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Tuesday, February 23. 2010

WSJ: The proposed new edition of Diagnostic and Statistical Manual of Mental Disorders could place large swaths of the population under the umbrella of pathology. One quote:

...good psychiatrists do not rely too heavily on the DSM when they care for patients. There is simply no substitute for observing the patient, listening to his story, and fine-tuning his treatments�psychological and pharmacological�as needed.

The framers of the DSM III knew this well. They cautioned against manual users taking too literally the sharp boundaries drawn between disorders and between disorder and mental health. "This version," they wrote in the preface, "is only one still frame in the ongoing process of attempting to better understand mental disorders." Thirty years later, despite undeniable progress in brain science, we are saying much the same thing.

Well said, Dr. Satel.

Ed. Addendum: Louis Menand, with wonderful clarity, looks at the tendency to pathologize everything into a "disorder" in The New Yorker. Every human has his own difficulties, weaknesses, pains, sorrows, limitations, fears, heartaches, struggles. No one can catalogue and categorize them all. Simply trying to understand one person is a heck of a challenge.

Posted by Dr. Joy Bliss in Our Essays, Psychology, and Dr. Bliss at 16:54 | Comments (20) | Trackbacks (0)

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During my extended time as an undergrad I worked for a year as an aide in a private psychiatric hospital. After I quit working there I took an Abnormal Psych course. The course would have been totally useless in dealing with patients there, as it dealt primarily with classifying people into pigeonholes such as are in the DSM.

Part of the issue is that when dealing with psych patients you need to deal with how they define their situation, not with whether they are obsessive-compulsive or paranoid schizophrenic. I am not saying that classification schema should be eliminated, but that they are often not useful in hands-on contact with psych patients- or anyone else, for that matter.

What I found useful in dealing with patients was what the psychiatrists and psychologists at the institution recommended for our writing up notes. 1) Describe patent's behavior/speech. 2) What were the dynamics behind the patient's acts? 3) What steps did you take to deal with the patient? By imposing an analytic frame on what could be rather intense situations, the instructions for writing were of assistance in deciding how to act .

#1 Gringo on 2010-02-23 17:45 (Reply)

Fortunately, most practitioners are cautioned on pigeonholing people with the DSM.
Unfortunately, it's required for insurance purposes.

It's somewhat useful for communication between doctors, psychologists, teachers and patients to have common descriptive terms.

#1.1 LP on 2010-02-23 20:12 (Reply)

The camel has his nose under the tent's wall as soon as talk turns to "mental health" as a normal, proper and beneficial state. "Mental health" automatically and necessarily implies/requires a polar opposite, "mental illness." Yet the concept of non-physical illness is nonsense -- it's a pure article of faith.

Freud pretended to found a whole new science on...how many cliinical cases? I can't recall, but I think it was less than fifteen. Those were the days in which "hysteria" was said to afflict females because they have uteri. Freud also praised cocaine for its ability to enhance the intellect. Of course he did.

It's time for medicine to mature and shed the fantasies and conceits of frauds and zealots. The DSM is more interested in abstract taxonomy than in science.

To the extent that insane behavior is caused by lesions, chemicals, genes or other physical phenomena, medicine should look for the causes and try to find ways to treat them.

"Mental illness" is not just a goofy concept, it's also dangerous. Thomas Szasz remains unrefuted, IMHO, though his seminal insights are usually damned with faint praise and then ignored.

#2 Benson on 2010-02-23 22:58 (Reply)

In my academic and professional career, I've met many brilliant, effective and highly competant engineers and scientists who were complete loons up to and including being socially inept at an almost autistic level.

Putting them into a box by defining their mien would be silly in my opinion. Every person has their flaws and oddball behaviors - we're only human after all.

#3 Tom Francis on 2010-02-24 01:09 (Reply)

For the record, I suffer from acrophobia and the sub set of aeroacrophobia - basically fear of heights/fear of high open spaces complicated by cremnophobia (fear of precipices), dystychiphobia (fear of accidents) and perhaps the most damaging phobia that all right thinking and intelligent people should properly fear if they knew about it -hippopotomonstrosesquipedaliophobia (fear of long words).

