Grand Rounds at Diabetes Mine
Posted by Phil in Carnivals and Fesitvals on March 15, 2011
Grand Rounds is up at Diabetes Mine. You will find the usual wide range of topics, so stop by and have a read.
Grand Rounds at Dr. Pullen
Posted by Phil in Carnivals and Fesitvals on March 8, 2011
Grand Rounds is up at DrPullen. There is the usual wide range of subjects – some light-hearted, others very serious. Stop by and take a look.
Diagnosis
Posted by Phil in A Behavioral Approach to Mental Disorders on March 6, 2011
I am writing this post as a response to a comment posted by medical blog in my previous post, More on So-called Bipolar Disorder.
In the summer of 2001 I became very ill. The symptoms were exhaustion and mild nosebleeds. I went to three different practitioners, but they all were dismissive of my concerns, assured me that I was in good health, and sent me on my way. On August 8th of that year I was admitted to the hospital in Greeley, Colorado with complete kidney failure. The nephrologist at the hospital gave me the diagnosis that had eluded the earlier doctors: Wegener’s Granulomatosis – a rare autoimmune disease that attacks lungs, kidneys, and airways. I have been on dialysis every since.
The reason I tell this story is to illustrate the meaning and significance of a medical diagnosis. In my case there were certain signs and symptoms. For instance, I told the doctors that I was tired and that this was not characteristic of me. I told them of the nosebleeds. And they could see that I was dragging. By the time I got to the second doctor, I was also vomiting and having difficulty sleeping.
Now the point is that until I got to the hospital in Greeley, there had been no diagnosis. One doctor said: “maybe you’ve got the flu?” But it didn’t feel like flu, and this tentative diagnosis wasn’t very convincing.
When we ask for a diagnosis we are asking for an explanation. So if you‘re very tired and you’re spitting up dreadful-looking phlegm, a doctor might diagnose pneumonia and would be able to substantiate this diagnosis through observation and lab tests. And – and this is critical – he would be able to show a clear causal link between the pathology and the symptoms.
In my case, the diagnosis of Wegener’s Granulomatosis explained the exhaustion (increased toxicity due to kidney failure) and the nosebleeds (Wegener’s Granulomatosis is believed to be triggered by an airborne pathogen and so the immune system becomes particularly active in this area).
The key is explanation. A good diagnosis pinpoints the pathology, explains the symptoms, and directs treatment. This is the model that has lifted Western medicine out of the charlatanistic quackery that predominated prior to about 1880. Modern medicine is remarkably successful precisely because it is based on an understanding of the pathology involved. Now obviously, as in my case, it sometimes isn’t easy to make a diagnosis, but in the vast majority of cases, people seeking medical help receive an accurate diagnosis early in the process, and this diagnosis guides and directs treatment, usually with a good deal of success.
Now let’s consider the so-called mental health diagnoses. Take the condition known as Attention Deficit Hyperactivity Disorder. The American Psychiatric Association says that this is a mental illness. In other words, ADHD is a diagnosis. And they list the symptoms of this diagnosis. I have reproduced these so-called symptoms in an earlier post, and it’s not necessary to reproduce them here, but here are three fairly typical items from the list:
- often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
- often leaves seat in classroom or in other situations in which remaining seated is expected.
- often runs about or climbs excessively in situations in which it is inappropriate…
Now what the APA have done is this: they have asserted that these are the symptoms of the mental illness that they call ADHD. Now if this means anything, it should mean that ADHD is the explanation of these misbehaviors. And this is precisely how the so-called diagnosis is used in practice. When a parent asks why his child is so unruly and undisciplined, the reply he is given is: because he has ADHD. The putative mental illness is routinely proffered as the explanation – as the underlying pathology which explains why the child is so misbehaved.
But in fact if one examines the matter further, one finds no substance to this so-called diagnosis. ADHD is nothing more than a name for this kind of misbehavior. The acid test here is the question: how do you know he has ADHD? And the only possible answer is: because he is so unruly and undisciplined. The only evidence for the so-called diagnosis is the very behavior it is supposed to explain.
