Maggie's Farm

From Dr. Frances, DSM-5 Badly Flunks the Writing Test

I do not have time to put together a coherent post on the topic today, but I believe that the mandarins of my profession have lost all connection to what taking care of hurting people is all about.

Dr. Frances does not go far enough, at all.

Sexual interest is obviously one of the primary human motivators. Blame it on biology, or God, or whatever. Wherever you put people together, especially young people in their prime, sexual curiosity will be in the air. This epidemic has been forever.

It doesn't matter whether they are gay, straight, or mixed-up. It happens when you put people together. People of strong character do not act on impulse when it is inappropriate, but many cannot resist the pull or just don't want to resist. It's fighting nature, and the addition of alcohol or other substances doesn't help. Neither does being away from home. People do get attached, form bonds, develop partnerships, loyalty, etc but raw desire has no respect for these civilized things. Furthermore, people need, at the very least, some form of "maintenance sex" for comfort but it is no insulation from reckless desires and romantic aspirations.

It seems to me that "sexual harassment" has come to include many expressions of virile or feminine sexual interest, extending the concept far beyond physical aggression (which is illegal. That is termed "assault," and can be felonious) to "unwelcome" advances.

In my life, I have been subject to hundreds of unwelcome advances from both men and women, and some of them were, well, forceful but not physically forceful. Weaker women might view much of it as harassment, but I took most of it in good humor because my brothers, my protectors, taught me about male tendencies. Women learn how to brush them off, but one of those advances turned out to be my husband of quite a few years and up to the present. A good guy, very shy and very smart, but who got up his courage to act like any other jerk because he felt he could not resist me. I could somehow tell that he was a good guy.

Now I read that the US Navy doesn't want guys looking at pictures of girls in the bathroom. What do they want these fellows to do for relief? Do they want an all-gay Navy? Or eunuchs?

From John Derbyshire, The Sexual Harassment Panic

The PC attitude seems to be to overstimulate children, but to de-sexualize adults. Or de-sexualize heterosexual adults, anyway. Does that make sense?

I think everybody's ideal is to have an internist or family practice doc who knows you well personally as well as medically, and where you can call or come in anytime if you have a concern. For various reasons this has become elusive. 

Based on what I have seen, three trends are growing. The first is the Doc-in-a-Box or, more likely, a PA in a pharmacy.

The second is concierge medicine in which, for a modest annual fee, you have unlimited contact - 24/7 - with your generalist.

The third is generalist docs who will not accept insurance but who charge modest fees and will offer a bill that you can send for your own reimbursement, if any. They can charge modest fees because they do not need to hire a large back office staff for coding and billing.

It's a good idea to have a generalist who knows you and your family. With ObamaCare, I think all three of these modes will grow in popularity, especially the last one. They are all working mostly outside the system. They are not likely to want to make time to see you, however, unless they have met you (except for the PA in a box trend).

Generalist physicians, whether Family Practice, Internal Medicine, or whatever, are the ultimate docs. They see everything, major and minor, and know when to refer. People who want to use their Medicare and Medicaid are going to have a tough time with office visits in the future.

I had always aspired to be a country doc, a generalist, in the New Hampshire countryside, but became too fascinated with what I now do. I had dreams of fixing broken arms, stitching up nasty cuts, treating poison ivy, delivering babies, consoling the terminal, sending appendicitis patients to a surgeon friend, etc. It's kind of funny, but my generalist friends tell me that half of their work is Psychiatry anyway.

With the training I had, I suspect that I could still do those country doc things pretty well, but my malpractice insurance does not cover it. In my training, I caught 42 babies. Some were dangerous and complicated. As I have admitted here in the past, I refused to participate in abortions not because I am so religious but because I did not want it in my memory.

Primum non nocere.

What psychiatry’s new diagnostic manual means for people on the autism spectrum.

The problem with the DSM is that it (the booklet) is taken too seriously. Nobody knows whether there is an Autism Spectrum.

Times have changed, but the concept of alimony goes at least as far back as the Code of Hammurabi.

With up to 40% of American kids being born today to single mothers, often with neither alimony nor meaningful child support, alimony, like marriage, is irrelevant to the lives of many Americans today.

