mental illness


I am struck by the lack of data in the gun-control conversation I have heard on TV and radio lately. Perhaps this is because, as my friend Ethan wrote, “the dialogue on gun laws in the US is locked between two positions that are both completely divorced from reality,” and there is no room for data in that kind of dialogue. Whatever the reason, casual listeners like myself hear a lot of talk and very little statistics.

What kind of guns fire the bullets that kill people in this country? If for some reason we’re only interested in mass killings (which most of the time seems to be the case), what kinds of guns fired those bullets? What percentage of the guns were purchased (new? used?) by the shooter? What percentage stolen? How many killings were “good guys” killing “bad guys”? In other words, how much of the killing that has happened would be have been effected by each set of proposed gun-control regulations?

What are the media diets of murderers? Do they differ in any real way from non-murderers? Is there any hint of a dose-response relationship between media violence/1st person shooters and murder? In other words, do you increase your chances of killing someone by playing Half-Life 2 for 900 hours?

I am in a similar state of frustrated ignorance about mental illness and mass killings, or murder in general. This is a subject that interests me greatly, as I work in the mental health system. It is somehow much more controversial to increase the regulations on guns than it is to create a national database of people who have been diagnosed with mental disorders. I can’t think of a better way to reduce the number of people who get help with psychological troubles that to create a database of them.

Maybe I could be swayed, though, if I had some facts to work with. How many murderers have been diagnosed with what disorders? What psych meds were they on? How many had inpatient vs outpatient treatment? How do those numbers compare to the general populations? Clinical populations?

One thing no one seems to talk about is that mass killings could be a trend the way methods of suicide have trends. I find this idea plausible and quite disturbing. Now, in the US, when you realize that you need to do something spectacularly evil, the obvious thing to do is go to a school or mall and kill a bunch of people. I went to school in the 1980s, before this trend established itself, and I feel lucky to have gotten out when I did. I remember at least one kid who was bullied so bad I’m surprised he didn’t bring a gun to school. It just wasn’t what you did yet.

From that perspective, it seems unlikely that making it more difficult to buy certain guns will make much of a difference. (Of course, I have no empirical evidence to back myself up there, and I am happy to be swayed by evidence.) From that perspective, the most and perhaps only effective intervention for the problem would be the media refusing to report the incidents. This seems way less likely than gun-control legislation, and media-control legislation is more obviously unconstitutional.

The question of constitutionality of gun-control is also confusing to me. Assuming “arms” was synonymous with “weapons” in 1791, there was a pretty good constitutional argument against any kind of weapons-control 200 years ago. That argument is long obsolete. I don’t hear anyone advocating unregulated access to rocket launchers or nuclear weapons. So we’re left in this zone that is not mentioned by the constitution, where we have to draw a line between weapons we want to regulate and those that we don’t using the democratic process. That process doesn’t seem to be about the constitution any more, except when gun-rights advocates invoke it without getting into the issue of rocket launchers or Adam Lanza with a combat drone.

Finally, I am most baffled by the folks who are talking about “starting another civil war” if the government tries to “take our guns.” It’s not just that no one of any consequence is talking about disarming anyone. It’s the most clear example of the pro-military-anti-government disconnect in the right wing. Just like conservatives never seem to be thinking of the military when they mention government spending or government employees, they must not be thinking of our military as “the government” when they talk about a civil war. A civil war would not be fought against corrupt, middle-aged bureaucrats and politicians, it would be fought and lost against the United States military.

 

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Schizophrenia is a fascinating set of phenomena, the study of which has launched a thousand ships including, arguably, my field, family therapy; many of the original family therapists left psychiatry to study schizophrenia (or, as the DSM would have me write it, Schizophrenia–capitalizing words gives them more authority, don’t you think?) as an interactive process. That is, if all behaviors make sense in their context, what context might make schizophrenic behavior necessary?

There was an almost violent backlash against this line of thinking, as it seemed to (and did, in many cases) blame mothers for their schizophrenic children–as in the unfortunate phrase “schizophrenogenic mother.” The conventional wisdom about schizophrenia these days reads like a pharmaceutical company press release, something like, “Schizophrenia is a biological disease of the brain which is at present incurable, but there are drugs which can help manage the symptoms, and if taken regularly can provide a decent quality of life.”

So schizophrenia is assumed to be a biological disease of the brain though it, like every other Mental Disorder, has no laboratory test that can detect its presence. The best we can do is a set of behavioral diagnostic criteria which, frankly, are a bit of a mess. You may notice as you read that different flavors of schizophrenia may have nothing or little in common with each other. Are they really the same “disease”? We don’t know.

