Tuesday, January 19, 2021

Comments by DrStrait

Showing 22 of 22 comments.

  • The only point of disagreement is that I think the rest of “medical” problems are also political, economic, and social, and I don’t believe there exists anything like “actual medicine and science” that is not structured politically and economically and constructed socially. Ivan Illich’s Medical Nemesis is especially instructive on this point, and I should note that I’ve mentioned nearly a dozen non-psychiatric “medical” disorders in the comments here, and continually pointed out that you all are systematically refusing to respond to those examples.

    I will not defend pediatric psychiatry as it is beyond the scope of my practice and personally much of what happens there alarms me. But no properly trained psychiatrist will ignore the patient’s explanations for their feelings or behaviors. I can’t even fathom how one would conduct a clinical interview without asking those questions. Usually this kind of problem comes when non-psychiatrist physicians attempt to treat mental illness, which they often (but not always) do poorly.

    You can’t refer to an illness as a “verifiable fact.” That we call something an “illness” in the first place, and consider it relevant to treat, is a social construction that is not grounded on any kind of non-intersubjective basis. Is male pattern baldness a “verifiable fact”? Is obesity a “verifiable fact”? Is hypoactive sexual desire disorder a “verifiable fact”? Is high blood pressure a “verifiable fact”? Is premature ejaculation a “verifiable fact”? Is chronic pain a “verifiable fact”? Each of these have “verifiable” aspects (much like mental illnesses have verifiable aspects — do you have this cluster of clinical signs and symptoms? Are you behaving in x characteristic way? Something like schizophasia is obvious and can be ‘verified’ in any number of ways), and yet the fact that it is considered an illness in the first place is a *value* judgment. (re schizophasia, we happen to consider it a problem if someone suddenly loses the ability to form sentences. And that problem is in the brain.)

    I am open to the fact that sometimes psychiatric treatment is poor, and that many times a diagnosis doesn’t serve a direct clinical purpose. I’ve said as much. You seem not so open to the fact that sometimes, it can be a great relief and reassurance to patients. When you talk about being rigidly committed to my position, we have a word for that: projection.

  • @oldhead — Perhaps you should familiarize yourself with how the institutions of medicine and science actually operate in the modern world. You might be surprised how relevant insurance accounting concerns are. Or pharmaceutical marketing imperatives. Should it be so? Well, no, but no one should ever get sick or suffer. Alas, that isn’t the world we find ourselves in.

    @jonathan, In the clinic, sure, but *something* would have to replace it that would provide a common language necessary to do research and to train residents (and clinical psychologists, social workers, nps, etc.). But the DSM is not terribly useful to anyone, and the APA doesn’t really understand what is at stake in various nosological controversies. For example, take something like narcissistic personality disorder. Does it ‘exist’? Well, sure, that constellation of symptoms and signs certainly show up in certain people. But those people are never help-seeking, at least not with respect to their narcissism. So why does psychiatry need the concept of NPD? Criminologists, sure. Just because some set of phenomena exist, are disabling, and are atypical doesn’t mean it is useful to have them appear next to a label in a book like the DSM.

  • Your argument is that because certain illnesses (again, you continue to fail to respond to my point about chronic pain etc.) don’t fit your definition of illness, that it is illegitimate for people to ingest certain chemicals that make them feel better. That’s the only reason why the category matters — it matters because of what you can do (or can’t do) institutionally as a result. There is no metaphysical ‘disease’ or ‘illness’ floating around with the forms. All there are are people suffering and you telling them that certain avenues of help should not be available to them.

    Let me let you in on a secret. Psychiatrists don’t care in the slightest bit about diagnoses. Generally, there is no good reason to even introduce the label to the patient. They serve the purpose of insurance reimbursement for psychotherapy and medication. A good psychiatrist is not going to “disempower” a person with an explanation or label that isn’t going to help them. On the other hand, some people find immense relief in discovering that they aren’t crazy, they just suffer from x or y. It is actually empowering to those people. They go from being distressed suffering people to becoming mental health consumers.

    Finally, I find your premise somewhat silly. When you find out that you have influenza, do you feel disempowered? It is certainly not normal to have influenza. Why would learning that you have high blood pressure (not a disease, incidentally, but a risk syndrome — are you up in arms about medication to “treat” that non-disease?), epilepsy, or parkinson’s, or panic disorder be disempowering? And why would you be seeking help from a professional if you would find that help disempowering? Take people seriously and give them credit. They are stronger than you imagine. They just need people with compassion.