Some states are ending lifetime alimony. One must wonder to what extent the risk of alimony is a deterrent to marriage. (It certainly can be a deterrent to divorce, at least for a while).

Pew had this report last week: Women are now the primary breadwinners in 40 percent of households with children in the US. I'm not sure what that means because I don't know whether that includes the single moms or not. Maybe we can assume it does, in which case it's relatively meaningless.

Nevertheless, there surely seem to be a lot more two-income households today than there were in the 50s (even though many women did work outside the home then). However, in the 50s there were almost no single moms other than widows. It was considered shameful.

Women married to functional men take jobs not as a matter of economic necessity usually, or as a matter of personal fulfillment. It's usually a matter of people wanting an economically-higher standard of living, better financial security, or the ability to pay escalating tuitions and housing costs.

In other words, for the family.

DSM 5 published. What's in it?

As I have said before, the DSM is a walking, talking obsessional disorder. A waste of time and money. And I helped work on it. Had I known the outcome, I would not have bothered.

A harsh critique of the "Psychiatry bible" (which is far from it): The Book of Woe: The DSM and the Unmaking of Psychiatry

The most curious aspect of the status quo in psychiatry, though, is how a scientific-looking manual put out by a small organisation with no public accountability has come to be viewed with such reverence. Not for nothing is the DSM known as “the psychiatric bible”. Perhaps its bullet-pointed diagnoses do satisfy a religious need, the old existential ache for reassurance that “even the hairs of your head are all counted” and there’s no reason to be afraid.

The humane treatment of the mentally ill was a major civilizational advance. At a time when there were really no effective treatments for the major disabling mental illnesses (ie Schizophrenias and Bipolar Disorder), providing these patients asylum from the rigors of real life was better than Bedlam or locking Aunt Jane in the attic.

Today, our treatments for Bipolar Disorder (aka Manic-Depression) are pretty good. Our treatments for the group of Schizophrenias are not very good. We can often remove acute symptoms but can not help people function at a normal level. They are mis-wired.

Efforts to help the seriously-ill, in hospitals, hospices, was termed "Moral Treatment." The asylum approach was largely undone with the deinstitutionalization movement under JFK. Thus bag ladies.

Here's a summary: A New Moral Treatment - Humane institutionalization can help the mentally ill and protect society. He might be right. I am not sure.

Under what circumstances is, or should underage sex be illegal? It's a complicated topic. We all know how much underage sexual activity takes place these days. How does one distinguish a sexual predator from a hormone-intoxicated person? And what does age have to do with it?

I have no answers. It's discussed here: Kaitlyn Hunt and the Romeo and Juliet problem.

Or, for that matter, in the hands of the IRS?

I can report, first-hand, that electronic medical records double the doc's time doing "paperwork," and thus halve their time with patients. There is only so much time in a day. As a private Psychiatrist, I have thus far been able to avoid it. Who would speak freely to me if my notes went into the cloud? I was offered a $40,000 check by the government to go to electronic records linked to the hospital and thence elsewhere, and I refused the offer even though the money would come in handy.

Obama’s Medical-Records Crony - Electronic medical records are being heavily subsidized — to one Democratic donor’s benefit.

Also, The Obama crony in charge of your medical records.

If you have a problem with this government-subsidized trend, ask your doc whether he, she, or it - or they - puts your records on the internet. Most hospitals require it, nowadays, as it is required of hospital-employed physicians. FYI, you may not know whether your doc is a hospital employee or not because many are selling their practices to hospitals in anticipation of Obamacare. Times are changing.

Ask, just so you will know.

By the way, I am not stupid but I cannot understand this: Yet Another Obamacare Design Flaw

Memory is famously faulty. Just as politicians and journalists attempt to create stories and "narratives" out of data points, all humans do the same. Often, our conscious memory stories are designed to support our positive self-regard, to rationalize, blame, find excuses, and so forth. Temperamentally melancholy people tend to do the opposite and are often more honest with themselves.