We do have good evidence that you can inherit, in some fashion, a tendency for one of these constellations of behaviors. There is good evidence that environmental factors are also important, though they are not a big part of the mainstream discussion. We also have evidence that therapy helps in a lot of cases. There is some (hotly contested, I’m sure) evidence from the World Health Organization that unmedicated schizophrenics can eventually recover while those on medication do not. Here is a trailer for a moving documentary about two recovered women and the public perception of schizophrenia, called Take These Broken Wings. Also, consider checking out the documentary A Brilliant Madness, about John Nash, in which puts the lie to A Brilliant Mind, which showed Nash recovering with the help of psychopharmaceuticals.

The DSM says that schizophrenia may be overdiagnosed (or at least is diagnosed more often) in African- and Asian-American men, that it affects men differently than women (men tend towards the negative symptoms were women tend towards delusions and hallucinations), and that incidence rates are something like .5-1.5% of adults.

Here are a few terms that you’ll need to know to get through the criteria:

affective flattening: does not show emotion. Also, “affect” means “emotion” to scientists and people who like to talk like scientists.

alogia: lack of speech.

avolition: lack of motivation.

prodromal: symptoms coming early on in the course of a disease.

echolalia: repetition of others’ speech sounds.

echopraxia: repetition of others’ movements

And here are the diagnostic criteria, word-for-word, from the DSM-IV-TR, pp. 312-319:

Diagnostic criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: For a significatn portion of the time since th onset of the distrubance, one or more major areas of functioning such as work, interpersonal relations, or self-care are mardekly below the level achieved prior to the onset (or when the onset is in childhood or adolewscence, faliure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuou signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. Doring these prodromal or residual periods, the signs of the ditrubance may be manifested by only negative symptoms or two or more symptoms listen in Criterion A pressent in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes are difined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms

Episodic With No Interepisode Residual Symptoms

Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms

Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms

Single Episode In Full Remission

Other or Unspecified Pattern

Diagnostic criteria for 295.30 Paranoid Type

A type of Schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Diagnostic criteria for 295.10 Disorganized Type

A type of Schizophrenia in which the following criteria are met:

A. All of the following are prominent:

(1) disorganized speech

(2) disorganized behavior

(3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Diagnostic criteria for 295.20 Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumptions of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Diagnostic criteria for 295.90 Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Diagnostic criteria for 295.60 Residual Type

A type of Schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

I’m learning about child abuse and neglect in my Child and Family Assessment class. Today I read about the ACE study, by the US Center for Disease Control. It is a huge study, with over 17,000 participants, where they gathered information about childhood abuse, neglect, and household dysfunction, and then proceeded to see what health outcomes and behaviors they could predict with that information. It turns out they can predict a lot. They’ve published 50 articles on the study and the research is ongoing–they are continuing to collect health information as the participants in the study age. I’ll present a few of their findings below. For more, see the ACE Study.

Here are some of their findings. I’ll paste in the definitions of the categories of adverse childhood experiences below. Strong correlations were found with the following:

  • alcoholism and alcohol abuse (4 or more categories of ACE meant 4-12 times increase)
  • chronic obstructive pulmonary disease (that is, lung disease)
  • depression (4 or more categories of ACE meant 4-12 times increase)
  • fetal death
  • health-related quality of life (way more inactivity, severe obesity, bone fractures)
  • illicit drug use
  • ischemic heart disease (IHD)
  • liver disease
  • risk for intimate partner violence
  • multiple sexual partners (4 or more categories of ACE correlated with 50 or more sexual partners)
  • sexually transmitted diseases (STDs) (4 or more categories of ACE meant 4-12 times increase)
  • smoking
  • suicide attempts (4 or more categories of ACE meant 4-12 times increase)
  • unintended pregnancies

Here are the kinds of abuse, neglect, and dysfunction they asked about, quoted from the site:

Abuse

Emotional Abuse:
Often or very often a parent or other adult in the household swore at you, insulted you, or put you down and/or sometimes, often or very often acted in a way that made you think that you might be physically hurt.

Physical Abuse:
Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at you and/or ever hit so hard that you had marks or were injured.

Sexual Abuse:
An adult or person at least 5 years older ever touched or fondled you in a sexual way, and/or had you touch their body in a sexual way, and/or attempted oral, anal, or vaginal intercourse with you and/or actually had oral, anal, or vaginal intercourse with you.

Neglect

Emotional Neglect1

Respondents were asked whether their family made them feel special, loved, and if their family was a source of strength, support, and protection. Emotional neglect was defined using scale scores that represent moderate to extreme exposure on the Emotional Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form.

Physical Neglect1

Respondents were asked whether there was enough to eat, if their parents drinking interfered with their care, if they ever wore dirty clothes, and if there was someone to take them to the doctor. Physical neglect was defined using scale scores that represent moderate to extreme exposure on the Physical Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form constituted physical neglect.

