Thursday, March 11, 2010

Beware, Prodromal Anosognosia!

Victoria Costello, a science writer, author, and Emmy Award winning documentary maker, complains in her blog for Psychology Today about what she sees as a recent "trend (back) towards the denial of mental illness, especially the debilitating disease of depression." She takes the opposite view to those who suggest that there are too many kids on psychiatric drugs, advocating "early intervention with high risk children as soon as symptoms appear". Ms. Costello is explicit in her presumption that mental illnesses like depression are brain diseases predisposed by genetics.

But the medical and scientific fact is that there is no proven biological basis for any mental disorder. Not one single objective medical test for any mental disorder, including schizophrenia, depression, bipolar, ADHD... has been recommended for inclusion in DSM-V. Prior to discussing the various hypotheses which Ms. Costello refers to with so much hope and fervor in her blog, and prior to discussing various other hypotheses which she neglects to mention, no up-to-date textbook on psychiatry never fails to disclaim, e.g., "The biological basis of schizophrenia remains unknown."

This is not someone's opinion, it's the actual state of medical/biological science. What is opinion is that maybe someday soon the causes of mental illnesses will be discovered to be brain or other somatic disease. But so far, no. Thus depression, no matter how much it has hurt Ms. Costello's family for three generations, is only a metaphorical disease. It is not a literal disease.

When someone "denies mental illness" in the sense that Ms. Costello says is so dangerous, they are most often just saying they don't want a particular treatment that somebody else is trying to force on them. Sometimes, they are saying that people generally should have the right to be truthfully informed about, and to refuse, for any reason or for no reason, treatments that others want to force on them. Imagine that!

I'm going to propose a new mental disorder: Prodromal Anosognosia. This is when people merely show tendencies toward possibly denying mental illness in the future. For example, anyone reading this blog more than once probably has sympathy for the idea that orthodox biological psychiatry can be legitimately criticized. This could be dangerous.

Anyone who tends toward denying mental illness should perhaps be treated to ensure that they don't develop any full-blown disbelief (anosognosia), and wind up really denying mental illness.

As a matter of fact, if you even suspect, right now, that Prodromal Anosognosia is a satirical invention, or that it could become a totalitarian political device, you're actually showing signs of the disease!

Tuesday, March 9, 2010

Melinda Beck, Health & Anger

In today's Wall Street Journal Melinda Beck speculates about "When Anger Is an Illness". She degrades her value as a health issues reporter with this pop-psychiatric nonsense.

There's a simple reason why "...professionals can't agree whether a pattern of angry outbursts signals a mental illness or simply a behavior issue" ...THERE'S NO DIFFERENCE!

There are people who have actual organic problems, such as brain tumors, which may cause or be accompanied by anger of some intensity. But of course, nobody with a brain tumor would be diagnosed as "mentally ill" for it, nor would a psychiatrist be the specialist to treat it.

There is no medical test in existence for depression, anxiety, bipolar disorder, obsessive-compulsive disorder, or intermittent explosive disorder. None are even proposed for these, or for the new temper dysregulation disorder, or for any other mental disorder, in DSM-V. The only tools for diagnosis of mental disorder are direct and indirect observation of behavior and evaluation of self-reports by patients.

Whether anger of any type or intensity is "mental illness" is ultimately a subjective, if not arbitrary, evaluation. One professional can say anger is an illness in a particular case, or that it is always an illness; another equally qualified professional can say with equal evidential basis that the same anger is just bad behavior, or that anger itself is never an illness. Nobody can prove, scientifically, which expert is "right" because there isn't any right or wrong about it. It's not even a matter of opinion, really. It's pure semantics. People can speculate and agree or disagree or abstain on this according to whim.

Even worse, it will always be so, because "mental illness" itself has no objective definition based in any physical/biological reality. It's a metaphor, merely reflecting our indomitable hope and desire that we might someday be able to fix people up, rather than just fight or punish them.

Melinda Beck has sufficient training and education to know this. Her article is misleading, definitely not educational or a public service. It's no better than average entertainment.

