Friday, June 22, 2012

The modern psychiatric diagnosis: DSM

This was an interesting NY Times op-ed about the DSM, its origins, and questioning its continuing role in society, written by a former contributor to the DSM.

I was heavily involved in the third and fourth editions of the manual but have reluctantly concluded that the association should lose its nearly century-old monopoly on defining mental illness. Times have changed, the role of psychiatric diagnosis has changed, and the association has changed. It is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy.

Psychiatric diagnosis was a professional embarrassment and cultural backwater until D.S.M.-3 was published in 1980. Before that, it was heavily influenced by psychoanalysis, psychiatrists could rarely agree on diagnoses and nobody much cared anyway.

D.S.M.-3 stirred great professional and public excitement by providing specific criteria for each disorder. Having everyone work from the same playbook facilitated treatment planning and revolutionized research in psychiatry and neuroscience.

Surprisingly, D.S.M.-3 also caught on with the general public and became a runaway best seller, with more than a million copies sold, many more than were needed for professional use. Psychiatric diagnosis crossed over from the consulting room to the cocktail party. People who previously chatted about the meaning of their latest dreams began to ponder where they best fit among D.S.M.’s intriguing categories.

The fourth edition of the manual, released in 1994, tried to contain the diagnostic inflation that followed earlier editions. It succeeded on the adult side, but failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children that has since occurred.

Indeed, the D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts.

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.

Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role.

There were a couple things I thought this this piece did a good job of illustrating.  First, that the history of the DSM wasn't Allah speaking directly to his prophet who then immortally inscribed these truths into the first issue of the DSM, but that it was largely just an attempt to assemble what most people thought about things out of the primordial ooze that was mainstream psychology as recently as a few decades ago.  Second, that despite these somewhat inauspicious origins, most people believe the word of the DSM like it is the bible, including decisionmakers like courts and legislatures.  Third, that there will never be a perfect DSM because of fundamental disagreements and the accompanying political machinations amongst the experts that write it.  So, in a word, the DSM is not the most reliable system in the world.

The conclusion:

Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots.

Thursday, June 21, 2012

Sociopaths in literature: Interview with the Vampire

I was given Interview with the Vampire by a friend and have been reading it over the past year on airplanes.  I was not surprised to see many parallels between the vampire protagonist and sociopaths.  I thought before I finished the book and discarded it in the seat of my next plane, I might share some passages that I thought were particularly relevant, like this one:


"Babette, the way you speak of her," said the boy. "As if your feeling was special."
  
"Did I give you the impression I could not feel?" asked the vampire.
  
"No, not at all. Obviously you felt for the old man. You stayed to comfort him when you were in danger. And what you felt for young Freniere when Lestat wanted to kill him . . . all this you explained. But I was wondering . . . did you have a special feeling for Babette? Was it feeling for Babette all along that caused you to protect Freniere?"

"You mean love," said the vampire. "Why do you hesitate to say it?"
  
"Because you spoke of detachment," said the boy.
   
"Do you think that angels are detached?" asked the vampire.
  
The boy thought for a moment. "Yes," he said.
  
"But aren't angels capable of love?" asked the vampire. "Don't angels gaze upon the face of God with complete love?"
  
The boy thought for a moment. "Love or adoration," he said.
  
"What is the difference?" asked the vampire thoughtfully. "What is the difference?" It was clearly not a riddle for the boy. He was asking himself. "Angels feel love, and pride . . . the pride of The Fall . . . and hatred. The strong overpowering emotions of detached persons in whom emotion and will are one," he said finally. He stared at the table now, as though he were thinking this over, was not entirely satisfied with it. "I had for Babette . . . a strong feeling. It is not the strongest I've ever known for a human being." He looked up at the boy. "But it was very strong. Babette was to me in her own way an ideal human being. "

