Is Mental Illness Defined by Society?

[indya]

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^^

Who is to say that things like religiosity, conservatism, liberalism, laziness, happiness, or love aren't mental illness? (I know that there is some board which in real life decides what is mental illness, but on a philosophical level, how do we decide what is mental illness?)

 

[Manicsleep]

^^

Who is to say that things like religiosity, conservatism, liberalism, laziness, happiness, or love aren't mental illness? (I know that there is some board which in real life decides what is mental illness, but on a philosophical level, how do we decide what is mental illness?)

Mental illness, very simply put, is a state of emotion, cognition or behavior that is relatively pervasive and interferes in a person's ability to function in society.

 

[whopper]

Who is to say that things like religiosity, conservatism, liberalism, laziness, happiness, or love aren't mental illness? (I know that there is some board which in real life decides what is mental illness, but on a philosophical level, how do we decide what is mental illness?)

Do you have access to the DSM? That book discusses these issues better than I could.

But to give you some information, because the human mental state covers such a large area of possibilities, the DSM has attempted to limit mental illness to a behavioral or psychological state that causes distress to a person that is not a normal part of their culture.

The law further has created safeguards to protect the rights of those who are considered mentally ill, in the sense that they should not be treated unless they willingly want treatment, unless there is at least some evidence that the mental illness is to the degree where that person will harm themself, others, or cannot care for themselves in the community on their own.

 

[kugel]

^^

Who is to say that things like religiosity, conservatism, liberalism, laziness, happiness, or love aren't mental illness? (I know that there is some board which in real life decides what is mental illness, but on a philosophical level, how do we decide what is mental illness?)

In a simple, and sarcastic, sense, "by consensus."

Just like it is society that defines any disease, whether society defines it actively (through legislation or open and public debate) or through inaction (allowing it to be defined by small groups which have specific agendas, like a medical specialty organization or a lobbyist group or a pharmaceutical company).

Is hypercholesterolemia a disease? It has no symptoms! It is really not a disease in the classic sense at all. It's just a risk factor for other diseases. But it has been defined as a disease by medical groups, gotten government blessing (ICD coding and MediCare payments for treating it) and pharma makes billions on it every year.

Is dementia a disease or just the inevitable course of aging, though some get it earlier in the aging process than others? Is osteoarthritis a disease or the physiologic result of over-use of a joint? Is fever a disease or a sign or is it good for you - sort of depends on the context doesn't it? Is erectile dysfunction a disease - or a lifestyle issue? That particular debate was very strong back when ED meds were first arriving on the market - but it seems to have been decided by the lack of any interest in whether collections of other people's money (insurance premiums) should be paid out for those medications.
[and just as I'm writing this I found out that the debate re: ED treatments is NOT over]
http://www.businessweek.com/ap/financialnews/D9HHBA5G0.htm

Why is the lab reading defining diabetes where it is and why has it changed so much over the last several decades? Has the disease changed? How did the ancients define diabetes mellitus? What did they see as signs and symptoms and course, vs how we define it now?

Are there any definitive lab or imaging tests to prove an upper respiratory viral syndrome? How can it be a disease if the diagnosis is so subjective?
"You haven't done any tests! How do you know I don't need an antibiotic?"

What schools of thought about medicine and treatments/cures, and medical education, were considered viable before 1900?
Hint: there were many.

Unfortunately, medicine is not really a philosophic endeavor anymore, and so these questions get lost on the grinding road to, "But what do I do for my patient NOW?" But understanding how these thoughts arose and why we answer these questions as we do yields understanding about what has come before and where we are going.

Your questions are valid for every field of medicine.
Who would consider an education in art or psychology or business to be complete without an understanding of the history of thought in that field?

Don't let the usual medical education system strip you of yearning for an understanding of how we got to where we are. Do some reading and/or course-work in the history of medicine.

And remember that the DSM was developed to provide a multinational glossary of mental illness terminology for the sake of research reliability. It was not meant to stop practitioners from diagnosing things outside the book. The ICD contains many diagnoses that are not in the DSM.
I'm not bashing the DSM, just trying to put it into perspective.

 

[dl2dp2]

The other fact to consider is that while you could potentially "define" a new mental illness that is "culturally specific", even in psychiatry there are phenomenologies that are less culturally sensitive. For instance, major depression, bipolar disorder, primary psychotic disorders, etc. perhaps there are different description and classification of these illnesses, the objective entities have always existed throughout history and in all cultures. "Madness" is a universal phenomenon, just as cancer, stroke and aging. So as a society we can refine the nosology of illness but it's simply a description of nature.

This is to say, psychiatry is to a large extent an objective science. We don't create entities arbitrarily or creatively for whatever goals the society has--at least that's the mainstream interpretation. There are other philosophical interpretations of psychiatry, of medicine, of science, and we don't necessarily need to go into it right now.

 

[RedPakotaSea]

Mental illness, very simply put, is a state of emotion, cognition or behavior that is relatively pervasive and interferes in a person's ability to function in society.

Correct. Therefore, I'd say it follows that mental illness is largely defined by society and the functional requirements thereof.

Different societies (as well as individuals within a society) can disagree on what constitutes a normal vs. pathological level of functioning. That's not to say there aren't certain cross-cultural commonalities of how psychological distress is experienced. Madness, which is characterized by abnormal patterns of behavior, has been recognized by virtually every culture throughout history. However, while every culture finds some behaviors abnormal or unacceptable, the definitions can vary quite dramatically. Optimal functioning is selected for and defined by the particular needs of a society.

For example, it would be absurd to diagnose ADHD in an agrarian society. Until optimal functioning became defined as quiet classroom attentiveness for many hours a day, hyperactive behavior had not been pathologized. And not until incentives were in place for pharmaceutical companies, was the process of pathologization completed.

Mental illness is not only defined in a culturally-specific manner; its manifestations are also culturally dependent. A good example is anorexia nervosa. While the disorder has long been identified by Western society, it is a relatively new phenomenon in China and Japan. As the ideal body image becomes thinner, there is a corresponding increase in the prevalence of the disorder.

Again, I am not arguing that there are not commonalities in the experience of psychological distress among individuals living in different societies. However, I am saying that the dichotomous cut-offs defined by the APA reflect the culturally-specific views of what constitutes mental illness by Western society. Therefore, our diagnostic criteria are not universally valid.

In a simple, and sarcastic, sense, "by consensus."

Just like it is society that defines any disease, whether society defines it actively (through legislation or open and public debate) or through inaction (allowing it to be defined by small groups which have specific agendas, like a medical specialty organization or a lobbyist group or a pharmaceutical company).

Is hypercholesterolemia a disease? It has no symptoms! It is really not a disease in the classic sense at all. It's just a risk factor for other diseases. But it has been defined as a disease by medical groups, gotten government blessing (ICD coding and MediCare payments for treating it) and pharma makes billions on it every year.

Is dementia a disease or just the inevitable course of aging, though some get it earlier in the aging process than others?

I see what you are saying. The term "disease" has no unambiguous, generally accepted definition.

However, it is the "disease realism" model that has predominated in psychiatry, with Emil Kraepelin as an early staunch advocate. This view states that a disease is "an objectively demonstrable departure from adaptive biological functioning". Therefore, clinical signs and symptoms do not constitute disease. It is not until the causal mechanisms are clearly identified that we are really speaking of a disease.

Debating what the normal range for HbA1c values should be is altogether different from determining what constitutes normal function or behavior. The former is based on risk for various complications and/or mortality. As our knowledge of risk factors and outcomes has increased, the optimal range has been adjusted accordingly. Behavioral norms, on the other hand, are much more subjective and are for the most part culturally defined. Perhaps this is most strikingly true for the personality disorders, but I believe it holds for many Axis I diagnoses as well.

I agree that defining dementia is somewhat arbitrary … a decrease of how many points on the MMSE? However, few would argue that Alzheimer's disease is not an organic brain disease. Imaging and post-mortem studies reveal relative consistency in underlying pathology. This is not the case with the majority of psychiatric conditions. In schizophrenia, for example, it seems that the only reliable post-mortem changes identified thus far are attributable to long-term dopaminergic blockade. There is no consistent underlying pathology.

I think it's fair to say that schizophrenia, if not a true disease, is a term that describes a heterogeneous group of manifestations that are at least loosely clustered. Perhaps, for certain rare subtypes, etiologies will be discovered. However, I find it exceedingly unlikely that the bulk of diagnoses (all psychiatric diagnoses) will be explained by reducing mental illness to neurochemical deficiencies or other biological etiologies.

To better illustrate the difference between medical and psychiatric "diseases," let's look at the disease-centered model of drug action, which has worked well in medicine. Drugs have been developed that act on the underlying causes of a disease or that reverse the pathology of a medical condition. Penicillin directly targets the organisms responsible for syphilis. Insulin works directly on the process that leads to symptoms, albeit not on the original pathology.

This model fails for many psychiatric diagnoses. Taking a psychiatric medication is not like taking insulin for diabetes. Antipsychotics do not work by correcting chemical imbalances as insulin works by correcting a metabolic derangement. Antipsychotics, like other psychiatric medications, are first and foremost psychoactive drugs. They create abnormal brain states – altered states of consciousness – and the therapeutic value is determined by the subjective state that is produced.

I may be going on a tangent, but my point is that psychiatric disorders (as well as a number of medical disorders) are not diseases in the traditional sense, and psychiatric treatments are not the disease-specific treatment that they are proposed to be.

The other fact to consider is that while you could potentially "define" a new mental illness that is "culturally specific", even in psychiatry there are phenomenologies that are less culturally sensitive. For instance, major depression, bipolar disorder, primary psychotic disorders, etc. perhaps there are different description and classification of these illnesses, the objective entities have always existed throughout history and in all cultures. "Madness" is a universal phenomenon, just as cancer, stroke and aging. So as a society we can refine the nosology of illness but it's simply a description of nature.

This is to say, psychiatry is to a large extent an objective science. We don't create entities arbitrarily or creatively for whatever goals the society has--at least that's the mainstream interpretation. There are other philosophical interpretations of psychiatry, of medicine, of science, and we don't necessarily need to go into it right now.

Interesting post.

I agree that it is society that "refines the nosology" of mental illness; however, I believe that psychiatry erred when the DSM-III was adopted, due to the creation of false dichotomies in an attempt to appear more respectable as a medical profession. While "madness" may be a universal phenomenon, the current nosology is not well supported empirically. As Kenneth Kendler states, "gene discovery in psychiatry is, on its own, unlikely to allow us to ‘carve nature at its joints,' thereby validating categorical psychiatric diagnoses" (Am J Psychiatry 163:7, 1138). The same goes for neuroimaging or any other biological test in psychiatry. The current nosology is deeply flawed and at least in part maintained in contradiction to available evidence by various powerful interests.

It's likely that many psychiatric disorders merge into others with no natural boundary in between. If we are giving an accurate description of nature, there should be what Kendler calls "zones of rarity." For example, attempts to demonstrate natural boundaries between major depressive disorder and normality have consistently failed. Instead, studies have demonstrated that the genetic basis of anxiety and depression are very similar, if not indistinguishable. What exists is a spectrum. The same goes for schizophrenia, psychotic affective illness, and a spectrum of other disorders, including szhizotypal/paranoid personality disorder.

