Maggie's Farm

Thanks to the people who email links to me:

The Battle Over the DSM-V:

Maybe I just have a case of too skeptical for my own good syndrome, with a touch of sick of the bullshit fugue. And maybe a little everybody seems to have a way to scam money from the government but me anxiety. Yeah, there's that.

Corrupting Psychiatry:

Indeed, APA members stand to gain from new regulations they lobbied for. In other words, if Til Wykes were an American psychiatrist, he too might be seeing dollar signs in temper tantrums and pot use “disorder.” But when it comes to medicine, America is the special interest state. And make no mistake: this is not the free market at work. It’s what happens when greed and government power commingle under a blanket of good intentions.

From F- Feelings' Feelbreaker:

Yes, you’ve probably heard some wise child guidance expert say “there’s no such thing as a bad kid; just a misguided parent,” and I wish that expert wasn’t full of shit.

There are an infinite number of ways to live life fully and energetically. I was thinking about that topic since I read the bio of a fellow I admire and have heard speak in the past, Sander Gilman. I am a fan.

Dr. Gilman spoke at a medical meeting I attended in NYC in December. He is a polymath. Here's his bio:

Sander L. Gilman is a distinguished professor of the Liberal Arts and Sciences as well as Professor of Psychiatry at Emory University. A cultural and literary historian, he is the author or editor of over eighty books. His Obesity: The Biography appeared with Oxford University Press in 2010; his most recent edited volume, Wagner and Cinema (with Jeongwon Joe) was published in that same year.  He is the author of the basic study of the visual stereotyping of the mentally ill, Seeing the Insane, published by John Wiley and Sons in 1982 (reprinted: 1996) as well as the standard study of Jewish Self-Hatred, the title of his Johns Hopkins University Press monograph of 1986. For twenty-five years he was a member of the humanities and medical faculties at Cornell University where he held the Goldwin Smith Professorship of Humane Studies.  For six years he held the Henry R. Luce Distinguished Service Professorship of the Liberal Arts in Human Biology at the University of Chicago and for four years was a distinguished professor of the Liberal Arts and Medicine and creator of the Humanities Laboratory at the University of Illinois at Chicago. During 1990-1991 he served as the Visiting Historical Scholar at the National Library of Medicine, Bethesda, MD; 1996-1997 as a fellow of the Center for Advanced Study in the Behavioral Sciences, Stanford, CA; 2000-2001 as a Berlin prize fellow at the American Academy in Berlin; 2004-5 as the Weidenfeld Visiting Professor of European Comparative Literature at Oxford University; 2007 to the present as Professor at the Institute in the Humanities, Birkbeck College; 2010 to 2013 as a Visiting Research Professor at The University of Hong Kong.  He has been a visiting professor at numerous universities in North America, South Africa, The United Kingdom, Germany, Israel, China, and New Zealand.  He was president of the Modern Language Association in 1995.  He has been awarded a Doctor of Laws (honoris causa) at the University of Toronto in 1997, elected an honorary professor of the Free University in Berlin (2000), and an honorary member of the American Psychoanalytic Association (2007).

I work hard, make myself as useful as I can, and read quite a bit, but I am a slouch. I stand in awe of such productive people, who are blessed with abundant talents and use them to the full.

Many have heard about the latest kerfuffle at the American Psychiatric Association, which has decided to eliminate Narcissistic Personality Disorder from their next DSM edition (the DSM V). They have also eliminated some other personality disorders.

I really do not care what those clinical researchers on those committees vote for or against, because their view of the world is not mine. 

The reason things like the DSM have little meaning to me is because their "diagnoses" have no internal validity (and, indeed, they focus more on consensual validity - meaning that docs can agree on a label - than internal validity, which they feel could be either unattainable, or too "theoretical"). Regardless of its origin, it all comes out in the DSM cookbook as "Anxiety Disorder, Panic Type" or something like that.

For example, let's say there are as many pathways to panic attacks as there are people who have this nasty symptom. Some of it might be inherited, some acquired, most some mix - and all embedded in a personality of a certain structure (which is our way of saying predictability).

This idea, I believe, is to make Psychiatry so "scientific" that the doc can then refer to the latest therapeutics manual and decide what medicine to offer. To my thinking, this is "pseudo-medical." Anxiety, in my view, is a symptom and not a "disorder." Analogous to a fever. Thus saying somebody has an Anxiety Disorder is not the end point of diagnosis - it's the beginning of a search for understanding.