Wednesday, June 20, 2012

Living in the moment

I read this NY Times column and thought it was an interesting and hopefully relatable example of how (I believe) sociopaths think most of the time, in terms of compartmentalizing fear and living in the moment.  The author is describing how liberating it feels to ride a bike in busy, traffic-ridden New York because he is plagued by a vague sense of anxiety, but is rather focused and in the moment:


Natural selection has made us hypervigilant, obsessively replaying our mistakes and imagining worst-case scenarios. And the fact that we’ve eliminated almost all of the immediate threats from our environment, like leopards and Hittites, has only made us even more jittery, because we’re now constantly anticipating disasters that are never going to happen: the prowler/rapist/serial killer lurking in the closet, a pandemic of Ebola/Bird Flu/Hantavirus, the imminent fascist/socialist/zombie takeover. The disasters that do befall us are mostly slow, incremental ones that seem abstract and faraway until they suddenly blindside us, like heart disease and foreclosure. So we go about our days safer and more comfortable than human beings have been in five million years, constantly hunched and growling with a low level of fight-or-flight chemicals in our bloodstreams. My doctor assures me that this is the cause of most of our chronic back and neck problems; my dentist says nocturnal tooth-grinding became so endemic in New York after 9/11 it actually changed the shapes of people’s faces by enlarging their masseter muscles. He sells a lot of night guards.

Which is why it’s such a relief, an exhilarating joy, to break the clammy paralysis of worry and place yourself at last in real physical danger. Even though it’s the time when I am at most immediate risk, riding my bike in Manhattan traffic is also one of the only times when I am never anxious or afraid — not even when a cab door swings open right in front of me, some bluetoothed doofus strides into my path, or a dump truck’s fender drifts within an inch of my leg. At those moments fear is a low neurological priority that would only interfere with my reaction time, like a panicky manager shoved aside by competent, grim-faced engineers in a crisis. I doubt that the victims of sudden violent accidents die terrified; they’re probably extremely alert, brains gone pretty much blank while their galvanized bodies try to figure out what to do. I don’t think our minds are designed to accept that there’s no way out. Based on my own close calls, I suspect that if I am killed while biking, the state of mind in which I am likeliest to die is extreme annoyance. And at least it won’t be by drowning.
***
When I’m balanced on two thin wheels at 30 miles an hour, gauging distance, adjusting course, making hundreds of unconscious calculations every second, that idiot chatterbox in my head is kept too busy to get a word in. I’ve heard people say the same thing about rock-climbing: how it shrinks your universe to the half-inch of rock surface immediately in front of you, this crevice, that toehold. Biking is split-second fast and rock-climbing painstakingly slow, but both practices silence the noise of the mind and render self-consciousness blissfully impossible. You become the anonymous hero of that old story, Man versus the Universe. Your brain’s glad to finally have a real job to do, instead of all that trivial busywork. You are all action, no deliberation. You are forced, under pain of death, to quit all that silly ideation and pay attention. It’s meditation at gunpoint.

I’m convinced these are the conditions in which we evolved to thrive: under moderate threat of death at all times, brain and body fully integrated, senses on high alert, completely engaged with our environment. It is, if not how we’re happiest — we’re probably happiest in a hot tub with a martini and a very good naked friend — how we are most fully and electrically alive. Of course we can’t sustain this state of mind for too long. People who go through their whole lives operating on impulse tend to end up in jail. We are no longer purely animals, living only in the moment; we are the creatures who live in time, as salamanders live in fire, prisoners of memory and imagination, tortured with dread and regret. That other, extra-temporal perspective is not the whole reality of our condition. It’s more like the view from the top of the Empire State Building, of people as infinitesimal dots circulating ceaselessly through a grid. Eventually we have to descend back to street level, rejoin the milling mass and take up our lives; you lock up your bike and become hostage to the hours again. But it’s at those moments that I become briefly conscious of what I actually am — a fleeting entity stripped of ego and history in an evanescent present, like a man running in frames of celluloid, his consciousness flickering from one instant to the next.

