasingly, that the practice of psychiatry for me is a difficult balancing act of believing in my role while increasingly disbelieving many of the principles by which our approach is ‘explained’ and justified. Biomythology is a great term for it. The emperor has few clothes…

Ethics of Physicians’ Sexual Relationships with Patients

Medicine

A good introduction to the issue; helps you to understand the strict medical ethical guidelines against intimacy with our patients and even former patients, even when the parties are two consenting adults insistent on the consensual nature of their liaison. The ‘transference‘ to the authority of the physician, the AMA says, makes free choice on the part fo the patient difficult. The situation is even more thorny, the violations more egregious, and the condemnation of the profession more emphatic in my discipline, psychiatry, as you might imagine.

Related:

What Doctors (Supposedly) Get Wrong about PTSD

This article in Scientific American by David Dobbs reports on the growing concern that “the concept of post-traumatic stress disorder is itself disordered”. The writer is critical of a culture which “seemed reflexively to view bad memories, nightmares and any other sign of distress as an indicator of PTSD.” To critics like this, the overwhelming incidence of PTSD diagnoses in returning Iraqi veterans is not a reflection of the brutal meaningless horror to which many of the combatants were exposed but of a sissy culture that can no longer suck it up. As usual, the veil of ‘objective’ ‘scientific’ evidence is used to cloak ideological biases.

FmH readers know that I too am critical of the frequency of PTSD diagnosis in modern mental health practice, but I think that is not a problem with the theoretical construct of PTSD but its slapdash application. With respect to domestic PTSD, the problem is one of overzealous and naive clinicians ignoring the diagnostic criteria and, more important, misunderstanding the clinical significance and intent of the diagnosis, labelling with PTSD far too many people who have ever had anything more than a little upsetting or distressing happen to them. Essentially, PTSD is meant to refer to the longterm consequences of either an experience or experiences that are outside the bounds of what the human psyche can endure. Both emotionally and neurobiologically, the capacity of the organism is overwhelmed and the fact of the trauma assumes an overarching and inescapable central role in future information processing, functioning and sense of self. Experience that occurs when the body is flooded with unimaginably high levels of stress hormones, when the nervous system is in the throes of the fight-or-flight response, and when the normal processes for making sense of what we are going through utterly break down are encoded differently in the body and mind, with immeasurable effects. Only someone who did not grasp this at all could misrecognize simple anxiety, depression or adjustment difficulties as PTSD. But it happens all the time, especially in the treatment of depressed women, largely because of do-gooder clinicians’ desires to be politically correct and not be seen as insensitive to their clients’ suffering. Unfortunately, what it mostly does is train these clients to remain lifelong inhabitants of a self-fulfilling inescapable victim role.

The concern, on the other hand, with soldiers returning from the wars in central Asia, is the opposite. All evidence is that PTSD is being underdiagnosed, because of systematic biases within the government and the military to deny the scope of the problem. Articles such as this, and the research that it depicts, should be seen as nothing but a conservative backlash, an effort to blame the victims. If coping with the scope of PTSD is a problem, deny the reality of PTSD. Certainly considerable research suggests that a proportion of soldiers returning from the battle front in bad shape will have shown their resilience, will no longer show a high magnitude of emotional disturbance, and will not warrant a diagnosis of PTSD if reassessed months or years later. Research also suggests that early intervention using a trauma paradigm may do more harm than good, perpetuating the vulnerability of the patient. And most Defense Dept. research on the effects of combat trauma is intended to figure out how to block the stress reaction so that a soldier can remain functional and return to a combat role as soon as possible. But it remains the case that the human nervous system did not evolve to endure the horrors of modern war, and that the indefensibility and anomie of this war in particular, based as it has been entirely on lies, amplifies the intolerability and makes it far less likely that a veteran can find sustaining meaning in the suffering they endured. This will inevitably turn into higher rates of PTSD than among veterans of other wars.

To deny the scale of PTSD in our returning veterans is to be an unquestioning apologist for the untrammelled American imperialist projection of power in lawless aggression. As Dobbs describes it, the PTSD deniers construe us as having a cultural obsession with PTSD which embodies “a prolonged failure to contextualize and accept our own collective aggression.” What horse manure. Our cultural neurosis, rather, lies in the unquestioning acceptance of suggestions like Dobbs’ that we should mindlessly embrace such aggression as natural. This was the neurosis that made it possible to elect Bush and his handlers to enact an administration that set about violating every supposed principle of our democracy and our humanity. I know we are not supposed to draw this particular analogy, but this brand of PTSD denial strikes me as akin to nothing as much as Holocaust denial. Via Scientific American.

