Genetic Basis of Schizophrenia

Discussion in 'Psychiatry' started by solumanculver, 09.19.14.

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  1. solumanculver

    solumanculver 7+ Year Member

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  3. Shikima

    Shikima 10+ Year Member

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    What do you think about it as you're getting your PhD?
     
  4. solumanculver

    solumanculver 7+ Year Member

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    Ah, sadly that PhD became an MS. I've corrected my profile. As I said, I haven't read the actual article - just the popular press reports. I think it's big news for schizophrenia. It suggests pathways to work on that could lead to new science and new drugs, and it's just overall holy grail type of stuff if it's the way it's being described. But... I'd like to hear the views of the experts.
     
  5. nitemagi

    nitemagi Senior Member 10+ Year Member

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    I'm cautiously hopeful. The more we can identify legitimate subgroups within a diagnosis, the better we will be able to prove what works and what doesn't -- less of losing the signal within the noise.
     
  6. whopper

    whopper Former jolly good fellow 10+ Year Member

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    I'm wondering if these genetic subtypes correlate at all with the DSM-IV subtypes that were dropped in DSM-V. I didn't like that they were dropped. A paranoid schizophrenic is different than a disorganized one and these do have significant differences in prognosis, risk of violence, etc.

    Sometimes I question if DSM-V was conforming to the bad psychiatrists out there. Several psychiatrists were lazily misdiagnosing schizophrenia-paranoid type or undifferentiated type for every other schizophrenia because of the argument they presented that paranoid type was more common-so just put that one down, or undifferentiated so they could have someone else do the work later and give a more specific dx. I also feel that way about the GAF. If done correctly this scale does actually work and give the other clinician a better sense of how debilitated the patient is, but the majority were ignoring it out of laziness.

    Aside from that, on a clinical level, it doesn't really help me much because we don't yet have knowledge on how these genetic differences can allow us to offer better treatment. It does, however, fan my intellectual flames.
     
  7. Armadillos

    Armadillos 2+ Year Member

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    I wonder how many schizophrenia related trials have blood samples banked on participants, will be interesting to see reanalysis based on these different genetic groups. Or if they dont have blood banked, there are a bunch of studies just waiting to be done.

    (This is assuming this study is as intriguing as it seemed from the short lay press article, havent seen the real paper yet,)
     
  8. hamstergang

    hamstergang Chief Resident 2+ Year Member

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    I thought that the subtypes were dropped because patients often changed subtypes in each episode, making them not useful prognostically. They didn't help to inform treatment. I also don't know how useful they really were for predicting violence or other things. As these subtypes were truly heterogeneous groups anyway, they more or less required you to explain the risks in your assessment to convey meaningful information.

    I feel similarly about the GAF. To begin with, the number itself doesn't differentiate between people who are that low due to functional impairment vs symptom severity. So to make it clear what the number meant required you to explain in your assessment. Though if you're writing a good enough assessment anyway, then what value is that number, really?
     
  9. Ibid

    Ibid Posting total rubbish 5+ Year Member

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  10. splik

    splik 7+ Year Member

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    They were dropped because of the poor reliability and validity of the subtypes, that they had been disappearing from the literature such that academics weren't being used anymore, and the lack of stability of the subtypes overtime. For example, there is no evidence those with the DSM-IV "paranoid" subtype continue to be paranoid throughout the illness course, actually they often go on to be "disorganized" later on. If you reflect back on your comment about genetics, you will see why it is silly. Genetics cannot explain the different presentations of schizophrenia at all. It's all cultural. The paranoid presentation is the most common in the west, but is almost conspicuous by its absence in other parts of the world. The catatonic subtype was extremely common 100 years ago but is very rare today in the west. "Simple schizophrenia" which was in ICD-10 but not DSM is also very common in some cultures as a presentation but we rarely see it in the West. In the same way that it is uncontroversial that the content of delusions and hallucinations are the result of cultural factors, the same can be said of the different "subtypes" of schizophrenia. Which is why there were thrown out. One of the most evidence-based changes to the DSM in fact.


    In the study they talked about "positive" and "negative disorganized' schizophrenia and those with Positive and negative schizophrenia. bizarrely they characterized those with First-Rank Symptoms as having "negative disorganized" schizophrenia. What was interesting was they found those who had particular SNP subsets had particular risk profiles for developing schizophrenia which in some cases was as high as 100%. They do claim that different symptoms are related to different SNP sets but the ways these were classified is somewhat bizarre.

    I have no idea how they ended up claiming that schizophrenia is 8 different diseases. Their study doesn't really support this genetically. It suggests that there are 42 SNP sets that confer more than 70% risk of schizophrenia and 98% SNP sets can account for 90% of the schizophrenia cases in their samples. Remember, about 5% of schizophrenia can be explained by copy number variation, or those that may be almost entirely explained by environmental factors. It also suggests that non-genetic factors are still highly significant in many cases.
     
    Last edited: 09.20.14
  11. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    The chance that any of this genetic flim flam will have any utility ever is negligible..... its all smoke and mirrors.....

    http://www.hearing-voices.org/ pity things like this don't get the attention they deserve......
     
  12. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    What works for a lot of people is getting as far away from the mental health system as possible and just getting on with life..... the chance of ever proving who this will work best for is remote imo.....
     