Psychiatrists and Psychoanalysts know how to listen stories and information as "memory data" with all of the selection, distortion, factual accounts, mental constructions, etc. which are part of memory. We are trained to listen as if watching a movie. Since we are not judges or juries, "truth" is not necessarily our pursuit although we can be quick to call "bullshit" when needed because people lie and manipulate too. We are not truth-relativists, but our focus is elsewhere.

One of the fascinating things about Psychoanalysis is to see how memory narratives change during the process.

Even recent memories are subject to distortion: Trust your memory? Maybe you shouldn't.

That's the view of Dr. Alan Frances, and I tend to agree. However, I never liked the DSM 4 either. 

Psychiatry's New Diagnostic Manual: "Don't Buy It. Don't Use It. Don't Teach
It."

Related, from Dr. McHugh: DSM-5: A Manual Run Amok - It's time for psychiatry to drop its field guide and try to
learn about mental ills

We discussed salt last week. Here's The Bogus Public Health Attack on Sugar

Sugar in soda pop is no more fattening than any other carb, eg fruit, bread, milk, fruit juices like apple juice and orange juice. Nevertheless, it's not a "public health" issue, it's an individual choice issue. I like that light brown granulated sugar in my coffee.

It's brown, so it must be healthier, right?

The only thing new about Obamacare is its mandatory nature, its lack of choice, and its one-size-fits-all. It's antiquated thinking, like subsidizing mandatory buggy whips.

Government programs like this inhibit change, innovation, flexibility, and creativity, and hand control to government bureaucrats. When Prof. Mead discusses evolving alternatives to the old fee-for-service model of primary care, he might be forgetting that Obamacare has set it in stone just as Medicare did for the over-65.

Left alone, medical care would evolve according to markets and peoples' choices. As we have surmised before, Obamacare was designed to fail and to bring in single payer, also a blast from the past which would inhibit innovation.

Salt is one of those things that drive dietary cranks, control-freaks, and ignorant do-gooders nuts.

There really is no reason for that. Most of us docs have been saying this for years and I have made this point here in the past. Salt is an absolutely necessary nutrient for all animals, and very low levels of sodium chloride can make you sick or dead.

The average, normal human body contains around 50 quarts of salt water.

The reason people used to advise "low-salt" diet is because excess dietary sodium is a bad idea for people with kidney failure and congestive heart failure, and people with uncontrolled high blood pressure (with its associated higher risks of heart attack and stroke).

However, salt does not cause those things.

Significantly-high blood pressure is easily dealt with these days. Heart failure will likely kill you in time regardless of what you do (barring a heart transplant), but it is treatable with medicines and some salt restriction.

The new study from the CDC: No Benefit in Salt Restriction.

The American Heart Association is not up to date on the topic: Sodium is Your enemy.

If you have high blood pressure, get it under reasonable control with your doctor. If you have organ failure (eg kidney or heart failure), or have some other ailment, do whatever your doc says. If you're healthy, enjoy your salt. It makes food taste better.

One recipe tip: I always season a salad with salt and pepper. It makes rabbit food taste almost good. Don't get me on the topic of whether green salad is "healthy." (It's neither healthy nor unhealthy. It's just filler.)

Readers know that we do not approve of using mental health terms as ad hominems against those with whom we have honest disagreements on political, or other, topics. I have been guilty of sometimes opining that "big, benign government types" are indulging in infantile fantasies of ideal parents, and I should not do that.

World-views differ, as do views of human nature. It makes life interesting and interestingly-contentious.`

Still, once you get past the insulting title this is a good post: On the Arrested Development of the Left:

At some point, one needs to grow up. The fact is, the human quest for salvation, whether personal or social, cannot be left to the reckoning of children. Given the perilous condition to which progressivist utopianism is taking our country, its pubescent psychology deserves to be even more carefully scrutinized. The soft-focus, Pollyanna attitude of the left, which has come to be known as the therapeutic perspective on the world, is often accompanied by unmitigated savagery. Even if the assault on culture is not physical but legislative, its effects are almost universally devastating. The historical register shows that the effort to improve the world by revolutionary violence or by comprehensive and indiscriminate cultural revisionism — therapy gone wild — is practically guaranteed to cause far more misery than it attempts to alleviate.

