Monday, June 11, 2007

The Disorder Is Sensory... 

...The Diagnosis, Elusive: "No one has a standard diagnostic test for these sensory integration problems, nor any idea of what might be happening in the brain. Indeed, a diagnosis of such problems is not yet generally accepted. Nor is there evidence to guide treatment, which makes many doctors, if they have heard of sensory problems at all, skeptical of the diagnosis.Yet in some urban and suburban school districts across the county, talk of sensory integration has become part of the special-needs vernacular, along with attention deficit disorder and developmental delays. Though reliable figures for diagnosis rates are not available, the number of parent groups devoted to sensory problems has more than tripled in the last few years, to 55 nationwide.And now this subculture wants membership in mainstream medicine. This year, for the first time, therapists and researchers petitioned the American Psychiatric Association to include 'sensory processing disorder' in its influential guidebook of disorders, the Diagnostic and Statistical Manual. Official recognition would bring desperately needed research, they say, as well as more complete coverage for treatment, which can run to more than $10,000 a year." (New York Times )

Labels: neuro, psych

6/11/2007 11:40:00 AM   •  

Thursday, April 26, 2007

Why Cho Was Not Committed 

Psychologist Jonathan Kellerman writes a thoughtful Wall Street Journal op-ed piece , with which I largely agree, grappling with the ethical responsibility of the mental health profession with respect to violence:

"If the Virginia Tech shooter had been locked up for careful observation in a humane mental hospital, the worst-case scenario would've been a minor league civil liberties goof: an unpleasant semester break for an odd and hostile young misanthrope who might've even have learned to be more polite. Yes, it's possible confinement would've been futile or even stoked his rage. But a third outcome is also possible: Simply getting a patient through a crisis point can prevent disaster, as happens with suicidal people restrained from self-destruction who lose their enthusiasm for repeat performances."

Kellerman does, however, place too much responsibility at the feet of the "liberationists" and "libertarians", exemplified by R.D. Laing and Thomas Szasz for the historic failure of the mental health system to effectively address such issues. Would that Laing's thought had had more of an influence! Kellerman summarizes the Laingian perspective as the principle that "[not] only wasn't psychosis a bad thing, it was evidence of a superior level of consciousness". But Laing's opposition to psychiatric medication and hospitalization were just the window dressing on his more essential contribution — an existential perspective which gives inroads into the inner world of our psychotic patients that inherently humanizes our care. This is not incompatible with the responsible mainstream practice of clinical psychiatry, IMHO, and I can cherish Laing's influence on my psychiatric philosophy without cognitive dissonance even though I medicate and hospitalize patients. About Szasz I have less kind things to say, especially given his collaboration with the Scientologists.

Deinstitutionalization and the failure of the community mental health system were not driven nearly as much by such idealistic philosophical vision as they were by the fiscal betrayal of the severely mentally ill — a socially insignificant constituency without serious advocates, and one our society is all too ready to shun and stigmatize — in the service of budgetary constraint. As Kellerman observes, "this was baby-and-bathwater time." The crux of the matter, he goes on to observe,

"...[the] basic premise of Community Psych--that severely mentally ill people could be depended on to show up for treatment voluntarily--never made sense to me. The core of the most common and debilitating psychosis, schizophrenia, is degradation of thought and reason. So the idea that people with fractured minds could and would make rational, often complex decisions about self-care seemed preposterous."

I would amplify on that; schizophrenia (and other major mental illness) involves not only a general degradation of reasoning but also a specific loss of insight into the nature of one's illness and recognition of the need for treatment, known as anosognosia, that can be understood both in terms of psychological denial and neurochemical dysfunction of particular brain regions, and which makes noncompliance with followup treatment and medication the single most important cause of deterioration and relapse.

While exercising due diligence in raising caveats, Kellerman infers that Cho had a serious mental illness and, unfortunately, all we will have is speculation:

"Diagnosis from afar is the purview of talk-shows hosts and other charlatans, and I will not attempt to detail the psyche of the Virginia Tech slaughterer. But I will hazard that much of what has been reported about his pre-massacre behavior--prolonged periods of asocial mutism and withdrawal, irrational anger and hatred, bizarre writing and speech--is not at odds with the picture of a fulminating, serious mental disease. And his age falls squarely within the most common period when psychosis blossoms."