Monday, March 8, 2010

NAMI offensive re Pentagon shooter

Patrick Bedell's family released a statement containing the following two (sequential) sentences:

We may never know why he made this terrible decision. One thing is clear though: his actions were caused by an illness and not a defective character.

What can this possibly mean? If Patrick Bedell made a decision of any sort, the decision must somehow reflect his character. If he had made a good decision, e.g., to not shoot anyone, even though he wanted to or demons told him to, wouldn't that have reflected good character? On the other hand, if his actions really were caused by an illness, then why bother to say that he made a terrible decision?

The Bedells' statement is obviously incoherent from grief. I hate to invade their privacy during a desperately tragic time by even mentioning the family's name in this blog. And I do not think a single decision, no matter how consequential, ever defines all aspects of anyone's character.

But NAMI's press release ... trumpeting the incoherent statement by an aggrieved family, is a grossly offensive and disrespectful act. It is gratuitous, spiritually pornographic, political opportunism. This is like a TV news reporter approaching a mother whose children have just been brutally murdered, as the small bodies are carried out of the house to an ambulance, and asking, "How do you feel?"

Logically, if we try to say a person decided to do something, and simultaneously maintain he was caused to do it by an illness, then one "fact" or the other doesn't mean very much.

NAMI would have it that mental illness means everything. They try to obscure the implication that such things as decision, individual responsibility, human dignity, honor and ethics thus mean nothing.

I'm a lawyer, so to me intent, responsibility and decision are vitally important. Without such concepts there would be no call or purpose for law to begin with. We could just turn ouselves and society over to omnipotent, benign experts in social engineering.

I do not obscure the necessary implication of my view: mental illness means nothing.

People and families feel joy and sadness and have character, because they are alive and responsible, and act according to their decisions. Life decides. It is not caused by illnesses and chemical reactions between transmitters and receptors in brains.

Saturday, March 6, 2010

APA & Harvard vs. Shorter

Alan F. Schatzber, M.D., President of the American Psychiatric Association, and Henry J. Friedman, M.D. of Harvard Medical School offer an odd assortment of points, ostensibly to oppose Edward Shorter's views on why psychiatry is in trouble. (The Wall Street Journal, March 6-7, 2010.)

Schatzenberg wants readers to believe that the new diseases created by DSM-V are all perfectly circumscribed as problems of emotional regulation. They are not normal-range human emotions and reactions just being called disorders, because "minimum levels of pathology" are so clearly defined. Pathology...? This guy would love to sell you some swampland in Florida and a couple of Brooklyn Bridges, too.

"Emotional regulation" sounds biological, or at least technical. It's not. It's an arbitrary evaluation about whether somebody is justified to feel the way they feel. There's no objective test of whether emotional regulatory machinery in any human being -- whatever that is in any context -- is functioning properly, or has functioned properly, or will function properly. It's absolutely no more scientific than a couple guys sitting around saying, "Well, he seems pretty crazy to me, what do you think?" -- "Oh, I don't know, maybe the boss is just nagging him this week, give him a break."

I've seen how subjective the criteria are for mental disorders when nuthouse psychiatrists ask courts to order involuntary medication (forced drugging). If the patient is truly violent or unable to even feed or dress himself, then no "mental illness" excuse is necessary to pre-empt his rights because "self defense" and "emergency life -saving" are more to the point. But almost anyone can defeat an involuntary medication petition, especially if he or she is defended by a competent, zealous attorney who doesn't believe a priori that all psych patients, just by definition, need their medication.

Often, if forced to really litigate involuntary treatment, state psychiatrists will change the patient's diagnosis instead. Delusional, bipolar or schizo-affective disorders, even schizophrenia, can just as well be called substance induced psychosis, for which non-medical treatment is perfectly logical. I've had several cases over the years which went exactly this way. The point is they can call it whatever they want. Treatment comes first, diagnosis is mere justification after the fact.

Dr. Schatzberg actually verifies this when he points out the impetus for inclusion of "prodromal schizophrenic disorder" in DSM-V: people who don't meet the criteria for schizophrenia need to be treated.