  13. Nasrudin

    Nasrudin Apropos of Nothing 10+ Year Member

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    I'm not sure arguing against discrete genetics proves anything. I think genetics could quite possibly blow its own mind in the coming decades. Heritability of acquired characteristics or culture as your indicating it, is posing a serious threat to the current paradigm of how evolution acts only on heritable traits.

    I think genes are speaking with human culture and environment via some as if yet not understood mechanism. And this conception of the two being opposing view points will be obsolete before we finish our careers.

    As far as certain patients doing better without us. I think, given our current understanding that's entirely possible. Although I don't think circling the wagons on a entirely social or cultural framework is any more helpful than searching for SNP frequencies.
     
  14. whopper

    whopper Former jolly good fellow 10+ Year Member

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    You could be right though I'm also wondering how much of it could be the neurodegeneration that happens with lack of treatment or treatment with neurotoxic psychotropics. That may also explain the differences you mentioned in different countries as treatment availability differs, and possibly the genetics too are playing a factor here since I don't know how variable the genes depending on the population of those areas.

    As for the lack of validity and reliability, I'm wondering how much of that is from the people doing the diagnosis. I've rarely seen people actually try to pin the subtype to the right one, as I've often seen people say the GAF is complete BS, so then clinicians often-times just put the GAF based on billing convenience, but if one were to actually commit some effort to it, and this is my own personal belief, I think there would be more validity and reliability to it.

    I've seen some clinicians be very exact in their GAF and diagnosing with schizophrenia and those clinicians tended to have accurate subtypes pinned to the patient.

    The other thing I was going to add is that when the general media reports a scientific discovery they tend to be way off because the person writing the article doesn't understand the science. I don't know how fair it is to take in this article without seeing an actual journal article. The NY Times is one of the few sources I've seen where the writers seem to actually take the time to understand the science behind it. I remember their articles on CATIE seemed to be from the perspective of a very experienced psychiatrist. Their mad cow disease articles were written as if the person understood the concept of prions.
     
  15. nitemagi

    nitemagi Senior Member 10+ Year Member

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    Avoidance and disdain doesn't help the suffering. Progress comes through hard work, not by throwing the baby out with the bathwater.
     
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  16. Artefact

    Artefact

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    Ibid - this is an interesting view. How did you develop it? It seems more influenced by ideas from continental philosophy than science. Are you a psychiatrist?
     
  17. Artefact

    Artefact

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    Right, and once a clinical entity is identified with a specific pathology and transitions from a "syndromal" definition to a pathologic one our ability to come up with new science and new treatments explodes. I'd like to see which pathway these genes are involved in and which downstream effectors are altered - this could lead to an explosion in molecularly targeted therapies and really improve outcomes with schizophrenia. Also - given their high degree of correlation between genotype and disease, this could open possibilities for early interventions and improve diagnostic certainty. Lots of exciting stuff!
     
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  18. tr

    tr inert protoplasm 10+ Year Member

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    Not really. They started with 342 highly-overlapping phenotypic sets derived from phenotypic data only (no genetics). Some of them were found to be specifically associated with particular networks of SNPs. They ended up grouping everything into eight classes but the phenotypic descriptors of those classes are limited to a severity assessment and the presence of positive or negative symptoms. So no, they don't match the old subtypes, which is totally unsurprising since as was previously pointed out in this thread those subtypes had extremely poor stability and reliability and so would be unlikely to be related to inborn genetic factors.
     
  19. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    Yes, if you are saying it is the patient who needs to do the hard work I agree..... as to the behavioural genetics I'm not hopeful at all that anything useful will ever come of it..... looking back at the history of physical interventions the record it not good and I don't think thats to controversial a view..... even discounting that some, I mean a really limited number of psychiatrists, being able to use neuroleptics and so on cautiously and "appropriately. I would include the modern era of physical interventions in the woeful category...... I guess that seems harsh but i'm not convinced that isn't an accurate description....

    I'm a guest on this forum. I try not to abuse it.... although in the past ive let myself down by getting into heated debates that got out of hand.....the moderators have been kind to me and I appreciate that.

    Broadly speaking my view is that in hindsight..... and the hindsight bit is important...... I do feel that when doctors lobbied to run the asylums, where psychiatry was born, that was probably unfortunate, given the subsequent biological reductionist path that the profession took.

    The enlightenment, the enclosure of the insane (so called), the beginning of the modern novel, an interest in peoples internal life..... all these things coincided with the birth of psychiatry..... of course if it had been left to lay people and so called moral treatment something of a professional class of people who took an interest in mad people would have developed..... how that would have worked out and how they might have developed as a professional body and where they would have trained is anyone's guess..... arguably things might have worked out worse than they have...... i'm critical of the system here not psychiatry as such...... I can't see that the system is working out well for the most part..... a lot of people get a pretty raw deal....

    As for science..... as it can enlighten so to it can blind...... as it can lead to debate so to it can be abused to silence and obscure.....

    When talking of genetics and psychiatry I feel that a sober nod in this direction is appropriate...... this is a paper all students of psychiatry should read..... I believe the author is an Israeli psychiatrist.... http://www.annals-general-psychiatry.com/content/6/1/8

    Note: of course at the time re the above everyone, everyone was a believer in eugenics..... still
     
  20. nitemagi

    nitemagi Senior Member 10+ Year Member

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    The issue of mental illness/health is complex. Turning a blind eye to science is not the solution, nor is the "biologic reductionism" prevalent in much of the field.

