Bernards Voices

Two Personalities, One Brain? (broadcast Friday, November 13th, 2009)
http://www.sciencefriday.com/program/archives/200911133

NPR Science Friday‘s Ira Flatow interviews Psychotherapist Kathy Steele and Psychiatrist Numan Gharaibeh on dissociative identity disorder. Once the 2 guests get past the DSM semantics debate, and get past agreeing on the disservice of popular media, they do get the the crux of the question: can you have two distinct personalities in one brain, or is dissociation like tuning out the road and traffic while driving to work, not a second personality, just the one personality in a different state of awareness.

On the Science Friday website, this link to the Skeptic’s Dictionary was useful.
http://www.skepdic.com/mpd.html

On Slate’s DoubleX website, Dr. Peter Kramer posts an article joining the DSM V debate.

The APA’s attempt to keep the decision-making process secret is indefensible. The other matter, whether the diagnostic system needs and is ready for revision, is extraordinarily complex.

Kramer is writing a book on the way psychiatrists diagnose patients, and focuses the bulk of his post on this.

A fundamental change in the way that informed psychiatrists see the project of outlining and justifying diagnoses. Psychiatry has, by and large, dropped the illusion that its diagnoses are what philosophers call “natural kinds.” A natural kind is something that simply exists in nature.

This makes it hard.  There isn’t a specific test: the presence of a bacteria (or its antibodies), a virus, a gene, that identifies the mental illness. This is true in many areas of medicine.

Even for a near-universally accepted disorder like schizophrenia, a unifying cause will prove illusory.

High blood pressure and asthma are legitimate diagnoses even though their causes are diverse, and reasonable observers disagree on the conditions’ lower limits. And good diagnoses have “predictive validity”: they suggest how disorders will progress, which symptoms they will produce, and which remedies will ameliorate them.

The cause of the illness doesn’t have to be unifying or unique or single, but the illness itself  has to be consistently recognizable.  A lot of the controversy has to do with the conditions’ lower limits.  Take depression for example.  The lower limit from the point of view of time is two weeks … if your blues persists for two weeks then you have depression.

In the first year after my tragedy, when I was seeing both a psychiatrist and psychologist, they were constantly testing me (by interviewing me, watching my reaction … not by taking blood) to see if I was falling into depression.  Did I have good days between the bad days?  Did the amount of bad days slowly ebb over time?  What did I do on my bad days?  Did I play tennis?  Did I eat?  Did I talk to anyone?  This was a major, recurring theme in my grief therapy.

Yes the criteria seems a bit arbitrary: why 14 days instead of 10 days, 20 days, 5 days?  Just because professionals in the field may debate the time period strenuously doesn’t mean that ultimately they don’t agree that one has to exist.  You have to start somewhere.  Every individual is different, but there has to be yardstick.  In the DSM the APA has to take a position

For all its flaws we can’t do without diagnosis. Think of a patient who comes to a doctor after a series of panic attacks and is reassured: “You don’t have heart disease. You won’t die from these palpitations. We have ways to treat panic, with medication or psychotherapy.” Or think of a parent whose child has anorexia and learns that the condition is life threatening. We need to be able to name the thing—panic disorder, anorexia—and convey what we know about it. Similar requirements exist for research. Schizophrenia in Verona must be schizophrenia in Boston.

We need to be able to name the thing.

This is a very damning article. Everything said in this article is important to discuss, but I have my concerns.

Does this article make a person more or less likely to seek help from a mental health professional? Less likely.
Does this article reinforce a lay perception that MH pros are just a bunch of quacks? Yes.
Does this article increase the stigma for someone that seeks help from one of them? Yes.

I realize the author, and probably Slate‘s editors, share some of my concerns, and would argue that it is the APA itself that is creating these risks, and they’re just reporting it.

But as I read the first, second, third, fourth, fifth … paragraphs it feels as if Lane is driving nails into the coffin of something we shouldn’t kill.  Do you hear the nail splinter the pine box with each hammer strike?  I’d like him to be a little more relenting, create a little less collateral damage.

Ok, I’ve said my peace. Now the article in Lane’s own words.

The American Psychiatric Association has no clear definition of the cutoff between normal and pathological responses to life’s letdowns.

The association risks losing sight of that distinction by grimly—and rather inexpertly—debating whether avid shopping should be considered a sign of mental illness. The fifth edition of the association’s Diagnostic and Statistical Manual of Mental Disorders is expected in 2012. The APA isn’t just deciding the fate of shopaholics; it’s also debating whether overuse of the Internet, “excessive” sexual activity, apathy, and even prolonged bitterness should be viewed, quite seriously, as brain “disorders.”

Allen Frances chaired the DSM-IV task force. Robert Spitzer editted DSM-III and -IV.