Is it really bad to be sad?

“…Misery is inconvenient, unpleasant, and in a society where personal happiness is prized above all else, there is little tolerance for wallowing in despair. Especially now we’ve got drugs for it. …So it’s no surprise that more and more people are taking them.

But is this really such a good idea? A growing number of cautionary voices from the world of mental health research are saying it isn’t. They fear that the increasing tendency to treat normal sadness as if it were a disease is playing fast and loose with a crucial part of our biology. Sadness, they argue, serves an evolutionary purpose – and if we lose it, we lose out.

“When you find something this deeply in us biologically, you presume that it was selected because it had some advantage, otherwise we wouldn’t have been burdened with it,” says Jerome Wakefield, a clinical social worker at New York University and co-author of The Loss of Sadness: How psychiatry transformed normal sorrow into depressive disorder (with Allan Horwitz, Oxford University Press, 2007). “We’re fooling around with part of our biological make-up.”

Perhaps, then, it is time to embrace our miserable side. Yet many psychiatrists insist not. Sadness has a nasty habit of turning into depression, they warn. Even when people are sad for good reason, they should be allowed to take drugs to make themselves feel better if that’s what they want.

So who is right? Is sadness something we can live without or is it a crucial part of the human condition?

…there are lots of ideas about why our propensity to feel sad might have evolved. It may be a self-protection strategy, as it seems to be among other primates that show signs of sadness. …it helps us learn from our mistakes. …even full-blown depression may save us from the effects of long-term stress. Without taking time out to reflect, he says, “you might stay in a state of chronic stress until you’re exhausted or dead”. …By acting sad, we tell other community members that we need support….Then there is the notion that creativity is connected to dark moods. …There is also evidence that too much happiness can be bad for your career…” (More)

via New Scientist.

Posting articles on this theme is, readers may have noticed, a recurrent event here on FmH. I began to be introduced to this notion, that depression might serve a useful purpose and that we had to rethink our knee-jerk readiness to vanquish it (and normal sadness as well, which is difficult to disentangle from pathological depression) whenever we encountered it, early in my career. I think it has fundamentally informed my skepticism about the way we organize and administer psychiatric services in this society. In addition, there are concerns that too readily resorting to antidepressant therapy may reinforce future propensity for depressive reactions and need for medication (which I’m sure will please the pharmaceutical industry to hear). I have always said that getting people off of medications, or refraining from prescribing them, are equally important functions of a psychopharmacologist as is prescribing astutely.

Living out the Truman Show

Eye-in-the-Sky

Truman Syndrome is a form of psychological delusion in which the patient believes that he or she is trapped inside in a reality television show, or that people are monitoring his or her every move. The name for this syndrome is a reference to The Truman Show, a 1998 film which revolved around a character who was living his entire life on camera without being aware of it. To those of sound mind, Truman Syndrome might sound a bit ludicrous, but not dangerous, although this is not, in fact, the case: this condition can actually be very dangerous for the people who suffer from it.

Psychologists have suggested that Truman Syndrome is a culture-based delusion, noting that it tends to arise in developed nations where there is a high level of surveillance, and where reality television shows are easy to access. Many people living in such societies have a certain amount of nervousness about being under surveillance or watched by the government, but people with Truman Syndrome take it to a whole new level, subverting very real concerns into a complex delusion.

Patients with this condition often specifically reference The Truman Show, along with other films and books with similar premises. They claim that they are living in an entirely artificial world where nothing is real and every action is carefully documented on a camera and watched by a television audience or government agency. Like the title character in The Truman Show, they think that they are slowly breaking through to the truth, but no one believes them.

Aside from the fact that delusions in general can be psychologically harmful, Truman Syndrome can also be dangerous. For example, people may think that specific actions will release them from the show, allowing them to win prizes, and these actions may involve dangerous activities. People may also become frustrated by the repeated denials of their delusions, lashing out at friends and strangers alike in an attempt to get people to admit that they are inhabiting an artificial world. Some people also have difficulty coping with real-life events, believing that these events were manufactured as part of the reality shows they inhabit.

Treating Truman Syndrome is complex. The use of anti-psychotic drugs and anti-depressants can help, but ultimately extensive talk therapy is the best option. Because the entire delusion rests on the premise that the world isn’t real, the treating psychiatrist or psychologist may struggle initially to be accepted, especially if he or she is confrontational with the patient, and this is a good thing to keep in mind.”

via Wisegeek.