    I found the essay by Ken Kendler in AJP this month particularly eloquent and comprehensive in trying to capture where the field needs to go, scientifically. It isn't one or the other -- brain or mind, genetics or social factors, effort or chemistry. Reducing to any of those is neglectful and incomplete.

    The truth is not about identifying which risk factors there are, or looking at only one piece, but seeing the whole picture and understanding how they all interact. He uses the metaphor of a house heating system. Pipes, furnace, thermostat, etc. Understanding everything there is to know about pipes wouldn't help to understand the heating system. It would never be enough. There needs to be an understanding of how all the parts work together.

    In this vein, it's great that X therapy helps with Y problem, and that Y problem has Z genetics. When we start to understand how the genetics lead downstream to brain vulnerability, social stressors exacerbate that, and therapy affects the gene expression with neurotransmitter corollaries in certain brain regions, then we start really getting at the complexity of the system.

    Of course data can be abused to push any argument. I'd go so far as to say that is only a snapshot of science, though. Over time and with repeated and improved experiments, and as long as data isn't ignored, then the truth should emerge.

    While I agree that psychiatry has had problems at times with abuse of power, that is a reflection of society not of the specialty. Just as medicine as a whole has had a questionable history at times, as has science (nuclear weapons). Science isn't morally right or wrong. It's a view of what is. It is in the hands of the individuals in how they use science and the resultant technology from it that is the moral choice.

    Otherwise we might as well throw out all knowledge, burn our books, and go back to living in caves.
     
  21. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    I will read the Ken Kendler article....

    I do have beliefs and while I accept that it isn't always helpful to hold some things as articles of faith..... I don't believe that what gets called schizophrenia has either a genetic basis or that people are born vulnerable to it..... my belief is that anyone could become psychotic..... anyone..... if any particular human experiences a sort of psyhosis its just down to their unique circumstance...... psychosis is just an optical illusion..... and if you train as a psychiatrist you are prone to being fooled by that optical illusion..... (I don't mean that in a rude way....just using a metaphor to try and explain myself..... and i'm not accusing psychiatrists of being insightful either)....

    I do feel that part of the problem is the training itself..... eventually every bit of data scientific..... or what patients say.... or colleagues might say.... if it doesn't fit with what has already been absorbed it doesn't just not get mixed in with everything that has already been absorbed..... it actually seems counter intuitive so it just doesn't stand a chance of getting into the mix...... ok..... I guess in a way I am accusing some psychiatrists of being insightful..... a sort of reverse anosognosia.....

    I'm not so sure that science is neutral in this context either..... the researchers have an agenda that comes before they even start doing their research...... it starts with the de facto belief that schizophrenia exists and is a real thing..... thats not neutral.

    Gene expression --> brain. regions --> neurotransmitters --> vulnerability..... all these posited separately...... I could accept looking at each but the problem I see is that when you put them together really its just connecting dots in a way that seems satisfying but really their is no reason why the dots must join up like that..... its just speculation......

    I guess after starting life as a scientist I just no longer buy the idea of humans as machines theory..... it doesn't work for me..... and I guess I see it as a problem.... in your analogy with the house I would say I get it with the house but the analogy ignores the garden..... and in my world view its the garden that is the important bit and the garden is far more complex than the house plumbing and electrics will ever be...... the garden should not be understood as constituent parts..... it has to be understood as a whole experience..... the experience of the garden being the operative phrase....

    Its just a different view I guess as it relates to what gets called schizophrenia......
     
  22. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    Also I agree with you about physical medicine.... it has a social control role as well.... to an extent...
     
  23. shan564

    shan564 Below the fray 7+ Year Member

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    I was talking to one of the professors involved in this study... there's a lot more exciting stuff in the pipeline...
     
  24. hamstergang

    hamstergang Chief Resident 2+ Year Member

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    Well this belief of yours directly contradicts some rather sound scientific techniques. This sort of willful disregard of facts isn't something to strive for, nor is it consistent with being a good doctor.
     
  25. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    OK..... i'm just being honest about what my beliefs are and i'm looking at the same data and coming to different conclusions. You have made an accusation and made it in a way that isn't conducive to good conversation, which is all this is... conversation. If you just want to say you disagree with me fine. I could just as easily accuse you of dressing up your opinions as facts and further suggest that you are being disingenuous about what your own beliefs are. I'd just say that you seem to start with a belief yourself, you are just not owning up to it.

    Anyway plenty of "good" psychiatrists hold views that are broadly in line with my own..... Pat Bracken, Philip Thomas, Joanna Moncrief...... Philip Thomas worked with Kandel early in his career and later with Nancy Andreason..... just for instance.... google any of them and you will see they are substantive characters.

    I expect I have just hit a nerve more than anything else...... give any of those above a go..... interested to know your reflections as long as you play nice and stay civil...... :)
     
  26. hamstergang

    hamstergang Chief Resident 2+ Year Member

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    What you call looking at data differently I call (willful?) ignorance of the data. If you think there is no genetic basis to schizophrenia, what do you make of the multitude of twins studies establishing a heritability around 80%? What do you make of the multitude of studies like the one that sparked this thread that find genes linked to schizophrenia?

    It's hard to take you seriously and treat you civilly when you ignore all this data. You can't be ignorant of it since you're in this thread. You could just be really arrogant and feel you understand the science and math better than the great majority of scientists studying this. What are my other options for what to believe?
     