Also, I'd argue that we do create entities arbitrarily. If we measured other dimensions of performance and behavior, perhaps we could pathologize individuals that score low on creativity testing. All we need is an effective on-patent treatment.

 

[snarfer]

Is dementia a disease or just the inevitable course of aging, though some get it earlier in the aging process than others? .

Good post, Kugel.

when one investigates the brains of individuals 75 and over by neuroimaging and post mortem studies, 90% of healthy individuals will show cortical atrophy, amyloid plaques and neurofibrillary tangles. Thereby, those with symptoms consistent with DAT will certainly have these findings! For diabetes, it's not quite so simple that insulin imbalance is the causal problem. For those of us with years of medical training, we know that it is and it isn't. Administering insulin, in many cases, do not correct the metabolic disturbances as one poster wrote. I can go on and on....

One of the problems in psychiatry is that many of its critics do not have appropriate medical training. And the lack of fundamental knowlege really shows up when they try to make argument, particulary with topics relating to physical vs. mental health disorders, against physicians.

 

[Ibid]

One of the problems in psychiatry is that many of its critics do not have appropriate medical training. And the lack of fundamental knowlege really shows up when they try to make argument, particulary with topics relating to physical vs. mental health disorders, against physicians.

One of the problems that some psychiatrists have is that they appear not to understand that the burden of proof for their theories lies with them. Critics can't just be spiffily dismissed as "not appropriately trained". It's the arguments that have to be addressed not the source of them.

Psychiatry can't be left to psychiatrists any more than diplomacy can be left to diplomats or banking left to bankers. Banking being the best example, who would doubt they understand how embedded derivatives work to rebalance counter party risk when combined with hedging in the underlying market? The question is, are they not a vested interest themselves. Psychiatry does not work in a vacuum and as awkward as that is it is a fact of life. Psychiatry or psychiatrists have to justify themselves and self referral is not good enough.

The imperative to be able to offer reasonable justification is of course most acute at the sharp end. The attitude that one knows best is easily identified in the most haughty practitioners. Perhaps not the individuals one would aspire to emulate of course.

 

[billypilgrim37]

One of the problems that some psychiatrist have is that they appear not to understand that the burden of proof for their theories lies with them.

It's not our job on an online forum to teach the nuances of the medical model to everyone that wants to criticize our field. They don't fit into posts in an online forum. That's why they are called nuances. We aren't particularly impressed when people criticize psychiatry in the context of a medical model when the person levying the criticism does not have a sophisticated view of the medical model. The ability or inability of physicians on a low-stakes online forum to explain the sum conceptualization of internal medicine doesn't particularly reflect much on the veracity of the field of psychiatry.

When Person A says X which relies on assumption Y, and walks into a room filled with People B that know that assumption Y is not valid, then why do you expect People B to suddenly feel compelled to argue the validity of not-X? They tell Person A to get his Y fixed, and come back when he's ready to play. If Person A insists on Y, then Person A is politely obligated to take his ball and go home, or watch People B disengage, snicker, and demean.

So is the burden of proof on psychiatry? Yes. Is the burden on an individual psychiatrist to put up with someone spouting off post-modern sophistry offering charges of neglect at best, and malfeasance at worst? Not at these salaries.

 

[Ibid]

BillyP

No one is compelled to post on this forum. No one is compelled to reply to posts on this forum. The site has terms and conditions and moderators.

If one looks back their is plenty of outright nastiness directed towards visitors to the forum. Thats very true. No one was compelled to be nasty but they decided to be and if one looks to quite a few people.

In your rather complex xyz abc example you make an interesting point. What you find if you visit patient forums are the occasional student psychiatrists posting. Now clumsiness is not the word. Well intentioned but probably foolish. You get the situation you describe but in reverse. The only real difference is that no matter how silly they sound they are never met with anything but politeness. A contrast to ponder.

btw
It's not our job on an online forum to teach the nuances of the medical model to everyone that wants to criticize our field.

I agree with that but you might have misunderstood my original point to snarfer. The thread is about society and my response was in that vein.

 

[dl2dp2]

However, while every culture finds some behaviors abnormal or unacceptable, the definitions can vary quite dramatically. Optimal functioning is selected for and defined by the particular needs of a society.

For example, it would be absurd to diagnose ADHD in an agrarian society. Until optimal functioning became defined as quiet classroom attentiveness for many hours a day, hyperactive behavior had not been pathologized. And not until incentives were in place for pharmaceutical companies, was the process of pathologization completed.

Mental illness is not only defined in a culturally-specific manner; its manifestations are also culturally dependent. A good example is anorexia nervosa. While the disorder has long been identified by Western society, it is a relatively new phenomenon in China and Japan. As the ideal body image becomes thinner, there is a corresponding increase in the prevalence of the disorder.

....

It's likely that many psychiatric disorders merge into others with no natural boundary in between. If we are giving an accurate description of nature, there should be what Kendler calls "zones of rarity." For example, attempts to demonstrate natural boundaries between major depressive disorder and normality have consistently failed. Instead, studies have demonstrated that the genetic basis of anxiety and depression are very similar, if not indistinguishable. What exists is a spectrum. The same goes for schizophrenia, psychotic affective illness, and a spectrum of other disorders, including szhizotypal/paranoid personality disorder.

Also, I'd argue that we do create entities arbitrarily. If we measured other dimensions of performance and behavior, perhaps we could pathologize individuals that score low on creativity testing. All we need is an effective on-patent treatment.

I don't think what you are saying is contrary to mainstream psychiatry. Most psychiatrists recognize that DSM is deeply flawed, psychiatric practices are very culturally influenced and that the boundaries between normal and abnormal are blurred.

However, I don't think that everything's a "spectrum." While there may not yet be biologic markers that demonstrate a clear "zone of sanity," if you spend a few months practicing actual daily psychiatry, you'll see that people who are affected and severely persistently mentally ill are not the same as normal individuals by a wide margin. Furthermore, the cultural specificity of diagnoses, while does exist, is often overblown in certain contexts. While other countries do not necessarily use the DSM, there is the ICD criteria that are used, and this set of criteria is similar to DSM.

As I said, contemporary mainstream psychiatry is based on science: neurobiology, clinical research, some social sciences. It's not just science--there's an element of social advocacy, there's an element of humanities/narrative medicine etc. but the bottom line is the only way you can categorically reject the medical model is if you argue that mental processes cannot be studied scientifically and mental illness should not be treated scientifically. While this view is espoused by certain individuals anywhere from Tom Cruise to Jacques Derrida, with varying legitimacy, it is very far from OUR cultural norm and mainstream. If my mother went insane, I'd rather have her treated with the most up to date psychopharmacology, evidence based therapy with the most scientifically demonstrated prospect for recovery, and I think most tax payers in the US agree with me, with or without big pharma even entering part of that equation.

 

[Manicsleep]

Ibid,

You post inflammatory comments and are offended when someone corrects you regarding a subject that you appear to have limited knowledge. You seem to have a habit of telling how it is with respect to psychiatry and seem to get corrected or ignored. Whether you see this as nastiness is your own personal issue. I am not sure the purpose of your consistently posting comments that are clearly unreasonable, untrue or based around partial truths other than a general desire or need to create chaos and turmoil.

 

[Manicsleep]

Correct. Therefore, I’d say it follows that mental illness is largely defined by society and the functional requirements thereof.

Different societies (as well as individuals within a society) can disagree on what constitutes a normal vs. pathological level of functioning. That’s not to say there aren’t certain cross-cultural commonalities of how psychological distress is experienced. Madness, which is characterized by abnormal patterns of behavior, has been recognized by virtually every culture throughout history. However, while every culture finds some behaviors abnormal or unacceptable, the definitions can vary quite dramatically. Optimal functioning is selected for and defined by the particular needs of a society.

For example, it would be absurd to diagnose ADHD in an agrarian society. Until optimal functioning became defined as quiet classroom attentiveness for many hours a day, hyperactive behavior had not been pathologized. And not until incentives were in place for pharmaceutical companies, was the process of pathologization completed.

Partially agree except the ADHD aspect. You need a fair amount of concentration to do the tasks of daily living required of an agrarian society and I am sure those people suffered. Whether they recognized it or not is a different story.

Schizophrenics also tend to do better in rural settings. That doesn't mean it is a disease made up by pharma or that it didn't exist a 1000 years ago.

 

[Ibid]

Manic,

That is a misrepresentation and I think you know it. BillyP was correct when he identified that my critique is essentially a post modern one. That is what is the root of the difference between us.

1. One of the planks of post modernism is not that the disease model is inappropriate but the approach of descriptive pathology that is misapplied. So yes that will get some people hot under the collar. That is a by product of an opinion that is gaining currency not an intention. Plenty of that notion applied to other areas on this board but you don't comment. Your prerogative.

2. A second plank and I can see why you dislike it, is that it, to an extent, postmodernism appears on first sight to be anti-technology. In fact it would be more correct to say that it accuses “traditional psychiatry” of working in a moral vacuum as if any advance is a priori “good”. You are an arch proponent of the application of technology and have posted that you see people being injected with nano-bots, just for instance, at some time in the future. So its no surprise you personally find me inflammatory but that is certainly not my intention. Would not the injection of nano-bots be the epitome of the positivist psychiatry that you support. With your suggestion you suggest an approach that posits psychiatry as objective, neutral and value free, exactly the postmodern critique.( I have posted about the alternative of an interpretive hermaneutic phenomenological approach being available but you chose not to respond to those posts. Instead you post subjective statements like “comments are clearly unreasonable”. If I am being corrected its not by you.

3. I put it to you that you are bothered that I have a back ground in neurobiology but still reject it and that rankles with you. I am sorry but I can’t help that.

4. My point about nastiness was nastiness directed to others. You can look back to old posts to see what I mean.

5. When I start a thread or respond to a post it is because I am just as interested in the other persons point of view. Otherwise its pointless. If no one posts on a thread I start I don’t take it personally, really.

6. Where I live the government of all shades is broadly post modern in that it stresses democracy, citizenship and the importance of social and cultural contexts in health care. You confuse being critical with being anti.

This is a thread about who defines abnormality. My own view is that psychiatry is broadly split in that one of the good things it does is to create a language that people can use to talk about their subjective experiences which work well for depression for instance. Unfortunately for psychosis and madness through the diagnostic process opportunity to express subjective experiences is suppressed. If you find that subversive rather than objective then so be it.

Schizophrenics also tend to do better in rural settings.

On a final note using the word schizophrenics like that is a terrible way to refer to people. It betrays the assumption that by using that word it tells you everything you need to know about them. A bit of friendly advice it's much better to write people with.....if you must. That sort of sloppiness might cost you a job one day.

 

[Manicsleep]

I don't care if your background may be in neurobiology (not convinced). You have shown that you don't understand psychiatry. That was clear from the "future of psychiatry" thread. You can go back and read my corrections there.

I won't go over all that again. You aren't worth it.

On a final note using the word schizophrenics like that is a terrible way to refer to people. It betrays the assumption that by using that word it tells you everything you need to know about them. A bit of friendly advice it's much better to write people with.....if you must. That sort of sloppiness might cost you a job one day.