Real diagnoses involve real pathology that one can identify, test for, and hopefully ameliorate. Wegener’s Granulomatosis, for instance is a real disease. And it is recognized as a diagnosis today because Dr. Wegener, a research pathologist working in Germany in the 1930’s, noticed certain microscopic anomalies in corpses he was dissecting. He began to tie these anomalies with symptoms observed before the individuals had died. His work was interrupted by the war, but after the war he refined his observations, and the diagnosis was firmly established. At first there was no treatment for WG – it was effectively a death sentence – but gradually drugs became available, and today the disease is eminently treatable, though because of its rarity, the diagnosis is often missed (as in my case).
In contrast, consider the so-called diagnosis ADHD. Prior to 1950 this diagnosis did not exist. Today it is deeply embedded in psychiatric practice, and indeed in our collective consciousness. This change occurred – not because of a discovery – but because an APA committee decided that ADHD is an illness. As preposterous as this sounds, it is exactly what has happened. In the six decades from 1950 to the present, the primary business of the APA has been redefining the ordinary everyday problems of living (that our ancestors tackled using ordinary time-worn tactics) as mental illnesses. And this has been done in collaboration with the pharmaceutical companies for one reason: profit - the selling of prescription slips and the selling of drugs. Psychiatry has degenerated into nothing more than drug-pushing. And the process of pathologizing normal problems of living continues. The much-heralded DSM-5 promises even further inroads in this direction.
The fundamental problem with the APA’s approach emerges from their definition of a mental disorder:
… a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress…or disability…or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom. (DSM-IV-TR, p xxxi)
If you examine this definition carefully, it is clear that it means nothing more than: any significant human problem.
It’s a castle built from sand. The logic is as follows:
- Any human problem is a mental disorder.
- X is a human problem
- Therefore X is a mental disorder!
As facile and ridiculous as this sounds, it is exactly what has happened. The simple assertion that childhood misbehavior is a mental illness explains nothing. It is simply a device used to legitimize drugging these children.
And the real causes underlying these problems are never even pursued. Parents are off the hook; the school is off the hook; the community is off the hook. And the cash registers at the pharmacy go ker-chung.
And similar considerations apply to all the other DSM creations. Depression is not an illness. It is a feeling we get in response to a major loss or when things are not going well for us. It has been pathologized by the APA and the pharmaceutical companies for gain. The so-called bipolar disorder is not an illness – it is largely rudeness and irresponsible behavior – again pathologized for gain.
It is said that the drugs work, so why quibble? Well the simple answer is that they don’t work nearly as well as the psychiatric hype would have us believe. But this post is already too long; perhaps we can pursue this another time.
Once again, apologies to my regular readers for the repetition. Medical blog, if you’re still reading, I can appreciate how a medic, schooled in the rigors of scientific research, might view all this with a measure of skepticism. It’s a great deal easier to dismiss me as a crank than to face the alternative: that modern psychiatry is an enormous hoax which is draining dollars from genuinely needed services and undermining notions of self-help and personal responsibility that are keystones of a thriving society. Please feel free to come back on any of these issues. It’s not just a question of trying “harder and smarter.” Some of the problems that confront people are truly overwhelming and require outside help. But they are not illnesses and the help needed is not drugs.
More on So-called Bipolar Disorder
Posted by Phil in A Behavioral Approach to Mental Disorders on February 24, 2011
A few days ago, I received the following email:
Hi Phil,
I would like to hear from you how we can survive the bipolar disorder, as I understand bipolar is a very serious disease.
Regards,
[Name]
The question seems important enough to warrant a more public response, though I have omitted the writer’s name to safeguard confidentiality.
So here’s my reply.
Firstly, the condition known as “bipolar disorder” is emphatically NOT a disease. Rather, it is a loose cluster of behaviors which psychiatrists – in concert with the pharmaceutical companies – have called an illness with the purpose of selling drugs.
The DSM criteria for this so-called diagnosis are set out in my earlier post on this subject.
In practice, the behaviors likely to attract a “diagnosis” of bipolar are:
- Hyperactivity of any kind for an extended period
- Marked irritability; grouchiness; snapping at family, co-workers, etc.
- Marked boastfulness; expressions of grandiosity
- Pronounced sleeplessness
- Excessive talk; rapid shifting from topic to topic
- Temper tantrums
- Behavior that would normally be called “irresponsible,” e.g. sexually reckless activity; buying sprees; gambling; risky ventures; etc.