  27. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    Well, firstly lover boy you can take me any way you want..... but i'm not uninformed about the data..... although I find most psychiatry students actually are....not surprising given they are usually only spoon fed half a story...... as to your other choices you could start by not hero worshiping and being a bit more critical about what your being told.

    http://jayjoseph.net/yahoo_site_adm...e_Taught_It_is_All_In_the_Genes.224201614.pdf
    The above runs through the environmental equivalence problem..... the poorly done stats.... the poor randomisation..... and so on...

    The below runs through the really appauling reporting of studies in 31 of the most read psychiatry text books. Hope your not relying on any of those for your info sunshine... :)

    Joseph, J. (2000). Inaccuracy and Bias in Textbooks Reporting Psychiatric Research: The Case ofthe Schizophrenia Adoption Studies. Politics and the Life Sciences, 19, 89-99.

    Joseph, J. (2013). The Use of the Classical Twin Method in the Social and Behavioral Sciences: The Fallacy Continues.Journal of Mind and Behavior, 34, 1-39.

    The whole problem with genetic studies in general is that the human genome project started with the belief that all that was required was a bit of mapping and most physical disorders would simply fall out of the results. Turns out this belief was faulty...... all those poor poor scientists......yes.... they were wrong wrong wrong..... apart from a handful of physical disorders it turns out the whole thing is vastly more complex than they had believed..... cue massive back tracking and a plea for everyone to wait another 30yrs...... thats before we get on to the much much messier issues subsumed in mental health......

    Cut it out with the name calling as well...... its unbecoming of you....
     
  28. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    and here is a write up of some of the most recent research by a psychiatrist at University College London...
    http://joannamoncrieff.com/ I really recommend her blog pages btw..... even if you dont agree with her its a refreshing alternative view... but then again you might like her...

    In the light of the much trumpeted claims that recent research has identified genes for schizophrenia, it is important to review the track record of this type of endeavor.1 Despite thousands of studies costing millions of dollars, and endless predictions that the genetics of schizophrenia would shortly be revealed, the field has so far failed to identify any genes that substantially increase the risk of developing schizophrenia.

    Following the advent of molecular genetics, some studies started to find weak associations between this or that gene and being diagnosed with schizophrenia, but attempts to replicate the findings generally failed. A large genome-wide association study published in 2008, for example, analysed the distribution of 833 single nuclear polymorphisms (SNPs) in 14 genes that were thought to be the most likely ‘candidates’ for being associated with schizophrenia in a sample of 1,870 people with schizophrenia and 2002 controls. The study found no statistically significant effects for any of the genes examined and the authors concluded that ‘it is unlikely that common SNPs in these genes account for a substantial proportion of the genetic risk for schizophrenia, although small effects cannot be ruled out.’2, p 497

    Since substantial effects were not showing up, larger samples were constructed by merging different genetic databases. These larger samples allow smaller effects to be detected. Moreover the search was broadened to include the whole genome, since early studies failed to confirm a role for ‘candidate’ genes3.

    The recent headlines were generated by a paper which reports a Genome Wide Association study in a combined sample consisting of tens of thousands of people diagnosed with schizophrenia and controls.4 Nine and a half million SNPs were examined. Out of these millions of SNPs, 128 were statistically significantly more common in people diagnosed with schizophrenia, using a ‘p’ value of 0.00001 to correct for the large number of tests conducted. These 128 SNPs were then mapped to 108 chromosomal regions or ‘loci,’ most of which had never previously been thought to have anything to do with schizophrenia. The paper provides no odds ratios or other measure of the strength of the associations between the SNPs and having a schizophrenia diagnosis, but the lead researcher confirmed that each genetic loci was associated with an increase in the risk of schizophrenia of approximately 0.1%.5 Using a method dependent on multiple assumptions (Risk Profile Scores), the maximum amount of variation explained by a combination of the genes identified was 3.4%.4

    The genetics of schizophrenia parallels findings in most common physical diseases. A small number of genes with substantial effects have been identified for a small number of conditions (breast cancer, Alzheimers and AMD). Other than this, the hugely expensive human genome project and all the research that has followed from it has failed to reveal that particular genes increase the risk of developing common and important diseases to any relevant degree.6

    As in the latest schizophrenia studies, some genes appear to be slightly more common in people with conditions like Type 2 diabetes compared to those without, but having one of these genes will increase the risk of developing the disease only marginally. But the fact that people’s genetic risk varies around the average is simply tantamount to saying that everyone is different.6 We knew that anyway.

    These results have lead some commentators to conclude that ‘genetic predispositions as significant factors in the prevalence of common diseases are refuted.’6 Yet researchers and the media continue to report genetic studies as if they represented evidence that bodily diseases and behavioural or mental disorders are genetic conditions- that is conditions that are determined in an important way by detectable genetic variation. The recent schizophrenia study was reported in just such a way. ‘They’ve really managed to show that genetics plays a role’ said one schizophrenia researcher.7The study authors claim their findings will help unravel the aetiology of the condition and lead to the development of effective and targeted drug treatments.1

    It is difficult to see that these findings will have any clinical implications for our understanding of schizophrenia or its treatment, however. Leaving aside the difficulty of defining mental abnormality or ‘schizophrenia,’ if the genes identified predict only about 0.1% of the risk, then whether you have one or two, or even a few or a lot of the genes concerned tells you very little about your particular vulnerability for developing the condition.

