Grand Rounds at Parallel Universes
Posted by Phil in Carnivals and Fesitvals on April 14th, 2010
Grand Rounds is up at Parallel Universes. Dr. Emer has very nicely taken an unthemed Rounds and sorted the posts into several interesting mini-themes. From dealing with death to high risk pools in the health insurance field, there is plenty of good reading.
Schizophrenia Is Not An Illness (Part 3)
Posted by Phil in A Behavioral Approach to Mental Disorders on March 20th, 2010
Hallucinations
In Schizophrenia Part 1, we noted that the APA lists hallucinations as one of the primary “symptoms” of schizophrenia. The APA defines an hallucination as follows:
“A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ.” (DSM-IV-TR, p 823)
In other words: seeing, hearing, smelling, tasting, or feeling something that isn’t really there. Typically the individual who has been “diagnosed” with schizophrenia reports that he hears voices that accuse him of some wrong or exhort him to some action, and sometimes threaten him with punishment or retribution.
A number of points need to be made.
Firstly, it has been established for many years that people who report auditory hallucinations are in fact talking to themselves. Sensitive monitoring equipment can pick up the minute vibrations of the vocal chords, and when these signals are amplified, it is possible to actually hear what the individual is saying to himself.
Secondly, apart from the kind of monitoring equipment mentioned above, the only way you can know if someone is hallucinating is if he tells you so or if he gives you some overt indication, e.g. cocking his head to one side as if listening to a voice from the other side of the room, etc.. Now the fact is that almost everybody engages in self-talk. Most of us, however, keep it private and even display a small measure of embarrassment when “caught” engaging in this activity. The difference between “ordinary” people and “hallucinators” is that the latter reveal the process publicly by a variety of methods.
The vast majority of people realize that their self-talk is just that: talking to themselves inside their heads. And although we may enjoy this activity, we afford more importance and pay more attention to external stimuli, i.e. the real world. And because the real world seems more important and relevant to us than our self-talk fantasies, we assume that this is the way it should be for everybody. The fact, however, is that paying attention is what behavioral scientists call an operant. We pay attention to certain things in life because the act of paying attention to them is rewarded, and we routinely ignore other material because there is no pay-off for attending to it. For instance, if you are driving in city traffic, it is worth your while to pay attention to traffic lights, other vehicles, and pedestrians. It is not worth your while to pay attention to windblown trash swilling and eddying in the gutters. In fact, if you’re paying more attention to the latter than the former, you will likely incur some very negative consequences. However, if you are sitting on a bench eating your lunch, you can watch the windblown trash all you like. Similar considerations apply to almost every aspect of life. If you’re in a meeting at work and the boss is talking, it generally makes sense to pay attention to what’s being said and to put the fantasy life on hold, etc., etc.
But what needs to be remembered in these considerations is that we assign more priority to external reality than internal fantasy only because historically this perspective has brought us success. We pay attention to the boss because in our experience this brings rewards. The reward may simply be a smile of appreciation, but because of our training and experience, we see these tiny rewards as important and cumulative. They’re like green stamps: save up enough and you get a prize.
For a person who has experienced little but failure, suffering, and grief, however, the situation is markedly different. His experiences tells him that it doesn’t really matter what you do or what you pay attention to, it all ends badly anyway. In this kind of context, a retreat to the internal fantasy world becomes very understandable and, in extreme cases, almost inevitable. The prioritization of internal over external stimuli is not in itself a pathological process, but is rather a natural and understandable consequence of repeated and significant failure. So young people who go out in the world lacking the kind of basic skills mentioned in my post on schizophrenia Part 1 are at high risk for experiencing profound failure in the three great challenges:
- emancipation from parents
- finding a partner
- launching a career
For these individuals, paying attention to internal stimuli is far more rewarding than continuing to invest attention and interest in external reality. In my experience, these are the essential dynamics in most cases where a diagnosis of schizophrenia has been assigned.
Now, of course, it’s possible for hallucinations to occur because of neurological impairment. Such impairment can be temporary (e.g. morphine induced) or permanent. But it is never safe to assume a neurological impairment on the basis of a behavioral problem. The behavioral explanation outlined above is more parsimonious and far more likely to be correct.
Next post: Schizophrenia is not an illness, Part 4
Grand Rounds at MD Whistleblower
Posted by Phil in Carnivals and Fesitvals on March 3rd, 2010
Grand Rounds is up at MD Whistleblower. With so many posts on a wide range of subjects, there is plenty of reading for everyone.
