June 20, 2007

Dr. Nasrallah Asks Questions That No One, Including He, Wants Answered

But I'm going to try.

His editorial appears in the journal Current Psychiatry, of which he is the editor.  I respectfully disagree.

  • Why did TV commentators assume the crime was caused by “evil” and “psychopathy,” instead of a medical illness in a young man with many psychiatric manifestations?

Because that’s the logical assumption.  The two are not mutually exclusive as implied by the question, and, while "evil" and "psychopathy" are attributions, medical illness requires a basis in pathology.  Commentators could not have known whether or not he was medically ill, nor if this illness had anything to do with the violence, but it is definitional that the act was evil.

Reversing the question reveals the fault in logic: why didn’t commentators assume he was mentally ill?  Is that the default assumption in the absence of evidence?


  • Why do most people assume that a psychotic individual driven by delusions is too “incompetent” or “confused” to plan and carry out a complex series of deadly assaults?

Does anyone assume this?  This is a straw man argument.  What is really being asked is: why do people assume that if the attack was complex and deadly, it had to be done by an evil mastermind, not a psychotic person?  And no one assumes that, either.  The question is sleight of hand; it tries to make the issue binary, psychosis vs. evil.  The two are not necessarily correlated in either direction (right?)  

As above, reverse the question to see the logical flaw: should people assume that complex, deadly attacks are the work of someone who is psychotic?   Is psychosis—or, indeed, any mental illness-- a risk factor for extreme violence?  That doesn't bode well for a society with "25%" mentally ill, as  claimed below.


  • Why did the mentally ill student receive no follow-up care before the crimes, even though he had received psychiatric treatment?

Perhaps he didn’t want any follow-up care?  I know: “but look what happened!”  Perhaps we can envision a scenario where a group of experts make a judgment about someone’s dangerousness in the absence of a crime or any concrete evidence (which would allow ordinary legal channels to be used), and then can commit, or restrict this person’s freedom, until they are no longer considered dangerous.  We already have this: it’s called Guantanamo.  And before you say there’s a difference, let me assure you there is not.  Quis custodiet ipsos custodes?

(NB: the context of the quote by Juvenal has an interesting parallel: it is about enforcing morality.   “My friends always tell me, lock her up! Restrain her! But who watches the watchmen? The wife will then start with them...”)

Several issues are being mashed together to extract the favored response, “we need better mental health care.”  But it's not valid.  If a psychiatric patient commits murder, he goes to jail. If you have good reason to suspect he is about to murder, you commit him. If you feel he is about to murder, but do not have enough evidence to commit him, you contact whomever is necessary (potential targets, etc).  And if he is a student, you tell the administration so they can put him on temporary leave.  

This is key: it is morally wrong, not to mention illegal, for a psychiatrist to force a person to get treatment he does not want.   But it is entirely legal, and desirable, for a school to insist that a person receive treatment as a necessary condition of returning to the school— if and only if there exists a risk towards others.


  • Do medical record requirements in the Health Insurance Portability and Accountability Act (HIPAA) protect individual privacy at the expense of public safety if a patient is seriously mentally ill?

No; did any one say they did?  If we have reason to suspect imminent risk of harm to self or others, we have multiple avenues/obligations to deal with the situation, confidentiality and privacy be damned.  In fact, if psychiatrists simply feel a person is dangerous in the absence of any concrete evidence (direct threats, storing weapons, etc), they can “violate” the patient’s (constitutionally non-existent) right to privacy.  They can tell anyone they need to—the school, parents, whomever.  What psychiatrists can't do is lock them up or commit them, or force them to take drugs, just based on their “feeling,” without a solid reason.  And thank God.


  • If the university administration had known about the student’s psychiatric disorder, would he have received better treatment and supervision? Or would he have been stigmatized or expelled, whether or not he responded well to medications and counseling?

What, exactly, is meant by “psychiatric disorder?”  Schools don’t expel people because they have a mental illness; they expel them because they are dangerous to have on campus.  If Cho had been determined to have been dangerous—regardless of the cause, whether it be mental illness, drugs, or Satan’s direct influence, why shouldn’t he be at minimum suspended? (This is very different than being suspended simply for having a mental illness.) 

I’ll repeat: it's not discrimination because he has a mental illness; it's discrimination because he is thought to be dangerous, regardless of the reason.

We can’t force him to get treatment, but neither do we have to tolerate his Oddboy, knife wielding nonsense.  Being on campus is a privilege, not a right.  He either stops, gets treatment, gets a girlfriend, whatever-- or he gets off campus.

  • How can roommates or teachers receive adequate information to help a mentally ill student or monitor for treatment adherence when HIPAA rules prevent even families from knowing details of mentally ill adults’ diagnosis or treatment?

I’m not sure how many different ways this question is wrong, but six is a fair guess. Why should roommates receive any information? (Or, if things are so bad that they should be receiving information about the person’s mental state, shouldn’t someone else be involved?)  Is the dissemination of information for the benefit of the patient, or the protection of everyone else?  It's different information.  Why is it roommates’, or teachers’,  or the schools’ responsibility to help monitor treatment adherence?   If they are “helping” monitor for treatment adherence, are there any repercussions for failing to do this? 