Harvard's Dr. Friedman seems like an old-timer, not as slick as the APA President. He's a bit unfocused with his arguments, mostly just appalled over the brutality of Edward Shorter's attacks on such good, honest organizations as Big Pharma, who would never consider inventing diseases just for a larger market and profits....

All in all, I think these two guys fail more miserably in their attempts to refute Shorter, than the heads of NAMI and CHADD did when they went up against George Will the other day. Which is amazing, considering Shorter is ultimately an apologist for psychiatry.

The bad guys all fighting each other and all losing. This is good.

Friday, March 5, 2010

NAMI & CHADD vs. George Will

Scott Jakovics, E. Clarke Ross and Mike Fitzpatrick attempt to counter George Will's excellent Feb. 28 column in today's Washington Post. Their arguments are instructive.

Supposedly, Will is on a crusade to "discredit science" (in general). He "denies" more than 50 years of research.

And supposedly it is "crucial" for such "misinformation" as George Will's column to be kept out of the media, so the public can instead be "enlightened" by NAMI and CHADD.

Well, what the hell, this is my own blog. Just as an exercise, I can be equally as strident as, and no less outrageous than Jakovics, Ross and Fitzpatrick. (My wife hates it when I do this, it pisses off the neighbors. But I'm occasionally allowed to get crazy, right? I don't drink too much, or gamble, or participate in extreme sports....)

I say these three individuals are dangerous, fringe-dwelling extremists. They covertly suggest censoring the free press and forcibly converting Americans to their mental illness faith. They should be fully investigated as to background and current illegal activity. They are depraved subversives, and possibly violent criminals. If this sounds incredible, just remember their names and google them every so often, and see whether I end up looking like a soothsaying psychic.

OK, fine. With a tip of my hat to Rodney Yoder, that's out of my system. I apologize to all conservative, respectable folk. I return to more careful, reasoned debate....

Does Mr. Jokovics really wonder if George Will (or for that matter, the rest of the human race) has insufficient experience with troubled teenagers? I've spent eight years working with every kind of seriously mentally ill person and their treatment teams in state nuthouses. These are the guys who went way beyond using marijuana and refusing to go to school or follow curfews. They're so screwed up that society has had to take away their liberty and restrain them behind locked doors for long periods of time.

Psychiatric "treatments" which attempt to neurologically disable even those miscreants I deal with from bad behavior merely make them worse and more dangerous. Something which could be called forensic psychiatry may be a useful or necessary social enterprise; but before they let a violent criminal out of the nuthouse, they should first withdraw him completely from all medications, and then make him demonstrate for at least a year that he can behave himself well enough to survive and get along in society. This is the opposite of current orthodoxy, where they try to brainwash the guy into the mental illness faith so he'll keep himself medicated/disabled even after he's out of the institution. Needless to say, the results suck.

But guess what, you don't even need a weatherman to know which way the wind blows. Medical science and common sense say too many people take drugs! All the research, and all the debate, is running strongly against Mr. Jacovics' presumption that we should err on the side of treating more people for more human imperfections.

The claim of the directors of NAMI and CHADD that the DSM "...provides clear, research-based criteria that distinguish impairments from character flaws" is simply laughable. Or it would be, were it not so creepily reminiscent of statements made in drug company FDA filings which were later discovered to be in violation of scientific ethics, or flat-out fraudulent, and which became legal evidence supporting billions of dollars in civil and criminal penalties.

I can't keep thinking about NAMI and CHADD in this context. It'll make me crazy again.

George Will's recent column is conservative, well reasoned, mainstream. The responses by Jakovics, Ross and Fitzpatrick are emotionally shrill and deceptive. NAMI and CHADD are losing the battle for public opinion. They will be gone, sooner than anyone thinks.

