June 17, 2010

A Diagnosis Of Schizophrenia

map of hobbit.jpg
should be accurate to 10 dolichoi


When I read psychiatric articles, I wonder if the authors think that because the stars in the sky are small, a microscope would be the best tool.

Nassir Ghaemi and Frederick Goodwin make the case that diagnostic divisions (between bipolar, schizoaffective, and schizophrenia, in this case) are still very important.

They write,

[The] overly broad use of the term schizoaffective was illustrated in a patient referred to one of us as schizoaffective. However, his manic and depressive episodes, both of which included periods of florid psychosis, responded prohylactically to a combination of lithium and valproate... When the lithium dose fell below 75 mg/day, psychotic symptoms recurred;  when lithium was reestablished at only 75 mg, the psychotic symptoms disappeared. Clearly, this patient is not schizoaffective but rather has severe psychotic symptoms integral to bipolar illness.

Slow down. 

II.

A 22 year old Omani male with no prior psych history, but with a family history of psychosis, presents with change in personality.  He says that he hears "spirits" that tell him other people because they have done bad things.  He says his food has been poisoned by spirits.  His father has been possessed by the devil.  He is not interested in doing anything, and does not want to do anything but sit in his room. 

However,

within traditional Omani society, abrupt personality changes or altered states of consciousness are commonly attributed to spirit possession.  The belief in possession is embedded in social- cultural teaching, in which invisible spirits are deemed to inhabit the earth and influence humans by appearing in the form of an anthropomorphic being.
Father confirms this is part of their belief system.

He is given Lamictal 100/d and Risperdal 2/d, and is cured.


III.

If you're confident he doesn't have a demon, applaud yourself for your advanced scientific insights.

One of the main tenets of a biologically based system of psychiatry is that an Omani man with schizophrenia may have different cultural manifestations of the disease, but it's schizophrenia nonetheless.  This looks like schizophrenia, not bipolar disorder.  The Lamictal was probably useless.

However, the neurologists found that even though he had no seizure activity on EEG, on SPECT scan he had low perfusion in the left temporal lobe while psychotic, and an improvement in perfusion when he recovered.

From a biomedical perspective, the condition of the current patient would suggest symptoms of chronic schizophrenia, a diagnosis that is supported by a family history of psychosis. In the parlance of modern psychiatry, the patient met criteria for schizophrenia and responded to risperidone, a known treatment for psychosis. [However] the possibility remains that lamotrigine may have ameliorated the patient's psychotic symptoms by controlling 'non-convulsive seizures'.

If you think he was merely misdiagnosed, you have missed the point.   There is nothing short of a SPECT scan that would have made this diagnosis.  Prior to these tests, he had schizophrenia-- not appeared, but had it-- formally, according to phenomenology, course of symptoms, family history, and degree of impairment.

No amount of evidenced based medicine will protect you from this.  A thorough SCID, family history, and full panel of labs would diagnose him with schizophrenia.  Under that diagnosis-- which he reliably has (several people using the same diagnostic techniques diagnose him the same)  there would be no "evidence" for the use of Lamictal. 

Worse, under Ghaemi's plan, improvement on Lamictal would be suggestive of bipolar disorder.  Which he didn't have at all, i.e. not based on either biology or phenomenology.

III.

An example.  You don't need to know anything about the internal anatomy or biochemistry of a rhinoceros to know one when he gouges you in the face.  Purely on phenomenology alone, you get it right 100% of the time.   This is important: 100% of the time.  It could be bigger, smaller, whiter, blacker-- none of this will confuse you.  Ever.  In the same way, there's no theoretical reason we would need to know the biology of schizophrenia to diagnose it accurately. 

However, the simple reason we get the rhino right is because we've all seen a picture of a real rhino. No one tries to identify a rhino based on compiling a list of shared characteristics of rhino-ness. We do it with a split second comparison to an already agreed upon sign.

rhino.JPGi don't like it when people try to impose labels on me  


Even the word "rhinoceros" is a sign.  You don't phonics out the letters "r-h-i-n-o-c-e-r-o-s" in order to know what it says.  The word is actually an image.

Schizophrenia isn't like that at all.  There's no "ideal" schizophrenic to match it to.  Even when you think you're sure, it could turn out to be... non-convulsive seizures.  Or bipolar.  Importantly, this isn't a case of "schizophrenia is wrong; he actually has non-convulsive seizures."  By the most rigid definitions, he has both disorders, in the same way a kid with pesticide toxicity also has ADHD.  Which, of course, is nonsense.

So how would you know?  You wouldn't, so what Ghaemi proposes is to take medication response as informative.  That's even less reliable. 

If a depressed guy responded to Seroquel in 1999, did he thus have bipolar?  The answer is thus yes, but of course not.

IV.

You think you can explain why bipolar disorder isn't schizophrenia? 

To show how hard this really is, try it with animals:  explain why a unicorn is not a rhinoceros.

Your immediate reflex will be to call up some other agreed upon sign, and compare it to that: "A unicorn is like a horse..."

Ok, horse-- but is it a type of horse?  Is it more of a horse than a rhino?  If it is-- if unicornness is closer to horseness than rhinoness, then why did Marco Polo think a rhino was a unicorn but the horse he rode on wasn't? 

What's a triceratops, then?

These difficulties exist with animals that everyone knows on sight.  Now, imagine trying to identify an animal without some common ideal type, just based on the reaction of the animal to something.

V.

We do that already, and we do it badly.  If I tell you "scaly cold blooded quadruped climbing a tree"  you'll at best say,  "umm, it's a lizard."  But if I tell you that the animal in question changes colors-- boom, "it's a chameleon!"

And now you are able to make numerous predictions about it, without ever seeing it: (e.g. changes color for camouflage.)

But it could be a gecko, right?  So at what level of taxonomy did you make the error?

  • Kingdom: Animal
  • Phylum: Chordata (vertebrate)
  • Class: Reptilia
  • Order: Squamata (lizards, snakes, worm-lizards; not crocodiles (crocodilia) or  turtles (testudines)
  • Family: ?
Forget species, forget genus.  You're stumped at the family level.  That's how wrong you are.   Gekkonidae vs.  Chamaeleonidae.  In order to do better than this, without resorting to an ideal image of the animal, you need not just more information, but exponentially more information. 

That's reflected in their common names: "gecko" and "chameleon" are derivations of the family name.  This is for animals which exist, that everyone "knows when you see it."

Psychiatric diagnoses suffer from the same exponential information function.  When you call someone a schizophrenic, all you're sure about is that he's either a snake or some kind of  lizard, but not a crocodile.
 

100px-Ophiophagus_hannah2.jpg 


100px-Plumedbasiliskcele4_edit.jpg

komodo dragon.jpg
don't lump me in with these freaks





VI.

It seems like lunacy for someone to criticize evidence collection as a basis for an empirical science, but here we go.

If you gave Aristotle ten thousand unplugged computers of different makes and models, no matter how systematically he analyzed them he'd not only be wrong, he'd be misleadingly wrong.  He would find that they were related by shape-- rectangles/squares; by color-- black, white, or tan.   Size/weight; material.

Aristotle was smart, but there is nothing he could ever learn about computers from his investigations.  His science is all wrong for what he was doing.   But Aristotle would think he knew a terrible amount about computers from his studies.  In fact, he'd probably be considered an expert.  "To fix this computer, we need to make it more rectangular.  Get chopping, malaka."