  • I don’t know why you are so hung up on categories. Categories don’t exist. They aren’t real. They are *useful* (or not). That’s it. Do you administer caffeine to yourself when you get tired? Does it matter in the slightest bit whether you want to call your tiredness an illness? Suppose you do, for some strange reason. Does the caffeine no longer help? There is no such thing as a disease except what we want to call a disease. Influenza, or cancer, or chronic pain (you’ve ignored my arguments about letting people suffer chronic pain since often there is no identifiable physiological explanation — I can only assume you would choose the cruel course of action to deny these patients medication that relieves their pain), or Alzheimer’s (or as perhaps you would call it, the medicalization of severe memory loss or some such nonsense) are only diseases because it is useful to call them diseases. That’s it. Forget categories and start thinking about helping people who ask for help. To dismiss insurance issues as ‘vagaries’ is the height of privilege — those ‘vagaries’ make a serious material difference in whether immense personal suffering can be relieved. They aren’t small issues — they are basically the only reason we have a DSM in the first place.

  • I’ve worked with substance abusers and I’ve worked with patients who have been taking adhd medication for decades under medical supervision. There is no comparison at all. First of all, a meth abuser can plausibly consumer up to a gram of methamphetamine in a single day. When we use an equivalent drug, desoxyn (d-methamphetamine), they come in 5 mg pills. So it would be like a patient taking more than six months of medication in a single day. As they say, sola dosis facit venenum.

    Secondly, look at behavior and functioning. I’ve never seen a stimulant abuser (that is, someone who consumes street stimulants, almost always administered non-orally, using doses orders of magnitude larger than therapeutic doses, and obviously not under medical supervision) who was high functioning and did not suffer terribly from their addiction. The patients that I know who have been taking prescribed stimulants for decades are productive, have normal sleep schedules, do not commit crimes, do not shirk basic responsibilities, and, in short, are stable. To say ‘oh well they are taking the same or similar chemical’ is either to grossly misunderstand how the body responds to different dosing regimes of stimulant medication, or to simply not care about the truth. It would be like comparing a chronic pain patient to a heroin addict. (Chronic pain, btw, often does not have an identifiable physiological cause — I suppose you people would say it isn’t real or worthy of treatment? Cruel.)

    As for the ‘but but ritalin is in the same class of drugs as cocaine’ — yes, drugs that have medical uses but are prone to abuse. I suppose you think that a patient who has been administered cocaine as an anesthetic for eye surgery is the same as someone who smokes crack?

  • I think that if someone comes to me and asks for help with a problem that is making their life a nightmare, I should try to help them rather than turn them away because some people debate whether or not the Platonic Ideals of ‘illness’ and ‘disease’ are inclusive of their problem. I think instead of throwing up artificial barriers to help seeking patients getting help, we should be trying to help people who ask for it.

    And, respectfully, I think it is silly to assert that mental illness has no biological correlate. I don’t know how you can be so certain of that, or why, even if true, that would be a good reason to refuse to help someone improve themselves or eliminate some problem in their life.

  • I don’t actually see anything wrong with what you’ve described re the skin disorder — that’s exactly what happens and how we deal with it. The line is really anything that interferes with functioning or well being that can be helped in some cases by physiological intervention. I’m not naive about the dangers of medicalization — but given the institutions we have, it is useful to treat many problems like this. The trick is to have a physician who is willing to pursue a variety of treatment modalities and who has a strong sense of discretion, and also the influence of pharmaceutical companies needs to be confronted. But, at the end of the day, if your vision for how the world should work doesn’t have a practical way for a patient with panic disorder who happens to really need anxiolytic medication to get that medication (and for it to be reimbursed), I simply can’t get on board. There are tens of thousands of help-seeking patients who are truly suffering in ways that would shock most people. Anything that interferes with their ability to obtain the help they seek is, in my view, cruel.