Thursday, March 4, 2010

Alan Frances and Samuel Sewell

Former Chairman of the Department of Psychiatry at Duke University School of Medicine and the task force that created DSM-IV, Alan Frances, MD, almost apologizes for helping to create false epidemics of attention deficit disorder, pediatric bipolar, and autism, in his March 1 LA Times editorial. To his credit, Dr. Frances warned us about psychiatric imperialism at least once before, with a June 26, 2009 article in Psychiatric Times.

But it's not a full apology. Those millions of children who were labeled and drugged according to the DSM since 1994 were "unintended consequences", which Frances' panel only brought about "inadvertently" despite their great and noble scientific efforts to avoid possible misuses of the system, their rigorous 3-stage procedures of empirical documentation, their transparent and inclusive blah, blah, blah, which was so explicitly accountable....

Just because all those kids were neurologically tampered with for no reason of real disease, just because their parents were defrauded, their bodies and minds altered without anyone's informed consent ... Well c'mon now, that's no reason to be harsh with a doctor, is it?

Frances speaks important truth to power when he writes, "Unfortunately, this therapeutic zeal creates an enormous blind spot to the great risks that come with overdiagnosis and unnecessary treatment. This is a societal issue that transcends psychiatry." He argues for caution against the forthcoming DSM-V, which he fears will make his own false-epidemic-creating work of two decades ago look positively benign by comparison.

He points out, "There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM-V."

This actually soft-pedals the more brutal truth, that after a full generation of empty promises, psychiatry has never learned to cure a single mental illness. They don't know what causes schizophrenia, or depression, or anything else, any better than they have ever known.

If Alan Frances wants to get right with his Hippocratic oath, I'm sorry, for my money he sure owes more than a half apology for inadvertent mistakes. He needs to be the guy who stops DSM-V cold. He needs to be a true hero.

An historical example I might recommend highly is that of Samuel Sewell, the only judge presiding at the Salem witch trials who later apologized. There are many parellels, actually.

Biographer Richard Francis writes in his introduction to Judge Sewell's Apology: The Salem Witch Trials & the Forming of an American Conscience, "An apology means repudiating an aspect of our past selves; in that way it's like a little suicide.... But there is another way of looking at it. Apology can be a creative act. It can liberate both the individual and his or her society. Apology frees you from the past and gives access to the future."

I hope we hear much more from Alan Frances and others in his shoes. And I sure pray for access to some future without this ... psychiatry.

Wednesday, March 3, 2010

Calling NAMI....

The official website of the National Alliance on Mental Illness offers a "Resource Library" which contains the book, Molecules of the Mind: The Brave New Science of Molecular Psychology by Pulitzer Prize-winning author Jon Franklin. This book was published in 1987, a full generation ago. It's basic point is evident from selected quotes:

"As the neuroscience journal articles arrive each month with their fresh crop of discoveries ... we come slowly to understand that the enigma of the mind is perfectly capable of solution.... We are in fact solving it, minute by minute and month by month, molecule by molecule. And in every piece of the puzzle we see the same theme, that the mind and the brain are one.... The smile of the baby that warms the mother's heart and solidifies her love is reducible to chemical equations, and to mechanism.... There will of course be a certain sadness as the 'human spirit' joins the flat earth, papal infallibility, and creationism on the list of widely held but obviously erroneous convictions."

"We will have to turn our backs on the duality, and with it, the faith of our fathers. Molecular psychology represents the most fundamental heresy ever committed by science, and we will have to embrace it. We will have to look into the mirror, surrender illusion, and make peace with the fact that we're staring at a machine. We are mechanisms, pure and simple, explainable without resort to the concept of soul."

"We may not like it, but we're puppets on chemical strings ... Materialism is the soul as well as the body of the future ... Most of us, regardless of what church we go to, have already tacitly if not overtly adopted science as our religion."

Fine. That was 1987, as I say, one full generation ago. But Molecules is still a recommended resource in NAMI's library to enlighten people about mental health research - right alongside a video, "Dosing Strategies of Atypical Antipsychotics to Maximize Efficacy".