What's the fever (or OCD or sex obsession or eating disorder) coming from? That's what I want to do the detective work on, one person at a time.

Docs like me prefer to work in depth, and find the DSM exasperatingly superficial and reductionistic.

The Last Psychiatrist discusses further: Narcissism Out Of The DSM-- And Into The Open

The Arizona massacre highlighted the age-old issue of violence and the mentally ill. We see things like this: Lawmakers call for hearings, help for the mentally ill after Giffords shooting.

I do not wish to go over old ground here, about which I have posted at length in the remote past in the wake of other similar situations, but I can assert a few basic facts:

1. Dangerously ill people rarely seek help, want help, or cooperate with help. There is no shortage of "help" out there. Paranoid people, especially, distrust and avoid any forms of help. It is often said that those most desperately in need of help cannot recognize their need - or most fear what they might find out about themselves.

2. Just being delusional does not get you hospitalized, and getting hospitalized does not necessarily mean you will get help that you want to use. Lots of people are quietly psychotic out there in the world. At least 1% of the population, probably.

3. The ability of Psychiatrists to predict violent behavior, or self-harm, is approximately zero. That is because the incidence is so low. We usually just hedge our bets, and take our chances with the judiciary. If a court lets them go, nothing we can do. It's a free country, including free to be nuts. In Russia, Cuba, or China, they just mysteriously disappear. One of the prices of freedom is messiness. In authoritarian nations, the government provides the messes, behind the scenes.

Unlike all of the amateurs with their pet theories about why somebody would kill strangers, I offer no opinion. I don't know the guy. I would rather post about something else.

This post was prompted by this case in the UK: Fattest man in the world suing NHS for "letting me grow."

If a patient of mine got fat, or killed people, can I be called liable? I have been twice named in medical malpractice lawsuits. It is an appalling, demoralizing, painful, and time-consuming experience. It makes you want to quit medicine.

The first case was a teenaged gal who got herself knocked up. The claim by the teen and her anti-abortion parents was that, since she was an impulsive kid, it was my medical duty to make sure she used birth control. I had mentioned it to her, but I had not written that down in my deliberately-sketchy notes.

My second was a guy who cut his wrists in a suicide attempt (or gesture?). He and his wife and lawyer decided that they could make a case that I had prescribed an inadequate amount of antidepressants to prevent him from doing this. Even though the guy's main problem was a personality disorder, they found a psychopharmacologist to testify that the fellow's mood swings and tantrums represented Bipolar Disorder. He was wrong, but that didn't matter.

Both cases sued me to triple the max of my insurance. The first case was a charity treatment case, in a clinic to which I donate one day per week. I suspect they figured out on Google that my husband is a banker. Both plaintiffs lost in trial, but both experiences left me feeling dragged through a sewer, slimed. A trial lawyer can always find somebody to pay to say you did something wrong. In my field of work, everything is a judgement call, and there is rarely or never a right and wrong.

I had felt, with both patients, that I had had a good, constructive, and friendly relationship, and that I had helped them quite a bit. Interestingly, both sued me for their behavior and their behavioral choices, as if I were responsible for those - as if I were God.

Like most docs I know, I try to do the best that I can to help the people I see, but my powers are limited. Still, lawsuits are always in the back of every doctor's mind in the US. My guess is that about half of medical tests are done with lawsuits in mind (eg $700 CT scans for tension headaches). Lots of hungry, parasitical trial lawyers out there, and plenty of people who are willing to toss away a relationship with a doctor if they think they can hit the jackpot by doing so. They can always find another doctor (although few doctors are willing to see litigious patients. I will refuse to treat anyone who has sued a physician. In other ways too, I select the people that I am willing to help. It's my prerogative.).

The lesson: Evil lurks in human hearts. No doubt about it.

Women like their men to be brave in the face of what life presents. Women appreciate men who will take it on, and not hide, retreat, or run from the things in life. Furthermore, they appreciate men who will get out there and take things on, new things, challenges, and mix it up with life. Not in a sociopathic way, but boldly.

However, many or most men are full of secret fears and timid in some ways about the risks in life. In many ways, more so than the average female (but that is another post). Fears of being hurt, killed, lost, confused, vulnerable, humiliated, ego-damaged, etc. Especially ego-damaged.