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You are being watched...

Secrecy behind the new book of human troubles

“Diagnoses decided by an unelected committee in secret sessions that are legally prevented from discussing their work. Science marches on.”

Many are up in arms about the closed-doors process being used to draft the next edition of the American Psychiatric Associations’s Diagnostic and Statistical Manual, or DSM, the ‘bible’ defining all permissible psychiatric diagnoses.

via Mind Hacks.

University of Manchester Psychosis Research Project wants your help

Jane Kelly. If We Could Undo Psychosis 2.
Jane Kelly. If We Could Undo Psychosis 2

“How does online information on psychosis affect people’s beliefs and knowledge about psychosis? A survey of podcast listeners… If you wish to take part, you will be asked to answer several questions about psychosis, in particular what psychosis means to you and what you know about psychosis. You will be asked to answer some questions both before you listen to the audio information and afterwards. Questions will be about why you are interested in psychosis, what your knowledge and beliefs about psychosis are, and what you thought of the podcast.”

via www.psych-sci.manchester.ac.uk.

Self-Embedding Disorder: NOT


This is a newly-coined term appearing in a press release by the Radiological Society of North America to describe a form of self-injurious behavior, with which we psychiatrists are (unfortunately) far too familiar already. Placing foreign bodies such as hairpins and straightened paper clips into self-inflicted wounds and embedding them under the skin is, admittedly, a new trend in self-abuse, if we can believe the radiologists, whose press release describes the safety and efficacy of minimally-invasive image-guided treatment for the extraction of such objects. However, there is no need for a new diagnosis. Indeed, self-injuriousness in general is not an illness, or a diagnosis, unto itself, but rather a symptom of a variety of diagnoses. A fortiori for a particular kind of self-injuriousness. This illustrates one of the epistemological confusions plaguing the system for diagnosing behavioral problems, and is a perfect example of the needless proliferation of diagnostic categories.

Via The Neurocritic (By the way, I think the Neurocritic piece meant to discuss “foreign bodies”, not “foreign bodes”.)

The Meaning of Psychological Abnormality

Attention-deficit hyperactivity disorderADHD

Distinguished developmental psychologist Jerome Kagan argues that the current spate of childhood mental health diagnoses such as ADHD and bipolar disorder do not represent biological diseases but rather convenient explanations that get us off the hook by covering up social problems. He discusses social trends that may account for childhood behavioral difficulties.

via Cerebrum

I agree that childhood disorders are overdiagnosed and that, in general, we are in an era of overmedicalization of behavioral problems for a variety of reasons, not the least of them being the influence of Big Pharma. I hope no one thinks any longer that psychiatric diagnoses are immutable gospel truths. From revision to revision, the nomenclature changes. The boundaries of what is considered psychopathology expand and contract (in this era, mostly expand) and the internal pigeonholes are everchanging. Our research practices, supposed to contribute to “evidence-based” medical reasoning, compound the errors, because drug companies have a subtle and not-so-subtle vested interest in the results, they fund much of it, and there is an inherent bias against the publication of negative or disconfirmatory results.

On the other hand, let us not throw the baby out with the bathwater. We should be long past the need to debate nature vs. nurture in mental ilness, social context vs. biology. There are of course contributions of both, and Dr Kagan’s argument should not be seen as dismissing the biological bases of behavioral problems whole hog. I do agree with him, vehemently, though, that overdiagnosis and overattribution is rife, and that it is obscene when you look at the major consequences, the pathologizatioon and the foisting of enormous volumes of medication on our children and youth. A good psychiatrist’s role should be as much to take patients off medication as to get them on it.

Wall of shame, psychiatric version

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These are some of the most influential men in psychiatry. Trainees have been taught to reference their journal articles as authoritative. And, I believe, this is just the tip of the iceberg:

Florida Teen Live-Streams His Suicide Online

‘A Florida teenager who used a webcam to live-stream his suicide Wednesday was reportedly encouraged by other people on the Web site, authorities told ABCNews.com.

Authorities say approximately 1,300 people watch as the boy takes his life.

"People were egging him on and saying things like 'go ahead and do it, faggot,' said Wendy Crane, an investigator at the Broward County Medical Examiner's office.

Abraham Biggs, 19, of Pembroke Pines, Fla., had been blogging on an online body-building message board and had linked to his page on Justin.tv, a live video streaming Web site, where the camera rolled as he overdosed on prescription pills, according to Crane.