After Frances made his objections public last month, he and Spitzer followed up by sending the APA an open letter: “Unless you quickly improve the internal APA DSM-V review process, there will inevitably be increasing criticism from the outside. Such public controversy will raise questions regarding the legitimacy of the APA’s continued role in producing subsequent DSMs—a result we would all like to avoid.”

Spitzer and Frances also strongly disagree with a proposal to include “subthreshold” and “premorbid” diagnoses in the new manual. Both terms give cover to the so-called “kindling” theory of mental illness in children and infants—some psychiatrists believe that it’s possible to stamp out ailments before they burgeon into full-blown disorders.

This idea of kindling relates to my post yesterday on catching schizophrenia during prodrome before it turns psychotic.

In practice, as the St. Petersburg Times reported in March, psychiatrists in Florida alone gave antipsychotic drugs off-label (without formal FDA approval) in 2007 to 23 infants who were less than 1 year old at the time. They extended the practice to 39 toddlers aged 1; 103 aged 2; 315 aged 3; 886 aged 4; and 1,801 aged 5. One shudders to think what is going on in other states.

If you’re still reading down here at the bottom of the post, you may be wondering what is the DSM for. Here is wikipedia:

Many mental health professionals use this book to determine and help communicate a patient’s diagnosis after an evaluation; hospitals, clinics, and insurance companies also generally require a ‘five axis’ DSM diagnosis of all the patients treated. The DSM can be used to establish a diagnosis or categorize patients using diagnostic criteria. The DSM may also be used in mental health research. Studies done on specific diseases often recruit patients whose symptoms match the criteria listed in the DSM for that disease.

The wrong coding in the DSM may excuse your insurance company from paying.

Psychopathy is not my favorite subject.  But I find myself reading a cross section of articles on mental health, and letting the ideas pollinate across the various subjects.  In this article I do sense distance between the author John Seabrook and the researchers, Dr. Kiehl and his mentor Dr. Hare.  For example when Seabrook was interviewing Dr. Hare, he commented, “Hare was friendly but wary of me.”  I share that sense of distance with the author.  I know the subject is important, but I’m not sure I want to get too close to it.

I’ve excerpted some quotes below just to give a bit of the background on Hare and Kiehl.

At thirty-eight, Kiehl is one of the world’s leading younger investigators in psychopathy, the condition of moral emptiness that affects between fifteen to twenty-five per cent of the North American prison population, and is believed by some psychologists to exist in one per cent of the general adult male population.

In order to distinguish psychopaths from non-psychopaths among the Western volunteers, Kiehl and his students use the revised version of the Psychopathy Checklist, or PCL-R, a twenty-item diagnostic instrument created by Robert Hare, a Canadian psychologist, based on his long experience in working with psychopaths in prisons. Kiehl was taught to use the checklist by Hare himself, under whom he earned his doctorate, at the University of British Columbia.

Today, Kiehl and Hare have a complementary but complicated relationship. Kiehl claims Hare as a mentor, and sees his own work as validating Hare’s checklist, by advancing a neurological mechanism for psychopathy. Hare is less gung ho about using fMRI as a diagnostic tool. “Some claim, in a sense, this is the new phrenology,” Hare said, referring to the discredited nineteenth-century practice of reading the bumps on people’s heads, “only this time the bumps are on the inside.” (Hare himself is a “strong proponent” of brain-imaging technology, but he noted that scans in isolation will always be insufficient.) Hare sees himself as a generalist, and Kiehl as “more of a data-driven guy.” Hare added that, while Kiehl’s brashness sometimes puts people off, “that’s why Kent gets things done.

And it was this paragraph below, that made me want to excerpt the article for this blog.  It illustrates much of the misinformation out there which we have to deal with regarding mental health awareness.  And this misinformation or distortion (I’m searching for the right word … casualness?) is coming straight from the mouth of Dr. Kiehl, a PHD, doing fundamental research, an expert in the field.  1. The DSM definitions are subjective, cover a broad, continuous range of symptoms, and are mutable.  You cannot take a blood test and get a definitive diagnosis.  When Dr. Kiehl says “so much” it almost implies too much.  2. He mentions the famous drug companies that fund research, and profit from treatment.  Quotes like this make the general public suspicious of what is happening.  When you read commentary in the MSM you always run into this.  3.  The categorization of the disorder is influenced on whether it treatable or not.  (I have added the blue for emphasis.)

If a biological basis for psychopathy could be established and pharmacological treatments developed, the idea that many people have at least a little of the psychopath in them could well become accepted. As Kiehl points out, “It used to be the case that it was very hard to meet clinical criteria for depression in the fifties and sixties. However, the definition of depression has been broadened so much with DSM-IV that nearly every person will meet the criteria at some point in their lives. One reason for this is that drug companies have lobbied to change the criteria—because they have a treatment, a drug, that can help people even with moderate levels of depression. It’s a completely different issue whether this is appropriate.” He added that “even moderate levels of psychopathy may someday be considered a disorder—especially if we can treat it.”