This is the creep into a custodial society, the social consciousness flip side of Bush style privacy violations.  I know it looks like we want this; I swear to you we don't.


  • Because the home-to-college transition can be very stressful, should colleges require freshman courses on how to recognize distress and seek help?

My head just detonated.   How many credits will this be worth?  Is there a test?


  • Given that schizophrenia, bipolar mania, and psychotic depression often emerge between ages 18 and 25, why have colleges and universities not adopted early screening and intervention?

Because they are colleges, not health maintenance organizations.   They don’t screen for pregnancy, STDs, lymphoma… By the way, if the university administration did screen for students’ psychiatric illnesses, are you obligating intervention?  If the student refuses, then what?  Expulsion? 


  • Are mentally ill persons more dangerous than the general population, or is that perception based on highly dramatized media reports of isolated incidents?

This question should have been asked first.  If they are more dangerous, then this debate is really about screening for mental illness as a risk factor for violence.  It means that it is ok to expel people for having a mental illness; for more aggressive commitment and supervisory maneuvers; for, well, Kansas v. Hendricks.  If you want to go down this road, good luck, I’ll wait for you in Russia.  But if they are not necessarily more dangerous, then most of your other questions are moot; we should be treating mental illness, not violence; and we should be dealing with violence as violence, not as the inconvenient symptom of mental illness.


  • When will health insurance cover brain diseases that manifest as thought disorders or behavioral aberrations, such as schizophrenia or obsessive-compulsive disorder, in parity with brain diseases that manifest as muscle paralysis, such as stroke or multiple sclerosis?

When you can show that they are diseases, not heuristic labels of behaviors.  Schizophrenia is easy; what about ADHD?  Should it be covered in parity with strokes?  Asked another way: given finite resources, are they better allocated towards the treatment of strokes or ADHD?  I’m not making a moral judgment, I’m asking about practical outcomes.  Do you get the same outcome for your dollar in ADHD as in strokes?


  • Given that >25% of the U.S. population has a diagnosable and treatable mental disorder, why is our mental health system so fragmented, so inadequate, and so underfunded? And why is there no public outcry to fix it?


25% have a diagnosable mental disorder?  What definition are we using here?  If we are talking about the DSM, then does voyeurism count?  (NB: I refuse treatment.)

As evidenced by this editorial, more and more behaviors are classified as, or at least taken as prima facie evidence of, mental disorders.   Following, it is a simple exercise to determine that, in fact, 100% of people have a diagnosable mental disorder.  100% of people have a medical disorder as well, if it includes the disorder “pain.” 

It’s sleight of hand.  Psychiatry can help these 25% (or 100%), regardless of whether they really have a “disorder” or not.  But that doesn’t identify them as necessarily the realm of medicine or psychiatry.  This is the "mission creep" of psychiatry-- away from biology, as it claims it relies upon, and towards an instrument of social change.  Perhaps it can tackle poverty, globalization, and terrorism next?  Furthermore, labeling (not discovering-- labeling) something as a psychiatric disorder is done to imply exclusivity: e.g. if it "was" mental illness, than it wasn’t evil.  People will dispute me on this, but re-read this editorial, its point is exactly this distinction.


  • Finally, as a parent and husband, I have one last question: how can we console the bereaved families of the Virginia Tech students and faculty who suddenly lost a son or daughter, husband or wife in the prime of life?

One way would be to not reduce what happened to the simple result of an untreated illness.  “If only he had been in treatment.” Really?  Is that all it takes?


  • For them, improvements in mental health care on our college campuses will come too late.
And for the rest of us, these "improvements" come perhaps too soon.



This page has the old dread... (Below threshold)

June 22, 2007 2:26 AM | Posted by Robert: | Reply

This page has the old dreaded diagonal dark-grey lines background - very hard to read.

Congratulations on fixing your main page, but subsidiary pages need the same treatment!

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"This is key: it is morally... (Below threshold)

June 25, 2007 5:27 AM | Posted by Douglas Cootey: | Reply

"This is key: it is morally wrong, not to mention illegal, for a psychiatrist to force a person to get treatment he does not want. But it is entirely legal, and desirable, for a school to insist that a person receive treatment as a necessary condition of returning to the school— if and only if there exists a risk towards others."

Great points. Couldn't agree more.

"Because the home-to-college transition can be very stressful, should colleges require freshman courses on how to recognize distress and seek help?"

Is this guy serious? Most people I know are lousy at self-analysis, never mind delusion psychopaths bent on murder and destruction. Even if Cho, for example, had taken such a class, who is to say such a class would have caused him to change any of his actions?

"we should be treating mental illness, not violence; and we should be dealing with violence as violence, not as the inconvenient symptom of mental illness."

Another excellent point. Many people who responded to my article on Cho saw a separation between Depression and violence despite what the media seemed to be pushing. Others, however, seemed to confuse the issue with their own issues. It seemed they felt that any attack on Cho was an attack on them, so they became vociferous in his defense, despite his despicable acts. There was more sympathy for Cho than the victims of his actions. I was simply stunned.