  • No psychiatrist should be using the phrase “chemical imbalance.” It is unfortunate that such language made it into pharmaceutical marketing copy. Certainly no psychiatrist actually thinks in those terms, even if they use such language with lay folks in a misguided attempt to convey the neurobiological basis of affective disorders. That said, it is true that the hippocampus loses mass during episodes of severe depression or mania, and it is also true that effective antidepressant treatment (whether medication, omega-3 fatty acid supplementation, cognitive therapy, light therapy, excercise, etc.) produces neurogenesis in the hippocampus through BDNF which produces measurable increases in mass. Obviously we can’t talk about causation, but this is a well established correlation. The idea that neurotransmitters are out of “balance” is a throwback to medieval medicine…

  • How do you define “pathology”? Surely everything that happens in the mind is mediated by the brain. So whatever it is that someone is feeling or experiencing or doing tracks with something happening biologically. So the key issue is what biological phenomena do you consider to be ‘pathological.’ Do you use some kind of medieval humoral ‘too much/not enough’ of x criterion? Perhaps you are trying to compare the functioning of an organ to some idealized ‘normal’? Or perhaps you are looking for anatomical lesions of some kind? That would exclude quite a few legitimate medical disorders.

  • I was simply replying to the claim that ADHD medication prescribed to children increases the likelihood of substance abuse. That claim seems not to be supported by the evidence. I don’t know why my “credibility” would be enhanced if I cited literature about some issue that we aren’t discussing.

    There are scant few studies on the long term effects of stimulant therapy. It is extraordinarily difficult and expensive to do the kind of longitudinal studies that are needed.

    I am skeptical about prescribing psychiatric medication to children. But I know quite a few adult patients who have been successfully maintained on stimulant medication for decades. And it has nothing to do with making them more “manageable.” These people are help-seeking and their symptoms are very well controlled by the medication, for years.

  • @oldhead – Why isn’t anxiety a medical problem? Is chronic pain a medical problem? Those are mediated similarly in the central nervous system. There is no such thing as a mind that exists independently from the body — everything that happens in the mind happens in the brain. The mind is *epiphenomenal* of the brain. And beyond that, as I’ve argued, there are institutional problems with saying that anxiety isn’t a medical problem: if so, people can no longer be reimbursed by their health insurance. To take away treatment from patients with panic disorder, or to suddenly make it too expensive to receive treatment, is astonishingly cruel.

  • @SomeoneElse – Certainly I would agree that any forced treatment is problematic, whether in psychiatry or any other field of medicine. Here I’m exclusively talking about dealing with help-seeking adults. I think there is a good critique to be made of pediatric psychiatry, as well as other coercive uses of psychiatry with adults — but you can take the rhetoric too far and start undermining the efforts of help-seeking adults to gain relief.

  • It is an important problem, and there are related issues of diversion, but the data seem to indicate that children diagnosed with ADHD and prescribed stimulant medication are not more likely to become substance abusers, and, indeed, might be *less* likely:
    “ADHD medication was not associated with increased rate of substance abuse. Actually, the rate during 2009 was 31% lower among those prescribed ADHD medication in 2006, even after controlling for medication in 2009 and other covariates (hazard ratio: 0.69; 95% confidence interval: 0.57–0.84). Also, the longer the duration of medication, the lower the rate of substance abuse. Similar risk reductions were suggested among children and when investigating the association between stimulant ADHD medication and concomitant short-term abuse.
    We found no indication of increased risks of substance abuse among individuals prescribed stimulant ADHD medication; if anything, the data suggested a long-term protective effect on substance abuse. Although stimulant ADHD medication does not seem to increase the risk for substance abuse, clinicians should remain alert to the potential problem of stimulant misuse and diversion in ADHD patients.”

  • Yes, very familiar. I think he makes some very important arguments about coercion and also is an important voice concerning forensic applications of psychiatry. But I think he vastly overstates his case, and his tendency toward polemic interferes with his ability to deal with arguments in a scholarly way sometimes.

  • Also, regarding your last question, there’s nothing to stop us from defining any problem as a disease — but we only do so when it is useful. Given the realities of insurance reimbursement, it is often useful to define something as a medical problem. Even when insurance isn’t on the table, it can be useful when there is medication that helps with a problem because of the institutional logics of the state’s regulatory apparatus. For example, male pattern baldness used to be thought of as a cosmetic problem. But now that we have medication that works for it, we call it alopecia and treat it medically. We do so entirely because it is useful in terms of providing aid to help-seeking individuals. Generally, the threshold is that the issue causes significant distress and/or significantly interferes with basic functioning.