Biggs, who had reportedly been discussing his suicide on the forums, also posted a suicide note on a body-building forum, which has since been taken down, in which he wrote, "I hate myself and I hate living." ‘

via ABC News

Deja vu tied to familiarity with past

The human brain

“In a report, published in Current Directions in Psychological Science, Anne Cleary of Colorado State University says deja vu may occur when aspects of a current situation resemble aspects of previously occurring situations — the more overlap between the elements of the new and old situations the stronger the feeling of familiarity”

via UPI

I haven’t read the research paper; just this account in the popular press. But it seems problematic. Most people I know can tell the difference between a deja vu experience and something reminding them of something from the past. The first response when something feels familiar is to ask what it could possibly be reminiscent of. The deja vu experience is so uncanny precisely because of that distinction — the nature of the situation promoting the sense of familiarity is one in which, after consideration, you know it cannot possibly be reminiscent of anything. It is more likely the case that deja vu represents a malfunction of the machinery of recognition or familiarity in the brain, in which the sensation of familiarity is too readily activated in inappropriate (i.e. novel) situations. This occurs, for example, in temporal lobe epilepsy, because the abnormal electrical activity autonomately activates areas of the brain associated with memory and recognition without the usual input. The research referenced here seems to misunderstand a fundamental aspect of deja vu, in short. This is my take on contemporary psychological research alot of the time. Hmmm, doesn’t that sound familiar?

Related:

An Epidemic of Depression?

baldclutchIn an abbreviated version of the argument they expound in their book The Loss of Sadness: How Psychiatry Transformed Normal Misery Into Depressive Disorder, psychologists Allan Horwitz and Jerome Wakefield say that the epidemic of depression arises from changes in the definition of the disorder, and specifically the loss of context. There is a bereavement exclusion but it is the only place where psychiatrists recognize that there is a difference between a ‘normal’ reaction to a painful loss and a depressive disorder. In fact, in my training, the ‘naive’ comment, “You would be sad too if that was going on in your life” was presented derisively as the caricature of ignorance about depression. The ‘bible’ of psychiatric diagnoses, The Diagnostic and Statistical Manual (DSM), currently in its fourth edition, devalued the time-honored recognition by physicians that the context in which symptoms arose was an important considderation in determining whether what the person was experiencing was normal. This goes hand in hand with other pressures in my field to medicalize and pathologize normal emotional reactions, of which I have written with concern here in the past.

via Psychiatric Times

Paranoia on the rise, experts say

Paranoia

Paranoia, once assumed to afflict only schizophrenics, may be a lot more common than previously thought.

According to British psychologist Daniel Freeman, nearly one in four Londoners regularly have paranoid thoughts. Freeman is a paranoia expert at the Institute of Psychiatry at King’s College and the author of a book on the subject.

Experts say there is a wide spectrum of paranoia, from the dangerous delusions that drive schizophrenics to violence to the irrational fears many people have daily.

“We are now starting to discover that madness is human and that we need to look at normal people to understand it,” said Dr. Jim van Os, a professor of psychiatry at Maastricht University in the Netherlands…”

via Las Vegas Sun

Cortex, Volume 44, Issue 10 (November-December 2008)

Example of a subject in a Ganzfeld experiment.Ganzfeld experiment

This is a special issue on the ‘Neuropsychology of Paranormal Experiences and Beliefs’

Contents include:

  • The paranormal mind: How the study of anomalous experiences and beliefs may inform cognitive neuroscience (Peter Brugger, Christine Mohr)
  • Visual attentional capture predicts belief in a meaningful world (Paola Bressan, Peter Kramer, Mara Germani)
  • Sentences with core knowledge violations increase the size of N400 among paranormal believers (Marjaana Lindeman, Sebastian Cederström, Petteri Simola, Anni Simula, Sara Ollikainen, Tapani Riekki)
  • Apophenia, theory of mind and schizotypy: Perceiving meaning and intentionality in randomness (Sophie Fyfe, Claire Williams, Oliver J. Mason, Graham J. Pickup)
  • Believing in paranormal phenomena: Relations to asymmetry of body and brain (Günter Schulter, Ilona Papousek)
  • Paranormal experience and the COMT dopaminergic gene: A preliminary attempt to associate phenotype with genotype using an underlying brain theory (Amir Raz, Terence Hines, John Fossella, Daniella Castro)
  • Event-related potential correlates of paranormal ideation and unusual experiences (Alex Sumich, Veena Kumari, Evian Gordon, Nigel Tunstall, Michael Brammer)
  • The transliminal brain at rest: Baseline EEG, unusual experiences, and access to unconscious mental activity (Jessica I. Fleck, Deborah L. Green, Jennifer L. Stevenson, Lisa Payne, Edward M. Bowden, Mark Jung-Beeman, John Kounios)
  • Ganzfeld-induced hallucinatory experience, its phenomenology and cerebral electrophysiology (Jirí Wackermann, Peter Pütz, Carsten Allefeld)
  • Magical ideation and hyperacusis (Stéphanie Dubal, Isabelle Viaud-Delmon)
  • Psychological aspects of the alien contact experience (Christopher C. French, Julia Santomauro, Victoria Hamilton, Rachel Fox, Michael A. Thalbourne)

