Wednesday, August 26, 2009

It's About Time!

In a 138-page report released on Wednesday, August 5th, the American Psychological Association said that there is little evidence to suggest that efforts to change a person's sexual orientation from gay or lesbian to heterosexual are successful. In fact, such efforts can cause harm. The findings of the American Psychological Association Task Force of Appropriate Therapeutic Responses to Sexual Orientation indicate that efforts to switch a person's sexual orientation through psychological interventions can lead to loss of sexual feeling, suicidality, depression, and anxiety.

The task force reviewed the literature on 87 studies that were undertaken from 1960 through 2007. They found serious methodological problems with the majority of the studies. The few studies that were methodologically strong showed that lasting change was rare. Judith M. Glassgold, chair of the task force said that "contrary to claims of sexual orientation change advocates and practitioners, there is insufficient evidence to support the use of psychological interventions to change sexual orientation...."

At the annual meeting of the American Psychological Association, the Council of Representatives passed a resolution that urges mental health professionals not to recommend change of sexual orientation through therapy or any other methods. Homosexuality was removed from DSM in 1973.

What is your experience in working with the gay, lesbian, and transgendered population? Should the American Psychiatric Association be producing a similar review of treatment with this population?
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Skepticism Remains but They'll Give it a Shot

The New York Times recently reported that the US Army plans to provide intensive mental stress training for its troops. In an effort to reduce potential mental health problems such as depression, posttraumatic stress disorder, and suicide, the US Army will require that all active-duty soldiers, reservists, and members of the National Guard undergo stress training. The training will also be available to family members and civilian employees.

There is still some skepticism about whether the program will be effective--it is modeled on techniques that have been tested mainly on middle school children--or whether the training is really needed. The army's chief of staff, General George W. Casey Jr, said that many in the military consider talk of emotion to be a sign of weakness. "I'm still not sure that our culture in ready to accept this [emotional resiliency training]."

The primary objective of the program is to teach resiliency. The training draws on recent research that suggests that people can manage stress by thinking in terms of their psychological strengths. Ultimately, the goal of the training is posttraumatic growth.

It seems that more troops these days are returning with a greater degree of mental health problems. Does anyone know if this is really the case? Or are we just hearing more about it than in the past? Why do you think there is such a high prevalence of problems for returning troops and their families? Is it because the nature of the wars we are fighting has changed? Read more!

Monday, August 10, 2009

Gone But Not Forgotten: Remembering and Learning From the Events at Camp Liberty

Thank you Psychiatric Times for your eulogies to the fallen mental health workers and patients at Camp Liberty last month ("Death of Psychiatrist and Other Soldiers Triggers Inquiry Into Military's Mental Health Care", July 2009). Dr Houseal and Springle were truly dedicated humanitarians and patriots. I extend my condolences to their families and the families of the fallen patients as well.

I am a psychiatrist at a VA Clinic stateside. We are anxiously awaiting the onslaught of returning veterans who struggle with mental illness and posttraumatic stress disorder (PTSD).

Existing studies regarding PTSD and our knowledge from working with Viet Nam veterans and Gulf War Veterans elucidates our failures more than our successes. The foremost is the failure to learn from our mistakes. Combat stress is in part dose and duration related. Killing is entrained but not extinguished by existing rehabilitation efforts. Young men and women with a history of abuse and familial mental illness are at higher risk, but they continue to be enlisted with regularity despite claims to the contrary. We glorify the soldiers’ motives to participate in conflict but do not look critically enough at the cultural and national issues that cause leaders to choose to decimate a significant part of the character and stability of our future generations. This is not just a job you may not live long enough to leave; it is a job that never leaves you.

Phyllis Henderson, MD
Board Certified Psychiatrist
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Tuesday, August 4, 2009

Psychiatrists, Pain Specialists, and the Physicalist Fallacy: Who Are the "Real" Doctors?