An important part of being and feeling manly is confronting fear, uneasiness, and discomfort, and overcoming the fear. Vitality entails risk. I suppose those are cliches, but true. Males are supposed to put on a game face when they are nervous or afraid. Life isn't meant to be easy, and males are meant to exit the comfort zone and to enter the jungle. The women of America are sick of pussified, metrosexual males who are afraid of splinters, rock-climbing, snowstorms, rough water, and strong women.

Two things brought this ancient topic to mind:

Banning Bravery: From Yale to the NFL

Are Americans Wusses or Just Fond of Trash Talk?

Transcranial magnetic stimulation. 

I am only recently hearing about this new thing. I don't know whether it sounds more like voodoo or more like light shock treatment. It is said to work for some, but I wonder how much is placebo effect.

Psychiatrists are setting up centers to provide this. It is very expensive.

You Can Have the Placebo Effect, Even If You Know It's a Placebo.

Placebos are strangely effective medicines. Thus it's no wonder that people feel better when they eat organic, or buy into nutritional schemes and health food store products. It's called "hope" and "self-deception" and all of that "mind-body" stuff.

Posted at Bernard Goldberg, My Genes Made Me Do It!

Funny how we humans want to take personal credit for things we feel good about, and how quick we are to come up with excuses and rationalizations for the rest.

The author included this handy-dandy elementary life skills chart, for those who never learned it. Readers might be amazed by how many adults never mastered Life 101. Sadly, the "awareness" part is often the biggest challenge:

A Ghostwritten Psychiatric Book Hints at a Much Larger Problem: The Story That Is . . . and Isn't Told in Psychiatric Textbooks

Today, Psychiatry contains two camps: The psychopharmacologist "Biological Psychiatrists," and what I can only term "Whole person" Psychiatry. I practice the latter - or try to.

What makes my life difficult is that, with the growing dominance of the Pharmacology shrinks, "best practices" become redefined in favor of medicine treatments. We do have remarkable medicines nowadays but they do not really "fix" anything and, in my experience, are widely over-used.

I will get to the DSM personality disorder flap when I get the chance. Since I think the DSM is sort of silly anyway, it's hard for me to get excited about the topic.

Some report claims that 20% of the population, and 30% of youth, had a mental illness last year.

I think this must be a gross over-diagnosing of people who are going through tough times in their lives.

Feeling depressed, fearful, and even having suicidal ideas, however, can be quite normal for people in jams. If you apply a DSM checklist to 100 random people, you could come up with at least one diagnosis for every one of them.

Sometimes I feel that modern Psychiatry and pharmacology imagines that anybody who doesn't feel perfect all the time must be assigned a diagnosis (and maybe given a pill or two). Here at Maggie's, we term that Psycho-utopianism - and we have the trademark on that term.

Life is tough. Being a person can be tough. Most people's problems stem from dealing with themselves. I cannot assign a diagnosis to many of the patients I see (but I make them up when need be, for their insurances). If you have trouble with your feelings or your behavior, there is some help out there. Few cures, but plenty of help despite what the article implies.

I did get a kick out of this part:

The survey also found that 23.8 percent of women had some form of mental illness, compared with 15.6 percent of men.

We all know why the gender inequality there: hormones, and having to deal with kids and men.

Marriage is a tough thing, with or without passion and eternal romantic love. Everybody knows that.

4 in 10 say marriage is becoming obsolete:

As families gather for Thanksgiving this year, nearly one in three American children is living with a parent who is divorced, separated or never-married. More people are accepting the view that wedding bells aren't needed to have a family.

I have no idea how anybody can run a family or a household, or build a good life, without a loyal and dependable partner. I couldn't do it.

A patient told me last week that her brother had been arrested again, for the 17th time.

What now? I asked.

Mugged somebody with a knife.

What's he been doing since he got out of jail?

On probation, living on Disability, he gets Medicare. Those are my tax dollars. A Psychiatrist gave him the diagnosis of Bipolar Disorder, but did not know he was using crack at the time. He got Disability, plus he gets extra money for taking online college courses. He has better benefits than I have on my job.

What's he doing out on the street again?

Lost his apartment. Didn't pay the rent. He hates to pay rent. He wants to be back in jail. He's a member of The -----s, they are a big deal in jail. In real life, he isn't. No job is good enough for him.

Talk to him yet?