That's where we are now.   But  modern science is so "advanced,"  surely it can come closer to the truth?  No.  But surely the amount of data we have on psychiatric diseases must amount to something?   No.

The last time they did this kind of taxonomy, they built a brontosaurus and told us it was real.   

And they, at least, had real bones to work with.


VII.

I understand the temptation to refine a paradigm that's worked ok so far.

And I understand that there's a feeling that we're on the right track.  "No matter what you say, I know a schizophrenic when I see one."

I know you do, that's not my argument.  My argument is that what you think you know is lessening your knowledge, not increasing it.  When you say he has schizophrenia, you may know what you mean by that, but I don't know if it isn't a seizure.  

You have it backwards.  You think saying "schizophrenia" is some kind of detection, a whittling down of possibilities, informative.  Similarly: "I've screened him for ADHD, I think he has it."  But those diagnoses don't exclude any other possibilities at all.  Do they mean he doesn't have a seizure, depression, pesticide poisoning?  Your ghost term doesn't exclude any real things. 

You think you're telling me "he has a cluster of symptoms and behaviors that generally resemble X."   But every time we make a diagnosis, the world pauses: oh, so that's what's wrong with him.

How long would the Omani man have had "treatment resistant schizophrenia" without an uncalled for Lamictal prescription or a waste of money SPECT scan?  Forever.  "We just need to improve our diagnostic skills, tests."  You're not listening: the diagnosis of schizophrenia was the specific reason he wasn't given a SPECT scan.

"We need to improve the accuracy of the diagnosis."  No.  The diagnosis isn't going to get more precise the more we know; the diagnosis is going to disappear, replaced by thirty other more specific diagnoses.

Sure, in the meantime I'm happy to go with "schizophrenia" and chuck dopamine blockers at everyone, because that's the best we can do today.   But why the pretense that we need to refine the diagnosis, or the whole DSM, when we don't have the tools to do it?  Shifting around consonants and vowels, substituting one fairy tale for another doesn't make it more accurate.  Schizophrenia vs. bipolar isn't a distinction, it's a distraction.  "I don't think he has a demon, I think he has too much black bile."  Then it's settled.  Send the priest home and bring out the leeches.


---

http://twitter.com/thelastpsych







Comments

I hope, with these entries,... (Below threshold)

June 17, 2010 6:47 PM | Posted by Jim: | Reply

I hope, with these entries, that you're laying the groundwork to establish the need for your forthcoming overhauled fundamental model of psychiatry and not just telling us "This whole field is fucked and that won't change anytime soon."

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So if I've got your point r... (Below threshold)

June 17, 2010 7:02 PM | Posted by Nik: | Reply

So if I've got your point right, you are upset by the championing of a single diagnosis and the disregard of other co-morbid pathologies? Or the consolidation of symptoms into labels? Or the reliance of diagnosis on successful drug treatment? Or that psychologists/psychiatrists don't know/recognize the limits of their abilities and knowledge? Or all of the above, perhaps?

I'm usually picking up what you're throwing down, but this time I feel like you're making multiple points. Hopefully I didn't miss the message completely.

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Here is what I got...... (Below threshold)

June 17, 2010 8:13 PM | Posted, in reply to Nik's comment, by Anonymous: | Reply

Here is what I got...

The label (schizophrenia) does not add to your understanding of the patients condition. Worse, it gives you the feeling that you do understand the patients condition and your level of suspicion (and the odds that you will learn more about the patients condition) is reduced. Not only are the labels useless to you, they negatively affect your behavior.

Thus, you shouldn't be spending your time redefining a useless label. You need to be searching for the evidence that will create a useful one.

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This is the reason some the... (Below threshold)

June 17, 2010 8:27 PM | Posted by Sasha: | Reply

This is the reason some therapists dislike giving diagnosis. This is the problem with easy availability of information to non-professional public. People read small bits of the internet, self-diagnose and then self-treat.

In many ways, possession by spirits is a way better explanation for many behaviors than psychiatric labels. It might not be falsifiable but at least it has perfect explanatory power. At least there is a clear belief that spirits can leave you.

This is also the reason the idea that the source of mental disturbances is spiritual in nature is so attractive. In the world reduced to observables, mistakes are bound to happen.

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RE: "A 22 year old Omani ma... (Below threshold)

June 17, 2010 8:49 PM | Posted by markps2: | Reply

RE: "A 22 year old Omani male He is not interested in doing anything, and does not want to do anything but sit in his room."
I think he has spent too much time inside a room. Also notice he does not have a girlfriend/female/mate, does not have a job-income. But everyone overlooks that.
In any other animal species that is physically mature and isn't getting any action, we would try to get the animal some action. gorilla, orangutan, dolphin, elephant.
This guy needs antipsychotics for life, right. Not.

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"Here be Dragons"T... (Below threshold)

June 17, 2010 9:03 PM | Posted by Basil: | Reply

"Here be Dragons"

Terms like that impart a sort of pseudo-knowledge; their description jives with reality enough to discourage real investigation, even as they point in a misleading direction. They provide a placeholder for real knowledge, and absent some pressing reason or another to look for a better explanation, the placeholder stays. Especially when you're pressed for time, or when it's not in your interest (consciously or not) to think harder.

For example: ask someone to explain how magnets work. No, really, try: "well, electrons rearrange themselves in the atom and, uh...". The problem is a mismatch between what you know and what you think you know. This happens all the time and, though frustrating, it's not really a problem. If I really wanted a thorough understanding on electromagnetism, I can read a book, or take a class. I am in a position where I can say "I don't know".

That, right there, is the problem with medicine. People expect doctors to be enormously competent, and they expect the books that inform the doctors to be correct down to the last letter. When a patient doesn't respond to treatment, or doesn't quite fit the most obvious diagnosis, the explanation is that it's idiopathic, or some sort of sub-species (like you suggested). The possibility that you were wrong, the literature was wrong, and it could be something entirely different never even occurs. Just keep churning through patients, and your self image stays intact. Hey, even Kobe has an off day. Somehow, it all comes back down to narcissism/identity. (I am reminded of the guy who tried to introduce basic sanitary practices in hospitals and met so much resistance: "Doctors are spreading disease? But Doctors treat disease. Surely you're mistaken")

Terms like schizophrenia, or ADHD, or bipolar and anti-depressant/convulsant/whatever are thrown around, imprecisely defined, because somehow that's easier than saying "I don't know". The obvious solution is a more precise taxonomy, one that doesn't pretend that we know more than we do. I'd quote the site's byline, but anyone who can muster the attention to read four paragraphs probably knows it, anyways.

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See, the problem is that th... (Below threshold)

June 17, 2010 9:30 PM | Posted, in reply to Nik's comment, by syntaxfree: | Reply

See, the problem is that there's no inferential content in those labels. For contrast, assume a man is bipolar. Mixed states exclude type II, which is why mixed states are _useful_ -- the distinction between "hypomania" and "mania" just isn't enough to ride on.

Now, of course, that's DSM-IV fantasy-land. I'm not saying the type I/II means anything, just that it's an example where the general epistemological void Alone is complaining about is not present.

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good info, but very cranky.... (Below threshold)

June 18, 2010 12:11 AM | Posted by Anonymous: | Reply

good info, but very cranky.

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Really, psychiatric diagnos... (Below threshold)

June 18, 2010 12:14 AM | Posted by Anonymous: | Reply

Really, psychiatric diagnoses are descriptive whereas medical diagnoses are definitive (usually).