"One way would be to not reduce what happened to the simple result of an untreated illness. “If only he had been in treatment.” Really? Is that all it takes?"

Again, I heartily agree with you. There is an arrogance in the psychiatrist field that they can fix all of society's woes if they but only had the opportunity and trust to do so. Cho's actions have been relegated to an aberration of a psychiatric disorder left untreated, as if all he had to do was visit one of them and he'd be happily medicated ever after. But what of free agency and choice? What about Cho's decisions to revel in his hatred? Why is it so hard for them to accept that maybe Cho chose to kill for pleasure or glory? Instead, they see this as an opportunity to pimp themselves as the saviors of society. And the media buys it lock, stock, and barrel.

The Splintered Mind - Overcoming Neurological Disabilities With Lots Of Humor And Attitude

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Thank God that there is at ... (Below threshold)

June 25, 2007 10:46 AM | Posted by JC: | Reply

Thank God that there is at least one other person with the capacity for critical thinking in psychiatry and psychology! Articles like those by Dr. Nasrallah frighten me.


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Are the numbers of people i... (Below threshold)

June 25, 2007 10:47 AM | Posted by JC: | Reply

Are the numbers of people in psychiatry and psychology who have the capacity for abstract thought so few? Articles like those by Dr. Nasrallah frighten me. Hopefully someone else is reading . . .


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Personally I believe that t... (Below threshold)

February 20, 2008 8:22 AM | Posted by redfairy: | Reply

Personally I believe that the actions of a "mentally ill" person are so hard for people to understand or believe, that their actions are dismissed by law enforcement until they commit a crime which cannot be ignored. I have been on the receiving end of a "mentally ill" persons tirade for the last six years. I have reported every incident to the courts, and law enforcement, yet even with emails from this "mentally ill" person clearly stating that she will never leave me alone, and watches every thing I do, law enforcement cannot or will not stop her. The last six years have envoled many court battles, and nothing to stop her. I cannot get a restraining order, because there are no clear threats to my life. The only threat, according to the courts, is that she will continue to harass me for the rest of my life. She has admitted in court that she is mentally ill, and taking a number of anti pyscotic medications, along with Adderall, prozac, and seroquil. I have been advised by law enforcement,and the state courts to change phone numbers, move and avoid all contact. When I did this, she went to court and filed charges against me. On the day of court, speaking to the Judge she admitted they were all lies, and that her purpose was to just get me into court. Again I asked for an order of protection, and was denied. ?????
Law enforcement and the court system, along with everyone who has not had the misfortune of dealing with the mentally ill, must realize these are not stupid people. They know exactley how far they can go without getting into trouble, until they snap. I live everyday of my life wondering what she will do next. Over the last year, when I call the police to report harassment, they are amused. It is funny to them now, the way they see it, she has been doing this for so many years, "if she was going to really hurt you she would have done it by now". That statement makes me wonder what will be said when she does attempt to physically harm me. What is left for me to do? How do I protect myself and my family from this woman, who has the protection of being tagged "mentally ill" ?

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Stimulating topic. Medical... (Below threshold)

July 11, 2008 2:45 AM | Posted by bev : | Reply

Stimulating topic. Medical ethics are mind boggling. Here is one mentally disturbed person being psychologically post mortemed in detail. was he legally insane or not? Should he be punished for crimes or not.
This seems to be one of the only times the mentally ill go under the public microscope. Whatever the problem this fellow became a murderer. When I think of the millions of children, families, individuals who suffer from mental illness and could benefit from help it boggles my mind. If they had broken legs or diabetes they would get help and no questions asked. We are still living in the dark ages.

I work with children as a counsellor. Some of their problems are horrific. For instance, a child who is aged seven who has minimal brain damage from shaken baby syndrome. At the time he was diagnosed he was found to have many broken bones, some of which had healed. He is now having dreams about the event. He could go either way at this point I think. He could become an offender or a survivor. He needs lots of help now.

For some reason there is little done to help disturbed children. As a society we wait until they hit the prisons before they are helped. I find it hard to understand. we still treat children as if they don't have huge personalities. They are reachable when young.

There is a code of silence in the counselling and psych. fields. There is so much pain and suffering that goes on and yet people are not willing to talk about it or to listen.

I watch lots of commercials about helping dogs and solicitations to help abused animals but no one talks about the chidren. It is almost like a conspiracy of silence. I know lots of professionals don't want to criticize where they work because of already pitiful funding but it is about time someone made a sound.

This blog is a good start.

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I was diagnosed with level ... (Below threshold)

May 13, 2010 6:37 PM | Posted by BSW: | Reply

I was diagnosed with level 3 paranoid schizophrenia several years ago and since have acquired my bachelor's degree. I researched enough about the disease to know that it is mind over matter. No matter how frightened I was or insecure, paranoid; I was still able to feed my mind enough new information to overwhelm the psychotic symptoms into remission and successfully complete a 4 year degree in 3 and between the ages of 35-38. During this time I had numerous paralyzing migraines and was able to pin point triggers that caused the nuero-transmitters in my brain to react and evoke my disease. By eliminating those triggers from my life I have been able to control my schizophrenia.

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