You should tell that to schizophrenics anonymous.

http://en.wikipedia.org/wiki/Schizophrenics_Anonymous

😆

 

[dl2dp2]

Manic,

That is a misrepresentation and I think you know it. BillyP was correct when he identified that my critique is essentially a post modern one. That is what is the root of the difference between us.

1. One of the planks of post modernism is not that the disease model is inappropriate but the approach of descriptive pathology that is misapplied. So yes that will get some people hot under the collar. That is a by product of an opinion that is gaining currency not an intention. Plenty of that notion applied to other areas on this board but you don't comment. Your prerogative.

2. A second plank and I can see why you dislike it, is that it, to an extent, postmodernism appears on first sight to be anti-technology. In fact it would be more correct to say that it accuses "traditional psychiatry" of working in a moral vacuum as if any advance is a priori "good". You are an arch proponent of the application of technology and have posted that you see people being injected with nano-bots, just for instance, at some time in the future. So its no surprise you personally find me inflammatory but that is certainly not my intention. Would not the injection of nano-bots be the epitome of the positivist psychiatry that you support. With your suggestion you suggest an approach that posits psychiatry as objective, neutral and value free, exactly the postmodern critique.( I have posted about the alternative of an interpretive hermaneutic phenomenological approach being available but you chose not to respond to those posts. Instead you post subjective statements like "comments are clearly unreasonable". If I am being corrected its not by you.

3. I put it to you that you are bothered that I have a back ground in neurobiology but still reject it and that rankles with you. I am sorry but I can't help that.

4. My point about nastiness was nastiness directed to others. You can look back to old posts to see what I mean.

5. When I start a thread or respond to a post it is because I am just as interested in the other persons point of view. Otherwise its pointless. If no one posts on a thread I start I don't take it personally, really.

6. Where I live the government of all shades is broadly post modern in that it stresses democracy, citizenship and the importance of social and cultural contexts in health care. You confuse being critical with being anti.

This is a thread about who defines abnormality. My own view is that psychiatry is broadly split in that one of the good things it does is to create a language that people can use to talk about their subjective experiences which work well for depression for instance. Unfortunately for psychosis and madness through the diagnostic process opportunity to express subjective experiences is suppressed. If you find that subversive rather than objective then so be it.

Schizophrenics also tend to do better in rural settings.

On a final note using the word schizophrenics like that is a terrible way to refer to people. It betrays the assumption that by using that word it tells you everything you need to know about them. A bit of friendly advice it's much better to write people with.....if you must. That sort of sloppiness might cost you a job one day.

While I see some value in postmodernism as a means for systematic critiques of philosophical, ethical values of science and technology, in practical terms continental philosophy's view of psychiatry more specifically and the scientific method in general is not particularly useful and sometimes damaging to the public. While it is true that the scientific method had a specific cultural origin (the West), it is not at all true that the methodology itself depends on cultural specifics for its sustainability. Rather it's the practical usefulness that puts it as the main method of inquiry in contemporary society. Furthermore, categorical rejection of scientific universals can be quite dangerous in our society where there's already much undue ignorance about science, from hysteria about vaccines to removal of evolution from textbooks.

We can begin a postmodern critique of your "democracy, citizenship and the importance of social and cultural contexts in health care" in that this goal in itself is strongly colored by your specific cultural context. In fact, there is little evidence that the degree of democratic freedom and the sensitivity to cultural context enhances healthcare in general, and there are definitely specific examples in which democratic institutions are very poor in implementing healthcare programs. If you've seen "Sicko" you would know that Cuba probably has a better healthcare program than the US.

The fatal flaw in postmodern social critique is that categorical rejection of universals is logically internally inconsistent, and is incapable of in itself build a system of any intellectual usefulness. But it is able to raise some awareness from an advocacy perspective in specific instances in finding issues that were previously not recognized. In literature it's commonly known as "got-cha" literary critique (i.e. oh Thomas Jefferson wrote a great essay on individual freedom, but did you know he owned slaves? Gotcha!), in science and technology studies it's trying to bring in some ethical discussions that are previously neglected, though it can be obfuscating (see "Fashionable nonsense"). However, postmodernists will never write a novel themselves or conduct a single experiment, and as I said taxpayers are probably unwilling to fund their activities (to any significant extent) for good reasons.

The mainstream medical model in psychiatry and in medicine, that is based on what we know scientifically, is that we believe in objective definition of disease entities that are caused by a combination of biological and environmental factors that are definable by the scientific method. We believe that treatment of psychiatric illnesses, just like medical illnesses, should be based on science, evidence, data and facts, as limited, complex and multifaceted as they can be. If you reject these basic premises on the bases of a postmodern criticism of the scientific method, then there is nothing to do but to do what BillyP said...

 

[Ibid]

Manic,

Really you are a funny chap. A wiki link and an emoticon, really I am beginning to think you are on an intellectual tight rope. One inch either way and its a long way down. It's no skin off my nose.

Sluox

Very interesting.
A lot I agree with there. Just to flesh out my point of view though it is important to distinguish a post modern critique of descriptive pathology from the scientific method which is not in doubt. What |I am positing is that there are other legitimate forms of explanation. The reason that I suggest a interpretive hermeneutic phenomenological approach is that it able to deal with social and psychological factors in a way that a causal model can not. By can not I mean the disease model, how ever it is defined, is limited to considering cultural, psychological and social factors simply as independent variables robbed of their context. Context is what explains human behaviour not the causes of it.

The benefit of this approach is that it results in a shift from a descriptive approach to an interpretive one that places a persons life history centre stage. If one is to accept recent advances in neurobiology and I do, this makes a lot of sense especially if outputs from the brain are not ultimately algorithmic. If that is true btw it really does put positivism and causality as useful tools more or less in the dustbin for the purposes of explaining psychosis imo.

I agree with you about their being little evidence to support the idea that democracy itself leads to better health care. I should have fleshed that out. Certainly if you look at the UK health inequalities exist that a socialised system are failing to address and in the US there is a problem with simple access for all, so I agree. What I really meant by democratic was a concern that the needs of entire populations health needs were successfully met and by successfully met I mean democratic as in equitable. Still I don't disagree with what you wrote.

Where I agree with you most is the possibility that a hermeneutic phenomenological approach may lead to an eternal regression. How ever I still think it is potentially useful from a practical standpoint if it leads to psychosis being understood in the way that people who experience it prefer. Being honest the disease model has its own logical problems in that it starts with subjective judgements that scientifically derived tests could only hope to confirm or tend to deny. What would be the point of a test that provided a positive result when the subjective opinion was in the negative? Would one treat these people. That would be the logical course. Also the other posit of course is that the disease model leads to damaging side effects and these are played down.

So broadly I agree with your final point. The approach I suggest may only be useful in the hands of someone already familiar with a descriptive categorical approach. Secondly it may well be a blind alley intellectually and only lead to the building of a new categorical system. But and I think it is a big but, is that it points the way to a more collaborative exploratory approach that is the difference (apologies for speaking in a cartoon way now) between doing things with some one as apposed to doing things to some one and this has to many benefits to ignore and why I think the approach is worthy of further exploration.

I take your point about the dominant medical paradigm but the approach I have outlined is gaining currency and not with out good reason and with the main stream, not just back water no where land. It goes with out saying it needs a critical eye run over it as well.

 

[billypilgrim37]

Awesome, I turned this into post-modernism on trial!

Ibid, thank you for tolerating my Person A Monkey B Argument Delta-K etc...

 

[RedPakotaSea]

^Man, I can't keep up with you guys.

Also, for what its worth, I enjoy debating/discussing these issues with you all. Psychiatry is a fascinating field...it certainly provides plenty to think about. And to those who disagree with my current opinions (i.e. I'm sure they will evolve and change), don't worry, I don't take the criticism personally.

I don't think what you are saying is contrary to mainstream psychiatry. Most psychiatrists recognize that DSM is deeply flawed, psychiatric practices are very culturally influenced and that the boundaries between normal and abnormal are blurred.

However, I don't think that everything's a "spectrum." While there may not yet be biologic markers that demonstrate a clear "zone of sanity," if you spend a few months practicing actual daily psychiatry, you'll see that people who are affected and severely persistently mentally ill are not the same as normal individuals by a wide margin. Furthermore, the cultural specificity of diagnoses, while does exist, is often overblown in certain contexts. While other countries do not necessarily use the DSM, there is the ICD criteria that are used, and this set of criteria is similar to DSM.

As I said, contemporary mainstream psychiatry is based on science: neurobiology, clinical research, some social sciences. It's not just science--there's an element of social advocacy, there's an element of humanities/narrative medicine etc. but the bottom line is the only way you can categorically reject the medical model is if you argue that mental processes cannot be studied scientifically and mental illness should not be treated scientifically. While this view is espoused by certain individuals anywhere from Tom Cruise to Jacques Derrida, with varying legitimacy, it is very far from OUR cultural norm and mainstream. If my mother went insane, I'd rather have her treated with the most up to date psychopharmacology, evidence based therapy with the most scientifically demonstrated prospect for recovery, and I think most tax payers in the US agree with me, with or without big pharma even entering part of that equation.

Thanks for the thoughtful reply.

I agree that thoughtful clinicians are well aware that diagnostic categories are simply concepts. I also understand that there are individuals who are severely and persistently mentally ill who would be easily functionally distinguished from a cohort of "normal" individuals. However, the existence of these two groups is equally compatible with continuous variation.

Let's say you spent some time with some profoundly mentally ******ed individuals, and compared them to your friends and people you grew up with. Clearly, there appears to be a dichotomy. But psychometrics tells us that IQ scores are more or less scattered in a normal distribution.

I'm not arguing that all psychiatric conditions will be amenable to a dimensional classification, with each dimension following a normal distribution. I'm also not saying that we should get rid of classification altogether. Cluster analyses have demonstrated that mania, depression, and acute schizophrenia stand out clearly and consistently from a background of heterogeneous symptoms. My point is that the current nosology is antiquated and often does not serve patients well. Instead of refining current diagnostic criteria, and adding new, unfounded diagnostic concepts to the DSM-5, we should be rethinking the classification, and put more effort into acknowledging fuzzy boundaries where they exist.

My biggest worry is that psychiatry will continue to expound the view, at least to the public, that psychiatric diagnoses are discrete entities, while steadily expanding the pathologization of human behavior. Some suggestions for the DSM-5 could potentially redefine millions of people as mentally ill through adding diagnoses such as Psychotic Risk Syndrome, Mixed Anxiety Depressive Disorder, and Minor Neurocognitive Disorder. Not only would this likely result in more people on questionable and potentially harmful treatments, but it would also have a larger impact on society. Excessive medicalization results in misallocation of resources, an implied lack of faith in human resilience, and most importantly a reduced sense of personal responsibility and sense of control.

when one investigates the brains of individuals 75 and over by neuroimaging and post mortem studies, 90% of healthy individuals will show cortical atrophy, amyloid plaques and neurofibrillary tangles. Thereby, those with symptoms consistent with DAT will certainly have these findings! For diabetes, it's not quite so simple that insulin imbalance is the causal problem. For those of us with years of medical training, we know that it is and it isn't. Administering insulin, in many cases, do not correct the metabolic disturbances as one poster wrote. I can go on and on....