Right this very second, I'm having logophobia (fear of words) even thinking about something like the dread and suffering caused by hippopotomonstrosesquipedaliophobia.

I also think I might have another phobia type problem logizomechanophobia (fear of computers) for two reasons - my computer plots against me and logizomechanophobia sets off my hippopotomonstrosesquipedaliophobia.

Eye kan haz phobias? Yez eye kan.

#3.1 Tom Francis on 2010-02-24 01:31 (Reply)

Right now, Tom, I want you to invent another new word for the phobia I've got. Let me describe it.

My daughter-in-law, who is in her 50s and has a college degree from somewhere or other, has decided to try for an advanced degree in psychology concerned with elder counseling. In order to be accepted into this advanced degree training, she has written a paper on the effect of prolonged stress on the older person's mind [or lack of it]. She gave us the document to us to 'vet' for copy mistakes and similar corrections.

In my opinion, it is a very confusing, badly written essay. To begin with, I disagree with the basic premise. Of course, extreme prolonged stress can take its toll on the physical and mental health of the person being counseled. I don't argue with that. But stress, and our handling of it, is a basic building block of life, and an agent of mental and character growth. What are we here on earth for, after all? Stress, and one's handling of it, in my opinion, makes us grow into successful happy adults, if we handle it right.
It's a bad idea to eliminate all stress. Dolores Del Rio, a famous movie star of the 1930s, slept 20 hours a day out of every 24, to keep herself from aging. She didn't live any longer than the average age back then, but she sure had a boring life. And she got older anyway.

Anyway, Tom. I'm getting a really bad feeling about psychiatrists and psychologists who want to diagnose me and my elderly friends as mentally disturbed, mentally failing and in need of treatment, just because we may no longer leap to conclusions and rush to judgment. We like to take our time. What word would you use or invent to describe my "phobia?" How does one defend oneself against intrusive folks who want to solve problems you don't think you have?

Anyone else want to chime in? Feel free.

Marianne

#4 Marianne Matthews on 2010-02-24 11:11 (Reply)

Ah M'Lady Marianne - such grace in defense of us Ancients.

But stress, and our handling of it, is a basic building block of life, and an agent of mental and character growth.

Damn straight it is. That's the whole premise of military boot camp - you strip and stress and train molding a new high strength steel out of cold mallable iron.

Having said that, stress can be a bad thing as it can cause many other health issues - I grant that. However, you have to balance the bad stress with good stress. You have a bad day, take a brisk walk, play with the dogs - heck, my lovely bride of 35 years has a bad day at school she comes home and mops the kitchen floor with a vengence similar to the Marines storming Mt. Suribachi. :>) You know she really has a bad day when she knits a complete baby sweater and hat in one evening (I'm not joking). Some psychiatrists and psychologists might consider that behavior a disorder - its just a normal reaction to everyday life.

Me? I take Suzie De Doberman out for a walk in the woods and watch her chase rabbits and squirrels - it's the funniest thing you ever saw.

How does one defend oneself against intrusive folks who want to solve problems you don't think you have?

Tell them to buzz off and mind their own damn business. :>)

Unfortunately, the propensity of psychologists and psychiatrists is to pigeon hole all human behavior as if somehow we are automatons responding to a preprogrammed set of behavior rules considered as "acceptable" and any deviance from the norm is considered somehow dysfunctional. Which, with all due respect to Dr. Bliss whose postings I enjoy, is silly and ill informed - in fact, it could be a form of discrimination, but that is a subject for another time.

So my response to your question is simple - unless and until I cannot take care of myself, leave me the hell alone and shove your classifications and theories where the sun don't shine - only be polite about it - I'm an old cranky curmudgeon - a persona I have carefully cultivated over the years - amazing how it keeps people from doing and saying silly things around you. :>)

#4.1 Tom Francis on 2010-02-24 16:45 (Reply)

Now that I think about it, I want to add something here.