Household Dysfunction

Mother Treated Violently:
Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, and/or ever repeatedly hit over at least a few minutes and/or ever threatened or hurt by a knife or gun.

Household Substance Abuse:
Lived with anyone who was a problem drinker or alcoholic and/or lived with anyone who used street drugs.

Household Mental Illness:
A household member was depressed or mentally ill and/or a household member attempted suicide.

Parental Separation or Divorce:
Parents were ever separated or divorced.

Incarcerated Household Member:
A household member went to prison.

Elizabeth Gilbert, in her book about marriage, Commitment, lays out her interpretation of a Rutgers report on divorce statistics. Here’s her list of things that correlate with divorce, in the order she mentions them. She lays them out with a lot more subtlety, humor, and personality, but read the book if you want that.

Your parents are divorced

You are alcoholic

You are mentally ill

You cheat on your spouse

You gamble compulsively

You are violent

You are younger than 25

You have not gone to college (especially the woman)

You have children

You lived with your spouse before marriage

You have different racial backgrounds

You are different ages

You have different religions

You have different ethnic backgrounds

You have different cultural backgrounds

You have different careers

You don’t know your neighbors

You don’t belong to social clubs

You don’t live near your families

You are not religious

The man does not do housework

I posted in February about how the committee that is redesigning the DSM is accepting feedback on their proposed changes. The Diagnostic and Statistical Manual of Mental Disorders is the book used around the world by clinicians to determine what kinds of human suffering count as mental disorders, what symptoms one has to show to qualify as having one of those disorders, and what what can get covered by insurance. The content of this book will shape the lives of those who will interact with the mental health system for the next generation. Being labeled with a mental disorder is a big deal, and which one you get can mean the difference between decent and indecent treatment. Personality Disorder? You’re pretty much screwed. Very few people think they can help you and no insurance will cover you. Adjustment Disorder? PTSD? You’re in luck, most likely. We’re all very hopeful for, and will pay for, your recovery.

If you’re life has in any way been affected by anything labeled a mental disorder, I encourage you to look at the appropriate proposed changes to your future and the future of your loved ones, and write them an email about what you think. You have until April 20, 2010.

Structural, Cross-Cutting, and General Classification Issues for DSM-5
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Delirium, Dementia, Amnestic, and Other Cognitive Disorders
Mental Disorders Due to a General Medical Condition Not Elsewhere Classified
Substance-Related Disorders
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity Disorders
Eating Disorders
Sleep Disorders
Impulse-Control Disorders Not Elsewhere Classified
Adjustment Disorders
Personality Disorders
Other Conditions that May Be the Focus of Clinical Attention

The Diagnostic and Statistical Manual of Mental Disorders is revised every decade or so, and a revision is under way right now. Up until recently, there has been criticism that the proceedings were taking place in secret. This is not unusual, as I understand it, but it is significant for many people. Mental-health clinicians, for example, have to use the diagnostic categories in the DSM to label their clients, and if the categories and descriptions listed don’t coincide with their experiences or beliefs, this can be quite difficult. It is significant for mental-health clients, too, for complementary and even more personal reasons. What will happen to your diagnosis? In? Out? Changed? These decisions have a big impact on social issues, like stigma, and economic issues, like what insurance companies will pay for.

The DSM committee is proposing, for example, to subsume the diagnosis of Asperger’s Disorder into Autism Disorder. This seems to make a lot of sense, unless you or your child is benefiting from the existence of Asperger’s because of insurance company rules, state regulations, or other regulatory factors.

The content of the DSM is important to people for political reasons, too. For example, the third revision of the DSM eliminated homosexuality as a mental disorder. That was in 1973, for the DSM-III. (We’ve since had the DSM-III-R, DSM-IV, and DSM-IV-TR. They are currently working on the DSM-V.) It may be hard to believe that being gay was an official Mental Disorder, but it was. People were even lobotomized for it: Here, let me “help” you with that unnatural sexual attraction by forcing an icepick in over one of your eyes, through your skull, to twist it in your brain. The removal of homosexuality from the DSM was very controversial in its day, but no one credible is fighting for it to go back in.

That is to say, the DSM can reflect the changing mores of society, which in turn influences the way society sees mental health and illness. This process can effect the quality of a lot of our lives. And now the DSM committee has revealed the changes they are contemplating and is asking for feedback. This is from their website:

“Your input, whether you are a clinician, a researcher, an administrator, or a person/family member affected by a mental disorder, is important to us.  We thank you for taking part in this historic process and look forward to receiving your feedback.”