    Some commentators have concluded that the lack of evidence for a genetic contribution to common diseases shows they are fundamentally environmental conditions. Certainly we know that, in contrast to the effects of particular genes, environmental risks contribute substantially to the risk of many diseases, as well as to mental disorders, albeit in different ways. Work by biologists such as Richard Lewinton, however, shows us that many features of living beings are the result of random variation, and not predictable from either genes or environment.7

    To me, the fact that genetics contributes little to our risk of disease, or our likelihood of developing behavioural and mental disturbance, seems a matter of celebration. The idea that we are doomed by our genetic make-up to develop life-threating or disabling conditions is surely a profoundly depressing one.

    We will likely never be able to fully account for why some people experience extreme mental states, but we know that poverty, unemployment, insecure attachments, familial disruption, low self-esteem, abuse etc. play a role for many. We would be better concentrating on how to eliminate these from our society if we really want to reduce the impact of mental disorder, rather than pouring more money into the bottomless pit of genetic research.
     
  29. smalltownpsych

    smalltownpsych 2+ Year Member

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    You make some very good points about the flaws in our conceptualization and treatment of mental illness. However, I think that making the leap from this to a belief that schizophrenia has no genetic or biological basis seems to be a stretch. It is easy to point out the flaws in the research, we know very little about what is causing our patients to suffer, but there is a danger in coming up with a belief and then finding information to support that belief and it is not good science. That is why we come up with a hypothesis and then test it. My question to you is why does my own personal friend hear voices, have delusions, and dress kind of funny? He never had significant trauma, poverty, or abuse, but he does have some crazy relatives who had similar issues. He is highly intelligent and has learned how to cope with what he calls schizophrenia and also understands all too well the limitations of the medications and the mental health treatment system, but he also recognizes the benefits and utilizes both. I also have worked with patients with similar stories and symptoms and I know that it is a very complex question and I get frustrated by reductionist thinking coming from all sides of this argument.
     
  30. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    I can't take credit for the points I make.... although I make them in my own way....

    I'm increasingly convinced that DNA has as near a makes no difference nothing to do with psychosis..... of course we are embodied beings so to that extent biology is in the equation, I just dont feel that it is relevant..... its almost a philosophical point given the state of the art.... no matter how breathlessly its dressed up...... I get the logic but I just don't buy it.....

    Using your friend as a handy example...... I would just make the following points. The fact that they cope is the salient point and all that really matters. Searching for a definitive why imo just isn't helpful. I believe that the important thing is that people are allowed to come to their own conclusions about the why and also what it all means to them. I totally agree about the dangers inherent in being dogmatic about ones own personal favorite explaination for these things. Trauma works well for some people as an explaination for other people a broke brain theory (not my own favorite obviously) seems to work for them. As long as the person themselves is the owner and final arbitor of the explaination or non-explaination even that is what counts. I say this because I see a lot of people having explainations foisted on them and even demanded of them.... not always but enough to convince me that it is a huge problem.

    I don't believe that the content of what gets called psychotic thought is always meaningful...... but I do feel that the opportunity to make meaning out it shouldn't be taken away from people..... the disease model rather does do that.... it makes the experience meaningless for people. That I believe is wrong. If people come to that conclusion themselves then thats another mater....

    Thats pretty much how I feel about that..... I get that as a practitioner the not knowing why seems somehow incomplete but along with a focus on symptom obliterating at the expense of meaningful living (of course this is a balance.... just one that I thing is miscalculated more often than not..... ie a person is symptom free but left as a husk more or less unable to function and this is called success.... :-( ).... these are common mistakes....
     
  31. hamstergang

    hamstergang Chief Resident 2+ Year Member

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    An interesting suggestion given what you have presented. Basically, you are currently presenting the work of 2 anti-psychiatry heroes, Jay Joseph and Joanna Moncrieff. An issue with this is that they have written books on this topic, and I don't have the time or energy to respond with a book of my own. Instead, I'm relying on the fact that they are still outside the mainstream. That means that there are plenty of others who do know the research more intimately or have done it themselves that feel these 2 have it wrong.

    I did consider, though, that maybe these 2 know what they're talking about. So I researched them a little. Allow me to quote from Joanna Moncrieff's wikipedia page, for a moment:
    "In early work Moncrieff analysed the evidence for the efficacy of lithium. She claimed there was no evidence that lithium was superior to other sedatives for the treatment of acute mania, and that lithium’s efficacy in preventing a relapse of manic depression was due to the adverse effects caused by the sudden withdrawal of lithium. In later work she showed that studies on the outcome of lithium treatment in the real world fail to demonstrate useful or worthwhile effects, and suggest it may even worsen the outcome of manic depression."

    This is the sort of thing that doesn't pass my sniff test. Lithium has been well established as effective for bipolar disorder. I don't believe everything I am told, and I do my own literature reviews so I can argue intelligently with the anti-psychiatry crowd without supporting something not true, but I certainly don't believe someone trying to sell me on lithium being not worthwhile. It makes me question Dr. Moncrieff's scientific understanding and bias.
     
    Last edited: 09.24.14
  32. smalltownpsych

    smalltownpsych 2+ Year Member

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    These are two very different points. One is about the cause of a condition the other is about the treatment. To your first point, the better we understand the mechanisms of illnesses, the better we are at designing treatments. We have a long way to go in this and I agree that genetics is overemphasized and many see it as a cure-all but I think most practitioners know that is far from the truth.
    Your second point is that there is a lot of poor treatment and over-reliance on medications by many in the mental health field. You won't get much disagreement from me on that point, but I would say that most psychiatrists and psychologists are aware of that but are confounded by a system that is severely flawed and focused on compliance and control as opposed to treatment.
     