Traditional psychiatry says that if you’re functioning in this fashion, you have an illness called “bipolar disorder.” The formal criteria call for a certain number of behaviors within certain time frames. Also, a measure of oscillation is required – i.e. the “symptoms” abate periodically, then resurge. And so on. In practice, any of the behaviors listed above will attract this “diagnosis.” And the “treatment,” of course, is: drugs. Usually lithium carbonate – but in the past decade or so other drugs are being used to impact these behaviors. Especially worrying in this regard is the prescription of these drugs to very young children to treat tempter tantrums. (I am aware that temper tantrums as such are not included in the DSM criteria list, but over the past decade or two, proneness to temper tantrums has been conceptualized as “mood swings,” and has become a kind of backdoor feature of this so-called mental illness.)
But, back to the question in the email. What should one do?
Well the answer, of course, depends on what kind of problem behavior we are talking about.
Let’s say that the problem behavior is irritability and temper tantrums.
The first requirement is to describe the problem clearly and completely. “Temper tantrum” can mean different things – everything from stomping one’s foot and saying “drat,” to throwing the furniture out the window. So if a person feels that he/she has problems with anger control, the first thing is to write down exactly what kind of behaviors are occurring and with what frequency (Daily? Weekly? Monthly? etc..)
Duration is important. Has it been going on for years or just in the past few days?
Context is also critical. Where does the problem behavior occur? At home? Work? When visiting in-laws? etc.. Or perhaps everywhere?
And triggers. What kind of situations seem to “trigger” the anger response? Other people’s driving? People talking on cell phones? Outbursts of anger usually occur when we feel frustrated or attacked. Frustration arises when we are trying to do something but can’t manage to do it. And attacks may be real or imaginary.
And substance abuse. Is there a problem with alcohol or other drugs?
And so on. The point being that a simple phrase like “temper tantrums’ or “bipolar disorder” tells us nothing. What’s needed is a detailed written statement of the problem.
I do not know the enquirer personally, so it would not be proper for me to give him/her specific advice. And I don’t know if temper tantrums is the issue or what – but the point is this: specify the problem as honestly as possible and with as much detail as possible.
Often at this point the solutions start to suggest themselves. For instance, if a person is routinely throwing temper tantrums when the car breaks down, then maybe it’s time to get some repairs done or get a new car – or even just decide to get stoical about it – try to let it wash over one.
The point here is that finding solutions to behavioral problems is not quantum physics – usually if one has done a thorough and honest job identifying the problem, then the solutions are forthcoming.
In this regard it is often helpful to break problems down into components and tackle them one at a time. Or to set intermediate goals. A person who identified over-talkativeness as a problem might initially aim to sit silent for one minute, then two, and so on.
I have mentioned elsewhere in this blog the importance – indeed I would say the necessity – of having at least one good friend – someone with whom one can be completely honest. Often the kinds of problems we are talking about here benefit from a second perspective. Other people often see us more accurately than we see ourselves. A best friend can be a spouse, a brother, sister, or just the guy who lives next door. The point is that if I have a significant behavioral problem and if I genuinely want to change this, then asking for help is clearly a positive step.
Some other pointers:
- Try to find and pursue an activity that is incompatible with the target activity. For instance if you feel a temper tantrum coming on, start singing or whistling. It’s difficult to have a temper tantrum while singing a happy tune.
- Acknowledge successes. If you had been having daily temper tantrums and you’ve got it down to one per week – that’s great – acknowledge the gain, but keep working.
- Avoid triggers as much as possible. If a person finds that he has temper tantrums whenever the dog starts barking, then maybe it’s time to get rid of the dog – or get one of those bark suppression collars.
I’ve picked the example of temper tantrums and used it in this reply. But I’m conscious of the fact that this might not be the issue of the enquirer. That’s one of the problems with the term “bipolar disorder.” It simply is not specific enough. But the essential point here is that whatever the behavior is that attracted the diagnosis of bipolar disorder, this behavior can be identified, specified clearly, and remediated. And in this regard you have to do what we all have to do with life’s problems – exploit your strengths to counter your weaknesses. In other words – use your ingenuity. Find solutions to the problem. Don’t give in. Don’t go on doing things the same. Break patterns, etc..