Schizophrenia Is Not an Illness (Part 2)
Posted by Phil in A Behavioral Approach to Mental Disorders on February 21st, 2010
Delusions, contd.
In my last post I pointed out that schizophrenia as defined by DSM is a confusing collection of human problems with no evidence of a common etiology or indeed any valid justification for including them under a common heading. I discussed delusions and made the point that cognitive distortions of this kind are a normal response to failure. When the experience of failure is profound and pervasive, the delusional speech tends to be commensurately extreme. Delusions are not symptomatic of an underlying illness, but rather are a normal human reaction to severe stress or profound failure, particularly in the late teens/early adulthood phase of life. This is the time of life in which our general coping skills are subjected to their first serious tests, and when people experience profound failure at this time, there is a risk that they will drift towards delusional speech. Onset of delusional speech is typically later for women than men, and probably corresponds with the process of giving birth and caring for small children. The potential for strong feelings of failure is high at this point of life also.
Although delusional speech emerges most often in late adolescence and early adulthood, it is obvious that feelings of profound failure can occur at any age and can precipitate delusional speech. In the previous post I listed some of the skills that might be lacking in individuals who fail in this way and the question naturally arises as to why some people develop these skills without apparent effort while others do not. The answers of course are as varied and diverse as human life itself. As parents we try to teach our children how to cope with life and its various vicissitudes, but this ongoing process of teaching doesn’t always go smoothly. Death and other forms of tragedy assail all families at some time, and these experiences can disrupt the normal day-to-day teaching/training of the children. Even in normal times, parents are sometimes overly protective and in particular try to protect their growing children from the experience of failure. But it is only in dealing with the small day-to-day failures of childhood that we learn to cope with major failures later on. Realistic critical self-appraisal is an important component of success in almost all walks of life – indeed in the very business of life itself, but it is only acquired through helping and encouraging the child to reflect constructively on adverse events. The overly protective parent who shelters his/her child from these kinds of situations unwittingly denies him the opportunity to learn from his particular mistakes and to learn how to cope with mistakes generally.
The bio-psychiatric school, of course, claims that the behavior labeled “schizophrenia” is caused by a brain disease, and they vehemently repudiate any attempt to link these behaviors to early family experiences. In my view, the notion that “schizophrenic” behavior is not rooted in childhood learning experience simply flies in the face of common sense and an abundance of evidence (Dozier et al), (Mickelson et al). Most of us as parents do our best to raise our children to be strong, healthy, resourceful adults. But it is naïve to imagine that this desire to do the right thing always translates into actual successful training. There are many obstacles to be overcome. Sometimes we simply don’t know what is the right course of action. Other times we are too busy with work or too engrossed with pressing problems to recognize the child’s need. And tragically, of course, there is the significant number of cases when the child is being blatantly abused at home, bullied at school, or victimized in some other way. Poverty also takes a toll, in that parents who are pre-occupied with financial hardship are often unable to devote as much time and energy to childrearing as they might like.
In short, there are many forces that militate against the child’s acquisition of the skills he/she needs to cope with adult life, and in particular to cope with the experience of failure. Telling parents the palliative falsehood that their child’s delusional speech is the result of a brain disease and has nothing to do with his/her childhood experiences is nothing short of insulting.
Delusional speech arises directly from the experience of failure – from the individual’s misguided attempt to deflect the blame for this failure onto others. And he does this because he has not acquired the skill of accepting and processing the experience of failure in a more rational and productive manner. This kind of speech is then maintained by the attention and various other benefits that it attracts. For instance, in most developed countries it can form the basis for a disability income. In regard to the latter, it is worth noting that people with delusional speech in underdeveloped countries recover much more quickly than is the case in the developed world.
The best way to help a person who habitually speaks delusionally is
- Ignore the delusional speech.
- Pay attention to sensible speech.
- Encourage other instances of cogency and common sense.
- Identify skill deficits. (The list in the previous post would be a good starting point.)
- Teach/coach the needed skills.
- Be patient
- Help the person find some measure of success, initially perhaps in small matters, but as skills develop, in more substantive areas.
- Remember that the skill deficits in question are ones that most of us take for granted (e.g. social interactions) but are extraordinarily taxing for the individuals concerned.
- Remember that delusional speech and “ordinary” speech are on a continuum. There is often a measure of cogency in delusional speech and a measure of nonsense in “ordinary” speech.