I won't talk to him. He is such a charmer and spinner of words and tales he could convince you that the moon was blue cheese. I gave up on talking him long ago because he just drags you into his web of lies. He comes across as very earnest and sensitive. Then you start caring, and that's when he gets you. He is evil.

A re-post of Shrinkwrapped's fine and thoughtful essay on the causes of poverty in prosperous and opportunity-filled places. He begins with a quote from Heather MacDonald:

A welfare mother in Central Harlem is not poor for the same reasons that a subsistence corn farmer in Mexico is poor. That�s just one of the many self-evident conclusions to emerge from a dangerously misguided antipoverty program begun by New York City Mayor Michael Bloomberg in 2007. Bloomberg�s initiative, Opportunity NYC�Family Rewards, bestows cash rewards on (for the most part) single parents and their children if they act responsibly�by attending school, for example, or by working. Interim results for New York�s effort, which is modeled on a program in Mexico that targeted agricultural peasants, are now in. Not all of them are as blindingly obvious, though, as the fact that multigenerational urban poverty in America is far different from Third World rural poverty. One detail in particular stands out: that the lives of America�s underclass are characterized by a degree of disorganization that is rarely grasped or acknowledged. The implications of this revelation will be difficult, if not impossible, for the welfare industry to accept.

We have often discussed here that modern life is not only packed with opportunity, but that it is more demanding and challenging than that of the life of a serf on a Lord's estate or of a slave on a plantation. Freedom and free markets are part of what makes it challenging and worthwhile.

America is about opportunity, not security. That's why people want to come here. People who just want freebies go to England or Germany.

Perhaps this sounds like a heartless post during an extended recession. We believe in charity, but we also believe in holding people accountable for their fates and expect them to take charge of their lives as best they can. Furthermore, we do not view truckloads of money as the ultimate goal of life.

Our shrink friend has another post on the topic this week: The Culture of Poverty.

Those without socialist ideologies know that poverty in America is often temporary, often by life-style choice, sometimes by bad luck, and often because of dysfunctional life choices and/or character flaws and mental disability and illness.

And, for contrast, here's the view from the Left.

From an article about the wonderful Dr. John Ioannidis of the above title in The Atlantic (my bolds):

In poring over medical journals, he was struck by how many findings of all types were refuted by later findings. Of course, medical-science �never minds� are hardly secret. And they sometimes make headlines, as when in recent years large studies or growing consensuses of researchers concluded that mammograms, colonoscopies, and PSA tests are far less useful cancer-detection tools than we had been told; or when widely prescribed antidepressants such as Prozac, Zoloft, and Paxil were revealed to be no more effective than a placebo for most cases of depression; or when we learned that staying out of the sun entirely can actually increase cancer risks; or when we were told that the advice to drink lots of water during intense exercise was potentially fatal; or when, last April, we were informed that taking fish oil, exercising, and doing puzzles doesn�t really help fend off Alzheimer�s disease, as long claimed. Peer-reviewed studies have come to opposite conclusions on whether using cell phones can cause brain cancer, whether sleeping more than eight hours a night is healthful or dangerous, whether taking aspirin every day is more likely to save your life or cut it short, and whether routine angioplasty works better than pills to unclog heart arteries.

But beyond the headlines, Ioannidis was shocked at the range and reach of the reversals he was seeing in everyday medical research.

Clinical research always must be taken with a grain of salt, and today's "best practices" will be tomorrow's worst. The general press is utterly incompetent at evaluating such studies. I think they just grab at potential headlines, eg Study: Broccoli Cures Causes Cancer.

I know plenty of folks who have been told to "Take it - studies say it might help, and won't hurt." Who knows? I find it amusing to think that today we are no longer certain of a direct relationship between cholesterol levels and heart disease.

As Dr. Newmark points out in his post, psychiatry remains profoundly different from the rest of medicine, where diagnosis is everything, in this respect. If a patient presents with chest pain, it is supremely important to know whether it is due to a heart attack, aortic dissection, bronchitis, pulmonary embolus, gastroesophageal reflux, or costochondritis, because each of these calls for clearly distinct treatments. Psychiatry is not like that. Deciding whether a person's diagnosis is depression, bipolar disorder, or schizophrenia will suggest moderate differences in treatment, but the latter will derive more from specific symptoms and personal background. This goes to show that psychiatry remains far more art (or "art") than science. The research-powers that be have yet to persuade the practitioner otherwise.