Psychiatric illnesses are not real illnesses, they are just descriptions of symptoms. If we knew more about pathophysiology, every psych illness would have a medical diagnosis to explain the psychiatric diagnosis (symptom description). The patients that don't have a medical diagnosis probably aren't really ill anyway and they need to get a job and stop laying around the house chewing on xanax paid for by SSDI. Srsly.

Diabetes type I describes a genetic predisposition (HLA type) to develop an autoimmune attack on the pancreas beta cells. The autoimmune attack usually occurs early in life, and may be triggered by exposure to dairy proteins which are perceived as antigenic by these people. This causes symptoms of profound insulin deficit, hyperglycemia, and all that entails.

Diabetes type II is a polygenetic disorder which predisposes a person to develop generalized metabolic disorder; people with diabetes type II a genetically predisposed to develop mitochondrial defects resulting in impaired glucose oxidation and resultant insulin resistance; insulin hypersecretion early on with later insulin hyposecretion; a hallmark trait of diabetes type II is that the liver is simultaneously insulin resistant and also has an abnormally increased ability for gluconeogenesis. The liver is probably the major abnormality in people with diabetes type II as the abnormal and excessive glucose output puts that "tipping point stress" on their already fragile glucose tolerance, and pushes the person into hyperglycemia. Every case of diabetes type II is different, everyone has a combination of these problems (insulin resistance/glucose oxidation disorder, excessive gluconeogenesis, eventual insulin hyposecretion secondary to beta cell burnout/death).

Diabetes type I is a straight forward autoimmune disorder, diabetes type II is a metabolic disorder and the heart of it is abnormal mitochondria and an abnormal liver.

Now, compare this to PSYCH diagnoses.


Bipolar disorder type I describes a person who has met the criteria for a manic episode at one point in their lives, without it being induced by taking drugs.

Bipolar disorder type II describes a person who has been diagnosed with major depression, or at some point did have major depression, and has also in their life met the criteria for a hypomanic episode.

This means bullshit. This doesn't even begin to define the cause. It's not a real illness, it is describing a description.

Even diabetes type II, with its sketchy biological background and diverse patient population is pathophysiologically based. The cells resist insulin, the cells have mitochondrial damage and do not oxidize glucose correctly, the alpha cells of the liver are too numerous, make too much glucagon, do not respond to insulin correctly to suppress it.


A psychiatric version of diabetes would be this:

"diabetic disorder is diagnosed when a patient has the following symptoms:
psychological fixation with eating and drinking,
resultant polyuria; weight loss is observed in the type I , weight gain in the type II, as a result of the psychological fixations.
Somatization including numb feet & parasthesias, a perception of blurry vision
Very low energy particularly after eating; chronic lethargy,
Mood apathy, depression, and/or anxiety
An observed tendency to develop infections, slow healing wounds, infections and wounds become much more severe than expected for the patient's age
These symptoms have persisted for >3 months, and are not explained by an acute stressor, loss, or another illness"


If psychiatrists managed diabetes, that is how they would diagnose it.

The reason psychiatry refuses to become medicalized is because they can't do it as well as neurologists, and if they TRIED, they would immediately be pushed out of the way by the neurologists as any medically defined brain illness automatically falls under neuro territory. Plus, they would lose out on all that pharma money being shunted into putting mentally normal people on drugs they don't need (i.e. all the fake ADHD and bipolar and depressed people out there who are actually mentally normal but living a shitty lifestyle or have some other medical condition which is easily treated by supplemental nutrients, diet change, sleep change, lifestyle change, or medication already invented that is not profitable and requires minimal physician monitoring).

A combination of inferiority/ineptitude and greed keeps things the way they are. Mostly greed, I think.


TLP: The reason people are diagnosed with x and nothing else is ever investigated is because psych illnesses are as defined above - not real. That's not to say the symptoms aren't real (often, they are very real), all I'm saying is that the illnesses are fake. They are made up. They mean nothing, medically speaking. So, one fake name is as good as another fake name.

If psychiatry were a real branch of medicine, this wouldn't be common place. When a person comes in presenting with fatigue, weakness, the doctor orders a CBC, SMA7, thyroid, liver function, all sorts of crap... the doctor isn't saying "ah, fatigue, weakness... IT'S ADDISONS!" right off the bat the way a psychiatrist does with their 10 minute-assessment diagnoses.

Sure, medical misdiagnoses happen, but they are an exception not a rule. In psychiatry, it is the rule... if you go to see a psychiatrist you're going to be diagnosed with something, within a few minutes probably.

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I've felt this way for a wh... (Below threshold)

June 18, 2010 12:27 AM | Posted by V: | Reply

I've felt this way for a while, but my question to you is: why not characterize conditions by which drugs affect them (and how)? If we know A is 'more normal' on SSRIs then off them, why not say he positively responds to SSRIs / has a serotonin deficiency (or whatever verbiage is accurate) instead of depression or Alone's Disease?

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V:Because then Alone... (Below threshold)

June 18, 2010 5:10 AM | Posted by R. Kevin Hill: | Reply

V:
Because then Alone would have Rum Deficit Disorder, which is silly.

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V:Because someone ... (Below threshold)

June 18, 2010 5:55 AM | Posted by Philip: | Reply

V:

Because someone responsive to chemo therapy doesn't have a "chemo deficiency", he has lung cancer because he smoked his entire live. Calling it chemo deficiency would impede cancer research and excuse the cigarettes.

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Soon the diagnosis Of Schiz... (Below threshold)

June 18, 2010 7:13 AM | Posted by sanitizer: | Reply

Soon the diagnosis Of Schizophrenia may involve asking whether the person has a cat...
http://www.medgadget.com/archives/2010/06/common_parasite_seems_to_affect_human_behavior.html

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Yes, yes, yes. Taxonomy. I ... (Below threshold)

June 18, 2010 10:30 AM | Posted by jessa: | Reply

Yes, yes, yes. Taxonomy. I love your comparison to Aristotle attempting a taxonomy of computers. Why do we think we are any better at a taxonomy of mental illness than Aristotle at taxonomy of computers? It took centuries to get a taxonomy of animal species that seems relatively reliable at the moment, and there we had actual physical objects to look at, study, take apart, etc. With mental illness, we have none of that. It would be like trying to create a taxonomy of animals without ever seeing the animals themselves, basing the taxonomy on the holes dug. Those two holes look pretty similar, but we don't know that their digger's footprints are very different, so we don't know to separate them. Those two holes look different, but we don't know that everything else about their diggers is very similar, so we don't know to put them together. How do we know which differences are important enough to be a different "species" (animal- or illness-wise) and which are just a variation between individuals? How long was it before it was generally accepted that people of different races are not different species? And that still isn't universally accepted.

Taxonomy is hard. Even if we don't know where someone fits in the taxonomy of mental illness, even if we don't have a proper taxonomy of mental illness, even if we aren't sure if mental illness is really the category that needs to be sorted, people still have lives that suck and we still want to help their lives suck less. Really, I don't think diagnosis is sufficiently useful to this endeavor to surpass the harm that diagnosis causes. Yes, there is the trouble of treating the symptom rather than the disease. But that is really all we are doing with the diagnostic taxonomy we have now, so it isn't like that is a step backward anyhow. I'm for trying treatments one at a time, making educated guesses for what has the highest chance of working (evidence-based treatment can give us a starting point since we have some idea of what seems to work the best for the most people with the most similar set of symptoms). Every treatment we try gives us more information to work with for judiciously choosing the next treatment to try. Open-ended talk therapy is kind of exploratory, changing direction based on what comes up, and seems like a good model for the process of choosing a series of less open-ended treatments (drugs, CBT, exposure therapy, etc.) or as a forum for some of those treatments.