The brain is a pattern-seeking machine. It searches for meaning and regularity in the vast array of data presented to it by the senses. When a young person experiences profound failure within a social ethos in which failure is routinely condemned and censured, he has two options. He can acknowledge his skill deficits or he can search for an alternative explanation for the failure. The brain simply needs to make sense of what has happened/is happening and it is a small step to thoughts like “They’re out to get me,” or “I have special status that they don’t understand”, etc..
Next post: Schizophrenia is not an illness, Part 3
Grand Rounds at Musings of a Distractible Mind
Posted by Phil in Carnivals and Fesitvals on February 4th, 2010
Grand Rounds is up at Musings of a Distractible Mind. There are various categories (eleven groupings in all), with plenty of reading on a wide range of subjects.
Schizophrenia Is Not An Illness (Part 1)
Posted by Phil in A Behavioral Approach to Mental Disorders on January 21st, 2010
The APA defines schizophrenia by the presence of two or more of the following, each present for a significant portion of time during a one-month period:
(1) delusions
(2) hallucinations
(3) disorganized speech
(4) grossly disorganized or catatonic behavior
(5) negative symptoms i.e. affective flattening, alogia or avolition
Signs of the disturbance must have been present for at least six months and there must be significant deficits in one or more areas of functioning such as work, interpersonal relations or self-care.
The “two or more” concept constitutes a substantial flaw in the so-called diagnosis. An individual who is displaying hallucinations and delusions (criteria 1 and 2) will be assigned a diagnosis of schizophrenia. But a person whose behavior is grossly disorganized and whose affect is flat (criteria 4 and 5) can be assigned the same diagnosis. Superficially these presentations are very different, and the only reason for assigning the same diagnosis is that the APA say so. This state of affairs is found throughout DSM. Elliot S. Valenstein, Professor Emeritus of Psychology and Neuroscience at University of Michigan has this to say:
“Although those who directed the DSM-IV project claim that “there has been a stronger emphasis on research data than with previous revisions,” scientific considerations do not play a significant role in the manual. Instead, the psychiatric tradition and sociopolitical considerations seem to have played the major roles in shaping this document. Dr. Allen Frances, who directed the DSM-IV project, stated that “we didn’t want to disrupt clinical practice by eliminating diagnoses in wide use.” Very different symptoms are included under the rubric of “schizophrenia” mainly because they have always been grouped together, rather than because of any new scientific evidence that they share a common etiology.” (Blaming the Brain, 1998, p 161)
This contrasts markedly with general medicine. For instance, there is a disease called Wegener’s granulomatosis which is caused by inflammation of the blood vessels. In the large vessels the inflammation does relatively little harm, but the small vessels can become completely occluded, leading to significant damage in kidneys, lungs, nerve endings, etc.. People with this disease may present very different clinical pictures, but the underlying disease process is essentially the same and the same antibody will be found in their blood stream.
It is widely assumed among the general public that some kind of similar commonality is present in schizophrenia, and that psychiatrists and other mental health professionals are aware of this pathological link. This is simply not the case. Selecting two “symptoms” out of five leads to ten different presentations. Selecting two or more out of five yields 25 different permutations. Whilst one can acknowledge that a measure of overlap and commonality might exist in these various presentations, there is no evidence that all of these people have the same underlying pathology. They are assigned the same diagnosis and deemed to have the same “mental illness,” simply because the APA says so.
The central point of this blog is that the concept of mental illness is essentially spurious, and that the vast majority of the problems set out in DSM are problems of daily living and learned behavior. The so-called diagnoses are routinely presented as explanations of abnormal or unusual behavior, when in fact they are nothing more than labels.
Let’s examine the schizophrenia “symptoms” one by one.
Delusions
A delusion is a false belief. Now the only way you can discern a person’s belief is through his speech, writing, or other overt indication. All of these indicators are behaviors. Speech is behavior, and our patterns of speech are subject to the same behavioral influences as any other behaviors. So when people express nonsensical ideas (or more accurately, when they speak nonsense) we need to ask why. Under the DSM system, we don’t ask why. The delusional speech is simply a “symptom” of the “illness” called schizophrenia, and nothing remains except the prescription of major tranquilizers. In fact, it is widely believed, and promulgated to students, that nothing can be done to ameliorate delusional speech.