Addressing the tough realities of the real world, and the depressing limits of one's own self, are the best vitamins.

Mr. Solway references Rieff's challenging book, The Triumph of the Therapeutic: Uses of Faith after Freud.

I've mentioned here several times that the DSM is no "bible" for me or for most of my colleagues. We rarely find our patients in there, or human beings, for that matter. When the premise is wrong (that surface symptoms and complaints lead directly back to a neuro-chemical abnormality), then the entire endeavor is only useful for completing insurance forms (with a handful of partial exceptions).

A few relevant and interesting links:

- The Real Problems With Psychiatry - A psychotherapist contends that the DSM, psychiatry's "bible" that defines all mental illness, is not scientific but a product of unscrupulous politics and bureaucracy.

Not to mention the pharmaceutical industry. Always question Authority!

- Psychiatry’s Guide Is Out of Touch With Science, Experts Say in the NYT via 1 Boring Old Man's Groundhog Day

- How Scientific Is Psychiatry?

Like many fields of endeavor, good Psychiatry is part art, part science, but mixed with much life experience, much interpersonal experience, and as much painful self-knowledge as the doc him- or herself can handle to "sharpen the scalpel" as it were. We are called upon to be experts in real life, relationships, religion, the brain, the mind, the body, and the soul. It's a tall order which is why it is often termed "the impossible profession."

Readers know that I have trademarked the term "psycho-utopianism" to refer to the naive and reductionistic notion that, if all our our chemicals and all of our neurons were straightened out, and if we docs could fix it all by a cookbook, we'd all be some kind of "normal" and some kind of moral and some kind of "happy" of a serene, bourgeois sort. It ain't never gonna happen, and it's for the best that it cannot.

It would not be human, and it would not be real life. I recently was referred an evaluation for depression. Patient fit the DSM perfectly, but it didn't "smell right" to me so I took a chance and ordered her a total body MRI. She had an undiagnosed gastric cancer.

As an MD Psychiatrist and Psychoanalyst, I agree entirely with the sentiments of Gary Greenberg.

I do not have time to go into it now, but I tend to think that the whole thing is a pseudo-medical charade, designed for the drug industry and for the insurance industry's convenience.

If "mental health" cannot be defined, how can you draw lines to define "mental illness"? You can, at the extremes, but otherwise you can't. Everybody is a little nuts.

I never have done so even though stretching makes you look like a serious athlete. Reasons Not to Stretch

Jumping Jacks or Jump Rope are excellent warm-ups, if one wants it.

Executive decision-making is a skill. Good executive decision-making seems to be a talent. These are neither skills nor talents that I was blessed with, but that's probably just as well. I've never been much of a leader, and never a good follower either. My major life decisions have always made me nauseous. Medicine has been the right field for me. Independent work, endlessly interesting, and cautious, careful, conservative decision-making comes easily to me.

From Harvard Biz School, "While elevated narcissism and self-promotion has been shown to result in quicker promotion early in one's career, its negative impacts are revealed in positions of higher authority."

As in the sports world, in the biz world, if you cannot produce winning decisions consistently and with integrity, you will eventually go down. It's rough out there. I hear all of the stories and all of the excuses, but the most talented and honest do pretty well and never make excuses for their disappointments. Competition is a big part of life, and an exciting part of it.

Reflections of a Medical Ex-Practitioner - The glow of the personal relationship with patients is being extinguished:

 When I graduated from medical school in 1962, the profession of medicine was for many graduates an opportunity to provide care—as distinguished from, though aligned with, treatment—and to provide it to individuals, not to populations or governmentally specified groups. Young doctors hoped to establish an independent business, enjoy lifelong intellectual excitement as knowledge and therapies expanded, and have an income sufficient to live decently and support a family. There have always been some who entered medicine, as with any vocation, to maximize income. Yet most of us who came into the profession in the early 1960s had modest financial aspirations and substantial social commitment...

There is no "should". This foolish and, I think, exhibitionistic piece in the WSJ, How Often Should Married Couples Have Sex?, has been getting attention all over. I don't think it is very illuminating. Sexual frustration, however, does make both guys and gals cranky, and tends to make them want to look elsewhere for their instinctual romantic and sensual drives (which normal people do anyway, but even more so).