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Taxonomy is a bogus concept... (Below threshold)

June 18, 2010 11:07 AM | Posted, in reply to jessa's comment, by syntaxfree: | Reply

Taxonomy is a bogus concept. The question is whether existing _models_ of mental illness are useful. Bipolar can't rule out ADHD, and ADHD can't rule bipolar, and the symptoms overlap -- that's not good. Mixed states rule out bipolar II, regardless of the subjective distinction between "hypomania" and "mania" -- that's useful, at least if the models are a good fit anyway.

Even if we had instruments for diagnosis as fine-tuned as they have in oncology, taxonomy would still be bogus. The taxonomy of cancers is bogus -- anyone who has watched some House MD can tell you that.

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Philip has a geat response ... (Below threshold)

June 18, 2010 11:39 AM | Posted by medsvstherapy: | Reply

Philip has a geat response to the miles-long anonymous genetic post: there are resaerchers who are looking for the genetics of smoking addiction, and the gentics of lung cancer. They are probably hot on the trail. But if someone does not smoke, they will not get lung cancer from smoking, regardless of genes.

Anyone can decide that smoking is genetic, or lung cancer is genetic, or DMT2 is genetic.

To me, those seem like chair-arrangement plans for the Titanic. Sure, it is part of the problem, but a tiny part.


The overwhelming incidence of obestiy is a recent phenomenon. Did our genes change? No. Our eating and exercise habits changes.

Where is the grant money going?

To genetics.

Why?

Because, like anonymous genetics commentor, we "buy in" to the medical model.

This guy is having delusions. We slow down his brain activity with Lamictal. He has a reduction in delusions.

We could possibly have achieved this same efect with dramamine (antihystamine), or Ritalin (stimulant).

This does not tell us that the guy had allergies, or attention-deficit.

It tells us that, likely, there was something going off-track in his brain wiring (structure) or activity (process).

Finally, it most certainly could be due to his lack of social involvement; a family systems model might be more accurate than the biologically-based-brain-disorder model. Why is only one member of the nuclear family having hallucinations, and why is it the sociodevelopmentally delayed young adult male, with onset after the age of 20 rather than before? And, are we hurting more than helping if we further identify this young man as the scapegoat/whipping boy of the family constellation? And, with drug treatment, will he go on to make more of his life than before the dx-and-tx?

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I work in finance and exper... (Below threshold)

June 18, 2010 12:10 PM | Posted by Catalin: | Reply

I work in finance and experiencing the same type of issue. It has nothing specific to do with psy*, it's just that people are not trained to recognise improper language.

By improper language I mean something which means nothing, but can be written, read or spoken.

Cause? People do not actually think. They just label "good"/"bad" using an excess of words to make it sound like it's not about them.

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I think the diagnosis of sc... (Below threshold)

June 18, 2010 5:01 PM | Posted by Manolo: | Reply

I think the diagnosis of schizophrenia is useful from a pragmatic point of view in that in most cases it informs treatment which in many cases works. I am sure that there will be other ways of diagnosing mental disorders in the future which will be more accurate. I do not think we are there yet.

(The other day I attended a presentation by a psychiatrist who told us he actually believes in possession by spirits. I think he was seriously considering this in his differential diagnosis.) (!)

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*drools and plays with a di... (Below threshold)

June 18, 2010 5:28 PM | Posted by Psychiatry Student: | Reply

*drools and plays with a distracting, shiny object*

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I think you'll find this st... (Below threshold)

June 18, 2010 9:47 PM | Posted by Alexei: | Reply

I think you'll find this story interesting: http://lesswrong.com/lw/if/your_strength_as_a_rationalist/

It's (and a lot of other posts on that website) are about how a theory needs to predict things that *can't* happen. If a theory allows everything, it's no good.

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75mg/day of lithium?? WTF? ... (Below threshold)

June 19, 2010 1:11 PM | Posted by Anonymous: | Reply

75mg/day of lithium?? WTF? Will that even register on a blood test?

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Gotta upgrade you on that o... (Below threshold)

June 19, 2010 9:17 PM | Posted by Anonymous: | Reply

Gotta upgrade you on that one Alexei -- that's the basic definition of real science. If you can't prove that a theory is wrong, it's a bad theory. Unfortunately most of Psychiatry (and cosmology for that matter [rant for another time]) are hardly more than psuedoscience that hoodwinks people with big words. At least cosmology doesn't try to give you drugs based on string theory. Psuedoscience and treatments together are dangerous. Personally I think I'd give the nuerosciencists a crack at psychatry, at least they can usually find some odd things in a brain scan.

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" think I'd give the nueros... (Below threshold)

June 19, 2010 11:31 PM | Posted by information addict: | Reply

" think I'd give the nuerosciencists a crack at psychatry, at least they can usually find some odd things in a brain scan."

They may find "odd" things but do they know what they are? Are they part of normal variation that hasn't really been well understood?

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Response to Meds vs therapy... (Below threshold)

June 19, 2010 11:33 PM | Posted by Anonymous: | Reply

Response to Meds vs therapy: "Did our genes change? "

My understanding is that genetic does not mean inherited. Exogenous factors can change genes and turn them "on or off" as well.

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"They may find "odd" things... (Below threshold)

June 20, 2010 2:08 AM | Posted, in reply to information addict's comment, by Anonymous: | Reply

"They may find "odd" things but do they know what they are? Are they part of normal variation that hasn't really been well understood?"

Does psychiatry? Rather, do they create explanations, like castration anxieties, oedipal complexes, or narcissism for that matter, to explain odd behavioral things we don't really understand.

At least with a fMRI you can see activity and make predictions based on it. "I see kindling in the amygdala, I expect X to be happening." Give me an example of an individual with a dx of narcissism and predict when they'll express narcissistic rage. Calling it after the fact is a post hoc assumption of events.

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Re; 75 mg of lithium<... (Below threshold)

June 20, 2010 2:51 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Re; 75 mg of lithium

I noticed that too. I can only assume they accidentally typed the lamictal dose (they meant 75mg of lamictal), OR they meant 750mg of lithium. Lithium does not even come in 75 mg/ day so this is clearly some kind of typo.

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No, we don't know what they... (Below threshold)

June 20, 2010 2:58 AM | Posted, in reply to information addict's comment, by Anonymous: | Reply

No, we don't know what they are yet... and as long as psychiatrists treat people with behavioral mental health disorders, we never WILl find out what they are, since psychiatrists as a rule pretend they are not physicains and have zero interest in anything physiological, medical, pertaining to the body... well, other than to run a few thyroid tests and cholesterol/ hgA1C tests to CYA for the insurance companies/potential lawsuits when their patients blow up to 300 pounds and develop type II diabetes on their drugs. But other than CYA labs, psychiatrists pretend they aren't doctors at all.

If a patient has a symptom, they are given a med for it without even PRETENDING to figure out why it is happening. Psychiatrists, as a rule, have given up on figuring out the medical reason behind mental symptoms. They know if they try they will be infringing on neurologists, and it is generally not profitable to do that. Cures are not profitable, fat schizophrenics with TD and EPS are. Telling that 17 year old girl she isn't bipolar and she is just a spoiled brat isn't profitable either, you want that girl coming back for her lamictal prescription, amirite???.