The reality is quite different. For decades numerous researchers have demonstrated that delusional speech can be reduced and eliminated through appropriately designed behavioral interventions. Ayllon and Haughton (Modification of symptomatic verbal behavior of mental patients in Behavior Research and Therapy, 1964, 2, 87-97), for instance, achieved a 60% reduction in a hospital patient’s delusional speech by training the staff to ignore these kinds of remarks over a period of 6 months. The individual in question routinely referred to herself as “the Queen,” and would question staff as to why she was not being afforded treatment befitting this exalted position. This had been going on for fourteen years. The staff were trained to simply not respond, to look away, to appear bored, to shift their attention elsewhere, etc., whenever she made these kinds of delusional statements, but to respond normally to non-delusional speech.
The essential point is that delusional speech is behavior and follows the same general principles as any other behavior. In particular, speech which attracts positive attention and approval is more likely to increase in frequency, while speech which attracts no attention or disapproval tends to be eliminated. This is as true of everyday conversations as it is of the delusional speech of mental health clients.
In the same article mentioned above, Ayllon and Haughton describe two mental hospital clients, one with a diagnosis of schizophrenia, the other depression. Both were females and both spent a good deal of time complaining about their health, even though no physical problems had been detected. This had been going on for years. Here again, the hospital staff were trained to ignore the somatic complaints, and to respond positively and attentively to normal speech. The incidence of delusional speech declined rapidly, and by 18 months had been reduced to virtually zero. This research was done 45 years ago! More recent examples can be found at Wilder et al (Journal of Applied Behavior Analysis, 2001, V 34, No 1, 65-68) and Mace and Lalli (Journal of Applied Behavior Analysis, 1991, V 24, No 3, 553-562)
What’s particularly noteworthy here is that mental health staff unwittingly but routinely reinforce delusional speech. Under the DSM system, this kind of behavior is considered a symptom, and the staff tend to “prick up their ears,” so to speak, when clients emit this kind of speech. The staff member may even take notes. Mental health clients are as adroit as anybody else at reading signs of attention and approval, and staff become the unwitting coaches for delusional behavior. This kind of interaction is a direct consequence of the DSM system, under which schizophrenia is conceptualized as an incurable disease, one of whose symptoms is the presence of delusions. If one focuses instead on delusional speech as a dysfunctional behavior which is learned, then the appropriate response becomes clear: ignore the delusional speech and encourage normal speech. Note that this is not the same as trying to talk the individual out of his delusions – trying to persuade him that he is mistaken. These kinds of attempts are generally unsuccessful, because they provide attention and therefore reinforcement.
In Western culture the three great challenges of early adulthood are: emancipation from parents; launching a career; and finding a life partner. At the risk of stating the obvious, some individuals are more successful in these endeavors than others. Most young people, however, manage to stumble through these difficult times and to emerge into adulthood with a reasonable measure of success in these three areas.
Some hapless individuals, however, fail miserably in one or more of these challenges, and a small number of people fail in all three. Whenever we fail – whenever we don’t succeed in meeting an objective – whether the matter is large or small – we always have two options. We can recognize the failure and take corrective action, or we can reorganize our thinking so that the failure gets relabeled as something else. This fundamental truth is expressed nicely in the old adage: A bad carpenter blames his tools. If I decide, for example, to make a window box and the project is a disaster, I can acknowledge that I need to improve my carpentry skills, perhaps even attend some classes, or I can complain that the tools were no good or the lumber was defective, or that my wife is a nag for asking me to do the project in the first place, etc.. In other words, I can change my behavior (in this case my carpentry skills) or I can change my thinking. In general the latter is usually easier than the former.
In the case of the window box, the outcome is relatively trivial. In the case of major failures, however, the outcome is very significant, and the cognitive distortion can be considerable.
Consider the example of a young man who leaves home after graduating from high school, and finds a job in another town. He is filled with hope and a sense of independence, but after a couple of months he is fired. He is so dispirited that he doesn’t seek another job, and a month of two later is evicted from his apartment. Finally, in desperation, he calls “home” and his parents wire him the bus fare and pick him up at the bus station. For good measure, let’s also say that his girl friend has dumped him
Now if he’s an exceptional young man, he might say something like this:
“Thank you mother and father for rescuing me. I really didn’t have the discipline, stamina, or interpersonal skills necessary to succeed in the adult world. If it’s all right with you, I’d like to stay here with you for another year and work on my skill deficits. I’ll get a job and pay you rent, and I’ll join Toastmasters to help me develop some confidence in my dealings with other people, and I would greatly appreciate any feedback or coaching that you could give me.”