How does the sociopath accomplish this in daily life?  I believe through extreme compartmentalizing, that actually allows him to quiet all of the mental buzz clogging up most people's neural pathways and hyperfocusing on the moment.

Tuesday, June 19, 2012

Buddhism = healing from a sociopath

More on Buddhism, this time a reader recommends Buddhism as a way to come to terms with a broken relationship with a sociopath:


Well, ME, two and half years post end of sociopathic relationship, I am finally coming to terms with it all.

I'm writing to you because maybe you'll post this and give some guidance to those recovering from a relationship with a sociopath.

Really, Buddhism is the way to go post-recovery.  You need to get control of your thoughts and yourself.  There is no other way.

Buddhism will teach you to let go of all of the anger, resentment, shock, and surprise at their treatment of you.  Meditation will teach you to stop the negative thought spirals implanted by them (and carried on by you, of course).  You must do this with focused effort.  

Buddhism will teach you to view the sociopath as a teacher, and to be grateful for them.  If this relationship is used correctly, it will make you a wiser, more compassionate, and give you a greater sense of your own agency.  It will make you take care of yourself like you never have before.

So, yes, sociopaths do a service, ME.  They are true predators - they cull the weak from the herd, and make those who escape grow stronger.  In recovery you have to ask - which one do you want to be?


Monday, June 18, 2012

Just world hypothesis

I have been reading "Power: Why Some People Have It and Others Don't," by Stanford Business School professor Jeffrey Pfeffer.  I may highlight other aspects of the book, but I was struck by his description of the just world hypothesis (or just world fallacy) and how it limits the way people learn and (more importantly for this book) acquire power:

The belief in a just world has two big negative effects on the ability to acquire power. First, it hinders people’s ability to learn from all situations and all people, even those whom they don’t like or respect. I see this all the time in my teaching and work with leaders. One of the first reactions people have to situations or cases about power is whether or not the individual “likes” the person being studied or can identify with the object of study. Who cares? It is important to be able to learn from all sorts of situations and people, not just those you like and approve of, and certainly not just from people you see as similar to yourself. In fact, if you are in a position of modest power and want to attain a position of great power, you need to pay particular attention to those holding the positions you aspire to.

Second, this belief that the world is a just place anesthetizes people to the need to be proactive in building a power base. Believing that the world is fair, people fail to note the various land mines in the environment that can undermine their careers.
***
The pervasiveness of the belief in a just world, called in social psychology the “just-world hypothesis,” was first described by Melvin Lerner decades ago. Lerner argued that people wanted to think that the world was predictable and comprehensible and, therefore, potentially controllable. Or, as another psychologist described it, from early childhood “we learn to be ‘good and in control’ people.” How else could we navigate a world that is random and can’t be controlled without feeling thwarted and frustrated much of the time? The desire for control and predictability results in a tendency to see the world as a just place because a just world is one that is also understandable and predictable. Behave by the rules and you will be all right; fail to follow the rules and bad things will happen.

The just-world hypothesis holds that most people believe that “people get what they deserve; that is, that the good people are likely to be rewarded and the bad to be punished.

I really like the point about trying to learn from any and all sources, regardless of whether we respect or like that source.  I think when I was a small child I had a very acute sense of fairness.  It was only after I (at a very young age) realized that the world was not fair that I attempted to do my own version of gaming it.  Sometimes I wish that the world was more meritocratic, but if I'm honest with myself, I like the element of chance and excitement that this world provides.  It's hard work, and I often find myself on the losing end of a power struggle, but I bet I would be immediately bored if it were any other way.

A final thought from the book about the just world hypothesis and how good a judge of character most people are:

Most important, the phenomenon works in reverse: if someone is seen to prosper, there is a social psychological tendency for observers to decide that the lucky person must have done something to deserve his good fortune. He or she becomes a better person . . . simply by virtue of the observed rewards.




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