Highlights include:

  • part of the variance of strength of belief in paranormal phenomena can be explained by patterns of functional hemispheric asymmetry that may be related to perturbations during fetal development
  • an inconclusive attempt to correlate a specific phenotype concerning paranormal belief with a dopaminergic gene (COMT) known for its involvement in prefrontal executive cognition and for a polymorphism that is positively correlated with suggestibility.
  • a study concluding that (a) religious people have a stronger belief in meaningfulness of coincidences, indicative of a more general tendency to maintain strong schemata, and that (b) this belief leads them to suppress, ignore, or forget information that has demonstrably captured their attention, but happens to be inconsistent with their schemata.
  • electrophysiological findings suggesting that paranormalideation may be associated with alteration in contextual updating processes, and that nusual experiences may reflect altered sensory/early-attention (N100) mechanisms.
  • EEG patterns of subjects with high levels of belief in paranormal phenomena and more frequent unusual experiences were similar to those found in schizophrenic-spectrum disorders.
  • People reporting contact with aliens (‘Experiencers’), compared with matched controls, were found to show higher levels of dissociativity, absorption, paranormal belief, paranormal experience, self-reported psychic ability, fantasy proneness, tendency to hallucinate, and self-reported incidence of sleep paralysis.

Wrangling over psychiatry’s bible

Light bedtime reading

“Over the summer, a wrangle between eminent psychiatrists that had been brewing for months erupted in print. Startled readers of Psychiatric News saw the spectacle unfold in the journal’s normally less-dramatic pages. The bone of contention: whether the next revision of America’s psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders, should be done openly and transparently so mental health professionals and the public could follow along, or whether the debates should be held in secret.

One of the psychiatrists (former editor Robert Spitzer) wanted transparency; several others, including the president of the American Psychiatric Assn. and the man charged with overseeing the revisions (Darrel Regier), held out for secrecy. Hanging in the balance is whether, four years from now, a set of questionable behaviors with names such as “Apathy Disorder,” “Parental Alienation Syndrome,” “Premenstrual Dysphoric Disorder,” “Compulsive Buying Disorder,” “Internet Addiction” and “Relational Disorder” will be considered full-fledged psychiatric illnesses.

This may sound like an arcane, insignificant spat about nomenclature. But the manual is in fact terribly important, and the debates taking place have far-reaching consequences.”

via Los Angeles Times

Sharing Their Demons on the Web

Eight women representing prominent mental diagnoses in the nineteenth century.
Eight women representing prominent mental diagnoses in the nineteenth century.

Health Professionals Fear Web Sites That Support Theories on Mind Control (New York Times ). The internet may have fundamentally changed the experience of those who believe they are stalked or persecuted. Sites filled with stories from people calling themselves victims of “mind control” or “gang stalking” offer support and validation, in contrast to the isolation and pejoration with which they were treated in the pre-internet era. Many mental health professionals are alarmed that such sites encourage delusional thinking. The growth of such a community of sufferers with shared beliefs presents a fundamental challenge to the definition of delusions, as beliefs that are at odds with those shared by one’s culture or subculture.

The interest of law enforcement and government agencies in covert surveillance, mind-control and chemical interrogation techniques (cf. MK-ULTRA)is enough evidence to encourage such beliefs, and their dismissal by health professionals and others is seen as evidence of a cover-up of the truth.