Unfortunately a more likely scenario is that he sulks in his room, neglects his personal hygiene, and persuades himself that he would have been ok if people hadn’t had it in for him. In a context of significant failure, these kinds of paranoid thoughts feed on themselves, and in extreme cases reach a level that would be described as delusional. A good measure of family tension usually ensues. Sometimes this degenerates into overt hostility, which further feeds and confirms the young person’s paranoia.
At this stage, he (or she) discovers that delusional speech has a significant pay-off. It reduces expectations. He is no longer expected to find a job, set up home for himself, or find a life partner. He is referred to the mental health system, where he is given a diagnosis and a prescription for a major tranquilizer. He may also be awarded disability status with financial and medical benefits. By this stage the chances of emancipation and functional independence are slim. (The major tranquilizer, of course, dampens down the problem behavior. But real improvements in functioning are rare, and the side effects of the drugs can be truly devastating.) If the parents ask why their son is so paranoid and withdrawn and unmotivated, they will receive the reply: “because he has schizophrenia.” This looks like an explanation, but if the parents were to press the matter and ask: “how do you know he has schizophrenia?” the only possible reply is: “because he is so paranoid, withdrawn, and unmotivated.” The “diagnosis” of schizophrenia is nothing more than a label describing the very behaviors it purports to explain. And a destructive label at that, in that it stifles and suppresses genuine exploration into the true cause(s) of the problem, and genuine remediation of the original skill deficits.
It needs to be stressed that I’m not suggesting that our hypothetical individual is deliberately and consciously faking his “craziness.” It is simply the case that behavior that is reinforced tends to increase in frequency whilst behavior that is not reinforced or which attracts negative consequences becomes less frequent. In the case in question, the behavior of launching out on one’s own, finding a job, and a partner, etc., all ended disastrously. But the behavior of sulking in his room expressing angry paranoid thoughts was rewarded with attention, solicitous concern, home-cooked meals, and an extraordinary measure of power and control over his parents. The outcome is not surprising. An essential point here is that delusional speech and normal speech are on a continuum. People express mildly delusional ideas all the time. Listen to any talk radio show. Listen to politicians railing against their opponents. Listen to religious zealots. Listen to racial stereotypes. Listen to people who insist that the Earth is only 6000 years old. Listen to golfers after they’ve played a bad stroke. Listen to people who get passed over for promotion, etc., etc., etc.. The processes that promote this kind of mildly delusional speech can lead to severe delusions if the conditions are ripe.
It is noteworthy that our young person’s real problem – i.e. a marked lack of general coping skills – never gets addressed. The skills we’re talking about here include:
- critical self-appraisal
- bringing tasks to completion
- not procrastinating
- making good dietary decisions
- managing money; budgeting
- interacting appropriately with supervisors and other authority figures
- interacting with peers; resisting negative peer pressure
- managing a checking account
- getting to bed at a reasonable hour
- “chatting up” prospective sexual/relational partners
- dating
- personal hygiene
- buying and maintaining a car
- house-cleaning and general management of personal space
- choosing friends
- cooking
- good management of time
- etc., etc., etc.
Our culture is generally unsympathetic to individuals who are in trouble because of basic skill deficits. We have helpful programs for vocational skill deficits, but not for the more fundamental skills, such as those listed in the previous paragraph. Individuals with these kinds of deficits are usually subjected to censure and negative labeling (e.g. lazy, dirty, slovenly, prodigal, brash, stupid, klutzy, etc.)
The point here is that the three great challenges: emancipation from parents, launching a career, and finding a life partner – are just that: great challenges. They are not easy. But this fact is seldom acknowledged. The cultural expectation is that young people should be able to do all this without difficulty. And the fact is that most of us do manage to muddle through these years with at least some measure of competency. Others, however, don’t, and some of this latter group crash disastrously and become mental health clients for life. In this regard it is noteworthy that the majority of people who are assigned a “diagnosis” of schizophrenia are “diagnosed” in their late teens and early adulthood – precisely when the basic skills demands are greatest.
Of course the bio-psychiatric school would contend that these individuals were already “sick” before they started their emancipation endeavors – that they had a brain disease which impacted their ability to function effectively. This position may be correct. But the APA’s definition of schizophrenia includes the criterion that “(the disturbance is not due to … a general medical condition.” So delusional behavior that is caused by a brain malfunction is not (by definition) schizophrenia. If indeed it could be established that there are individuals with compromised brains and that this neurological damage was truly the cause of problems in living, then the disease needs to be recognized as such, given an appropriate name (e.g. Smith’s neuropathy or whatever), diagnosed neurologically, and treated appropriately. Meanwhile, assuming a neurological deficit on the basis of unusual or abnormal behavior is intrinsically unsafe. When we are considering people’s behavior, there are always multiple paths to the same place. Consider eleven people on a soccer team playing a game on a Saturday afternoon. They are all engaged in the same activity (playing soccer), but the sequence of events that led them to this point will be extremely diverse. One player, for instance, might be motivated largely by a desire to please his father, while another might be there primarily to annoy his father. A third might be simply trying to lose weight. A fourth is showing off for his girlfriend. A fifth may be trying to dissipate feelings of anxiety and tension, etc., etc., etc..