One of the problems in psychiatry is that many of its critics do not have appropriate medical training. And the lack of fundamental knowlege really shows up when they try to make argument, particulary with topics relating to physical vs. mental health disorders, against physicians.

I understand that amyloid deposition and the presence of neurofibrillary tangles is not an all or none phenomenon, but the presence of an underlying pathology is what holds the diagnosis together. Even if there is a continuum between normality, mild cognitive impairment, and Alzheimer's disease, you still clearly have a disease process at work.

As for exogenous administration of insulin in diabetics, as I said previously, it works on the underlying process; insulin decreases blood sugar and compensates for the dysfunction in carbohydrate metabolism.

In regards to the last comment, unfortunately, this bit of friendly criticism is coming from within your own ranks ... though I don't buy the argument that they (i.e. everyone that disagrees with you) don't understand what they're talking about.

 

[dl2dp2]

The reason that I suggest a interpretive hermeneutic phenomenological approach...from a descriptive approach to an interpretive one that places a persons life history centre ... a hermeneutic phenomenological approach may lead to an eternal regression....

You need to read your own post again. You sound like someone who read way too much continental philosophy recently...the entire post is gibberish. WTF is a "hermeneutic phenomenological approach" [of psychiatry]? Are you saying we should apply critical literary theory to understanding of psychiatric illnesses? Which school of exegesis do you want to use? Reader response from Stanley Fish? Frankfurt school and critical Marxism? Do you want to do simiotics? Do you want to Lacanian psychoanalysis? Do you wan to argue the obscure difference between implicit vs. explicit positivism in Heidegger? Meanwhile, the schizophrenic in front of you is punching the nurses, and yelling obscenities and no amount of "hermeneutics" is going to help you an iota. But that 5 milligram of Haldol and 1 milligram of Ativan IM instantly calm him down and save the world.

This is exactly what irks me about most critical theorists (or rather, more likely, students of critical theories). Most of what these half baked students "appropriating" some big words form, say, Kierkegaard and pretend to sound smart to score some chicks, but don't know what in the world they are talking about. People who are actually competent in continental philosophy know better than try to amateurishly troll on SDN. I suggest you learn a bit more about postmodernism and continental philosophy before making further "arguments".

 

[dl2dp2]

My biggest worry is that psychiatry will continue to expound the view, at least to the public, that psychiatric diagnoses are discrete entities, while steadily expanding the pathologization of human behavior. Some suggestions for the DSM-5 could potentially redefine millions of people as mentally ill through adding diagnoses such as Psychotic Risk Syndrome, Mixed Anxiety Depressive Disorder, and Minor Neurocognitive Disorder. Not only would this likely result in more people on questionable and potentially harmful treatments, but it would also have a larger impact on society. Excessive medicalization results in misallocation of resources, an implied lack of faith in human resilience, and most importantly a reduced sense of personal responsibility and sense of control.

You needn't worry about this. People are WAY ahead of you in thinking about using modern machine learning techniques and multidimensional statistical techniques in doing nosology. This IS one direction "the future" of psychiatry is going. But you have to understand that (1) this is STILL science (2) It's still just research. (3) it is "medicalization" and it is mainstream medicine. If you read New England Journal, you'll see that things like cluster analysis (to use a rather unsophisticated example) are used all over the place in regular medicine. I just don't understand what is the opposite of "medicalization" of psychiatry that you are referring to.

DSM is an imperfect tool in an imperfect world. We are just not scientifically not THERE yet. But this doesn't mean that you should become paranoid and imply that it is some conspiracy of the military industrial complex to subjugate the "subaltern" underclass, which is what many of these perspectives that you enspouse invariably degenerate into.

 

[billypilgrim37]

Some suggestions for the DSM-5 could potentially redefine millions of people as mentally ill through adding diagnoses such as Psychotic Risk Syndrome, Mixed Anxiety Depressive Disorder, and Minor Neurocognitive Disorder.

This is a fundamental misconception, and demonstrates a problem with priorities. If we are more worried about "redefining people as mentally ill" than about alleviating the suffering caused by mental illness, then we really don't have any business being physicians. Almost half of the categories in DSM-IV demand that symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning."

And, when the context is for treatment (which IS THE CONTEXT OF PSYCHIATRY), what is so bad about saying someone has a mental illness? We say, "You're suffering. We have researched into people suffering in a way similar to you, and found that there are things we can do to make it less bad." Until we redefine the 1st amendment to make Zen the National Religion, I think we're in business.

Yes, I'm paranoid about pharma, too. Yes, I worry about the Brave New World and Big Brother and Terry Gilliam movies. Yes, I support NAMI, and I could write a book about family members who have committed suicide and are on disability for severe mental illness (and yes I worry about reproducing). Yes, I got a post-modern literature degree and wrote a seventy page exegetical thesis on a single 5-page William Carlos Williams short story, and my last office mate quoted Nietzche on a daily basis. And, yes, I agree there are plenty of reasons to be careful when talking about a Psychotic Risk Syndrome, to worry about pharma attempting to exploit a new market, and it's fairly obvious that the need for psychoeducation about such a diagnosis would be tremendous. But if our main concern is about labeling people with a mental illness, then we've read way too much Foucault, and not nearly enough of the DSM itself, and we are essentially advocating for people to receive less help and attention than they deserve.

What if I simply said that somebody wanted to work on identifying people that were at high risk for a psychotic disorder, with the intention of developing interventions that might lower the risk of the subsequent development of psychotic disorders. Sounds pretty great, right?

 

[RedPakotaSea]

^Where do we draw the line between psychiatry and cosmetic pharmacology? You mention Brave New World, so you clearly see the danger. If I remember correctly, there is/was a serious discussion about removing the "clinical significance" criterion required for disorders that have a fuzzy boundary with normality in the DSM-5. There was also a suggestion to remove the "functional impairment" criterion from ADHD and to allow the diagnosis to be based solely on the presence of symptoms.

Another problem is that, as physicians, we feel that we must do something for our patients. Unfortunately, this too often results in treatments that are unhelpful or even detrimental. We could put a few million more people on Aricept so they score 1 point higher on memory testing. As another example, huge sums of money have been allocated to early intervention programs for psychosis or high risk individuals, which essentially advocate putting these individuals on antipsychotics to protect from further deterioration; however, there is no evidence that putting these prodromal/early psychosis individuals on antipsychotics actually helps.

Lastly, a significant number of proposed diagnostic categories have no effective treatments. Why then should we define these individuals as mentally ill?

P.S. Props on the post-modern lit degree. I didn't even know what post-modernism was when I was an undergrad.

P.P.S. Re sluox: Practically speaking, I am criticizing excessive medicalization, not medicalization as a whole in psychiatry.

 

[hippiedoc13]

Another problem is that, as physicians, we feel that we must do something for our patients. Unfortunately, this too often results in treatments that are unhelpful or even detrimental. We could put a few million more people on Aricept so they score 1 point higher on memory testing. As another example, huge sums of money have been allocated to early intervention programs for psychosis or high risk individuals, which essentially advocate putting these individuals on antipsychotics to protect from further deterioration; however, there is no evidence that putting these prodromal/early psychosis individuals on antipsychotics actually helps.

Your concerns above rest on the faulty assumption that medications are the only available intervention for a defined mental illness or risk syndrome.

In the case of young people who are likely in the prodromal phases of psychotic illness, you are correct, there is no solid evidence regarding whether antipsychotic medications are actually helpful, either in their prodromal symptoms or in forestalling the onset of full-blown psychotic illness. However, we actually don't know the answer to that question one way or the other. I personally think it's worth finding out. If my brother appeared to have prodromal symptoms, and there was a chance that a treatment out there could keep him from developing full-blown schizophrenia and becoming permanently disabled and getting repeatedly hospitalized, you can bet I'd want psychiatry to find it. But aside from the question of medication--there are other helpful interventions for this group. By identifying young people who are at higher risk of developing psychotic illness, perhaps we can change the course of illness through psychoeducation and discouraging drug use. We can certainly educate the individual and their family and provide support for them. And we can facilitate early detection of fully psychotic illness, and facilitate getting them into treatment sooner, because the evidence DOES show that prompt treatment of psychosis results in better illness outcomes.

With regard to the example of "prescribing Aricept to raise everyone's score by 1 point on cognitive testing." That rests on a second faulty assumption, which is that if a drug exists, and a condition exists, that we (physicians, psychiatrists) will automatically blindly use that drug to treat everyone. In reality, we don't do that. ALL treatment decisions in medicine (including psychiatry) are based on risk/benefit assessment. If a treatment is likely to yield no significant clinical benefit to a patient, there is absolutely no reason for me to offer it to a patient. If the patient and I decide together that 1 point on a cognitive test doesn't represent enough of a gain to warrant the risks and cost of a medication, then we won't use it. Perhaps in defining a "minor neurocognitive disorder," we will be able to recognize an intermediate entity, and (hypothetically) perhaps we might find that the indicated interventions involve behavioral therapy, or modifications of the living environment, or further screening/surveillance for progressive or related disorders that would require treatment. As an analogy, for example when I examine infants, I look for external ear morphological abnormalities--not because I want to pathologize the appearance of their ears, and not because I want to do surgery on their ears, but because it can signal me to look closer for often-related, more serious anomalies.

Diagnostic categories are not created just so we will have something new to pathologize and throw medication at it. Defining diagnostic/clinical entities can be helpful for clarifying our own conceptualizations of the spectrum of mental health and illness. It's also helpful for delimiting groups of patients to research these conditions and have the hope of alleviating more suffering for our future patients.

 

[RedPakotaSea]

^Thanks for the reply.

I agree that early intervention programs have the potential to be very helpful. Clearly lack of intervention is not the best strategy. I also agree that some individuals genuinely benefit from the use of neuroleptics, though I think Moncreiff and Cohen have a sound argument for a reappraisal of our conception of these agents, as concisely explained in How Do Psychiatric Drugs Work?

The particular concern of mine that you quoted is not unique to psychiatry, but it is a reason to avoid excessive medicalization. Overtreatment is a ubiquitous problem. In all fields of medicine, we need to learn to provide rational care, instead of reflexively "throwing the kitchen sink" at the problem.

In psychiatry, while there are many thoughtful clinicians out there who are conservative in prescribing pharmacotherapy, there seem to be more who are not. I have a friend who suffered from a brief psychotic episode, and 6 months later, when asking about tapering the remainder of his medication, was told by his psychiatrist with a very stern look, "now you don't want to do that or we'll be scraping you off the floor in a few weeks." Terrible and not representative, I know. But even at a well respected academic institution, I often see children from disaster households maintained on 4+ psychotropic meds. For all patients, meds invariably are added more often than removed. A Healthcare Commission report in 2007 reported that greater than 90% of patients in contact with psychiatric services are prescribed psychotropic medication. Why? I don't think evidence would support these prescribing habits. I'd argue it's largely because we feel compelled to to do something and often act on less than convincing evidence.

 

[billypilgrim37]

A Healthcare Commission report in 2007 reported that greater than 90% of patients in contact with psychiatric services are prescribed psychotropic medication. Why?