However, others who see the isolation and quiet torment in which people with psychotic disorders live feel that the growth of a supportive community could be a good thing. In my own work with patients who believe they are subject to mind control or gang stalking, I do not find confronting and contradicting their beliefs is effective. In fact, I am sensitive to the ways in which it perpetuates the violence and persecution that has been done to them by other powerful individuals in their lives. Treatment, the aim of which after all is to relieve suffering, cannot be done in an intellectually dishonest way in which one acts out a charade of sharing the patient’s beliefs. But treatment must be experienced as a safe place in which to have one’s thoughts, whether agreed with or not. Contrary to the opinion of one psychiatrist interviewed for this article, who says that but for these internet sites reinforcing the thinking, it would fade away because never validated, the essence of delusional thinking is that it is logically self-validating. The sufferer has constructed an airtight explanation for disturbing experiences and perceptions they have, an explanation which is not falsifiable. Its assertions are self-fulfilling. That is the logic and, if you will, the beauty of delusional thinking. In my experiences, such thinking is not malleable and precisely does not fade away. To attempt to confront it is to invalidate the person in front of you, doing profound existential violence to an already quite vulnerable person. This is the essence of what I have always taught my students as a core approach to a psychotic individual.

This has been known for a long time in psychological circles, and it is merely the self-anointed but misguided role of mental health providers as arbiters of thought and vanquishers of mental illness that prevents our acceptance of immutable delusional thinking. My uncle, the psychologist Milton Rokeach, wrote in his 1964 book The Three Christs of Ypsilanti of an experiment in which he brought together three psychiatric patients each of whom believed he was Christ… sort of meeting irresistible force with immovable object. He hoped that the coexistence of logically incompatible beliefs would correct the delusions. He later wrote that he regretted the experiment, because as it turned out all that it had done had been to vastly amplify the distress and confusion of the three subjects.

In addition to my uncle, several of my mentors and teachers were influential in grappling with how to situate themselves properly with respect to the challenging beliefs of their patients, if they were neither to fraudulently say they agreed nor to contradict by brute force. R.D. Laing took a radical stance of refusing to make distinctions between ‘patients’ and ‘treaters’ as arbiters of the truth. This is an incredibly useful position to take, although I think Laing went too far in that the relationship is inherently asymmetrical; the patient is the one who comes to us with suffering, seeking guidance and succor. Leston Havens devoted himself to the technical craft of finding language and therapeutic stance that would allow the therapist to situate him- or herself as an ally, rather than an opponent, of people so difficult to ally with. John Mack’s work with alien abductees exemplified finding a way to be helpful with a subset of those sufferers whose beliefs are so at odds with prevailing notions.

It has been an area of my own fascination, teaching and research to watch how the lay public’s knowledge and beliefs about mental health issues are spread in the popular media, word of mouth and, more recently, the internet. These means of communication are not a cause of mental illness, but clearly important variables in shaping it. I wonder, WWLD (what would Laing do?) with the internet?

In a Novel Theory of Mental Disorders, Parents’ Genes Are in Competition

An MRI scan of a human brain. Many mental diso...

“…[S]weeping theory of brain development would change the way mental disorders like autism and schizophrenia are understood“. Essentially, the authors argue, it is competition between genes inherited from the parents which tips brain development in one way or another. A predominance of paternal genes confers autistic traits while a predominance of maternal genes a vulnerability to psychotic experience.

“In short: autism and schizophrenia represent opposite ends of a spectrum that includes most, if not all, psychiatric and developmental brain disorders. The theory has no use for psychiatry’s many separate categories for disorders, and it would give genetic findings an entirely new dimension.”(New York Times )

The article goes a little overboard in calling this “perhaps [psychiatry’s] grandest working theory since Freud”, which IMHO remains to be seen.

Small (?) Victory

In 1997, I traveled to Alabama to work as an expert psychiatric witness in the appeal of a death sentence of a young African American man convicted of a 1988 murder. I interviewed him extensively on Death Row and travelled to his childhood home in rural Alabama to build a psychological history of him from interviews with family and those who had known him as a child and youth. My profiling and testimony helped to establish that he had been horrendously abused throughout his childhood, that the pertinence of the abuse should have been considered as a mitigating factor in his sentencing, and that his original defense team’s failure to do so constituted ineffective assistance of counsel.

The judge who heard my testimony in the appeal ran his courtroom, his own personal fiefdom, like a burlesque show. He had been the trial judge in the original murder trial and had overruled the jury’s recommendation of a lesser sentence to impose the death penalty. Now here he was hearing an appeal of his own malfeasance and impaired judgment, and you could see how seriously he would take this unpleasant duty. At the appeal, I recall a group of Harvard Law students sitting in the courtroom observing the trial, shaking their heads in disbelief and scribbling furiously in their notebooks example after example of his outrageous courtroom behavior and abuse of the rule of law. The judge referred to me derisively as “post traumatic syndrome man” and my conclusions as “post traumatic syndromes, whatever that is” (yes, grammatically challenged as well), after I had spent two days painstakingly explaining the psychiatric facts and conclusions at a level any ignoramus could understand. When he was informed that my testimony was complete, he commented, “For the record, good.” Needless to say, he denied the appeal.