Similarly, it is clear that genes and physiology have an impact on people’s actions, and it is possible that one person’s delusional speech is the direct result of a brain malfunction. Another person, however, could be emitting very similar behavior without any neurological problem; the delusional speech in the latter case being the outcome of the kind of failure-ridden psychosocial history described earlier. The brain is a pattern-seeking apparatus. It looks for regularities and patterns in the data it receives and stores these patterns for later use. When it can’t discern a pattern (for whatever reason), it makes one up. In the case of our hypothetical young person mentioned above, the correct pattern was his significant lack of skills in a wide range of areas. This is a difficult thing to accept, so his brain invented the notion that other people were out to get him – were sabotaging his efforts. From his point of view this is a perfectly valid explanation for his failures. Of course, it’s not the true reason, and other people see him as paranoid and delusional, and if he is referred to the mental health system, he is given a diagnosis of schizophrenia.
The problem areas which the APA label as schizophrenia constitute an extremely complex topic, and inevitably this blog post has become very lengthy. I have more to say on this matter, but I thought I’d post this and continue with more thoughts on schizophrenia in the next post. Meanwhile, your comments – as always – are welcome.
Next post: Schizophrenia is not an illness (Part 2)
Mental Retardation: A Stigmatizing Label
Posted by Phil in A Behavioral Approach to Mental Disorders on December 6th, 2009
The first diagnostic category in DSM-IV is mental retardation, which embraces those individuals at the lower end of the intelligence spectrum. Intelligence is defined by psychologists as the ability to solve problems, adapt creatively to changing circumstances, and generally manage one’s affairs successfully and functionally. No definition of intelligence can truly do justice to the complexity of the matter, but various standardized tests exist, and within certain philosophical and practical limitations, they all provide reasonably accurate estimates of an individual’s general intellectual ability, as well as identifying areas of particular strength and weakness.
What’s not generally recognized, however, is that the cutoff point for mental retardation is arbitrarily set at the 2½ % ile mark. In other words, if a person’s measured IQ places him or her within the bottom 2½% of the population, then that person is considered retarded. On the other hand, a person scoring barely above this cutoff is considered to be not retarded. The DSM definition of mental retardation also requires that the individual shows some functional impairment in major life areas, but in practice the diagnosis is driven primarily by the IQ scores, which in the hypothetical cases mentioned above are too close to reliably say that one is more intelligent than the other. Nevertheless the former individual comes out of the testing situation with a diagnosis of mental retardation, the latter does not.
The need for a sharply defined cutoff is driven primarily by bureaucratic concerns. The Social Security Administration, for instance, considers mental retardation a disability, and there is an obvious need for clear answers when people apply for disability benefits. In addition, the federal, state, and many local authorities provide funding for services to people in this category, and there is a need for clear answers as to who qualifies and who does not. Schools receive a great deal of additional funding for each child with mental retardation enrolled in their programs, and formal procedures and cutoffs are clearly needed unless another way of conceptualizing these matters and funding these kinds of services is developed.
When the average citizen is asked about mental retardation, he or she generally conjures up a picture of a child or adult with Down’s syndrome or one of the other physical conditions that causes low intelligence (e.g., microcephaly). What’s not generally appreciated, however, is that about fifty percent of individuals who carry this diagnosis have no detectable physical problem or anomaly. This is a direct result of the arbitrariness of the cutoff point. Other things being equal, intelligence is “spread” or distributed through the population. There will be a small number of geniuses (people with very high IQ’s), most of us will lie somewhere in the middle, and there will be a relatively small number of people who are not very bright. This would be the case even if there were no people with Down’s syndrome or other obvious physical conditions that impact this matter.
By diagnosing mental retardation purely on the basis of IQ and functional limitations, we are lumping together two extremely different groups of people: people with clear neurological deficits and people who simply aren’t very bright. The former have something wrong with their brains, the latter do not. Their brains are fine, they are just not as efficient as those of brighter people, in just the same way, for instance, that one person’s lungs, heart, muscles, etc., might work better than another’s.