Elders (as in folks older than I [63]) need counseling, but to what effect? In my opinion, ill informed I admit, they need the opposite - stimulation. My Mom spent the last five years of her life in a home due to Alzheimers (sp?) and dementia. The interesting thing was that towards the end, she still recognized Suzie and everytime I brought Suzie to her nursing home, we left her with a smile. The nurses told me she behaved much better after our visits - there has to be something to that.

Since then, I've taken Suzie and the new dog Butch to local nursing homes and it's amazing to watch the reaction.

I must think about this some more.

#4.1.1 Tom Francis on 2010-02-24 17:06 (Reply)

Tom, thanks for the laugh of the day. I'm not even going to try and copy/paste or retype that word. And here I thought "antidisestablishmentarianism" was bad enough! I'm still laughing.......

#5 JoeC on 2010-02-24 11:31 (Reply)

Oh, and I forgot to answer the title question of the post: "Yes we are".

I took "jocrazy" as an underhanded compliment in my navy days 35+ years ago, and it resurfaced when AOL IM needed a name to be known by some 15 years ago now. I (think) I am more laid back than I was then, but that is only internal observation.

I shudder at the term "mental health" knowing that is a diagnosis by consensus.... That consensus gave us the Salem witch trials, the consensus KNOWING they were right. That consensus will huddle in their Marriott ballroom and vote on new tag for a mental aberration from which to derive a fee to fund more meetings and free drinks at the bar next year.

And some poor schmuck will find himself arrested by "mental hygiene police for muttering to himself after smashing his thumb with a hammer building the monument to "mental health".......

.... all by consensus.

#6 JoeC on 2010-02-24 11:48 (Reply)

One of Thomas Szasz's books is titled The Manufacture of Madness. It deals with, among other topics, witches. I think his best book is Law, Liberty, and Psychiatry. Related in many ways.

The persecution of a segment of society is virtually universal, unfortunately. It begins with the assignment of a stigma, and "mental illness" is just one historical example.

#6.1 Benson on 2010-02-24 12:58 (Reply)

Sitgma is bad and a sad thing. But the pain and disablility of it is real.

#6.1.1 Bird Dog on 2010-02-24 14:09 (Reply)

BD: Indeed - you're right as a stigma (classical definition - social shunning or disapproval) can be a bad thing - we see it everyday the most recent high profile example of a stigma being Trig Palin. People honestly believe that folks with Downs will not have worthy lives which is completely false and that Trig's life should have never been allowed to happen.

In my opinion, we need to be more accepting in general as a society. However human nature is to be mutually exclusive - tribes if you will. If you are a Red Sox fan you are supposed to hate the Yankees. If you are a social progressive you are supposed to believe that society should shun those who are less capable than the "norms".

It shouldn't be that way, but it is.

And for the record, the Yankees suck. :>)

#6.1.1.1 Tom Francis on 2010-02-24 16:56 (Reply)

Please allow me to clarify: there are many definitions of the word "stigma." The classical one may not quite fit the meaning I had in mind.

I meant to suggest that we identify a pattern in the characteristics (but not necessarily the behaviors) of some individuals, mark those who exhibit that pattern as different from the socially defined "normal," and then identify the group as distinct from us. That distinction is often followed by the attribution of causes responsible for the presumed effects we used when we defined this sub-class of humans.

The sub-class can be Jews, elderly people, people with certain medical conditions (e.g. Hansen's disease) and physical deformities, or people who display whatever new indicators we presume to dream up. Some cultures discriminate against left-handedness (as a lefty, I don't feel discriminated against -- just ignored, which is darn good when I consider the possibilities).

What usually follows is persecution and exclusion based on the unproved assumption that the sub-group does not enjoy the human rights normal people have.

The stigma is our invention, because even when it is prompted by visible physical phenomena (e.g. a shriveled limb) its negative cause is usually fanciful (demon possession and "mental illness" explain the same result, and both explanations are void) and its consequences are always dehumanizing. Those decisions/condemnations are social, arbitrary and faith-based.

See "burakumen."

Maybe "stigma" is the wrong word.

#6.1.1.1.1 Benson on 2010-02-24 21:49 (Reply)

I understood what you meant and stigma is appropriate as the classical definition covers your points perfectly.