If your problem behavior, in fact, lies in some other direction and you would like further thoughts, don’t hesitate to come back and let me know the specific behaviors that are causing concern.
Now, of course, having said all this, I should add that you can take the conventional step: go see a psychiatrist and take the “happy pills.” I’m not recommending this course of action, but I’m sure you realize that it is an option. Drugs can be effective in suppressing certain kinds of behavior. However, they always have negative side effects, and although they may suppress the worst aspects of the problem behavior, the result is a far cry from normal human existence.
Grand Rounds at The Covert Rationing Blog
Posted by Phil in Carnivals and Fesitvals on February 22, 2011
DrRich has Grand Rounds up at The Covert Rationing Blog. He has obviously put a lot of work into hosting this week’s rounds, with explanatory paragraphs concerning each entry. The reader is easily able to discern what is covered in each submitted post, so stop by to have a look, and read further.
More On Disability
Posted by Phil in A Behavioral Approach to Mental Disorders on February 16, 2011
In his book Anatomy of an Epidemic, Robert Whitaker drew attention to the increasing numbers on the Social Security disability rolls due to so-called mental illness. Robert raises the possibility that the drugs routinely used to “treat” depression may be contributing to the problem. In a recent post, he discusses this matter further.
I think the reasons for the increase in the disability rolls are as follows:
1. People who seek psychiatric help are being told routinely that they have brain abnormalities and that they need to take drugs for the rest of their lives –“just like diabetics.” This promotes a disability mindset which often translates into a disability application.
2. Applicants for disability based on the so-called mental illnesses are screened by either a psychiatrist or a psychologist. Both of these professional groups are immersed and heavily invested in the conceptualization of ordinary living problems as illnesses, and tend to accept uncritically the applicants’ claims that they “just can’t do anything.”
3. In the mid 1990’s there was a great groundswell in political circles to get people off the welfare rolls. It was pretty much an open secret (at least in my area) that Social Services Department caseworkers were referring their welfare recipients “across the road” to the mental health center, so that they could establish a treatment record for mental illness, with a view to applying for disability.
4. Mental health clients routinely share information concerning which “symptoms” to emphasize, what to say, etc., during the evaluation. Clients whose application for disability has been successful are often seen as resources for those coming behind.
5. Mental health workers inadvertently teach their clients how to qualify for a “diagnosis.” When the worker asks the client if he/she has been having trouble sleeping and writes down the answer in a case file, the client realizes that sleeplessness is a factor in determining disability. Similarly for “loss of energy,” “poor concentration,” “recurrent thoughts of suicide,” etc.. An even moderately motivated client can readily identify the criteria questions for whichever “diagnosis” is being pursued. This is because the worker’s primary objective is not to get to know and understand the client, but rather to assign a diagnosis – to get the client into a billable pigeonhole.
6. The APA’s infinitely flexible definition of a mental disorder and the equally flexible criteria for each particular “disability” make it possible for virtually anybody to receive a diagnosis. All that the client has to do then is leave a trail of disasters in his wake and make sure it is adequately documented. I knew a man one time who was receiving disability benefits for alcoholism (I think from the VA). This puzzled me because I had never seen him drunk or even drinking. But later his wife told me that three or four times a year he would go into town, have a few drinks, make a nuisance of himself, get arrested, and spend the night in jail. The ensuing paper trail was sufficient to sustain his disability status and income. You can’t fake kidney failure, but you can fake every DSM diagnosis.
7. And of course, the drugs themselves are causing damage which contributes to genuine disability. There is evidence that benzodiazepines shrink brain tissue. See my post Business as Usual. And an article by Nancy Andreasen (Long-term Antipsychotic Treatment and Brain Volumes) indicates that the major tranquilizers (or “antipsychotics” as the bio-pharma-psychiatric bloc likes to call them) also shrink brain tissue. Obviously as brains shrink, disability rolls expand!