This is why psych patients are usually pretty zombied out. Their doctors don't know shit and are only drugging them into submission, they have zero idea what is wrong and even less of an idea how to fix it, the best they can do is shut them down like a difficult computer that just won't install windows right.

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In medical diagnostics, the... (Below threshold)

June 20, 2010 5:32 AM | Posted by Frank Powers: | Reply

In medical diagnostics, there is a body of knowledge that has been accumulated over the course of centuries. This was possible because

a) objective descriptions of illnesses could be made, i.e. the symptoms of illnesses were accessible to every objective observer and independent of the patients self-awareness and -description

b) a suitable course of investigation with appropriate methodology, methods and instruments was established (although that took a couple of centuries as well)

In psychiatric diagnostics, no such objective descriptions of illnesses can be made, nor do we have an appropriate methodology, methods or instruments. Symptoms can arbitrarily be distributed to a wide variety of labels, because we only ever look at them from the outside, using a point of view (or viewing angle) borrowed from medical science (and physics, ultimately). Yet, the subjective experience is an essential element of any psychiatric condition; they cannot be exhaustively explained by using objective, prescinded data only, because this kind of data (i.e. symptoms) operates within a totally different frame of reference, an external, objective one, whereas the psychiatric illness (or malfunction or condition, whatever) originates in the realm of the patient's subjective experience.

In some rather rare instances, the subjective experience can be pinpointed to some organic root cause (as consciousness, and thus mental dysfunctions, are ultimately an emerging property of the brain), but more often than not the etiological relations between cause and effect are blurry at best, or too numerous to add up to an interpretable picture, and sometimes might even be inexistent. But that does not necessarily mean that the patient "just sits around in a dark room too much", which is in itself just an external description without any relation to the subjective experience, but that we might simply need an enhanced methodology, different methods and new instruments. Think introspection, think exploration of the subjective condition of man's consciousness, think Buddhism, if you'd like to, or "Eastern science", if that term suits you better.

Personally, I think we (or "Western science", which your posting is all about) have not even begun to scratch on the surface of human consciousness, its functioning and its mechanisms. All we have is physics (i.e. medical science), its paradigm of objectivism and a truckload of externalized symptoms that don't provide the smallest hint of explanation if you think about it (what you have done). Time for another Kuhnian moment, huh?

Kind regards,
Frank Powers (MA Psych.)

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Frank Powers - Ahhhh, the E... (Below threshold)

June 20, 2010 3:33 PM | Posted, in reply to Frank Powers's comment, by brainchild: | Reply

Frank Powers - Ahhhh, the Eastern vs Western dichotomy... I always find this particularly weird when applied to psychiatry or psychiatry since both Jung and Freud were quite aware of (and integrated) Eastern philosophy into their theories. It's actually kind of racist, in that liberal sugary way that idealizes other cultures (while ignoring the history of violence and oppression in Buddhism, for instance, in favor of a fairytale version of Buddhism that is not reality based). Where do think the idea of the uber ego (or watching consciousness) in psychiatry and psychology comes from? Psychiatry already uses introspection, that's what the talk therapy part is. Psychology does this even more - being focused on the therapeutic value of relationships (particularly the therapeutic one), talking (or other forms of self expression) and introspection.
CBT - or cognitive behavioral therapy - is perhaps the therapeutic modality the most akin to the Buddhist idea of being conscious and present in the moment. However, it has the benefit of not being wrapped up in religion or being led astray by magical thinking, ideas of demon possession and reincarnation, etc. Psychiatry doesn't need more religion, it just needs better science, less shady behavior by pharmaceutical companies, to shed the last vestiges of narcissistic illusion that the psychiatrist is actually a shaman or priest, and for there to be an acknowledgement that humans are social animals that are deeply effected by their environment (everything from diet to light exposure, to the company we keep...we're just apes that like to pretend we're not apes, thankfully there are signs that at least some of us are getting over that insane religious belief that our culture is built upon...and that's thanks to science, for all it's flaws and misuses by us mad apes). The problem isn't science itself when it comes to psychiatry, it's how it's being used (and how often pseudoscience is being presented as science).

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brainchild - In fact, I agr... (Below threshold)

June 20, 2010 6:39 PM | Posted, in reply to brainchild's comment, by Frank Powers: | Reply

brainchild - In fact, I agree with you on most of the issues you raise. Seems like i did not manage to express myself clearly enough.

To be honest, both Freud and Jung are today considered as being more like literature rather than science, and although you still get to learn quite a lot about those two when taking up psychology, they do no longer really matter - except to their disciples, of course (just ask a French psychiatrist). Today's psychology as I've come to know and experience it is rather based on a kind of utility-principle like quite some commentors already raised it: whatever works, works. Which is okay as a starting point in my opinion, but not the be-all and end-all.

When talking about Buddhism, I actually had in mind Zen buddhism, the most un-religious stance of it I can think of, where pure experience and nothing else matters. There are of course quite a lot of other flavours to choose from, but again I am mainly interested in what works, accompanied by as little ballast as possible. I myself consider myself an atheist, which may be the reason why Zen buddhism of all things appeals to me the most.

So, let me clarify my point of view, as apparently I didn't manage to do so before: I actually do not think that talk therapy, or any psychoanalytical therapy for that matter, qualifies as the kind of "eastern-western science" I had in mind. The thing is, when doing talk therapy, the therapist listens and acts on the same level as his patient does; he (usually) does not have any deeper understanding of the working mechanisms of his client's (or his own) consciousness. Yes, he may have some sort of paradigm as a crutch, but that's again only an assortment of labels, grounded in constricted perception and classification, but not in reality. I've done my share of meditation and awareness training myself, and I think that there might be some sort of comprehensive conscious mechanisms that apply to all of mankind, not just the psycho ones of us - how we perceive of ourselves, the way we differentiate between our self and our body (although there
might actually be no "self" at all), perceptional biases, self-value, symbolic self-enhancement strategies and the like. I am also pretty convinced that we have not even begun to understand the workings of our own consciousness, out of a first person-perspective, and that the number of human beings that have ever undertaken that venture is so negligibly small that it is of no consequence. Yet, I think that this might be the most important challenge to psychology/psychiatry as well as to mankind at the time being - understanding why we really do something, be it in an "abnormal" or in a socially accepted" way (sometimes some socially accepted practices deem me more weird than those "psychopathic" ones...).

I myself am a big fan of CBT and MBCT (mindfulness-based cognitive therapy), and think that they are a necessary first step into the right direction - but I think that there are still some (or: a lot) more steps to be taken, and we should better hurry, because the current state of affairs, as Alone pointed out, is rather unsatisfactory. In that respect, I think a better understanding of the mechanisms of consciousness itself, be it in an objective or subjective mode, would be a great improvement for psychology as a science - unencumbered by any religious baggage, of course.

As you say: We are just apes. Let's hope we finally earn that pretentious suffix "sapiens".

Kind regards,
Frank Powers

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"given up on figuring ou... (Below threshold)

June 21, 2010 2:49 AM | Posted, in reply to Anonymous's comment, by Vince: | Reply

"given up on figuring out the medical reason behind mental symptoms"

Often, this is because they are scummy, lazy, fucks. But, also, this is because it's an open question if there will ever be a biologically relevant single causal event underlying this problem. The question, when asked of the current DSM labels, is buttressed against the philosophical question surrounding reductionism and multiple realizability -- can you have disparate physical systems that create the same function output. The answer seems to be yes, there is huge convergence between the set of potential physical embodiments (physical space) and a functional definition.