I was never informed by the defense team (his case is now being handled by different counsel), but this evening, while surfing the web, I happened upon the news that the judge’s ruling has just been overturned, the appeals court finding that he had failed to appropriately consider the psychological evidence presented at the earlier appeal. After twenty years, his death sentence has been vacated.

For those of you who enjoy legalese, you can find the text of the ruling here (pdf). You can read about the horrific details of the crime and the see the total travesty made of the defendant’s rights in the Alabama judicial system. While I have consulted on other death penalty appeals, this was the only case in which I was on the stand and certainly the only three-ring circus I have attended in which a man’s life was at stake. If you use your pdf reader’s search facility to look for instances of “Gelwan” in the ruling, you will find more detailed reference to my work and my testimony on the case. It is one of the things I have done in my life of which I am most proud, and I am ecstatic to learn about this ruling. It could just as easily have been the case that I never found out.

[Does anyone have any references to Barack Obama’s position on the death penalty? — FmH]

The Disorder Is Sensory…

…The Diagnosis, Elusive: “No one has a standard diagnostic test for these sensory integration problems, nor any idea of what might be happening in the brain. Indeed, a diagnosis of such problems is not yet generally accepted. Nor is there evidence to guide treatment, which makes many doctors, if they have heard of sensory problems at all, skeptical of the diagnosis.Yet in some urban and suburban school districts across the county, talk of sensory integration has become part of the special-needs vernacular, along with attention deficit disorder and developmental delays. Though reliable figures for diagnosis rates are not available, the number of parent groups devoted to sensory problems has more than tripled in the last few years, to 55 nationwide.And now this subculture wants membership in mainstream medicine. This year, for the first time, therapists and researchers petitioned the American Psychiatric Association to include ‘sensory processing disorder’ in its influential guidebook of disorders, the Diagnostic and Statistical Manual. Official recognition would bring desperately needed research, they say, as well as more complete coverage for treatment, which can run to more than $10,000 a year.” (New York Times )
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Why Cho Was Not Committed

Psychologist Jonathan Kellerman writes a thoughtful Wall Street Journal op-ed piece , with which I largely agree, grappling with the ethical responsibility of the mental health profession with respect to violence:

“If the Virginia Tech shooter had been locked up for careful observation in a humane mental hospital, the worst-case scenario would’ve been a minor league civil liberties goof: an unpleasant semester break for an odd and hostile young misanthrope who might’ve even have learned to be more polite. Yes, it’s possible confinement would’ve been futile or even stoked his rage. But a third outcome is also possible: Simply getting a patient through a crisis point can prevent disaster, as happens with suicidal people restrained from self-destruction who lose their enthusiasm for repeat performances.”

Kellerman does, however, place too much responsibility at the feet of the “liberationists” and “libertarians”, exemplified by R.D. Laing and Thomas Szasz for the historic failure of the mental health system to effectively address such issues. Would that Laing’s thought had had more of an influence! Kellerman summarizes the Laingian perspective as the principle that “[not] only wasn’t psychosis a bad thing, it was evidence of a superior level of consciousness”. But Laing’s opposition to psychiatric medication and hospitalization were just the window dressing on his more essential contribution — an existential perspective which gives inroads into the inner world of our psychotic patients that inherently humanizes our care. This is not incompatible with the responsible mainstream practice of clinical psychiatry, IMHO, and I can cherish Laing’s influence on my psychiatric philosophy without cognitive dissonance even though I medicate and hospitalize patients. About Szasz I have less kind things to say, especially given his collaboration with the Scientologists.

Deinstitutionalization and the failure of the community mental health system were not driven nearly as much by such idealistic philosophical vision as they were by the fiscal betrayal of the severely mentally ill — a socially insignificant constituency without serious advocates, and one our society is all too ready to shun and stigmatize — in the service of budgetary constraint. As Kellerman observes, “this was baby-and-bathwater time.” The crux of the matter, he goes on to observe,

“…[the] basic premise of Community Psych–that severely mentally ill people could be depended on to show up for treatment voluntarily–never made sense to me. The core of the most common and debilitating psychosis, schizophrenia, is degradation of thought and reason. So the idea that people with fractured minds could and would make rational, often complex decisions about self-care seemed preposterous.”