The practice of labeling these people as “retarded” has a number of important effects, particularly in the area of diminished expectations. Consider a parent being told, “Your child is not very bright. In fact, in an average group of a hundred children, he would come pretty close to last in intellectual matters. There is nothing wrong with him, as such, it’s just the way he is, in the same way, for instance, that another child might be very short, etc..” Contrast this to, “Your child is retarded,” which is what this parent would be told under the present DSM system of diagnosis, labeling, and categorization. Quite apart from the unpalatability of the message, there is an almost inevitable tendency on the part of the parent to diminish expectations and to assume the child will be incapable of learning various material, much of which is, in fact, well within his or her potential. A great deal has been learned over the past fifty years concerning the negative effects of this kind of stigmatizing labeling, but this body of research is routinely ignored by those who promote and maintain the DSM categorization system.
These kinds of diminished expectations occur also in the classroom. When a teacher has been told that a particular child is retarded, he/she is more likely to accept a lower standard of work from that child than would have been the case had the “retarded” label not been applied.
Another problem with the “diagnosis “ of mental retardation is that it promotes the notion that the problem lies exclusively within the individual – a lack of “intellect.” This kind of thinking goes back to pre-scientific speculation about human activity. Today we know that there is no such thing as intellect. Rather there is behavior which is more or less adaptive – more or less intelligent. And we also know that behavior is always the result of an endlessly dynamic interaction between an individual and his/her environment. The fact is that some home environments are more fostering of intelligent behavior than others, and it is likely that many children currently labeled “mildly retarded” could be helped significantly in this area with some focus of attention on the home environment. The “diagnosis” of “retarded,” however, militates against this kind of intervention, in that the deficiency is presumed to lie within the child rather than in the child’s environment. Because the “diagnosis” appears to be an explanation of the poor performance, it stifles genuine exploration into the true nature of the problem.
Even with regards to the individuals who do have a physical etiology, similar observations apply, and in general mental retardation programs in recent decades have discovered that there is a great deal of untapped potential in their clients, much of which had been obscured in the past by the stigmatizing effects of the label.
Public attitudes towards people of low intelligence have softened markedly in recent decades, probably largely as a result of deinstitutionalization, and the fact that these individuals are routinely obtaining gainful employment in fast food restaurants, grocery stores, and other locations. In many areas despite the DSM label, mental retardation programs have tackled the problems of their clients creatively and energetically, and in many respects have managed to overcome some of the stigma and other negative consequences of the diagnosis.
In the 50’s and 60’s the term “retarded” gradually replaced the earlier technical terms, which were moron, imbecile, and idiot, and at the time represented a clear improvement. “Retardate,” however, has now become a term of disparagement, especially among school children, and the time for terminology update seems overdue.
Because the concept of retardation has been widely accepted in our society, there is a tendency to see it as an explanation for an individual’s low level of functioning. When a teacher, for instance, asks, “Why is Johnny so slow? Why can’t he learn this stuff?” the school psychologist replies, “Because he’s retarded. His IQ is only 65.” Like most mental disorder diagnoses, this looks like an explanation and is generally accepted as such by parents, teachers, and other concerned professionals. Nothing, however, could be further from the truth. The label “retarded” explains nothing. It just means that Johnny scored below a certain cutoff on a test. In other words, he’s not low-functioning because he’s retarded, but rather he’s called retarded because his level of functioning (as measured by this test) is low. This is a very important distinction, because the diagnosis of mental retardation provides the impression that the matter has been explained, and often removes the incentive for any further in-depth investigation or exploration of the individual’s problem. Despite the gains in recent decades, retardation is still widely regarded as an irremediable condition, and the label still carries heavy overtones of hopelessness and diminished expectations.
Grand Rounds at sharpbrains.com
Posted by Phil in Carnivals and Fesitvals on October 25th, 2009
Grand Rounds is up at sharpbrains. There are both themed posts and open submissions. Plenty of reading for all on a wide range of subjects.
Adjustment Disorder: Everyone can have a mental illness
Posted by Phil in A Behavioral Approach to Mental Disorders on October 15th, 2009
According to the DSM, the essential feature of this mental disorder is “…the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors.” The manual defines clinically significant as either:
“marked distress that is in excess of what would be expected given the nature of the stressor”
or
“significant impairment in social or occupational functioning.”