Because the entire reason that the majority of people come to a psychiatrist is because they were referred by their PCP who had already screened and decided that the level of psychopathology and required pharmacologic treatment required subspecialty level of care.

 

[hippiedoc13]

Because the entire reason that the majority of people come to a psychiatrist is because they were referred by their PCP who had already screened and decided that the level of psychopathology and required pharmacologic treatment required subspecialty level of care.

👍 Exactly.

If anyone would like to quibble with why "greater than 90% of patients in contact with psychiatric services are prescribed psychotropic medication," then I invite you to come spend a day with me in one of my two clinics. Meet the severely ill, extremely impaired patients who I work with on a daily basis, and you'll agree that they all need to be on medications.

Psychiatrists specialize in the pharmacologic and psychotherapeutic treatment of SERIOUS MENTAL ILLNESS. Psychiatric care is a scarce commodity in most communities. Therefore, in most cases, anyone who isn't ill enough to require psychotropic meds, won't be seeing us. If they just need psychotherapy, that can be done by a non-MD psychotherapist. If their mental disorder is milder, they are often being treated by their PMD.

I do intakes and occasionally determine that there is no indication for medication. Guess when I make the follow-up appointment for?? That's right, usually never...if they don't need psychotropic med management, they don't need to be seeing me. Especially not when my schedule is already booked out to the first week in October, and I have to overbook my very ill patients who really need to see me sooner.

 

[RedPakotaSea]

Hah, I should have known people would jump on that one.

I'll admit, it didn't add much to my argument. When looking at inpatients in the same study, 98-100% of were prescribed drugs. My point is that drugs have become the central focus of hospital treatment and often outpatient treatment as well, and this has occurred at the expense of psychotherapy. This is unfortunate, but understandable. Psychiatrists are under immense pressure to see increasing numbers of patients. When visits are limited to 15 minutes, most of that time ends up being spent talking about the drug regimen, side effects, discussions of dosing, changing drugs, etc. Unfortunately, this often results in ineffectual or potentially detrimental treatment. Not only that, but psychiatrists are being dishonest with patients by implying that pharmacotherapy is helping to correct an underlying biochemical imbalance and that taking psychiatric medication is like taking insulin for diabetes.

Anyway, we are straying far from the topic...

Whether or not you two agree that psychotropics are currently overprescribed, I'd like to know what you think about other points that I raised. I think that we are more in agreement than many are letting on. For full disclosure, I am going to be a psychiatrist, and these debates are helpful for me as I refine my understanding of mental illness.

Let me summarize my points thus far:

• Mental illness is to a large extent defined by society (this occurs via delimitation of the border between normality and pathology; I'm not arguing that severe mental illness doesn't exist)
• Excessive medicalization has negative consequences (misallocation of resources, reduced sense of responsibility and control; also blurs distinction between psychiatry and cosmetic pharmacology)
• The vast majority of psychiatric diagnoses are not "diseases" (but neither are many medical conditions, so no big deal, let's just be honest)
• Psychiatric diagnoses in the DSM-4 often do not reflect nature (instead of adding unvalidated diagnoses to the next iteration, we should be carefully rethinking current classifications)
• Chemical imbalance theories of mental illness are reductionistic and misleading
• Psychiatric drugs are not the disease-specific treatments that they are purported to be

 

[dl2dp2]

• Mental illness is to a large extent defined by society (this occurs via delimitation of the border between normality and pathology; I'm not arguing that severe mental illness doesn't exist)

• 
  
  This is not true. I think if you actually practice actual psychiatry you'll realize that most of what is considered "mental illness" is not per se "defined" by society but actually has a biologic reality. However, the nosology is defined by consensus. I'm not sure how this nuanced distinction is useful in clinical practice.
  
  

  [*]Excessive medicalization has negative consequences (misallocation of resources, reduced sense of responsibility and control; also blurs distinction between psychiatry and cosmetic pharmacology)

  
  So, unless you have solid data to back it up, it seems that the major problem in the US at least is the UNDERMEDICALIZATION, in fact, undertreatment of many psychiatric problems. I'm assuming that you have experiences with people who are generally high functioning etc., but if you actually see patients that are treated by a psychiatrist on a daily basis, you'll realize why and how they are UNDERMEDICATED often.
  
  I'm not saying cosmetic pharm doesn't exist, but if it's a service that is provided for the people who can afford it, why do you criticize it? I don't think there's any more false marketing in this field than any other "cosmetic" field.
  
  

  [*]The vast majority of psychiatric diagnoses are not "diseases" (but neither are many medical conditions, so no big deal, let's just be honest)

  
  What does this mean?
  
  

  [*]Psychiatric diagnoses in the DSM-4 often do not reflect nature (instead of adding unvalidated diagnoses to the next iteration, we should be carefully rethinking current classifications)

  
  I think we do need to think carefully about classifications, but I think DSM has its place and is in large part classifying "natural" behavioral/psychological phenomena. But unless you can come up with a system that's better, I'm not sure what you want to do in every day practice except to keep these caveats in mind when you approach patients.
  
  

  [*]Chemical imbalance theories of mental illness are reductionistic and misleading

  This is true. But provide me a better scientific theory? Again, unless you can come up with a better theory, I'm not sure what you want to do in every day practice except to keep these caveats in mind when you approach patients. Actually in some of my high functioning patients I'm starting to provide a more circuit oriented explanation to their illnesses, talking more about the mesocortical vs. mesolimbic circuitry and what dopamine circuitry actually does in assigning salience to stimuli in the brain, etc. I'm not sure if this is helpful to the patients, but at least it's slightly more satisfactory for me. In most schizophrenics though, the simplest explanation is their dopamine is too high, and we need to give them something to take it away. Also, these more complex mechanistic theories have not at all impacted our treatment plan, in picking drugs, etc. You can stay cynical about it, but just be aware that this is an active area of research.
  
  

  [*]Psychiatric drugs are not the disease-specific treatments that they are purported to be

  Actually psychotropics were NEVER purported to be "disease" specific. From the get go psychotropics are symptom oriented treatments, as we don't know the pathophysiology of almost all psychiatric disorders. And in every day practice you concoct a cocktail that addresses specific symptoms. The disease entities that you make your diagnoses simply provide a rough guideline for treatment and prognosis, but you are absolutely not confined pharmacologically.

 

[Ibid]

Sluox

*If you've seen "Sicko" you would know that Cuba probably has a better healthcare program than the US.

I know quite a bit about Cuban healthcare and that’s why I know your statement is not true. Of course I don’t get my information by going to see films at the cinema like you.

WTF is a "hermeneutic phenomenological approach" [of psychiatry]?

If you were as knowledgeable as you pretend you wouldn’t be asking.

*Most of what these half baked students "appropriating" some big words form, say, Kierkegaard and pretend to sound smart to score some chicks

The trailer trash vernacular does you no favours. As you have appropriated Heidegger in your own post but don’t know what hermeneutics are then it looks like you are talking about yourself. I am intrigued that you have come here to score though. I am taken btw. So no querty flirty big boy.

Meanwhile, the schizophrenic in front of you is punching the nurses, and yelling obscenities and no amount of "hermeneutics" is going to help you an iota. But that 5 milligram of Haldol and 1 milligram of Ativan IM instantly calm him down and save the world.

I have offered you an alternative approach to working with people who experience psychosis that applies first when they are not floridly psychotic and you reject it out of hand. Then when your way fails and you end up in the situation you describe and you come back to me and look for an answer to your problem. Of course your way of explaining whats wrong to your patients keeps you firmly in charge. No chance of the patient coming up with their own plans congruent with their own explanations, plans they would probably stick to btw. You are not an expert in mental experiences of other people you are just an expert explainer of your model. Maybe you just like delivering mini-lectures to a captive audience, as if they didn’t have enough to contend with. If you bothered to read the article RedSea posted you would understand the futility of your approach and why it doesn't work in practice.

BillyP

I understand.

Essentially my position is the same as RedSeaPakota, just a bit less delicate with my words. The work of Joanna Moncrief posted by RedSea is something I am fully signed up to as well. To me she never misses a beat and defends herself superbly. She did once write something about aberrant salience that made me twitch but I don’t think it was worth breaking out my green crayons and dropping her a line over. Mention her name here and you all you get is tumble weed. Not that this forum is representative of anything but itself.

Being ward based with out an office is really Rolls Royce btw. You mentioned that human distress or mental illness as you say should not be construed as so bad. That is a message that I try and sell to practitioners and people who use services alike so I couldn’t agree with that more. I would say though that while one can debate what one means when one uses the word disease, in the popular mind it serves, as the word is commonly understood, to create a sense of otherlyness towards people who have psychotic experiences. This contribution to the stigma associated with psychosis is reason enough to consign it to the bin other considerations aside as far as I am concerned.

Regarding Psychotic Risk Syndrome if one looks at the web page of the DSM working group the language used is so sloppy it beggars belief.

I think polite conversation over post modernism has faded out. Pity.

and yes I worry about reproducing

I am sorry, this seems incongruent with all your other postings. Why do you worry about this?

 

[dl2dp2]

If you were as knowledgeable as you pretend you wouldn’t be asking.

Ok. This was meant to be rhetorical. The affirmative statement is "hermeneutic approach" [of psychiatry] is meaningless gibberish. But since you are unwilling and/or unable to articulate what exactly it is and how it can inform clinical practice, I have nothing left to say. I'm not sure what the utility is for assuming whether or not I "pretend" to know anything about continental philosophy.

I have offered you an alternative approach to working with people who experience psychosis that applies first when they are not floridly psychotic and you reject it out of hand. Then when your way fails and you end up in the situation you describe and you come back to me and look for an answer to your problem. Of course your way of explaining whats wrong to your patients keeps you firmly in charge. No chance of the patient coming up with their own plans congruent with their own explanations, plans they would probably stick to btw. You are not an expert in mental experiences of other people you are just an expert explainer of your model. Maybe you just like delivering mini-lectures to a captive audience, as if they didn’t have enough to contend with. If you bothered to read the article RedSea posted you would understand the futility of your approach and why it doesn't work in practice.

Again, I don't really understand this "approach". Perhaps you can explain yourself in a bit more detail, and please refrain from using any jargon. And also, the implication that you only see agitated patients when mainstream psychiatric therapy fails is patently false. In fact, if you ever spent any significant amount of time in a psychiatric ER, you'll see that half of the patients coming in are in some degree of agitation and require psychotropic medication for immediate stabilization. Please illuminate me how hermeneutics is relevant in these situations.

I think I'm going to bow out of this thread now that I have sufficiently explained my perspective. I actually figured that you were a woman. I think though this doesn't change the fact that you were speaking gibberish, and I was using the hyperbole to demonstrate my frustration. My criticism of continental philosophy in general is not necessarily directed at you per se, and while I'm not world's greatest continental philosopher, I'm open minded enough to recognize that it has some value in psychiatry. What irks me though is the gibberish and pretense and obfuscation, so patently demonstrated in your previous posts. I suppose I can't expect everyone to write as well as Bertrand Russell, but please at least make an attempt at doing so.