  • @Oldhead — “high cholesterol” isn’t a defect in a bodily process. It is perfectly normal, and nothing is defective. But we treat it because it is a risk syndrome for various cardiovascular disorders.

    One could argue that panic disorder and other cases of crippling anxiety are ‘defects’ in the nervous system’s anxiety response, perhaps due to upregulated glutamate receptors or downregulated GABA receptors. If you come up with a definition of ‘defective’ that excludes this, you will be excluding quite a few disorders treated by other fields of medicine that I’m not sure you want to exclude.

    In general, I’m very suspicious of this Cartesian dualism that says that body and mind are utterly distinct. We know that the mind is epiphenominal of the brain, and that it is ultimately grounded in materiality.

    Then there are institutional problems. If you say anxiety disorders are a problem, but not a *medical* problem, then all those people who seek help will not be able to obtain insurance reimbursement for therapy and/or anxiolytic medication. I really don’t think we should be making it more difficult for help-seeking individuals to obtain help.

    @Steve — Yes, we know why bleeding occurs. But the point is that bleeding is a “normal reaction” to being punctured. What makes it a medical problem then, if you’ve defined medical problems as exclusively abnormality? Certainly, we should address the cause (by removing sharp objects that pose such a danger), but that doesn’t mean we shouldn’t also treat the effect (the bleeding). Similarly, if there is a help-seeking patient with crippling anxiety, and there is an identifiable external cause, we should address that, but that doesn’t mean we shouldn’t also consider anxiolytic treatment. We also understand the neurobiological pathogenesis of anxiety fairly well, so we can explain what is happening subjectively in terms of measurable physiological processes. This is less true of some other mental disorders, of course, but I picked anxiety since people are challenging the entire category.

    A rash is a symptom. Ever since Thomas Sydenham, we have defined discrete disease entities as syndromes that consist of constellations of clinical signs and symptoms that co-occur. But some “rashes” are themselves a disease, or at least are the central pathological element to a disease, e.g., perioral dermatitis. Other times, the rash is a reaction to an offending agent like poison ivy, to use your example. And in that case, the rash is a “normal reaction to abnormal circumstances” — and yet you surely would agree that it is perfectly appropriate to treat someone afflicted with a rash from contact with poison ivy. In fact, it is often appropriate to treat the symptoms even when we either don’t know the causes or can’t do anything about the causes. For example, if someone has a cold, decongestants are perfectly appropriate even though they do nothing about the underlying virus. Similarly, if I have a help-seeking patient with severe ADHD, that is seriously interfering with their ability to function at work or with their spouse or some other significant aspect of their life, I think it is perfectly appropriate to prescribe a psychostimulant even though I know it doesn’t treat the underlying cause (which is not well understood). The idea that physicians should turn away those seeking this kind of help is, from my point of view, shocking and abhorrent.

  • But what do you mean by the “traditional definition of disease”? The old classical/medieval view of humoral balance? There are quite a few modern definitions of disease, most of which are not grounded in physiology (which was particularly important because for a long time we did not understand the etiology or pathogenesis of most diseases).

    There are “diseases” in the modern sense that don’t have physical symptoms, e.g., “high cholesterol” or “high blood pressure,” which are really just risk syndromes for heart disease (among others). There are pain disorders that can only be measured by the subjective pain experiences of the patient, with no biological test. My point is that there is no easy definition of disease that would exclude mental illnesses but include everything else we generally include in the category of illness.

    Nor does it seem to me to be a good idea to exclude things for which people are actively seeking help. If a patient comes to me with crippling high anxiety, should I turn them away because anxiety isn’t a problem some deem worth solving?

  • But there are plenty of serious medical diseases with unknown etiology. Surely having unknown causation isn’t enough to disqualify an illness. Or do you mean something like an unknown pathogenesis? Even in that cases, there are diseases that no one disputes for which the pathogenesis is poorly understood. There has to be something more to the criteria by which we distinguish disease from non-disease.

    Being a ‘normal reaction to abnormal circumstances’ also isn’t enough. If you get stabbed and start bleeding, that’s a normal reaction to abnormal circumstances. Doesn’t mean you couldn’t benefit from medical treatment.