I would be the first to assert that psychiatry is a markedly imperfect tool at best for the prediction and prevention of violence, and that once on the slippery slope of preventive detention the dangers outweigh the benefits. But Kellerman's conclusion, that

"Penning up and carefully scrutinizing the killer was never an option. Not in Virginia or California or any other state in the union. Because in our well-intentioned quest to maximize personal liberty, we've moved conceptual eons away from taking the concept of dangerousness seriously"

should give us pause.

Labels: Cho, Laing, psych, violence, Virginia Tech

4/26/2007 10:32:00 AM   •  

Friday, April 20, 2007

When a Brain Forgets Where Memory Is 

New York Times psychology reporter Jane Brody on the fascinating phenomenon of dissociative fugue:

"People with this problem suddenly and unexpectedly take leave of their usual physical surroundings and embark on a journey that can last as little as a few hours or as long as several months. During the fugue state, individuals completely lose their identity, later assuming a new one. They don’t know their real names or anything about their former lives, and they do not recognize friends or family. They may not even remember how they got to where they are.

While loss of memory can occur for many reasons, dissociative fugue has no direct physical or medical cause. Rather, it is precipitated by a severe stress or emotionally traumatic event that is so painful the mind seems to shut down and erase everything, like a failed computer hard drive."

Several years ago on FmH, I wrote with fascination of an apparent case of dissociative amnesia, a largely mute piano-playing young man institutionalized in a British mental hospital after apparently washing up on a beach. But, although they appear with regularity as literary or cinematographic devices, fugue states are encountered rarely if ever by clinical psychiatrists like myself in the course of our work. Of course, an exhaustive effort to rule out other, more neurologically based, causes of acute memory failure must be made. At the other end of the spectrum, so too it is at times difficult to distinguish fugue states from more consciously motivated attempts to deny one's identity.

I am not alone in wondering if fugue is a disease of modernity, requiring an emphasis on the self and personal sense of identity to shape a subconsciously-motivated attempt to lose one's self. I wonder what effect the modern challenges to identity, such as the influence of mass media on identity, the diffusion of the self through online presence, or the threat of identity theft, will do the the manifestations of dissociative fugue.

Labels: dissociation, identity, psych, self

4/20/2007 11:34:00 AM   •  

Tuesday, March 6, 2007

NASA long ago devised mental breakdown plan 

But that was for a psychological crisis in space, not back on Earth: "Long before NASA was confronted with an off-duty astronaut's bizarre behavior and arrest in Florida earlier this month, the agency had developed procedures to deal with a mental breakdown in space.

The guidelines were developed to respond to an attempted suicide or severe anxiety, paranoia or hysteria aboard the international space station. Astronauts are instructed to bind the stricken flier's wrists and ankles with duct tape, restrain the torso with bungee cords and administer strong tranquilizers.

The procedures have been in effect for at least six years, but the space agency did not develop any protocols for dealing with astronauts who become unstable while on the ground." (Houston Chronicle)

Also:

"Welcome to Human Interactions in Space, a research program dedicated to identifying and characterizing the psychosocial issues that affect the health and well-being of space crewmembers and the mission control personnel that support them. The program goal is to develop countermeasures that will enhance the safety and success of people involved with long-duration space missions."

Labels: psych, space

3/06/2007 08:40:00 PM   •  

Wednesday, February 21, 2007

Emotional Decisions 

"Emotions are ordinarily conceived as irrational occurrences that cloud judgment and distort reasoning. This view is well entrenched, despite work in both philosophy and psychology that establishes a strong connection between emotion and cognition. During recent years there has been an explosion of research which indicates that rather than being natural adversaries, rational and emotional processes function together. Barnes and Thagard (in press) argue that emotions and inferences are both necessary when we empathize with other people. Social psychologists have explored the function of emotions in social perception and judgment (Forgas, 1991). But the interdependence of emotional and cognitive processes is perhaps most powerfully presented in recent neurobiological studies which establish that emotion is indispensable in rational decision making." (— Barnes and Thagard)

Labels: psych

2/21/2007 01:15:00 PM   •