Cut to today. NAMI continues to promote the Franklin book. But their Massachusetts affiliate is also on my Twitter homepage promoting an article entitled, "The Myth of Depression's Upside" by Ronald Pies, M.D., which is a response to Johah Lehrer's recent New York Times piece, "Depression's Upside". These are fascinating articles, both only somewhat predictable from their titles.

Here's the most interesting thing to me. Both Ronald Pies and Jonah Lehrer clearly presume that meds are for serious depression only, not for sadness, melancholy or low mood. Pies refers to science that may hint at a qualitative distinction. Lehrer also cites authorities who argue for a clear category difference. In any event, neither doctor seems to question today's medical wisdom: we should cut back on the ubiquitous over-prescription of antidepressants. Lehrer concludes with a memorable and very anti-materialistic phrase: "The challenge, of course, is persuading people to accept their misery, to embrace the tonic of despair."

Maybe these discussions could be heroically translated into arguable coherence with Jon Franklin's 1987 views, but there is inexcapable contrast. Twenty-three years later, "molecular psychology" has not cured schizophrenia or any other mental illness listed in the 1987 DSM. NAMI goes to lengths these days to make the public think they don't just push drugs for Big Pharma, they actually believe in talking to people, quite in addition to medicating the hell out of them. At the very least, fixing brains is a far more difficult and less promising project than what the NAMI faithful of the 1980's had hoped it might be. Western culture did not capitulate to the machine.

If a person is behaving badly enough, hurting somebody, etc., society will employ some kind of restraint. It doesn't matter much, I guess, whether that's a billy club or a shot of Haldol. But there's no great future in it either way, and no one (except perhaps the most arrogant and grandiose psychiatrist) pretends to be improving the perpetrator's life, let alone improving human nature.

Jon Franklin's brave new science was hallucination. We follow the traditional quest to understand whole people, rather than microscopic pieces of a mechanistic substitute. Improvement implies human intent, not mere brain chemistry. We have to deal with it.

I presume NAMI sells Franklin's book today, merely as a curious artifact of a misinformed era.

Tuesday, March 2, 2010

Another one bites the dust

Last week it was GlaxoSmithKline. This week it's AstraZeneca. Who'll be next? Is Big Pharma poised to just abandon the psychiatric enterprise of neuroleptizing the world?

It wouldn't be a big surprize in some ways. Drug companies want to make money, and they're pretty good at predicting market trends. I'd love nothing so much as to believe that these guys figure the public will no longer worship at the altar of the Great Pill once the current generation is sufficiently disabled by age alone to no longer require psychotropic meds. That won't be this year, of course. Drug research runs in a cycle of decades, but if Glaxo and A-Z are backing away from psych meds now, it's a good sign.

What might become very interesting is, if other pharmaceutical companies follow suit, an oddly cruel historical verdict will pronounce. So many bureaucrats, professional mental patients, professional families of the mentally ill, a whole panoply of NAMI fellow travellers, may come face to face with the fact that they've been conned. They've created identities and entire lives around the problem of diseases which, it turns out, were never in anyone's brain after all. They've made huge emotional/intellectual/existential investments in an idea which may be suddenly and utterly discredited, ejected from reality. The psychiatric project, the mental illness game, could just ... end. Lots of people would feel like cult members standing on the roof the day the flying saucers didn't arrive.

Drug companies would pay billions in damages as their cost of doing business, and escape essentially unscathed. Individual psychiatrists would get busy establishing how they were, each and every one, really on the correct side of these technical issues all along. A handful might be criminally prosecuted or justly fined for ruining countless lives and degrading all humanity. There might even be an exemplary Samuel Sewell somewhere in the mix.

But will anyone learn much about what and who we are? Maybe, maybe not. If Ely Lilly and Pfizer join the rats abandoning ship next week, the wreck will be looking pretty grizzly.

It will be damned hard to talk about medical progress against mental illness when the captains of science and industry are all admitting there's no future in it, and giving up.

Shorter Maleficarum

Dr. Vaughan Bell of King's College London comments on the Edward Shorter WSJ article, praising it but for the title, which he believes is mysterious and stupid. Bell can't understand why Shorter would headline his no-holds-barred criticisms, "Why Psychiatry Needs Therapy: A manual's draft reflects how diagnoses have grown foggier, drugs more ineffective."