The problem, which was smartly hinted at, is that current psychological thinking as embodied by the DSW is way too fucking abstract. You can pack a huge number of totally disparate physical causes into each, such as ADD being pesticide toxicity or a DRD4 polymorphism or NE imbalance, etc.

Hell, if a problem is due to the functional output of a neural network, there a hundreds of (thousands of) degrees of freedom you can tweak to alter the output. Could change it by tweaking synaptic vesicle exocytosis/kiss-and-run proportion, or release of Ca from internal stores, or a 2nd messenger concentration, or a co-transporter, or the neural membrane resistance, or voltage gated Nav1.2 concentrations, or axonal arborization, or gabaergic interneuron growth, or....

At the current DUI level of categorization, you're not actually fixing the problem facing the patient; you're just tweaking some shit which makes the output signal look sorta alright in some conditions. But don't shake the TV, it'll get all fuzzy again.

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I hope, with these entri... (Below threshold)

June 21, 2010 2:58 AM | Posted, in reply to Jim's comment, by Anonymous: | Reply

I hope, with these entries, that you're laying the groundwork to establish the need for your forthcoming overhauled fundamental model of psychiatry and not just telling us "This whole field is fucked and that won't change anytime soon."

(1) The DSM is fucked. And (2), he basically gave you the yellow-brick road:

The problem is information. As we gain a more fine-grained understanding of the neural systems underlying the problems, the DSW and it's ridiculous diagnostic catagories are "going to disappear, replaced by thirty other more specific diagnoses."

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What I find missing in this... (Below threshold)

June 21, 2010 1:55 PM | Posted by Anonymous: | Reply

What I find missing in this analysis is the factors that, for lack of a better word, "breed" this schizophrenia you speak so eloquently about.

In the field of genetics/genomics/genetosynthesis, how is it that certain genes find themselves expressed? Several commentators hinted at the biological events, etc, that lead to such instances of neurologically fucked output, but given the vast historical and medical empirical evidence for the 'disease', what specific modes of development cause this all encompassing super-disease?

Military training? Religious dogma purported as infallible truth? It would seem to me that any form of authoritarian regime that convinces a population of the regime's infallibility has thus created an atmosphere wherein the conflict of internal motivation with external factors breeds a crossed internal reference system.

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Beware of what you label, i... (Below threshold)

June 21, 2010 3:14 PM | Posted by crazybabydoc: | Reply

Beware of what you label, it may prevent you from thinking about it.
Art Aylsworth

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Like an anonymous commentat... (Below threshold)

June 21, 2010 4:50 PM | Posted, in reply to Anonymous's comment, by Andrew: | Reply

Like an anonymous commentator that infallibly knows exactly where to look for the causes and symptoms?

Before you define authoritarian, you need to define regime.

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Anonymous - I've got to won... (Below threshold)

June 22, 2010 8:40 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Anonymous - I've got to wonder if you actually know anyone suffering with schizophrenia....it's all fine to talk about authoritarian regimes and political science and theories but it really doesn't have that much to do with the reality of schizophrenia for people actually trying to live with brains that tell them that their own thoughts are coming from some external supernatural being that is controlling them, and who have a very hard time distinguishing what is real from what is imaginary, and whose overactive pattern seeking can create highly personalized, paranoid conspiracy theories. Schizophrenia certainly seems to have a social/environmental component but it's also a result of biology and is an extreme expressions of traits that are highly useful and functional when not expressed as an extreme (the same is true of autism). None of these traits are considered problematic until they start to interfere with someone's ability to function and navigate the world, and look after themselves and be self responsible.

Yes schizophrenia is a construct, so are all ideas and all culture. Is it a useful construct? Certainly more useful than the idea that people who are suffering from schizophrenia are talking to god or the devil and are the agents of the supernatural that should be sainted or demonized. Any alternate ideas you have about people who are schizophrenic are no less a construct than the construct created by psychiatrists so they can discuss and try to understand what is going on with people who manifest the behaviors and experiences of people suffering from what we have come to call "schizophrenia".

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So many of these ignorant p... (Below threshold)

June 29, 2010 8:18 PM | Posted by Anonymous: | Reply

So many of these ignorant posts are clearly from individuals who have never worked with people suffering from schizophrenia. The man wandering naked in the street muttering to the voice inside his head. The college girl locked in her room starving herself because the conspiring people outside want to poison her. The homeless elderly man laying shoeless in an alley with nowhere to go and no way to ask for help because he can't remember what he wants or how to ask for it.
These individuals are brought to psychiatric services and a week later are going home with a family member because antipsychotic medication, crude an instrument as it is, calmed the ascending dopaminergic tract and restored better (though not perfect) neurological function.
To those who criticize the crude instruments of psychiatry, you clearly haven't lived or worked with a schizophrenic person who is on, and then off, his or her meds. If you did you would certainly know that the illness is real, and that psychiatry has things to offer that nobody and nothing else can replace.
By the way, the people doing psychiatric research into neurobiological functioning in mental illnes aren't usually psychiatrists at all, but rather PhDs and neurologists who still don't know two shits about what causes schizophrenia. So much for them solving the mysteries of mental illness and curing the world.

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So, what if the guy never s... (Below threshold)

July 1, 2010 11:57 AM | Posted, in reply to Philip's comment, by John: | Reply

So, what if the guy never smoked?

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the concept of demon posses... (Below threshold)

July 21, 2010 2:30 PM | Posted by allo: | Reply

the concept of demon possession is seemingly absurd in today's Godless cosmology, but a Godless cosmology is what comforts people today. people believe they are unique and in control of their lives. people believe they are responsible for their success and failures fucked up and got what they had coming to them. all of these world-views may satisfy the requirements of social function today, but the relative functioning of the entire social system does not necessarily correspond to the reality of the way things are/work.

the underlying premise of the prevailing economic system is that people act in their own economic best interests. this is immediately falsifiable because people act in their perceived best interests which all too frequently manifests as something that wasn't in their best interest. to put this into context, many americans (western civilization) born in the 1950s have accumulated a lot of "wealth." i am defining wealth in the contemporary description as money and assets. the 50s generation believes their economic success is the product of their post-secondary education that their labor-peers did not receive and the natural consequence of their brilliance. on the contrary, the 50s generation has merely ridden the massive credit expansion and anyone who owned any assets during the past 30 years has benefited from the secular trend. the 50s generation has no idea what the bretton woods agreement was in name or in effect. the 50s generation just believes that they are better. the 50s generation does not realize that all money is debt and that their wealth is every bit as abstract as a ghost, but nevermind the abstract of debt-money as the diagnosis of their social status is that they are smarter and better than other generations and the purchasing power illustrates this plainly. this distortion between the 50s generation's perceived greatness and their historic "averageness" is in the process of being exposed regardless of whatever action is taken to perpetuate their delusion.

the fact remains that someone speaking on a cell phone 200-300 years ago would have been burned at the stake for being a witch. talking on a cell phone or sending any kind of communication wirelessly is an everyday event. there is absolutely nothing supernatural in today's world-view about wireless communication. before tesla, wireless communication would be understood and quantified in the context of supernatural phenomena. this is in spite of the fact that nothing about our physical world has changed in the past 300 years to enable wireless communication. wireless communication was possible thousands of years ago, but people just didn't understand how the world works as much as today's people.

coming back full-circle to the demon possession i think much caution needs to be lent to how we relate to the concept. humans are very self-important and perceive existence through the human-centric perspective. this is laughable as humans have absolutely no understanding of consciousness. we take for granted how easy it is to store and share information today because we are a computerized society, but before the 20th century we did not have the benefit of such information processing and storing technology. pythagoras was no-doubt a brilliant man, but he did not believe in zero, negative numbers or the concept of infinity. in his day pythagoras was perceived to be as smart as it gets and his world-view/cosmology with the earth at the center of the universe was embraced.

we experience life through a physical plane. anything that occurs has biological manifestations, so it is completely unremarkable to discover physical processes. if consciousness is merely a physical/electrical process than i would like to hear arguments as to why, if we unlocked the properties/process of consciousness, we couldn't live an infinite life within a wireless information system.

in summary, is master chief (halo) aware of the fact that he doesn't control any of his actions?

this is not an appeal to come to Jesus, but it is an appeal to keep an open mind and just remember what a bunch of ignorant people we are.