    Last edited: 09.24.14
  33. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    I can not see Mocrieff being characterised as outside the mainstream really.... she is a Consultant working in the NHS and teaching medical students at UCL..... I appreciate you are time poor but I would still recommend her blog pages.....

    Its worth having a look for a different perspective...... I think she is pretty circumspect in her writing to be fair...... Joseph Jay is a psychologist...... I don't know if he would call himself and anti-psychiatrist or not...... I quite sure that Joanna Moncrieff would reject that label outright....

    I get the irony of me being a fan of her work..... point nicely made and taken :)

    I agree that systems rooted in compliance and control are not helpful either to psychiatrists or their patients..... it impedes the creation of a good relationship...... actually I personally feel it just about prevents it in the inpatient setting....... something like 70% of patients end up lying about how they really feel just to get out of hospital..... that stinks..... it means you don't really know what is going on for them so you can't really help and they don't get the help they need...... I could go on more about this but its outside the thread and whole other topic as is the conversation about social control (I might bump the thread I started about that)...

    Another big problem is that many people, even when they accept/know they have a problem/troubles/an unwanted gift don't want to characterise those problems as an illness...... this problem is huge for people who get the schizophrenia diagnosis/label.... it totally impedes the creation of personal meaning and if the psychiatrist in question is dogmatic about how someone should understand themselves....... well..... their is no genuine relationship..... the person just feels put upon.... powerless especially in an impatient setting and basically the whole thing ends up stinking to high heaven.

    Plently of doctors work with people without a named disease..... my feeling as to why (cue huge over simplification and generalisation) psychiatrists tend not to want to engage people on another level or be sympathetic to alternate understanding is that they have a huge chip about not being "proper" doctors...... while I believe this is an accurate description of what is going on a lot of the time I also think that it is daft and they should just get over it..... the trouble being that their is a lot of discrimination from other doctors to live with and some public perceptions about not being "proper doctors"..... none of it is helpful...... I know I'm generalising but still I feel its a big problem in practice...
     
  34. nitemagi

    nitemagi Senior Member 10+ Year Member

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    Ibid,

    your criticisms presume that psychiatrists arrived at their current philosophy out of bias, ignorance, or prejudice. You would do better to presume that everyone comes to their place in the world with good intentions, rather than attempting to paint psychiatrists as evil, a stereotype that only alienates us.

    I would reflect back on the pot, kettle, and point out that you critique others for taking in information and swallowing it whole without analysis (which is easy to state from the peanut gallery), while you instead choose to opine philosophies that have little to no data to back it up.

    Lack of evidence is not evidence that the counter is true. You cannot critique others without real data to back up your statements. If you have actual research to back up your ideas, please cite them, otherwise you're stating others (with a wealth of research) are wrong because you say so, yet have no actual data to back it up (aside from some fringe practitioners that are in practice). Citing the editorials of providers is not evidence that current practice has it wrong. It's just another opinion. Where's the data?

    Now I'm as much a critic of the field as anyone, but I base that on clinical experience and I recognize the pros and cons of current practice, and use research articles to support my opinions whenever possible.

    You are more than generalizing, you're pathologizing psychiatrists as being the cause of mental illness. As if the issue is psychiatrists are sick of being marginalized, and so take it out on the patients.

    I encourage you that if you think you can do it better, then become a psychiatrist and prove it.
     
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  35. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    Well the best view is from the peanut gallery :) ..... interesting you don't appreciate being pathologized, a bit of an irony that one.... as for "illness" i'm an appreciative Szasz reader who while descending into hyperbole after a while was for the most part correct in his analysis.....imo

    As for becoming a psychiatrist thats a personal thing..... the pity is just how depolitisized it is..... not you specifically but the arrogance that flows out of the APA is astonishing....

    I'd be interested in what your criticism of the field of psychiatry amounts to......

    This will be heretical but i'm done with data.... so called data..... the data is in.... the system of label and drug is a busted flush.... bio bio bio is the death rattle of the MH system....
     
  36. smalltownpsych

    smalltownpsych 2+ Year Member

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    Again, you just criticize and offer very little in the way of solution. Yes. There is truth in the problem with label and medicate. Yes. The system in this country has major flaws and I have seen evidence that other countries do better with serious mental illness. No. nitemagi did not say he didn't appreciate being pathologized. He was merely pointing out, accurately I might add, what you were doing. If you really want to improve mental health treatment and outcomes blaming psychiatrists is the last place I would go. I don't know what their APA says, my APA doesn't say much! These issues are community, political, and cultural issues. The people want a quick fix and the corporations advertise it. We who are on the front lines see the problems with that every day. I eagerly await nitemagi's response but i couldn't help but answer for him when I saw his response was being mischaracterized. I have been following this interesting thread because I too have criticisms of the medical model, but to throw it all under the bus is not the answer IMO.
     
  37. nitemagi

    nitemagi Senior Member 10+ Year Member

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    I think you mean politicized, not depoliticized.
    Yes, it's political. My personal success is not intertwined with any industry, as I do good work and get paid well for that, working for myself.

    Anytime someone becomes entrenched in an ideology, they start over filtering and stop taking in new information. It is the nature of any bias.

    So when you say "I'm done with data," that automatically tells me you're entrenched in a position and can't really consider alternatives. Data is information. If you can't take in information then there is no point to a conversation.