 

Ten Secrets to a healthy marriage. Good, basic advice, but with nothing about the importance of daily sexual bonding, regardless of age.

Photo is Helen Mirren at 64. I fully intend to look at least that good for my own self-respect and out of love for my loving hubby. 

Via, Ars Psychiatrica. A quote from the article he linked:

If surveys conducted by physician recruiting companies accurately reflect current trends in the job market, the news is very good for psychiatrists�and less promising for many patients with mental health disorders. Chief among those who may not receive the psychiatric care they need are children and adolescents and people who live in areas that are not densely populated.

Also,

The Bureau of Health Professions predicts that demand for general psychiatry services will have increased nearly 20% between 1995 and 2020. The Bureau also foresees a 100% increase in the need for child and adolescent psychiatric services during that period.

I think one of the reasons that fewer American medical students are going into Psychiatry these days is because it is turning into more of a pill-pushing and check-list diagnosing specialty than the "understand the whole person in depth" specialty that I became interested in.

Freud's early studies of Hysteria led him (and Breuer) towards what is termed the Seduction Theory of neurosis - a trauma theory.

His eventual abandonment of Seduction Theory marked a deepening of Psychoanalytic respect for the role of fantasy - especially unconscious fantasy - as a shaper of a person's character and neurosis. His realization that memory, like all other mental activity, is shaped to varying degrees by thoughts of which we are unaware, was a key which opened many doors of understanding of human nature.

Some of this is detailed here.

Thus the fad of ascribing mental illness and emotional problems to childhood trauma in the 1970s and 80s was a big Been There - Done That to Psychoanalysts.

Today, Psychoanalysts understand that trauma at any age is just one shaper among many, including genetics, unconscious activity, early relationships, ego characteristics and strengths and weaknesses, etc.

Re childhood sexual encounters, we know that the acceptance of this, or the disgust with this, is highly culture-specific. Whether that matters or not to the discussion I do not know.

In "My Lie": Why I falsely accused my father, one very destructive and suggestible person explains how she got caught up in the trauma fad. Freud, I imagine, would offer a grim smile of recognition at this story.

Readers have been generous with their comments on my questions this week, and it's all been helpful and sometimes inspiring. (This question series is only for this one week.)

Here's my question for today:

Men are often viewed as the lustful ones with sinful hearts if not actions, while tradition has often held women to be more contained, demure, and lacking in ordinary lust. While men often tell me about their almost-drooling at babes while walking down the street - even happily married men - I rarely hear that from women. (Obviously there is a huge range in sex drive and sexual interest and imagination between individuals.)

So are women just quieter about reacting to hunks they see, or are men really more lascivious? In other words, are women just as prone to purely physical attraction as men, or do they really need a "relationship" to become interested? Or, to put it another way, are women as likely to make daily life as much of a pornographic experience as men do, on average?

How much sex is a person "supposed" to want? I don't think anybody can answer that question.

Short video: Is sex addiction a disease?

One of my (many) problems with Psychiatry's DSM is one of making "diseases" out of things I might either view as symptoms, or simply as behaviors which deviate from some shrinks' view of "normal."

When it comes to movie stars and the like (as the link mentions), it's another matter. Many of them seem to live like kids in a candy shop, relatively insulated from consequences. When handsome men or lovely beauties are throwing themselves at you all day long, what's a person to do? Especially after a few drinks, a few lines of coke, etc.

Psychiatry is able to justify viewing substance addictions as diseases because, for many people, continuous substance abuse can lead to an alteration of the reward pathways in the brain, resulting in a drive which is challenging to resist.

With sex, however, those reward pathways are already built in to the system as one of the strongest animal instincts we have to grapple with in life.

As usual, I must leave this post at mid-thought, but I will pose the question to our readers:

Is "Sex Addiction" a disease? Or is the idea a "diseasification" of decadent people with lousy self-control and poor capacity for delayed gratification?

I mean literally sleeping together - spouses sleeping in the same bed - not the other meaning. If any readers can help me find out the history of this habit, please let me know.

I do know that the wealthy and the nobility traditionally have had separate private suites and that beds and bedrooms are expensive, so I wonder whether bed-sharing began as a matter of lack of wealth more than anything else. Seems to me that separate suites could potentially be more romantic and more independent-adult.

It's a socio-anthropological question.

If anybody has time or interest to research the history of the topic for me, I'd appreciate it.