There are no mental illnesses. “Mental illness” is a spurious explanatory concept whose purpose is to medicalize for profit the ordinary problems of human existence which our ancestors tackled and resolved without drugs for thousands of years. The bio-pharma-psychiatric system is nothing more than a façade for legalized drug-dealing which is eating away at the quality of life and the fabric of our society.
Grand Rounds at Gruntdoc
Posted by Phil in Carnivals and Fesitvals on February 15, 2011
Grand Rounds is up at Gruntdoc. As usual, Dr. Roberts presents a very user-friendly rounds, simple to follow, easy to use. Close to thirty posts, with a wide range of subjects. Stop by and have a look.
Business As Usual
Posted by Phil in A Behavioral Approach to Mental Disorders on February 12, 2011
Christopher Lane, author of Shyness has written an interesting post. The gist of the matter is as follows.
There’s a class of drugs known as benzodiazepines (benzos for short) that are promoted by Pharma and prescribed by psychiatrists to “treat” anxiety. (As if anxiety were an illness!) See my post on the So-called Anxiety Disorders.
Benzos include such household names as Valium, Librium, Ativan, Xanax, etc.. When introduced in the 1960’s, these drugs were widely touted as “safe” tranquilizers. Readers may remember Valium as “mother’s little helper,” so called because it was marketed to millions of harried housewives as they struggled to adapt to an increasingly complex and multi-faceted lifestyle.
Almost immediately it began to be recognized in certain circles that these products were strongly addictive, but Pharma consistently denied this, and the psychiatrists went on prescribing. A psychiatrist I met in the 80’s once remarked: “You don’t take people off Xanax. Once you’re on it, you’re on it.” About the same time, I heard another psychiatrist say: “The only difference between Xanax and true love is that Xanax is forever.”
Within the addiction “treatment” field, benzos are described as “dry alcohol.” And indeed, they resemble alcohol in many ways. They have a sedating effect, they produce intoxication, and in fact, in hospital settings benzos are widely used to detox cases of chronic alcohol abuse.
Now all of this is well known. What’s new?
Well apparently in 1982, Malcolm H. Lader, Professor of Clinical Psychopharmacology, Institute of Psychiatry, University of London, demonstrated measurable brain shrinkage in individuals who had taken these products, and that the shrinkage was similar to that found in long-term alcohol abusers. Surprise!
But the plot thickens. It has recently come to public attention that Britain’s Medical Research Council (MRC) agreed – back in 1982 – that further large-scale studies were needed to explore and confirm Dr. Lader’s findings. But – and this is almost beyond belief – they marked the file “closed until 2014”! And the further investigations were never done.
Why not, you might ask?
Well here’s a clue. Britain’s Medicines and Healthcare Products Regulatory Agency (MHRA) is funded entirely by fees derived from the very industries they are supposed to regulate.
Remember – there are no mental illnesses, and the products sold to “treat” these fictitious illnesses are drugs. And the one abiding feature of all drugs – no matter how pleasant they may seem in the short run – is that they are dangerous. Drug dealing – whether it’s on the streets or in the local mental health center – is a dirty business where human life and human welfare are routinely sacrificed on the altar of corporate profit.
Grand Rounds at Suture for a Living
Posted by Phil in Carnivals and Fesitvals on February 8, 2011
Grand Rounds is up at Suture for a Living. Plastic surgeon Dr. Ramona Bates has included posts that cover many different subjects, some light, some serious. Stop by and have a look.
Overeating Is Not An Illness
Posted by Phil in A Behavioral Approach to Mental Disorders on February 7, 2011
DSM lists two principal “illnesses” under the heading Eating Disorders: anorexia nervosa and bulimia.
Anorexia Nervosa means chronic and pernicious fasting even though food is readily available. “Anorexia” is Greek for lack of appetite. “Nervosa” is Greek for nervous.
Bulimia means recurrent episodes of binge eating followed by self-induced vomiting or other methods of purging. “Bulimia” is Greek for “the hunger of an ox.”
Neither anorexia nor bulimia is an illness in any correct sense of the word. But my concern today is not with either of these issues, but rather with common, everyday overeating.
Many people are unaware that overeating is listed in the DSM, but if you go to the section headed Eating Disorder Not Otherwise Specified you will find the following:
“Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa”(DSM-IV-TR, p 595)
In other words: habitual overeating.