DSM provides a number of examples of the kinds of stressors that might precipitate a diagnosis of Adjustment Disorder. These include:
- termination of a romantic relationship
- marked business difficulties
- marital problems
- seasonal business crisis
- living in a crime-ridden neighborhood
- natural disaster
- starting school
- leaving one‘s parents’ home
- getting married
- becoming a parent
- failing to attain occupational goals
- retirement
- a chronic disabling medical condition
- financial difficulties resulting from a divorce
And these are just some examples. In other words, if you encounter any of life’s difficulties, and your response to this difficulty is excessive, as defined by a mental health worker, then you have a mental disorder.
There are six sub-types of this so-called mental disorder:
Adjustment Disorder:
- with anxiety
- with mixed anxiety and depression
- with disturbance of conduct
- with mixed disturbance of emotions and conduct
- and, of course, unspecified
It’s an obvious fact that life from time to time presents difficulties, some minor, some major. It’s also an obvious fact that sometimes we deal with these difficulties fairly effectively; other times less so. But who is to decide whether our reaction to the difficulty was “excessive”? Some people respond to crises in a stoical, confined way; others are very emotional. There is no yardstick for how effectively people cope with stressful situations. Nevertheless, the APA has invented this mental disorder as a way of broadening their psychiatric net to embrace as wide a client base as possible. And because of the vagueness of the criteria, anybody experiencing a stressful situation can be assigned this diagnosis. And because no distinction is made in practice between the terms “mental disorder” and “mental illness,” these individuals are deemed to have a mental illness and are routinely prescribed drugs.
So the person who has lost his/her job and is feeling down; the family whose house was destroyed by fire or tornado; people caught up in a hurricane, flood, or other natural disaster – all of these people are eligible for a diagnosis. Even less dramatic stressors can serve as portals to Adjustment Disorder. Working in a hostile environment, an unhappy marriage, or problems with neighbors would all qualify an individual for a diagnosis of Adjustment Disorder, provided only that his/her reaction to the particular stressor was “in excess of what would be expected.” And of course, it will be decided by a psychiatrist or other mental health worker whether the response is excessive. In practice if you go to a mental health clinic and tell them that there’s a lot of tension at your place of work and that the worry is keeping you awake at night, you will almost certainly receive a diagnosis of Adjustment Disorder, you will be enrolled in the ranks of the mentally ill, you will swell the statistics cited in earlier blogs, and you will be given a prescription for a sleeping drug (and possibly some free samples).
The primary theme of this website is that the medicalization of all human problems, which has progressed steadily for the past 40 years, is a spurious and counter-productive activity, and is promoted for the benefit of psychiatrists and pharmaceutical companies. Adjustment Disorder is perhaps the most glaring example of this activity, in that it widens the psychiatric net to every conceivable facet of human life. Any problem whatsoever renders an individual eligible for a diagnosis. So when a former Surgeon General stated that a fifth of all Americans will experience a mental disorder in any given year and that fully half of the population will have a mental disorder at some time in their lives, he was including in these statistics vast numbers of people who simply were experiencing an ordinary problem of daily living.
If individuals going to a mental health center with problems of this kind received some genuine support and guidance, the “diagnosis” might have some justification as a portal to this kind of assistance. What happens instead, however, is that the individual is given a prescription for an anti-depressive or anti-anxiety drug and is encouraged to “keep coming back” for future appointments. Additional “diagnoses” are often “uncovered” during this process, and the individual becomes a client for life.
Facing and overcoming difficulties is an integral part of human existence. I’m not suggesting that life should be one long arduous uphill struggle. But the notion that we can wave away our difficulties by calling them mental “illnesses” and taking drugs is a destructive and stigmatizing philosophy which undermines the value of human life. Psychiatry’s message to mankind, embodied in the DSM, embraced wholeheartedly by mental health workers everywhere, and endorsed by the pharmaceutical companies, is
“You can’t cope without our pills.”
The message is that as a species we no longer have to strive to overcome life’s vicissitudes. Just take a pill. To see psychiatrists and pharmaceutical companies promoting this philosophy is somewhat understandable. After all, they are businesses and their primary interest lies in the area of expansion and profits. To see politicians promoting such spurious and destructive concepts, however, is scandalous.
Next Post: Mental Retardation: A Stigmatizing Label
Grand Rounds up at Medicblog999
Posted by Phil in Carnivals and Fesitvals on September 13th, 2009
Grand Rounds is up at medicblog999. There are both themed posts and open submissions. Plenty of reading for all on a wide range of subjects.
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