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Hey,I love the com... (Below threshold)

August 1, 2010 3:44 AM | Posted, in reply to Anonymous's comment, by Sara: | Reply

Hey,

I love the comment from June 18 that contains a psychiatry-style description of diabetes. I would like to quote that in a blog post on my website. If Anonymous is still here, can you reply and let me know if I may quote you?

Thanks,
Sara

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The straw man parade is imp... (Below threshold)

August 1, 2010 3:59 PM | Posted, in reply to Sara's comment, by Anonymous: | Reply

The straw man parade is impressive. Psychiatry and neurology started as a common discipline (neuropsychiatry) and continue to share a board to this day. Only the ignorant or woefully ill-informed would attempt to separate the mind from the brain. 'Anonymous' sophomoric rant demonstrates the dangerous nature of the latter . . . a person that knows just enough to be misguided by their biases (often confirmation bias). I won't defend the excesses (and frivolities) of psychiatry but instead let's look at a somatic condition (diabetes) that's REAL as opposed to psychiatric conditions which are (not?).

Why did we change the names? It used to be juvenile, childhood-onset, adult-onset, mellitus, etc. We did keep gestational though. Kinda sounds like all of those were just descriptions without telling us anything substantive about pathophysiology or treatment. But that is NOT novel in medicine. It's a fairly recent phenomena that we stopped the nonsense of naming conditions after the people that first DESCRIBED them. Further, the very nature of differential diagnosis is a function of knowledgeable predecessors noting multiple inputs can lead to common symptomatic outputs. Our specificity (and sensitivity) improved with time and technology like most human endeavors.

Effective diabetes (insulin-related) treatment is less than 90 years old but Anonymous would have rightfully been labeled an imbecile in the early 20th century if s/he described diabetes mellitus as "not a real disease because it's just a description of walking with your legs apart and honey-like urine."

For anyone that wants to REALLY learn something about the history of medicine, read virtually anything by William Osler, arguably the father of modern medicine.

--
"The 19th century has witnessed a revolution in the treatment of disease, and the growth of a new school of medicine. The old schools - regular and homeopathic - put their trust in drugs, to give which was the alpha and omega of their practice. For every symptom there were a score or more medicines - vile, nauseous compounds in one case; bland, harmless dilutions in the other. The characteristic of the new school is firm faith in a few good, well-tried drugs, little or none in the great mass of medicines still in general use."
---

Anonymous does submit at least one useful tidbit. "If we knew more about pathophysiology, every psych illness would have a medical diagnosis to explain the psychiatric diagnosis (symptom description)." Anonymous is wrong in presentation but there's merit in part of the premise. Yes, if we knew more about the pathophysiology of psychiatric illnesses we would be able to explain the symptoms. But isn't that true about all of medicine?

What Anonymous fails to understand is that psychiatric illness (schizophrenia, bipolar, depression, anxiety) can exist without an identifiable underlying somatic illness in exactly the same manner as somatic illness (VCFS, Parkinson dz, epilepsy, hepatitis, diabetes, mitral valve prolapse, hyper/hypothyroidism) can exist WITHOUT psychiatric sxs.

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It may very well be that so... (Below threshold)

August 1, 2010 9:13 PM | Posted by R. Kevin Hill: | Reply

It may very well be that some of the things we regard as psychiatric illnesses will be found to be neurological illnesses: point for Diabetes Guy. But it is also the case that some things we regarded as psychiatric illnesses will come to be regarded as social prejudices against patterns of conduct once disapproved of but subsequently no longer (replace the "psychiatric" account of diabetes with the old psychiatric account of homosexuality). And to confound matters, unless some conduct has magical, Cartesian causes, presumably formerly socially disapproved of conduct (or subsets of it) correlates with neurological stuff which differs from the neurological stuff that correlates with formerly more exclusively approved of conduct.

So there's a big, messy problem here, and it is due to the fact that psychiatry is unusual in that most of its "symptoms" are *conduct*, and while it is in some sense straightforward to say that oily black vomit doesn't look like the sort of thing that is supposed to come out of mouths, what about socially unacceptable speech? Where is the model for "healthy, normal" speech going to come from?

Now I am certainly not denying that there are neurological diseases, nor am I denying that *some* psychiatric illness models/descriptions/symptom-criteria will be replaced by more straightforwardly neurological ones (though I have *not* interacted with a schizophrenic, I have had the experience of interacting with someone undergoing a slow neurodegenerative process, and observing how in the early stages this was misunderstood by family as conduct to be assessed in moral/social terms, more precisely, misconduct, so I fully appreciate the limits of a kind of global Szaszian skepticism). But as long as you have a branch of medicine which regards socially meaningful conduct as medical symptom, you're going to be entangled with more than merely biological normativity, and your classifications, diagnostic criteria, etc. will be inevitably, as we pomo philosophers say, a site of contestation. Rather than figure out who is right, the Szaszian skeptics, the neurological reductionists or the traditional psychiatric types, I think we should just realize that this is an interminable discussion in which there can't really be any winners except in specific cases, and there, perhaps only temporarily.

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Psychiatric disease is diag... (Below threshold)

August 7, 2010 12:07 AM | Posted by Anonymous: | Reply

Psychiatric disease is diagnosed by the clinical manifestations of the disease, just like most anything else in medicine, rather than by the underlying pathology, and the interventions are similarly targeted at reversing the output of the dysfunctional organ system and not the underlying pathology.
A diagnosis of diabetes type 1 is made based upon...serum glucose levels. It is often identified by clinical symptoms such as polydipsia and polyuria. The diagnosis is NOT based upon whether or not an autoimmune destruction of pancreatic islet cells is established. And interventions are NOT designed to fix the underlying problem, which is autoimmune assault on the pancreas, but rather to replace the end output of that organ, which in this case is insulin. Once the insulin is replaced the other physiologic processes dependent on normal glucose levels can continue to function adequately.
In schizophrenia we are similarly NOT going to make a diagnosis based upon established over-activity of the ascending dopaminergic tract or hypofrontality. Instead we look at the clinical symptoms, the output of the diseased organ system. The difference between schizophrenia and diabetes is that the organ system in the former is inestimably more complex. Regardless, we still intervene in a similar way: we try to reverse the end output of the diseased organ system. In the case of the pancreas it is glucose metabolism, in the case of the mind it is perception, sensation, thought, and behavior. We do this in multiple ways, trying less invasive means in the case of supportive therapy or more invasive in the case of dopamine and serotonin antagonists. Either way we seek to alter the end output of the diseased organ, the clinical manifestation, and we do not attempt to alter the underlying pathology which we do not yet really know how to do.
In diabetes and schizophrenia, we'll keep doing our best until we have better solutions but for now out imperfect interventions will have to suffice.