Elsewhere in the text (p 785) the APA offer more detailed criteria for further study, and it is likely that overeating will be included as a free-standing “diagnosis” in DSM 5. And that, of course, will be very good for business.
But regardless of what the APA claim, overeating is not an illness, although, of course, it causes a great many physical illnesses, including diabetes.
SOME BASICS
The human body is a biological machine, and like all machines, it needs a source of energy. And by energy, I mean movement and heat. Not “psychic” energy or “spiritual” energy or “cosmic” energy or whatever. Just plain old calories and watts. A car gets its energy from gasoline; people get their energy from food.
The human body needs the energy content of food to supply heat and movement. And movement includes not only walking around, but every kind of movement that occurs within the body: the beating of the heart, the movement of the lungs, the pulsing of nerves, etc., etc.. In order for any of these activities to take place, food has to be burned in the same way that the car burns gasoline. Biological burning is slower and cooler than automotive burning, but the process is essentially similar.
If you put more food into your body than you use, the body stores some of the excess as fat. This is an adaptive device that mammals developed millions of years ago, and it gave our ancestors a better chance of surviving food shortages. By overeating in times of plenty, they could – to some extent – live off their own fat through times of famine. Today, of course, at least in North America and Western Europe, the food supply is steady, and so we don’t have periods of famine. But the basic facts of physics and biology are the same: if you eat more than you use, some of the excess will be stored as fat.
OBESITY
We are creatures of habit. We tend to do the same things day after day – sometimes for years. My daily routine requires the expenditure of a certain quantity of energy – say 2000 calories. If I eat less than 2000 calories per day, then I will start to lose weight as my body consumes all my fat reserves. Then my body will start consuming muscle and other tissue in a desperate attempt to stay alive.
If I routinely eat more than 2000 calories, however, my body will store some of the excess as fat. So I go on with my daily routine – doing the same things I do every day, but – and this is critical – getting a little heavier every day. Now basic physics (and common sense) tells us that it takes more energy to move a heavier body than a lighter one. So even though I’m not doing anything extra in the way of exercises, etc., I am burning more calories simply because I’m getting heavier. Until finally equilibrium is reached in which my caloric intake is balanced by my output. The precise point at which this balance is reached, of course, varies from person to person. Some people will reach equilibrium at 200 pounds, others at 400 pounds. But the balance in all cases depends on two factors: habitual energy intake versus habitual energy output. And this is the key to understanding obesity.
Everything else is a side-show. Genetic pre-dispositions and metabolism rates are all interesting facets of the matter, but at the end of the day, if your intake exceeds your output, you will be gaining weight. And if you want to lose weight, you need to eat less and move around more.
So why don’t people just do this? Why is obesity such a problem? And the answer is simple – because it’s difficult. Food is so wonderful and we have such a variety readily available and such convenient methods of preparation, etc.. And moving around doing things is more difficult than sitting on the recliner watching a movie. I’ll discuss this further next post – but for now, back to DSM.
DSM AND OBESITY
As things stand today, overeating is already a “diagnosis” in the DSM. But it’s a concealed diagnosis. Its formal designation is: 307.50 Eating Disorder Not Otherwise Specified (binge eating disorder).
It also meets the APA’s definition of a mental disorder, which can be paraphrased as: any significant problem of human living. Well overeating is certainly a problem, and therefore there should be little difficulty making it a mental illness. But the APA recognizes the need to proceed cautiously in the business of re-defining ordinary human problems as so-called mental illnesses. If their claims seem too ridiculous, they will lose credibility, so there has to be a gradual process – a “softening-up” period so to speak – during which the public is introduced to the notion that what we had thought of as a normal human problem is really a mental illness.
In DSM-III (1987), overeating was not listed specifically. In DSM-IV (1994) it was sneaked in under the ever-elastic NOS category. And by DSM 5, I predict the process will be complete and habitual overeating will be a fully-fledged mental illness.
And this “diagnosis” is the mother-lode of all diagnoses. The psychiatrists are carefully and systematically engineering themselves to center stage in the war on fat. The answer, of course, will be to eat more pills, and the winners will be the pharmaceutical companies and, of course, the psychiatrists themselves.
More on overeating next post.