    What seems like the unspoken elephant in the room is the stigma likely witnessed by you in regards to those diagnosed with a mental illness. I'm hypothesizing, of course, but it seems to fit the particularly rigid counter-culture approach with which you take. When I try to understand that, my assumption is that you've witnessed less than fully humanistic medicine, which really occurs throughout all of medicine. Doctors with not great bedside manner, who don't take time to listen or see someone as a person. They don't see the person, but instead they see a problem-->intervention, which is a model throughout all of medicine. Even the structure of medical documentation involves the Assessment/Plan (problem list-->intervention). An internist note might say something like 1. Hyponatremia - Follow BMP qday, check urine electrolytes, rehydrate with hypertonic saline ...

    It's structured into medical thinking, and that most definitely went continues to bias the thinking of psychiatrists, but that doesn't mean diagnoses are wholly inaccurate, but instead a small step forward in improving the system (with many more steps to go).

    If you applied the same approach that you're really asking psychiatrists to use, which is to understand who someone is, and how they got there, then you might understand what doesn't work AND what does about the current system, and have empathy for those working in the system.

    As a psychiatrist who does a lot of therapy, criticizing how someone is doing something never helps them to change. You have to start by meeting them where they are, understanding them for how they got there, and only then can they be helped to a different place. If YOU, Ibid, applied that approach to understanding psychiatry and psychiatrists, then you wouldn't have to revert to hypocritically applying close-minded broad criticisms that only alienates those with whom you should be allying with.
     
  38. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    Yes... ive tripped up over some of the nuance....

    My critique isn't so much of individual psychiatrists but of the institutions that make up the mental health system. Their are problems in society, communities and families.... MH institutions serve to obscure these problems by personalising the problems in individuals and further obscure the real problems my medicalising the identified people. This is not just an injustice.... to tell someone that they are the problem and that the problem lies in them.... it also serves as a brake on the development of just societies.... in that way psychiatry serves as a brake on civilisation itself.

    Not enough people care about this and psychiatry is just one of a number of vested interests that work against the development of just societies.... imo

    In short psychiatry serves to support the status quo.....
     
  39. smalltownpsych

    smalltownpsych 2+ Year Member

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    Unfortunately, sometimes the problem does lie in the individual. I made really bad choices in my life some tied to my personal genetic background and some because of my abusive upbringing in a family system characterized by multi-generational deception, shame, and loss. Until I started making better choices in my life, my life sucked and the system was lined up against me. Now I work within the system to try to improve it and we are all a lot better off.
     
  40. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    Well.... first I do consider myself an ally.. I get it doesn't seem that way at first glance.... we are interested in the same thing..... we just see the problem slightly differently....

    Another point is that anyway you chop it their are many many poor psychiatrists...... this is a huge problem.

    I have outlined my thesis above about why getting a person to change is often wrong..... people don't need insight and a plan to change ..... they often need outsight, to see that their problems occur in a context and what they really need to help to change the world around them..... by focusing its attention on changing individuals to fit in to an unjust world..... it just permissions that injust world to continue. The message of the hospital to its patients is the world outside is good and just and right..... if you don't fit in you are the problem. Thats wrong wrong wrong......

    I'm not suggesting helping people is wrong but I am saying that the current mainstream approach comes at a heavy price. Ive said before on this thread that if just a bit of the money that goes into behavioural genetics went into social programs then the world would be a better place. The trouble is social programs are seen as dead money..... while research despite the obvious fact that it is never really ever going to translate into anything useful gets funded because careerers are at stake....

    btw I believe that the current approach will always feed stigma.....create it.... prop it up..... because thats how the message that thier is something wrong with these people will always translate to the world outside the mental health system..... like it or not.... it goes with the idea that if the world is perfect and you don't fit in or are unhappy with it then there is something wrong with you..... you can't get around that..... imo the MH system breed stigma and then to add insult to injury blames the victims of that stigma for their own oppression.....

    Yes.... its a different point of view I have.... when I say i'm done with the data I don't mean that new and interesting ideas don't present themselves..... what I mean is I'm done with data that is interpreted to serve an agenda that is not mine..... thats what I mean...
     
    Last edited: 09.25.14
  41. hamstergang

    hamstergang Chief Resident 2+ Year Member

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    What an interesting line. Not sure how you meant it, but to me it sounds like you recognize you have an agenda and are willing to twist data to fit that agenda even if it's not the truth. Excuse me for not buying into your agenda until it's on firmer ground.
     
  42. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    I'm totally upfront about my agenda..... I stateded it earlier on in the thread. I'm not hiding anything..... now maybe not you personally but lets face it the agenda of the biological approach to humanities problems is a house built on quick sand.....

    I'm not twisting any data...... i'm just being honest. Their is a lecture taking place in London at the institute of Psychiatry based on this research in a month or so called....."Now we know what causes Schizophrenia"......pmsl..... I mean come on..... who is twisting the data to fit an agenda..... its not me....jesus.
     
  43. smalltownpsych

    smalltownpsych 2+ Year Member

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    But there is a lot of money that goes into social programs. I have worked with and for these programs. Many times they cause the very problems that Szass was against such as control and mental health systems being aligned with the state. I am not sure what you are proposing as the solution. the world is not just or fair and I don't know if we ever could make it such, but many of my patients come to me so they can learn how to improve their ability to function in this harsh cold uncaring world.
     
  44. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    I guess more money for social programs..... demedicalisation of psychiatry... to an extent....keep drawing attention to where the real problems are..... support alternative to addmission, I mean make sure they get funded.....