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I'm at the tail end of stud... (Below threshold)

January 31, 2011 4:40 AM | Posted by Rookie: | Reply

I'm at the tail end of studying in psychology and earlier in my training I wrote a court report which suggested a guy met diagnostic criteria for ADHD. My supervisor pulled me up on it and told me to quit diagnosing and just identify the key behaviours/symptoms. She told me to think more like a psychiatrist, as any decent psychiatrist just treats symptoms, not diagnoses... I get what she meant now.

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People diagnosed with any s... (Below threshold)

June 22, 2011 6:12 AM | Posted by AMH: | Reply

People diagnosed with any sort of mental illness understand your post implicitly. I mean, yes: diagnostic categories say zilch about what's going on in the brain. Worse: they foreclose any possibility of going beyond the label to figure it out. Being mentally ill means you dwell in a staggering amount of possibility and uncertainty. And hey, I've read my Heidegger (the forgetfulness of disclosure and all that jazz).

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Thank you! The content is e... (Below threshold)

August 18, 2011 10:25 PM | Posted by cheap jewelry: | Reply

Thank you! The content is extremely rich.

cheap jewelry

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I agree with much of the ar... (Below threshold)

October 23, 2011 2:08 AM | Posted by Marie Gronley : | Reply

I agree with much of the article in that most of our mental illnesses are borderline issues of taxonomy or "naming a bundle of behaviors or symptoms". I would like to make one comment that might be a digression and that is the reality of the auditory, olfactory, or visual hallucinations that someone with psychosis experiences. To then these illusions they see, smell or hear are just as "real" as what we experience. I base this on a theory of perception called "representative realism" which states that we as humans cannot perceive the world as it is "intrinsically". As an example, suppose you see a red apple on a coffee table, well first off, color has no existence apart from a triangulation with light, the rods and cones in our eyes, and some quality of the molecules that provide an unknown causal connection to the degree that when our senses and minds are presented with these molecules we see the red apple. (by the way color has no existence apart from sentient beings who have the ability to interpret light waves as what we call color).

So this causal connection between the image viz. the apple which our mind sees is what gives a positive truth value to the proposition "There is a red apple on the table in front of me". Now here is where it gets interesting. To a psychotic person they may see an apple on the table and it is EVERY BIT as real in appearance to them as it would be to us; however, there are no molecules that posses this causal relationship with the image to ground it in reality.

The whole point of this is that when a psychotic person sees, smells, or hears something, it is usually not some wacky martin from space but rather an image-only one that does not have a causal relationship to a cluster of atoms or molecules. This is why it is so very difficult to convince someone with schizoffective disorder, or any form of psychosis that what they see isn't real because to a certain degree; it is real, it just lacks the causal relationship, that gives a correspondence to what their mind perceives and what is in the extended world. Of course this is one of many theories of perception however one that seems to do an adequate job of explaining the mediation between the mind and the extended world and how things can go askew. Forgive me for digressing too far but the post seemed to go in many directions and I thought this comment would be of value to working with someone with psychosis and understanding the challenge of demonstrating the difficulty of teaching them to discern what is real from what is illusion. I will close with Descartes: "I think therefore I am". All we can really prove with certainty in life is that we exist since we have thoughts!

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Dr. Gronley I visited your ... (Below threshold)

November 4, 2011 11:19 PM | Posted by John Smythe: | Reply

Dr. Gronley I visited your site at http://psychiatristscottsdale.com and enjoyed reading the complete article on your views of epistemology and perception. If we don't hold to naive realism you are correct, there is a very thin line between reality hallucination. A bit deep for most to understand and questionable that the article will prompt more questions versus answers, yet very true and a pleasure to read for the student of metaphysics.

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Great post , Thank you for ... (Below threshold)

January 21, 2012 2:17 AM | Posted by Riversidedental : | Reply

Great post , Thank you for writing so well on such a difficult but important subject. It was really helpful to solve my confusion,

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Thanks for the post. The su... (Below threshold)

January 21, 2012 2:20 AM | Posted by Pilot Medical: | Reply

Thanks for the post. The subject is very unique,
It was really helpful to solve my confusion.

Occupational Medicine

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Great post,Keep on w... (Below threshold)

January 21, 2012 2:23 AM | Posted by Medcal transcription company: | Reply

Great post,
Keep on writing such stuffs.
I will be keeping track of your next one.

Medical Transcription Company

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I wish you'd write more abo... (Below threshold)

March 4, 2012 6:07 PM | Posted by Anonymous: | Reply

I wish you'd write more about schizophrenia. I had that diagnosis one time. I still have MDD with psychosis; I don't feel depressed, I mean we'll see how it goes, but...and the psychosis is extremely mild, even pleasant, barely around. I can see, with increasing clarity, that getting sick served many purposes, at that time; you can't tell me that the mental illness one gets is irrelevant, the schizophrenia served me well, for a while. (Among other reasons, it gave me pills to take and some kind of recognition that *something* was majorly wrong, so I got some TLC and also awknowleged it was time to do therapy). (It was also a distraction from my trauma history). I've been off antipsychotics since November, I've had many periods of time when I've been off them with no psychotic symptoms. Also, they don't work; I still have hallucinations and delusions on them (and I've been on four of them). I want off for a while, see how it goes, plus I'm sick of seeing 'non compliant' on my medical paperwork. But I'm having to fight to try to get this to happen, right now, and I don't know what the outcome will be. It's pretty scary for me. I've been labeled and the label is sticking. Oh yeah, and, I am in some kind of therapy 5 days a week, right now. So I'm compliant, I'm trying to get help. I'm just sick of the antipsychotics.
Sorry- I ranted.

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Professor Kurt Audenaert (a... (Below threshold)

May 19, 2013 11:52 AM | Posted by Bruce Graeme: | Reply

Professor Kurt Audenaert (a Belgium psychiatrist, working for the State University of Gent) claims that he knows what causes schizophrenia !

Humans, he wrote, dispose of an intriguing part of the brain, the prefrontal lobe, which allows us to filter the many sensory stimuli entering the brain.

Professor Kurt Audenaert argues that there are neuropsychiatric disorders (paranoid schizophrenia) in which the prefrontal lobe is unable to respond adequately to sensory stimuli, so that the filter function fails.

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My overall considered judge... (Below threshold)

June 2, 2013 11:26 AM | Posted by Bruce Graeme: | Reply

My overall considered judgement is...

• that the independent evidence for
somatic causes as the only, or even
the main non-hereditary factor in
schizophrenia is not sufficient

• that the many findings of MRI and
fMRI changes in schizophrenia does
not make any difference with
respect to this issue

– that any judgement to the effect that schizophrenia is due to
heredity plus somatic (organic) factors is premature

– that a confusion with the obvious fact that schizophrenia has a
biological basis may contribute to such a premature judgement

– that the search for a psychogenic contribution has to be continued

– that schizophrenia is probably a partly sociogenic brain disorder

http://www.phil.gu.se/posters/schiz_Leiden.pdf

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Paralleling how we recogniz... (Below threshold)

June 9, 2013 1:15 AM | Posted by Video: | Reply

Paralleling how we recognize animals and illnesses was hilarious. Heard it before, but you do it so well.

Re diagnosis I guess a consequence of your view is that they are based on a shared experience; in some form you need to have seen/experienced the symptoms in order to truly understand the corresponding word(s).

How do we know what a chair is?

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