You know the drill, but in case you have repressed it, the antipsychiatry mantra goes something like this: “Real” disease is present only when we can point to a lump, bump, or lesion—or at least, to a specific physiochemical abnormality in association with a specific set of signs and symptoms. Anything else that we call “disease” is simply a label—a “social construct” akin to terms like “primitive” or “fanatic” without any scientific validity. By implication, “real doctors” are those who treat the corresponding “real diseases.” Since, for the major mental disorders, psychiatrists cannot point to causally implicated lumps, bumps, or lesions—or to specific pathophysiological defects—they are not treating “real” diseases; therefore, as the mantra goes, they are not “real doctors”! These arguments compose what I call the “Physicalist Fallacy” of psychiatric diagnosis, which is not to be confused with the concept of “physicalism” per se. The Physicalist Fallacy is a kind of philosophical mongrel with a lineage derived from logical positivism, Cartesian dualism, and a gene or two from “post-modernism.”

Rebuttals to these fallacious arguments have been given at length and I won’t risk inducing stupor and coma by rehashing them here. I won’t even belabor the point that when Eugen Bleuler wrote his classic text in 1911, he referred to “the schizophrenias” (plural); and that abnormal smooth pursuit eye movements (SPEMs) are one of several reasonably well-established biological findings in what is probably a related group of schizophreniform disorders (see "Beyond Reliability: Biomarkers and Validity in Psychiatry" and "How Clinical Neurophysiology May Contribute to the Understanding of a Psychiatric Disease Such as Schizophrenia" for further reading). Rather, to understand why psychiatry is in its present predicament—regarding the public’s jaundiced view of psychiatry and the raging debate over the DSM-V—it is helpful to examine the work of our colleagues in the field of chronic pain treatment. To escape our predicament, we need to examine the philosophers and psychiatrists (such as Karl Jaspers, 1883-1969) who have taken a phenomenological approach to the recognition of “disease”—a point my colleagues Michael A. Schwartz and Nassir Ghaemi have repeatedly stressed. To oversimplify greatly: phenomenology refers to the structure of the patient’s experience—how, for example, self and world are perceived during a bout of psychotic depression.

Based mainly on animal models, there have been major advances in understanding the pathophysiology of chronic neuropathic pain—yet there is a great deal we still do not know. Moreover, diagnosis and treatment of chronic, idiopathic pain (of unknown etiology) remains essentially grounded in the patient’s subjective complaints combined with objective findings in the doctor’s office or bedside examination. This is analogous to the psychiatrist’s initial history-taking and mental status examination. Pain specialists dealing with chronic, idiopathic pain cannot, by definition, point to a specific lump or lesion that explains the patient’s suffering. Yet—with the exception of those thought to be “malingerers”—we do not delegitimize the patient’s complaints. We do not regard individuals with chronic pain as having a “metaphorical” illness. We do not brand doctors who treat these patients as charlatans. On a societal level, we do not find a robust “Anti-Analgesia” movement, bristling with vicious blogs and insulting placards. Why, then, the animus toward psychiatric practice?

The answers are far too complex to cover in this space, but, in my view, relate to at least two factors:

1. Individuals with chronic pain are ordinarily self-identified and voluntarily seek treatment for their condition; in contrast, many individuals with serious psychiatric impairments do not. Indeed, it is the very nature of their illness that they often deny its presence or significance.
2. Legislatures, courts, and common-law tradition have not sought to impose mandatory or involuntary treatment upon those with chronic, idiopathic pain disorders; this is clearly not the case for some individuals with severe psychiatric conditions that represent “an immediate danger to self or others”. (For more on the public’s misunderstanding of the psychiatrist’s role in “commitment” procedures, see "In the US, Psychiatrists Do Not 'Commit" the Mentally Ill").

Arguably, these forensic aspects of psychiatry may call for legislative and societal remedies—but by themselves, do not impugn the legitimacy of psychiatric diagnosis and treatment.

That said, we should strive to be as parsimonious and “objective” in our diagnostic categories as possible. To paraphrase Ockham’s Razor, we must not “multiply entities unnecessarily” in creating our disease categories. We should certainly avoid creating new categories that are not grounded in careful empirical and phenomenological investigations. But whereas our long-term goals should include pinning our DSM categories to specific biochemical and genetic markers, we should reject the positivist “lumps and labs” model of disease. Our focus, rather, must remain on relieving suffering and incapacity in its infinite experiential presentations. In this, we need to learn from our colleagues in the chronic pain field.

Note: I wish to thank Michael A. Schwartz MD and S. N. Ghaemi MD for their helpful comments on this piece; however, I alone am responsible for the views expressed.

Ronald Pies, MD
Editor-in-Chief, Psychiatric Times
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