You almost certainly fall into one of those categories. Take part in this opportunity! Of course, our input being “important” to them does not mean they will pay attention to it, but it can’t hurt to try. The worst that can happen is that you will be better informed about your mental-health system. Here are the categories that they are considering changes in. Click on them to read the proposed changes. To submit feedback, you have to register with them, but it only takes a minute:

Structural, Cross-Cutting, and General Classification Issues for DSM-5
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Delirium, Dementia, Amnestic, and Other Cognitive Disorders
Mental Disorders Due to a General Medical Condition Not Elsewhere Classified
Substance-Related Disorders
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity Disorders
Eating Disorders
Sleep Disorders
Impulse-Control Disorders Not Elsewhere Classified
Adjustment Disorders
Personality Disorders
Other Conditions that May Be the Focus of Clinical Attention

Psychology hit the actual headlines last week, with Sharon Begley’s “The Depressing News About Antidepressants” in Newsweek. The story is that, if you look at all the evidence, not just the “successful” trials, SSRIs like Prozac and Paxil do not work better than a placebo for mild and moderate depression. Begley also tells the story as if she’s sorry to break the news and spoil the placebo effect. Here’s my version of the headlines from this story:

Pharmaceutical Companies Have Known For At Least Ten Years That SSRIs Work No Better Than Placebos: At least, anyone there who understood statistics and paid any attention to their research.

The Idea That SSRIs Are Better Than Placebos Was Propagated By Publishing Only the “Successful” Trials: This, obviously, was quite unethical.

The FDA Almost Certainly Knew That SSRIs Were No Better Than Placebos, Too: They had all of the research. Perhaps they did not read it.

People Who Read Psych Journals Knew SSRIs Were No Better Than Placebos Two Years Ago: The news caused a stir in my undergrad psych lab in 2008.

We Do Not Know What Causes Depression: The idea that depression has to do with the neurotransmitter serotonin was based largely on the (incomplete) evidence that SSRIs (selective serotonin re-uptake inhibitors) cured depression. In fact, we have pretty limited knowledge of what goes on inside a living brain. In fact, we have no ethical way to measure how much serotonin or any other neurotransmitter is where inside anyone’s living brain, so when a doctor tells you something like, “You are depressed because you have overactive serotonin re-uptake mechanisms,” they are passing on speculation, not science.

If You Recovered From Mild to Moderate Depression While On An SSRI, It Was Probably Your Own Hope That Lifted You Out: The thing about placebos is that they work pretty well. If you benefited from the placebo effect, it was your own strength, your own hope, that made the difference. You overcame that challenge. I think that’s pretty cool.

While SSRIs Do Not Treat Depression Better Than Placebos, They Do Have Side Effects: Here’s a list from wikipedia: Decreased or absent libido, Impotence or reduced vaginal lubrication, Difficulty initiating or maintaining an erection or becoming aroused, Persistent genital arousal disorder despite absence of desire, Muted, delayed or absent orgasm (anorgasmia), Reduced or no experience of pleasure during orgasm (ejaculatory anhedonia), Premature ejaculation, Weakened penile, vaginal or clitoral sensitivity, Genital anesthesia, Loss or decreased response to sexual stimuli, Reduced semen volume, Priapism (persistent erectile state of the penis or clitoris)anhedonia, apathy, nausea/vomiting, drowsiness or somnolence, headache, bruxism (involuntarily clenching or grinding the teeth), extremely vivid and strange dreams, dizziness, fatigue, mydriasis (pupil dilation), urinary retention, changes in appetite, changes in sleep, weight loss/gain (measured by a change in bodyweight of 7 pounds), may result in a double risk of bone fractures and injuries, changes in sexual behaviour,increased feelings of depression and anxiety (which may sometimes provoke panic attacks), tremors (and other symptoms of Parkinsonism in vulnerable elderly patients), autonomic dysfunction including orthostatic hypotension, increased or reduced sweating, akathisia, liver or renal impairment, suicidal ideation (thoughts of suicide), photosensitivity (increased risk of sunburn), Paresthesia, Mania, hypomania, sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished libido, a severe and even debilitating withdrawal syndrome, a slight increase in the risk of self-harm, suicidal ideation, and suicidality in children, neonatal complications such as neonatal abstinence syndrome (NAS) and persistent pulmonary hypertension, and platelet dysfunction.

Until Your Medicated Kids Are Old, We Will Not Know What All of the Side Effects of Treatment by SSRIs Are: This is true for any new drug, and it’s worth considering. If your child is on Prozac or other new drug, they are essentially part of a massive experimental trial.

Pharmaceutical Companies Pay for Psychiatric Educations: Why would it surprise anyone that treatment equals drugs in this case?

Most Antidepressant Prescriptions Written by Health Care Providers With No Significant Psychiatric Training: GPs, OBGYNs, pediatricians, etc account for 80% of SSRI prescriptions.

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