My point, badly expressed, is that stigmatization is the nature of humanity - one tribe hates the other tribe for no other reason than they have always hated the other tribe - the original reason lost in the mist of history. It is human nature at it's worst (sorry BD - I just can't get the hang of its/it's - I'm trying) - us good, them bad is ingrained in our psychology and is usually the result of historical issues.

I was first exposed to this concept in high school. Being a rather naive and somewhat open and accepting type of personality as a teenager, I never saw color, religion or disability - never understood why somebody could denigrate another person because of what they were in terms of religion, faith, color or whatever.

One time the garage band I was in interviewed keyboard players to add to the band. One of our members was of Armenian descent. The keyboard player we eventually settled on was Turkish descent. Both sets of parents were first generation immigrants. When they found out who the other members were it was quite a scene. I didn't even know about the Armenian/Turk conflict or genocide and neither did any of the other members with one exception but it didn't matter to him. We eventually had to find another keyboard player because of it.

To your point - yes, we do create our own stigmas by creating categories which fall outside of the "idealised" norm based on this, that or the other. We shouldn't, but we do.

Of course the real question here is simple: Are you or are you not a Yankees fan. :>)

#6.1.1.1.1.1 Tom Francis on 2010-02-25 01:46 (Reply)

"We have nothing to fear but fear itself."

=

Phobiaphobia?

#7 lordsomber (Link) on 2010-02-24 14:32 (Reply)

Phobophobia (fear of phobias)

I swear - its true.

#7.1 Tom Francis on 2010-02-24 16:08 (Reply)

Thanks for your wonderful response to my comment, Tom Francis. I was fascinated by your anecdote about your Mom and her Alzheimers condition while she was in a nursing home, and how when you brought your dog to see her it helped her to come back to reality for awhile. I have seen and heard about similar situations and how helpful they are to people who have lost their focus. You clarified what I was trying to say ... that stimulation of the mind can counter so-called stress and depression in people of every age. My post on my daughter-in-law's technical paper may have sounded unsympathetic, but I am disturbed at the direction of her interests right now. She and her husband have been out of work for more than a year at this point, and neither of them have much training in specific career areas. I agree that perhaps training in other area of work would help her to find a job, but investment in an area of work training which can so often be characterized by assumptions and conjectures means that one should be particularly rigorous and critical about the gray areas in that career field. The paper she wrote was rife with jargon -- 'thought valences' was one of the phrases which stopped me dead in my tracks. After a lifetime of training myself and others to write clearly and simply about complicated subjects, I'm easily irritated by arcane jargon which doesn't illuminate the thought being expressed. Instead it muddies it.

JoeC says above "I shudder at the term 'mental health' knowing that it is a diagnosis by consensus." And those are almost always incorrect, he notes, because people are too quirky and individual to be shoved into neat little boxes. We each have our individual dark areas, and as you age, they change frequently.

I would hope that I can remain here in my neat little house and familiar surroundings for some time to come. But I hope and pray that I don't fall into the hands of someone who thinks obscure jargon will help them understand me and my problems.

Anyway, thank you for your thoughtful answers. I wish I knew you better.

Marianne

#8 Marianne Matthews on 2010-02-24 21:15 (Reply)

tought valence

Good lord - jargon run amok. When you think about it, what the heck does that mean? I had to look that up because my only exposure to valence was in Chemistry. :>)

"the capacity of one person or thing to react with or affect another in some special way, as by attraction or the facilitation of a function or activity."

Ok - it's time for Dr. Bliss to step in and explain that - I don't get it. If the rest of the paper was written in terms like that, no wonder you are concerned. :>)

Well, I guess you know what they say - if you can't dazzle 'em with brilliance, baffle 'em with.....

#8.1 Tom Francis on 2010-02-25 02:08 (Reply)

LOL... Exactly, Tom. Valence. Hmmm.

Another candidate, maybe: the replacement of "original idea" with "the emission of an operant response."

#8.1.1 Benson on 2010-02-25 08:06 (Reply)

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Tuesday, February 23. 2010

Are we all nuts?