In my professional opinion, younger guys seem to be OK and relatively calm with sex twice daily. They are monkeys. Older fellows seem to get by with anywhere from daily to 3-4 times/week, depending on how hard and long they work at their jobs. Women are an entirely different topic, but my general advice to women is to remove the TV from the bedroom. Not to worry ladies - they will put it back in our bedrooms 24 hrs/day when we're demented widows in the nursing home. We can catch up with our shows and movies then. Carpe diem.

Apropos of the topic, I saw that Glenn Reynolds linked this book: Lube Jobs: A Woman's Guide to Great Maintenance Sex. Library journal commented about it, "Most people spend the largest part of their adulthood slogging through committed relationships, and they need books like this." 

Good cozy marital snuggles can make up for a lot of troubles. But "slogging"? If you're slogging, it's your own darn fault. I have patients deep into their 70s and 80s with quite satisfying and jolly sex lives even when they know far more than they want to know about their spouses, and when their equipment is not what it once was. We are, in part, biological beings.

Have Americans lost the sense of evil? I don't really think so. Some say that, nowadays, the cognoscenti can only use the word ironically, but I don't agree with that entirely either. After all, I have read too much vitriol from the Left directed towards people like me, labeling us (non-ironically) as evil.

In other words, I think "evil" has been secularized or politicized. At the same time, attempts are made to psycho-babbleize it away.

Without writing an opus on the topic, I'll make just a few points about evil (from a non-religious standpoint). Evil thoughts and impulses exist in everyone, to varying degrees, whether consciously or unconsciously. It never appears in pure form. 

A normal human conscience, along with social pressures, fear, a desire not to be destructive, etc. permit most of us to live without enacting very many evil deeds. Some people, in denial of their own dark sides, project evil into others. Some people attempt to deny the existence of evil anywhere. Some people try to erase the presence of evil by what we call "identification with the aggressor", of which the Stockholm Syndrome is an extreme example.

To look upon evil, wherever it is and however banal it may appear on the surface, is frightening. In the movies it can be exciting, but in real life it is deeply scary. Thus thoughts like this: St. Louis U. student asks, “Why don’t we talk about evil anymore?” and this: Why Does Evil Make Liberals Stupid? A quote from that:

This piece in The Atlantic is a good exemplar of the mushy liberal commentary that has proliferated in recent days. Authored by one Megan Garber, it is titled: “The Boston Bombers Were Muslim: So?” Before taking a close look at Ms. Garber’s article, let’s advise The Atlantic not to put away that headline. It could come in handy so often. “The Cole Bombers Were Muslim: So?” “The Embassy Bombers Were Muslim: So?” “The First World Trade Center Bombers Were Muslim: So?” “The September 11 Bombers Were Muslim: So?” “The Madrid Bombers Were Muslim: So?” “The London Bombers Were Muslim: So?” “The Shoebomber Was Muslim: So?” The Underwear Bomber Was Muslim: So?” “The Fort Hood Shooter Was Muslim: So?” “The Beslan Child-Murderers Were Muslim: So?” “The Times Square Bomber Was Muslim: So?”

And this one:  Jihad Will Not Be Wished Away - But willful blindness remains the order of the day.

I am sorry to say that Mukasey has it right:  Make No Mistake, It Was Jihad - Let's hope the administration gets over its reluctance to recognize attacks on the U.S. for what they are.

All sorts of things can help unleash the cruelty and destructiveness in people, but I won't get into all of that now because I only want to mention one of the things: communal support of evil. If only 7% of Muslims are inclined to active Jihad, that's 100 million people. That's no mob - that's a large nation of killers and would-be killers of infidels and they are all on the same page.

Jihadists believe the West is evil. "Submit or die." They are convinced of their virtuousness, but they are as wrong as can be because all that we in the West want is to be left alone and to truly "coexist" peacefully.

Here's an interesting 1996 book by Columbia Prof Andrew Delblanco: The Death of Satan: How Americans Have Lost the Sense of Evil