And one last thing, at the risk of sounding like a bully for the tyranny of the majority, the democratic institution in general that you speak so highly of does not think of humanities scholars and the kind of "research" they do is worth while--and I can refer you to series in the NYtimes about the "fall of humanities". While I personally disagree with the public in that regard, the kind of writing that you made contributes greatly to this. I sincerely hope that the humanities academic establishment would hopefully fix this ASAP or they'll only see a further dip of tax dollars going their way, as if that is even possible.

 

[Ibid]

Sluox

And one last thing, at the risk of sounding like a bully for the tyranny of the majority, the democratic institution in general that you speak so highly of does not think of humanities scholars and the kind of "research" they do is worth while--and I can refer you to series in the NYtimes about the "fall of humanities". While I personally disagree with the public in that regard, the kind of writing that you made contributes greatly to this. I sincerely hope that the humanities academic establishment would hopefully fix this ASAP or they'll only see a further dip of tax dollars going their way, as if that is even possible.

Oddly I picked up the International Edition of the NY times just yesterday for change. All the fact checking seems to suck the life out of it so it has a studied professionalism about it and makes it seem like it was written by a robot. Worth every penny though. The UK paper has got a lovely rustle quality that reminds me of the old international edition of LeMond. That crispy thin white paper…..those were the days….
I digress but funding the arts in Europe is seen as part of supporting a healthy society. Politicians cut funding at their peril esp in Germany just for instance.
I will google for the article you suggest.

The affirmative statement is "hermeneutic approach" [of psychiatry] is meaningless gibberish

Oh? Really, you think so? The brackets are yours and certainly muddle up what I wrote. What I wrote makes perfect sense.

Again, I don't really understand this "approach". Perhaps you can explain yourself in a bit more detail, and please refrain from using any jargon

Steady yourself and if you are not sitting down I suggest you do so now and I remind you that I have specifically explained that you have to start with the person when they are not actively psychotic. In other words the majority of the time. That is why it is relevant to the situation you describe.

http://www.ncbi.nlm.nih.gov/pubmed/16571572

Cogn Neuropsychiatry.*2004 Feb-May;9(1-2):13-23.
Hearing voices: A phenomenological-hermeneutic approach.
Thomas P,*Bracken P,*Leudar I.
Centre for Citizenship and Community Mental Health, School of Health Studies, University of Bradford, UK.
Abstract
The word "phenomenology" has a number of meanings. In this paper we briefly contrast the different meanings of the word in psychiatry and philosophy. We then consider the work of the philosophers Heidegger and Merleau-Ponty, as examples of what Hubert Dreyfus calls ontological phenomenology, in contrast to an epistemological approach. We present a brief outline of Merleau-Ponty's theory of embodiment, and contrast this with the dominant, epistemological (or Cartesian) view of experience. Through the example of a woman who experienced bereavement hallucinations, we try to show how this approach can open up a hermeneutic approach to the experience of hearing voices. An understanding of embodiment can help to counter reductionism, whether biological or social, and dualism (body/mind and mind/society). It is only when we consider the totality of human experience that we can understand its meaning. This has two main benefits. First, it legitimates the claims made by those who hear voices that their experiences are intrinsically meaningful. Second, it can provide a framework for those who work with voice hearers and who are interested in understanding these experiences. In this sense, phenomenology can become a valuable clinical tool.

You can tuck into another one of your industrial catering sized humble pies now as well. Happy eating.

 

[dl2dp2]

Cogn Neuropsychiatry.*2004 Feb-May;9(1-2):13-23.
Hearing voices: A phenomenological-hermeneutic approach.

While I still think this article is mostly gibberish, and the writing style is oh so obfuscating, there are a couple of points worth addressing. The summary of the article is essentially as I understand it, one point, which is that personal experience, including but not limited to psychiatric symptoms, is not fully accounted for by scientific methods. Techniques of literary criticism, therefore, may be helpful in clinical situations in understanding what these experiences "mean". I.e. meaning and being etc. etc. courtesy classic French/German 20th century philosophy.

While I think this basic critique is not in itself invalid, its content is really beyond the scope of psychiatry as a discipline. Psychiatry is a medical specialty, and the basic premise of Western medicine is the medical model, empiricism, etc. In limited instances, critiques such as this can serve useful purposes, but they are not able to create useful systems that can be applied. I.e. it's not possible to design a hermeneutic mental status exam, study efficacies psychopharmacology with hermeneutics, effectively delivery quality control and standard of care, improve care disparity and any number of these "real world" issues, while related to individual experiences, are not really relevant to the scope of critical literary understanding of human experiences--that is not relevant except in certain academic discussions in public policy, making laws, ethics discussions etc., which is why sometimes specialists in these fields ARE brought in when the situation arises.

But is this relevant for every day practice of psychiatry? The answer is no. Philosophy of medicine and psychiatry are very specialized fields that are irrelevant to every day practice except for the resident to occasionally learn one or two in their spare time. Furthermore, obfuscating points such as "aren't all psychiatric disorders cultural", which should be restricted to a certain context, are abused by individuals with dubious intentions to justify undertreatment and medication non-compliance.

 

[Manicsleep]

But is this relevant for every day practice of psychiatry? The answer is no. Philosophy of medicine and psychiatry are very specialized fields that are irrelevant to every day practice except for the resident to occasionally learn one or two in their spare time. Furthermore, obfuscating points such as "aren't all psychiatric disorders cultural", which should be restricted to a certain context, are abused by individuals with dubious intentions to justify undertreatment and medication non-compliance.

👍

This is a forum for psychiatrists and psychiatry. I think dubious intentions are only part of the problem. Poor comprehension contribute equally, perhaps fundamentally, to the propagation of misguided and at times, preposterous notions.

 

[ClinPsycMasters]

I think if you actually practice actual psychiatry you'll realize that most of what is considered "mental illness" is not per se "defined" by society but actually has a biologic reality.

So do hemorrhoids, but that don't make hemorrhoids a mental illness.

So, unless you have solid data to back it up, it seems that the major problem in the US at least is the UNDERMEDICALIZATION, in fact, undertreatment of many psychiatric problems.

Where is your data? Undermedicalization?! That's a laugh. You're not serious, are you? We made sadness into major depressive disorder, shyness into social phobia, normal worry into various anxiety disorders...and prescribe SSRIs and antipsychotics so often to have made Big Pharma rich beyond their wildest dreams. We even prescribe antipsychotics for people who are NOT psychotic. Why? Because they do not cure psychosis nor any other illness. They're tranquilizers and not disease-specific at all. They make you less hypervigilant. Of course they all give you a whole bunch of serious side effects.

I would say that a small portion of people are not getting the medical treatment that they need (the homeless with severe mental illness) but that the majority of people who are on psychiatric meds should not be on them at all. Look at the effect sizes. And the side effects. Yes, many of us are stressed and have mental health issues but drugs are not the answer for the majority. Why do we not look at sociological, political, economical, and psychological causes? Why should we medicalize normal reactions to difficult circumstances? Think of economy now, people getting laid off, losing their house, and I bet more than a few go to see a psychiatrist. Are they mentally ill or are they reacting to the harsh reality? It doesn't matter, I guess, because they are prescribed SSRIs and antipsychotics.

In most schizophrenics though, the simplest explanation is their dopamine is too high, and we need to give them something to take it away.

Well, that's just terribly reductive. First off, I would call them people with schizophrenia as opposed to "schizophrenics." Secondly, that is as bad as an explanation as me explaining that kids cry because their mouth stays open for too long so we can tape it shut and voila, no more crying. I would rather use very reductive explanations for a very simple and straightforward "broken leg" type of situation as opposed to something as complex and vague as schizophrenia. This is all correlation and there is no reason to assume dopamine imbalance is the cause of it--or serotonin imbalance the cause of mood disorders.

 

[Ibid]

Sluox

While I still think this article is mostly gibberish, and the writing style is oh so obfuscating, there are a couple of points worth addressing. The summary of the article is essentially as I understand it, one point, which is that personal experience, including but not limited to psychiatric symptoms, is not fully accounted for by scientific methods. Techniques of literary criticism, therefore, may be helpful in clinical situations in understanding what these experiences "mean". I.e. meaning and being etc. etc. courtesy classic French/German 20th century philosophy.


That generally that is how I understand the article as well. I just draw different conclusions. I don't think it amounts to a technique of literary criticism as much as just having an ordinary conversation with some one about their experiences. A psychiatrist an ideal person(perhaps not exclusively). You have mentioned a list of potential barriers but I can't really take seriously the idea that any of them prevent you talking to some one about their experience, especially if that is what the patient wants. The point to me is that understanding what the experiences means may be hugely important to the patient. So to that extent it should be to the psychiatrist as well even one who considerers them no more worthy of consideration than say the exhaust from a car.

You made a point about compliance, I would say concordance to a plan that you have put together (with each other) but no matter. The salient point is that all the evidence is that the variable that correlates most closely with a good outcome is the quality of the therapeutic alliance. That's oddly true for antidepressants and psychological therapies so it is clearly critical.

See the article below as evidence of the dearth of skill when it comes to speaking simply to people about their experiences.

Engagement of patients with psychosis in the consultation: conversation analytic study
http://www.bmj.com/cgi/content/abstr...e2=tf_ipsecsha

But is this relevant for every day practice of psychiatry? The answer is no.

I appriciate your point of view and you taking the time to expand on it. Pat Braken and Paul Thomas are both practicing Psychiatrists. Philip Thomas is a consultant psychiatrist with the Bradford Assertive Outreach Team UK. Patrick Bracken is Clinical Director of the West Cork Mental Health Services, Ireland.

During 2009 their was a debate in editorial pages of Psychiatric Bulletin now The Psychiatrist, I think, that made much the same points as you although the word nonsense featured. But gibberish would seem to be the internet forum equivalent.

Common sense, nonsense and the new culture wars within psychiatry. Invited commentary on... Beyond consultation
The Psychiatrist, July*1,*2009; 33(7): 243 - 244.*
[Full Text]*[PDF]*
http://apt.rcpsych.org/cgi/content/abstract/10/5/361

Funnily enough your final two criticisms were nearly identical to the two that I posited as potential ones in my much earlier post. I happy to concede that you made the points more eloquently and succinctly than me but my concern that some patients want to discuss the content of their psychotic experiences is over riding. Just my own opinion and I think by ignoring that one misses some thing important and potentially very helpful.

 

[RedPakotaSea]

I think if you actually practice actual psychiatry you'll realize that most of what is considered "mental illness" is not per se "defined" by society but actually has a biologic reality. However, the nosology is defined by consensus. I'm not sure how this nuanced distinction is useful in clinical practice.

You are missing the point. Insisting that mental illness has a biologic reality is not a useful argument. Of course there is a biologic reality behind each individual's psychological functioning, but that doesn't make the distinction between mental illness and normality any clearer. Most people with "mental illness" are not severely mentally ill. As mentioned by ClinPsycMasters, the majority lie close to the margin, and therefore are affected by where we as society draw the line.

To define (v.): from Latin definire, from de- + finire to limit, end, from finis boundary, end.

Is mental illness to a large extent defined by society? Yes, and this occurs via delimiting the border between normality and pathology.

Maybe what you are getting at is that my argument presupposes continuous variation. To argue that there is not continuous variation – that the distinction between normality and pathology reflects a real boundary – would be a meaningful counterargument, but as far as I am aware, studies have consistently failed to demonstrate such a natural boundary for the majority of psychiatric diagnoses.