    To be honest im quite optimistic..... I think things in places are going in the right direction even if they are still a long way off from being what I might like to see....

    Society keeps changing and plenty of it is for the better..... not everyone is a reactionary conservative..... the internet is a force that works in support of a progressive agenda more than works in the opposite direction..... and of course dinosaur psychiatrists eventually die off..... sorry I mean retire.....
     
  45. Armadillos

    Armadillos 2+ Year Member

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    Ibid, to make sure Im understanding correctly. Lets say we changed things around in the USA so that every person had a home, unlimited free education of their choosing, 50K guaranteed income and a social services system that greatly decreased occurrences of abuse/mistreatment. In this situation do you think that there would essentially cease to be people that were so disturbed by hallucinations or delusions that they would seek medical treatment?
     
  46. Ibid

    Ibid Posting total rubbish 5+ Year Member

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    I expect that no matter what the social settlement there will always be people who will go mad or will live in a permanent state of unshared reality...... what I hope will happen is that this will come to be seen as something not to be feared but just an ordinary part of being a person for a lot of people. The way that we respond to people who are overwhelmed by thoughts, feelings and emotions has a long way to go...... this is something that psychiatry could be potentially be very helpful with..... that is selling the idea that people who are different are not to be feared..... at the moment all the emphasis is on controlling people and selling the idea that they are dangerous and that psychiatry is the force that will protect society from the mad.... imo thats a pity.... but I fear the truth is that their is good money to be made out of the current system....

    I do believe that their is a vanishingly small number of people who society needs protecting from..... but its a very small percentage of the whole population of people who have unusual experiences...... this small group of people make the headlines and that to is a pity.....
     
  47. Armadillos

    Armadillos 2+ Year Member

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    I think you have a fundamental misunderstanding about how physicians approach their practice. With very, very few exceptions as a physician I don't owe jack to society as a whole. It isn't what is driving my decisions and don't think about whats best for society, I think and care about what is best for my patients. Immediate and clear danger to others is the obvious exception, but as you accurately state its quite rare for those with psychiatric illness to be an immediate danger to others.
     
  48. nitemagi

    nitemagi Senior Member 10+ Year Member

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    1. You conflate people with "unusual experiences," with dangerousness, just as the lay public conflates mental illness with dangerousness. Most dangerous people aren't mentally ill.
    2. The bigger issue is your belief that psychiatrists want the responsibility of protecting the public. For the most part, we don't. It is thrust upon us by the government. The DSPD phenomenon in the UK is a clear example, where a diagnosis was created by the government, and psychiatrists were assigned the responsibility to manage those people and protect the public.

    You also seem to return over and over again to some conspiracy, or as if it's about a big money grab.

    Psychiatrists in normal outpatient private practice do just fine financially without hospitalizing anyone, EVER. Without ever pushing any ideas of dangerousness or needs for medication. Furthermore, if your hypothesis was that doctors or the drug companies were attempting to instill fear (rather than the media), then I'd expect that drugs would be marketed and sold to reduce risk of dangerousness. But there are ZERO medications marketed for such purpose. None. No FDA approvals for that. So as usual I ask you to provide any evidence to support your conspiracy theory.

    Now there is a long fear-based reaction from the general population, that psychiatrists are "power mongers," eager to lock people up for our own power trips, as if we were drawn to the field to dehumanize others and strip away their rights. I no again ZERO physicians that went to medical school for that purpose, and no psychiatrists that liked the specialty because of that. You'd think that of the thousands of doctors I know I would have encountered one like that, but I honestly haven't.

    Perpetuating the myth of the mad power-hungry psychiatrist, is about as accurate as the offensive stereotypes of the "mad scientist," or "mad Arab" for that matter. They're all grossly inaccurate, and your buying into them just furthers a culture of fear. By all means, stigmatize those that treat the mentally ill. That'll surely solve the stigma problem :rolleyes:
     
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  49. Nasrudin

    Nasrudin Apropos of Nothing 10+ Year Member

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    Great thread.

    I particularly enjoy among other things, nitemagi, your accurate description of the rigidity of the left counter culture ideology. As if social engineering is the answer to everything. Aside from the obvious question of how or more importantly who would carry that out.

    I really cannot understand how people come to see genes and a biological perspective and social/cultural phenenomon as separate. It seems like the separatists of each camp are equally rigid and myopic. I think these types of discoveries are likely to explode and these separate 19th century narratives of biological and social determinism will become extinct.

    http://www.nature.com/news/epigenetics-the-sins-of-the-father-1.14816
     
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  50. HarryMTieboutMD

    HarryMTieboutMD 2+ Year Member

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    http://libd.org/viewpoints/understanding-schizophrenia

    Danny Weinberger and colleagues have been at the forefront of the genetics of schizophrenia for decades. In addition to being the premier molecular biological psychiatrist in the world, he also very much keeps in mind the greater picture of how the basic science research will impact patient care. People like Weinberger, Cloninger, Diesseroth, etc truly have changed, and continue to change the face of psychiatry.
     
  51. Artefact

    Artefact

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    It must be frustrating in psychiatry that even when there is peer-reviewed science published in major journals demonstrating genes with 90-100% association with schizophrenia, there will still be people posting about how Schizophrenia can't possibly be a biological illness.

    Something about the nature of psychiatry makes people think they can read a few popular psychology books and therefore have views that should be taken seriously by practicing psychiatrists.
     

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