Well, first of all, Shorter only criticizes expanding definitions of mental illness and huge increases in powerful drug prescriptions because these phenomena could ultimately be bad for psychiatry's image. It's an over-reach or a PR blunder. It could undermine public confidence and the authority of the essential dogma, that insanity is brain disease and individuals are just complex bio-mechanical things.

Shorter says the evidence is very strong that major depression and the depression in bipolar disorder are the same disease. But the evidence is beyond very strong - it's actually quite conclusive - that neither kind of depression is any disease at all. It's a matter of the definition of disease.

The proper medical-scientific concept includes a proven, demonstrable gross, microscopic or chemical abnormality which necessarily accompanies and presumably causes symptoms. There is no such proof for any mental illness in any edition of the DSM, including DSM-V. In fact, as historian Shorter certainly knows, whenever any mental illness was proven to be an actual brain disease (e.g., syphillis), it lost its status as a mental illness and became the province of neurology or some other medical specialty, not psychiatry.

Shorter pretends these are technical issues in the classification of disease. He knows better. They're technical issues in the politics of mental health.

Contrary to Shorter's pretenses, an absense of "careful attention to what patients actually have" does not distinguish American psychiatry from a European scientific tradition. No psychiatrist ever noticed or cared what a patient actually had. At best, their attention goes to specific behavior which somebody in power says must change. There's no connection to anything a patient has, it's what he does or says, and sometimes what he believes.

Psychiatry might need therapy because it's basically an ongoing social project, conducted by people who occasionally lose interest, forget, and become confused, contrary, or overzealous about goals, ethics, etc. - all things which therapy might be designed to resolve. Dr. Bell only thinks the title of the WSJ article is stupid because he mistakes psychiatry for a legitimate medical specialty.

The D in DSM stands for diagnostic, but there's no medical science, it's all politics. Read it, it's obvious.

And read the Hammer of Witches for comparison. I'm sure Edward Shorter could tell you that's a real eye-opener....

Monday, March 1, 2010

Non-existant diseases, ineffective drugs

Edward Shorter's Wall Street Journal article is getting some quick reactions. One I found interesting is from Phylameana lila Desy, who describes herself as an energy medicine practitioner, clairvoyant, intuitive counselor, and (of course) flower essence consultant:

"I don't know about you, but I generally feel better having been given a diagnosis. In my world, once an imbalance has been given a name, I'm one step closer to finding balance because at least I know who my enemy is. Easier to go into battle with something tangible, right? But, what if the diagnosis is merely a label, and not a true ailment? What are we supposed to do with that?"

Seems to me this just about says it all. A diagnosis gives people a tangible enemy because they figure it means there's a disease, and a disease is some kind of an evil microscopic creature, and it's so devious that you can't even see it.

But unfortunately for many of us, mental illnesses are not diseases like that, whatever psychiatrists and pharmaceutical companies might want the drug-buying public to believe. Nothing in the DSM is, or ever has been, any more legitimate as a disease than spring fever. That's why you don't find chapters in pathology textbooks discussing schizophrenia or depression. There's just no pathology to discuss. Edward Shorter is technically correct, psychiatry treats non-existent diseases.

Of course the fact deprives some people of a preferred enemy. There's no adventure or heroism in battling mere labels. That may be why NAMI's war on stigma never catches on. They're not creative enough to convince people stigma is a real bacterium or an invisible little alien organism of some sort. Why brain imaging can't show stigma just as easily as ADHD, I have no idea. Apparently NAMI's just damn poor at selling.

We all like a good fight. Personally, I'd rather fight people than bugs too small to see, or labels, or imbalances. To each his own.

I can understand, however, why your average energy medicine practitioner, clairvoyant, intuitive counselor, and flower essence consultant might feel cheated and betrayed when a perfectly good enemy suddenly disappears.

And without mental illness, we confront each other.