Regarding psychiatric nosology, this is a somewhat different problem. The current classification has no doubt been useful in many respects. The introduction of explicit definitions and decision rules has undoubtedly increased the reliability of psychiatric diagnoses. However, this partial solution has shifted attention to the more fundamental problem of the validity of currently accepted psychiatric diagnoses (i.e. whether or not they reflect reality). While it is clear that psychiatry faces challenges with establishing the validity of diagnostic categories – distinguishing existing diagnoses from each other – this appears to be more a problem of performing the requisite research. Personally, I anticipate that more boundaries will be dissolved than formed through future research.

Why is this distinction useful? Because if we don't acknowledge the lack of a real boundary, we could end up pathologizing nearly all of human behavior, and insist that everyone needs to be on medication. More on this below…

So, unless you have solid data to back it up, it seems that the major problem in the US at least is the UNDERMEDICALIZATION, in fact, undertreatment of many psychiatric problems. I'm assuming that you have experiences with people who are generally high functioning etc., but if you actually see patients that are treated by a psychiatrist on a daily basis, you'll realize why and how they are UNDERMEDICATED often.

There is so much wrong with this argument, I'm not sure how to respond. First of all, undermedicalization and undertreatment are vastly different things. When you speak of undermedicalization, you imply that there are people who are not currently labeled with psychiatric diagnoses, who would benefit if they were diagnosed whether or not effective treatment is available. I've already explained my opinion on excessive medicalization. As it stands, 46% of Americans meet criteria for a psychiatric diagnosis sometime over the course of their lives. Are you arguing that this number should be higher?

If I understand you latter point correctly, you are saying that if I were to spend time with low functioning individuals, which I have, I would see that they are undertreated (i.e. they could be doing better). In this respect, I agree. However, saying that these individuals are undermedicated implies that there are available medications that these individuals are not receiving, and that more medication is the key. Here, I strongly disagree. Even low functioning individuals are often overmedicated, and in my opinion, there is too little emphasis on actual rehabilitation.

What does this mean?

I explained the "disease realism" model earlier in this thread.

I'll respond to your last two points later, but suffice it to say, I disagree with those as well.

 

[Manicsleep]

So do hemorrhoids, but that don't make hemorrhoids a mental illness.

Hemorrhoids? You just brought in hemorrhoids? WTF?
That is a pointless statement unless the word was on your mind for other reasons. Again, you have zero background in medicine so it makes it difficult for you to comprehend. Don't strain your brain too hard though, you may blow a blood vessel somewhere.

Where is your data? Undermedicalization?! That's a laugh. You're not serious, are you? We made sadness into major depressive disorder, shyness into social phobia, normal worry into various anxiety disorders...and prescribe SSRIs and antipsychotics so often to have made Big Pharma rich beyond their wildest dreams. We even prescribe antipsychotics for people who are NOT psychotic. Why? Because they do not cure psychosis nor any other illness. They're tranquilizers and not disease-specific at all. They make you less hypervigilant. Of course they all give you a whole bunch of serious side effects.

So if mental illness is overtreated and there are already too many providers, why are you in the field. Get out.
I will point out again that you cannot comprehend the whole scope of psychiatry or medications without being a psychiatrist. So get your head out of your...well, don't make the hemorrhoids worse.

I would say that a small portion of people are not getting the medical treatment that they need (the homeless with severe mental illness) but that the majority of people who are on psychiatric meds should not be on them at all. Look at the effect sizes. And the side effects. Yes, many of us are stressed and have mental health issues but drugs are not the answer for the majority. Why do we not look at sociological, political, economical, and psychological causes? Why should we medicalize normal reactions to difficult circumstances? Think of economy now, people getting laid off, losing their house, and I bet more than a few go to see a psychiatrist. Are they mentally ill or are they reacting to the harsh reality? It doesn't matter, I guess, because they are prescribed SSRIs and antipsychotics.

Only the homeless with SMI are not getting the medical treatment they need? That is true because you "would say" it is. Your basis for this argument is effect sizes? Have you even heard of the biopsychosocial model? We don't medicalize normal reactions to difficult circumstances. That is done by people with...well get that treated will you.

Well, that's just terribly reductive. First off, I would call them people with schizophrenia as opposed to "schizophrenics." Secondly, that is as bad as an explanation as me explaining that kids cry because their mouth stays open for too long so we can tape it shut and voila, no more crying. I would rather use very reductive explanations for a very simple and straightforward "broken leg" type of situation as opposed to something as complex and vague as schizophrenia. This is all correlation and there is no reason to assume dopamine imbalance is the cause of it--or serotonin imbalance the cause of mood disorders.

Schizophrenics are people with schizophrenia. Its called language. What are you going to propose next. How about we call moms, people who provide maternal services or how about person who carried me during gestation and perhaps provided additional services?
As far as reductionist. Its called science. Breaking things down to their fundamental points is ONE WAY that science works. If you notice, sluox was trying to make it 'simple' for you. You still didn't understand.

How about sticking to forums where you actually have some comprehension of what is being discussed.

 

[snarfer]

Where is your data? Undermedicalization?! That's a laugh. You're not serious, are you? We made sadness into major depressive disorder, shyness into social phobia, normal worry into various anxiety disorders...and prescribe SSRIs and antipsychotics so often to have made Big Pharma rich beyond their wildest dreams. We even prescribe antipsychotics for people who are NOT psychotic. Why? Because they do not cure psychosis nor any other illness. They're tranquilizers and not disease-specific at all. They make you less hypervigilant. Of course they all give you a whole bunch of serious side effects.

.

bravo, manicsleep.

This post does sound like someone is way over his/her head. This is a huge problem in psychiatry as the non-MDs read a few pamphlets, went to a few conferences, read a few articles, talk to a few MD and think they know it all.

 

[snarfer]

^
I’m not arguing that all psychiatric conditions will be amenable to a .

My biggest worry is that psychiatry will continue to expound the view, at least to the public, that psychiatric diagnoses are discrete entities, while steadily expanding the pathologization of human behavior. Some suggestions for the DSM-5 could potentially redefine millions of people as mentally ill through adding diagnoses such as Psychotic Risk Syndrome, Mixed Anxiety Depressive Disorder, and Minor Neurocognitive Disorder. Not only would this likely result in more people on questionable and potentially harmful treatments, but it would also have a larger impact on society. Excessive medicalization results in misallocation of resources, an implied lack of faith in human resilience, and most importantly a reduced sense of personal responsibility and sense of control.

This is a common fear. I believe the intention maybe good but the fear is misguided. Overtime, we have seen that early diagnosis and interventions, including therapy and medications, have resulted in kids with autism and severe depression and adhd attending colleges and join the work place. Before, these kids would have dropped out of school, gotten involved with drugs and spend the rest of the lives in and out of federal assistance programs, jail/rehab and in treatment at hospitals and clinics for kinds of ailments (physical and mental). This would be a prime example of misallocations of society resources.

As for personal responsibilities and such hogwash. It is against human nature to want to be diagnosed with any illnesses (physical and mental). Celebrities and malingers are the exceptions and not the rules.

 

[RedPakotaSea]

Overtime, we have seen that early diagnosis and interventions, including therapy and medications, have resulted in kids with autism and severe depression and adhd attending colleges and join the work place. Before, these kids would have dropped out of school, gotten involved with drugs and spend the rest of the lives in and out of federal assistance programs, jail/rehab and in treatment at hospitals and clinics for kinds of ailments (physical and mental). This would be a prime example of misallocations of society resources.

First of all, I agree that treatment in the form of therapy and, in rare circumstances, medication is likely warranted due to the repercussions of attentional deficit in our society. However, the scenario you have described is simply not supported by evidence.

"Greenhill and colleagues[42] conclude that stimulant treatment studies show robust, short-term efficacy and a good tolerability profile. Longer-term studies[10-15] are few in number, but have produced no conclusive evidence that careful therapeutic use of these medications is harmful."

Notice the wording. According to the author, the burden of proof appears to rest on the naysayers. This is a review paper that supports the use of stimulant medication in children; however, the data led me to a different conclusion. The same paper goes on:

"Most authors who have examined stimulant treatment in childhood as a predictor of hyperactive adolescent outcome have found no effect – as if the initial benefits of medication cited by many studies do not somehow carry over into positive long-term out- come. Thus, Ackerman and colleagues[46] found that stimulant drug treatment had no dramatic long-term results on academic achievement in their three groups (hyperactive [n = 23], hypoactive [n = 14], and normoactive [n = 25]) of learning-disabled boys at age 14 years."

"In an early study, Weiss and colleagues[16] compared three groups of hyperactive children. The first group (n = 24) received methylphenidate 20–50 mg/day for 3–5 years; the second group (n = 22) received chlorpromazine for 18 months to 5 years (mean dose 75 mg/day); while the third group (n = 20) received no medication treatment. The three groups were matched for age, IQ, gender, and socioeconomic status. At adolescence, no significant differences in emotional adjustment, delinquency, or academic performance were seen in the three groups."

"Riddle and Rapoport[47] also found no difference in academic achievement between a subgroup of 20 hyperactive boys who had been randomly assigned to receive methylphenidate for 2 years in their total group of 72 hyperactive boys, some of whom were taking imipramine."

"Blouin and colleagues[19] compared two groups of hyperactive adolescents. One group had received methylphenidate treatment in childhood (10–60 mg/day, mean 20 mg/day) for 1 month to 7 years mean 2 years [n = 23]), and the other did not (n = 22). The two groups were matched for age, IQ, and academic achievement at initial assessment. The authors stated that even when good and poor responses were examined separately, no beneficial effect of the drug on academic achievement, intellectual ability, or behavioral ratings was evident."

"Hechtman and colleagues[29] compared the outcome of this untreated group with the 20 young adults (mean age years) with ADHD who received 3 years of sustained stimulant medication (methylphenidate 20–50 mg/day) between 6 and 12 years of age and a matched control group. Results indicated that in many areas (e.g. school, work, and personality disorders) patients with ADHD treated with stimulants functioned significantly worse than matched controls, but similar to the untreated patients with ADHD."

Another paper critiques the International Consensus Statement on ADHD:

"The authors of the consensus statement (Barkely et al., 2002) claim that untreated ADHD leads to significant impairment and harm for the afflicted individual; not only do the authors conflate a statistical association with cause but other evidence suggests that drug treatment has at best an inconsequential effect on long-term outcome (Joughin & Zwi, 1999; Zwi, Ramchandani, & Joughlin, 2000)."

 

[dl2dp2]

"Most authors who have examined stimulant treatment in childhood as a predictor of hyperactive adolescent outcome have found no effect – as if the initial benefits of medication cited by many studies do not somehow carry over into positive long-term out- come. Thus, Ackerman and colleagues[46] found that stimulant drug treatment had no dramatic long-term results on academic achievement in their three groups (hyperactive [n = 23], hypoactive [n = 14], and normoactive [n = 25]) of learning-disabled boys at age 14 years."

there are a couple of points here which i think is worth clarifying, because it is controversial and the public in general has the wrong ideas with psychotropic medications.