I would amplify on that; schizophrenia (and other major mental illness) involves not only a general degradation of reasoning but also a specific loss of insight into the nature of one’s illness and recognition of the need for treatment, known as anosognosia, that can be understood both in terms of psychological denial and neurochemical dysfunction of particular brain regions, and which makes noncompliance with followup treatment and medication the single most important cause of deterioration and relapse.

While exercising due diligence in raising caveats, Kellerman infers that Cho had a serious mental illness and, unfortunately, all we will have is speculation:

“Diagnosis from afar is the purview of talk-shows hosts and other charlatans, and I will not attempt to detail the psyche of the Virginia Tech slaughterer. But I will hazard that much of what has been reported about his pre-massacre behavior–prolonged periods of asocial mutism and withdrawal, irrational anger and hatred, bizarre writing and speech–is not at odds with the picture of a fulminating, serious mental disease. And his age falls squarely within the most common period when psychosis blossoms.”

I would be the first to assert that psychiatry is a markedly imperfect tool at best for the prediction and prevention of violence, and that once on the slippery slope of preventive detention the dangers outweigh the benefits. But Kellerman’s conclusion, that

“Penning up and carefully scrutinizing the killer was never an option. Not in Virginia or California or any other state in the union. Because in our well-intentioned quest to maximize personal liberty, we’ve moved conceptual eons away from taking the concept of dangerousness seriously”

should give us pause.

When a Brain Forgets Where Memory Is

New York Times psychology reporter Jane Brody on the fascinating phenomenon of dissociative fugue:

“People with this problem suddenly and unexpectedly take leave of their usual physical surroundings and embark on a journey that can last as little as a few hours or as long as several months. During the fugue state, individuals completely lose their identity, later assuming a new one. They don’t know their real names or anything about their former lives, and they do not recognize friends or family. They may not even remember how they got to where they are.

While loss of memory can occur for many reasons, dissociative fugue has no direct physical or medical cause. Rather, it is precipitated by a severe stress or emotionally traumatic event that is so painful the mind seems to shut down and erase everything, like a failed computer hard drive.”

Several years ago on FmH, I wrote with fascination of an apparent case of dissociative amnesia, a largely mute piano-playing young man institutionalized in a British mental hospital after apparently washing up on a beach. But, although they appear with regularity as literary or cinematographic devices, fugue states are encountered rarely if ever by clinical psychiatrists like myself in the course of our work. Of course, an exhaustive effort to rule out other, more neurologically based, causes of acute memory failure must be made. At the other end of the spectrum, so too it is at times difficult to distinguish fugue states from more consciously motivated attempts to deny one’s identity.

I am not alone in wondering if fugue is a disease of modernity, requiring an emphasis on the self and personal sense of identity to shape a subconsciously-motivated attempt to lose one’s self. I wonder what effect the modern challenges to identity, such as the influence of mass media on identity, the diffusion of the self through online presence, or the threat of identity theft, will do the the manifestations of dissociative fugue.

NASA long ago devised mental breakdown plan

But that was for a psychological crisis in space, not back on Earth: “Long before NASA was confronted with an off-duty astronaut’s bizarre behavior and arrest in Florida earlier this month, the agency had developed procedures to deal with a mental breakdown in space.

The guidelines were developed to respond to an attempted suicide or severe anxiety, paranoia or hysteria aboard the international space station. Astronauts are instructed to bind the stricken flier’s wrists and ankles with duct tape, restrain the torso with bungee cords and administer strong tranquilizers.

The procedures have been in effect for at least six years, but the space agency did not develop any protocols for dealing with astronauts who become unstable while on the ground.” (Houston Chronicle)

Also:

“Welcome to Human Interactions in Space, a research program dedicated to identifying and characterizing the psychosocial issues that affect the health and well-being of space crewmembers and the mission control personnel that support them. The program goal is to develop countermeasures that will enhance the safety and success of people involved with long-duration space missions.”

Emotional Decisions

“Emotions are ordinarily conceived as irrational occurrences that cloud judgment and distort reasoning. This view is well entrenched, despite work in both philosophy and psychology that establishes a strong connection between emotion and cognition. During recent years there has been an explosion of research which indicates that rather than being natural adversaries, rational and emotional processes function together. Barnes and Thagard (in press) argue that emotions and inferences are both necessary when we empathize with other people. Social psychologists have explored the function of emotions in social perception and judgment (Forgas, 1991). But the interdependence of emotional and cognitive processes is perhaps most powerfully presented in recent neurobiological studies which establish that emotion is indispensable in rational decision making.” (— Barnes and Thagard)