(1) antidepressants being as effective as placebo.

first of all, this is only true for mild and moderate depression. secondly, while placebos are as effective in "producing" remission in mild to moderate depression, the RELAPSE rate of patients on antidepressant is significantly lower than the relapse rate for placebo, something like 35% vs. 65%. This is well verified in multiple studies--you can pick up the APA textbook on psychophamacology and there's a detailed discussion about this.

(2) antipsychotics are overused

multiple studies showed actually the earlier you start antipsychotics, the better the outcome is measured by a variety of measures. a major major problem in chronic psychotic patients is medication non-compliance, undertreatment, and "undermedication" (i.e. not sufficient dose, irregular dose, insufficient medical followup, fewer augmentation etc.) sometimes patients run out of money to pay for this. this is also verified time and time again through a variety of studies. some may argue that certain second generation antipsychotics have "neuroprotective" effects.

(3) "overmedication" of "worried-well" neurotics

while there's no evidence that any medications do anything for the neurotics, some people find psychotropics helpful in dealing with stress, calming people down etc. while you are right that these people don't "need" meds to manage their basic life functions, who is it to say we shouldn't treat them and make them a little happier with the tools that we have now? and for all practical purposes these newly created diagnostic entities are really there to deal with insurance and managed care so that they would pay for these services. and why is it that you insist that people suffer when we have things for them so they won't have to? I find this logic very puritanical. it's like, yes, modern life sucks, but it's not a "disease", so even though prozac (which is dirt cheap, btw, so pharma is not really reaping profits from it or anything) might make you feel better we aren't gonna give it to you---so deal with it and suffer. ???

Also, it's been shown in many studies that antidepressant alone is as effective as therapy alone (of course a combination is the most effective of all.) but if i were a neurotic, but is short on time, why wouldn't i choose to just pop a pill and skip the hour long inquisition into my childhood? I mean isn't this whole don't take a pill cause it's the easy way out philosophy as perverse as the puritanical principle behind prohibition? and i can guarantee you that with this kind of logic the ones who in the end suffer are going to be the poor people, as history has demonstrated again and again.

put it in another way: i hate my life and i'm depressed because my girlfriend dumped me and i lost my job. you are telling me, because this is all "normal" i am not eligible for a medication which would perhaps make me feel a little better. if i had a girlfriend and a job i wouldn't be depressed, sure, but how is this very obvious fact at ALL helpful? and how could a doctor or a therapist help someone get a job if the economy is at fault? perhaps you should quit your job and work for the federal reserve. the entire premise of this argument is absurd. the whole point of cosmetic psychiatry is that yes you are stuck in a funk and we can't do anything about it, but at least we can fiddle with your brain chemistry so it's a bit easier for you. I just don't see why this is so evil.

(4) "overmedication" of children

i refer you to Judith Warner's excellent book, "we've got issues". the problem with child psychiatry today isn't over medication at all. child psychiatrists are particularly well-known to be very careful with meds. but the lack of resources makes it a huge problem for dealing with pediatric behavioral problems. again the diagnoses and medication use is an imperfect solution to a very complex problem, and it's not nearly as simplistic as "the evil pharma trying to make as much money as possible."

(5) "isn't all mental illness cultural?"

i think the correct answer from mainstream psychiatry is that yes all mental illnesses are cultural. But at the same time, they are not JUST cultural. Mental illnesses are caused by a combination of biological, psychologic and cultural factors, and in the end the combination of these factors effect a maladaptive change in your brain and a dysfunctional behavioral pattern. The science is still at its infancy, and sometimes we make mistakes. Some mental illnesses are undermedicated in some populations, others may be inappropriately medicated. But the underlying philosophy is that all these issues can and will be addressed by the methodology of modern medicine: double blind randomized trials, longitudinal studies, animal models and basic mechanistic investigation into the neurobiology of disease, and careful analysis of medical/legal/policy/systems issues and evidences.

While I think parts of psychiatry is not per se scientific and science is limited in its capacity to appreciate individual experiences, and "critical psychiatry" can be useful in certain circumstances, the field of psychiatry, as part of medicine, is at the end of the day not a creative process, and mental illness as conceptualized in the medical model is not an expression of individuality or a product of culture. We are not in the business of writing sitcoms or lobbying political action committees. And if you insist that this is the case I don't know what to tell you.

 

[Manicsleep]

If the focus of the debate is mild depression or other such diagnoses its one thing. However, the idea that only the homeless are the ones not getting the treatment they need is idiotic. The problem is that there is a myth that given unlimited resources, physicians would continue to act in the same way they do currently. Also, there is a myth that the actions of a very few physicians with respect to pharma characterize those of us all.

The problem comes down to allocation of resources. Psychiatry has seen a massive increase in the prescription of generics over the past few years. I know some people doing large epidemiological studies on this and data should be available fairly soon.

To those who would argue for psychotherapy, I would ask, who is doing the psychotherapy? Perhaps some significant resources can be reallocated here.

Studies have indicated that education/degree has little to do with a good therapist. I know my grandmother is an excellent one although she has no formal training in anything to do with mental health.

 

[Manicsleep]

I’m not arguing that all psychiatric conditions will be amenable to a dimensional classification, with each dimension following a normal distribution. I’m also not saying that we should get rid of classification altogether. Cluster analyses have demonstrated that mania, depression, and acute schizophrenia stand out clearly and consistently from a background of heterogeneous symptoms. My point is that the current nosology is antiquated and often does not serve patients well. Instead of refining current diagnostic criteria, and adding new, unfounded diagnostic concepts to the DSM-5, we should be rethinking the classification, and put more effort into acknowledging fuzzy boundaries where they exist.

My biggest worry is that psychiatry will continue to expound the view, at least to the public, that psychiatric diagnoses are discrete entities, while steadily expanding the pathologization of human behavior. Some suggestions for the DSM-5 could potentially redefine millions of people as mentally ill through adding diagnoses such as Psychotic Risk Syndrome, Mixed Anxiety Depressive Disorder, and Minor Neurocognitive Disorder. Not only would this likely result in more people on questionable and potentially harmful treatments, but it would also have a larger impact on society. Excessive medicalization results in misallocation of resources, an implied lack of faith in human resilience, and most importantly a reduced sense of personal responsibility and sense of control. .

The DSM 5 scare tactics have been propagated by many groups including antipsychiatry and by those of the psychologists wishing to prescribe. They are afraid that they need to have some control over the process and are therefore engaging in the despicable politics. What is the solution, use their model based on the ICD (which is based on the DSM).

The DSM is misunderstood because it is not taught properly and it is most often abused by non physicians. It is a guide and not something definitive in clinical practice. I often use diagnoses that are not in the DSM but that fit my patients perfectly. Does that mean these new diagnoses will somehow 'infect' the world. The DSM is a good thing that is used improperly. The answer is to teach how to use it, not to throw the baby out with the bath water.

 

[Ibid]

ClinPschMasters
First off, I would call them people with schizophrenia as opposed to "schizophrenics."

Manic
Schizophrenics are people with schizophrenia. Its called language. What are you going to propose next. How about we call moms, people who provide maternal services or how about person who carried me during gestation and perhaps provided additional services?


Brilliant Manic. Because when you hear the word moms it brings to mind all sorts of horrible images doesn’t it? Moms are such a stigmatised and marginalised group of people. Great argument, you really have a grip of your subject. You are a real people person.

 

[billypilgrim37]

A) I agree that the terms "schizophrenics" and even "diabetics" have outgrown their welcomes just as "******s" and "idiots" did long ago. Language is mutable, and the meanings of words grow. "Schizophrenics" no longer just means people with schizophrenia, and as professionals who DO in fact value the experience and humanity of our patients, one small way we can do that even more is to try to use terms that apply best to the current zeitgeist.

B) OH MY GOD IF YOU ARE ONE OF THOSE SNIDE HIPSTER TOADS THAT LIKES TO CORRECT OTHER PEOPLE'S USE OF LANGUAGE BECAUSE YOUR GRADUATE SEMINARS SPENT WHOLE HOURS TALKING ABOUT THIS CRAP INSTEAD OF TEACHING SOMETHING USEFUL, YOU SHOULD GO LOOK IN THE MIRROR AND SMACK YOURSELF UNTIL YOU REMEMBER THAT SMUG PUNKS HAVE THEIR OWN LEVEL OF HELL RESERVED FOR THEM.

That is all 😀

 

[Ibid]

BillyP

A) Of course you agree with me. I knew you would without you posting it but thank you for the support.

B) OMG are you one of those people who post with out reading the whole thread? I have outlined a position to Manic and his responses amount to nothing more than sniping. Hipster? Smug punk? History has a lesson for us here. The sexual revolutionwas a bitterly fought battle. No one fought harder than the reactionary conservatives who had the most to lose. All manner of intellectual heavy weaponry was deployed by them but the truth was of course that they were just to ugly to join in. Manic won't have a substantive conversation with me fine but when he snipes I snip back. When it comes to a battle of wits I always treat the unarmed opponent most gently but it's up to him.

Cerberus the three headed dog gaurds the third ring of hell and if memory serves me right was lulled to sleep after being tricked into eating drugged honey cake. The third ring being for gluttons. Perhaps not gluttons for punishment.

 

[snarfer]

redpakota-
I'm not familiar with most of these studies and a quick pubmed search for the authors you had cited did not turn up any of the papers. I believe the ackerman study was done in the early 80s examining reaction time and cognition in 4 groups of children with ADHD and not what you are citing here. The Weiss study is from 1985 which does not requir further explanation.

The study you want to cite is the MTA. At 6-8 years following completion of the study, the treatment groups failed to show group differences vs. the comparison group in the domains of psychiatric hospitalizations, arrests, ODD, school performance. I think this would better support your argument.

However, further reading shows that this comparison group was also receiving treatment, including medications, in the community. And that the majority of the treated groups (medmgt, beh, combined) stopped medications and therapy (only 9% continued therapy) alltogether as early as at the 36 months followup. At the 6-8 year followup, the treated kids were less likely to receive school intervention programs (money saved here?). Lastly, the kids in this study were only 16-18 years old at the 8 year followup and not in college. A Farone study in 2010 of 100+ subjects over 11 y/o span and the remission, partial remission rate is also worth looking into. Read into in what you will but I think the key finding here is that treatment is not lifelong.

A week or so ago, John Gunthman at the american psychological association meeting presented a poster showing a rise in mental health illness in colleges. Their data ( n=2000+ over 12 year span) shows that this increased was due to the increasing numbers of kids entering colleges with preexisting mental health illness, including severe depression, who were receiving treatment, including medications (something on the order of 11% to 23%).

Those yearlong courses in biostats, research methology and critical literature reviews in med school, residency and again in fellowship really help deciphering the vast amount of data out there.

 

[billypilgrim37]

Cerberus the three headed dog gaurds the third ring of hell and if memory serves me right was lulled to sleep after being tricked into eating drugged honey cake. The third ring being for gluttons. Perhaps not gluttons for punishment.

I was thinking more Dante's Inferno, which has lots of secret passageways and special halls, more like a labrynth in the Legend of Zelda.

 

[Ibid]

BillyP

I know. So was I (insert smile face thingy).

http://en.wikipedia.org/wiki/Inferno_(Dante)

I think on I am course for circle two if anything btw.