MCN | Medical Consultants Network

The Power of a Second Look

Home / MCNTalk / Tag: brain

Viewing items tagged:

brain

More on the PTSD-Military Conundrum

By Brian Grant, MD

The in-depth article, “Mind Field: PTSD & the Military,” from Seattle Weekly was impressive in its nuanced tone. The reader is left with more questions than answers, as befits such a complex topic. Themes include the impact of systems on behavior, the nature of psychiatric diagnosis, the impact of combat, how media exposure may impact others including family members of those traumatized, politics and partisanship and more.

The author of the article, Keegan Hamilton, wryly notes: “While noble in its intent, the monetization of PTSD diagnosis has created a classic catch-22.” One should ask whether veterans are better served with treatment upon diagnosis or compensation, and if the impact of a minimum of a 50% disability rating upon diagnosis serves the veteran and society? How often, once awarded a disability pension, does meaningful treatment occur and benefits reduced after such treatment? What is the impact upon treatment if it is tied into economic factors?

Every case should be addressed based upon individual facts, but it would be naive to suggest that the basic assumptions and economics of the veterans’ compensation and pension system do not significantly impact individual and group behaviors and outcomes. Passions and politics are inflamed. To frame the issue another way, we should ask ourselves under what circumstances in society do individuals actively desire a medical or psychiatric diagnosis, rather than strongly hope for a finding of good health or at least a short-term malady? PTSD is real. It is also treatable. The diagnosis is fairly easy to make based upon the criteria and a diagnosis does not equal impairment. We have written on this topic recently in previous posts, “Military Psychiatrists Under Fire for Doing Their Jobs,” and “Madigan Commander Reinstated After Army Investigates PTSD Diagnosis.”

The article also makes note of “secondary PTSD”. This is not a recognized diagnosis, but would appear to be an interesting social construct, perhaps reflecting the all too frequent drive to create medical diagnoses for the bad things that happen to people and societies in the course of life. Anyone who witnessed the constant televised replays of the Twin Towers collapse in the days following September 11, 2001 was traumatized, upset, and perhaps depressed. They may even have had many of the diagnostic criteria required for PTSD.  Many avoided flying, were fearful of individuals who reminded them of the bombers, felt numbness and estrangement from others, psychic numbing, and a variety of autonomic symptoms upon certain cues. Life in the U.S. changed tangibly, along with our group psyche. When the abnormal becomes normal, does it warrant a medical diagnosis or literary and journalistic treatment?

Detection of Malingering, Not Too Hard When Clinicians are Skilled

By Brian L. Grant, MD

This excellent article from Slate addresses the popular but incorrect notion that folks can easily fake illness, including insanity. In truth, insanity is a rare defense and even rarer to be successful due to the stringent legal criteria of such a defense – that few defendants qualify for, though many may indeed have a mental illness. A mental illness is necessary but not sufficient for a successful insanity defense.

Additional requirements depending upon jurisdiction, include the inability to refrain from the act, the inability to appreciate the immorality of the act and other criteria. Furthermore, a finding of insanity may serve to alter the location of confinement to a locked psychiatric unit, but not eliminate removal of the accused from society.

The article, “Can you Fake a Mental Illness? How forensic psychologists can tell whether someone is malingering,” focuses on psychiatry, but in any setting where factors such as compensation, avoidance of responsibility, acquisition of narcotics, and other factors beyond the desire to obtain necessary diagnosis and treatment come into play, malingering must be considered. Malingering is a big word for lying or faking it. It is willful on the part of the perpetrator and goal directed. Detection of malingering requires a combination of a willingness to consider the possibility, skills appropriate to one’s specialty, and enough information in the context of the examination, along with external evidence including medical and other records, investigation and other factors to allow one to reasonably conclude that one is malingering.

Most or all who enter the medical profession while young, are aware that there are a group of individuals they may encounter in the course of their practice who have less than admirable goals which include deceiving clinicians and others. Detection of malingering is not a typical part of the training of young clinicians. It generally takes experience, on the job training, and continuing education seminars to develop the necessary skills. Needless to say, any forensic medical reviewer must have a working knowledge of the subject in their specialty.

Follow Up: Madigan Commander Reinstated After Army Investigates PTSD diagnoses

Photo Credit: Sgt. Christopher M. Gaylord
Colonel Dallas Homas (far right), commander of Madigan Army Healthcare System at Joint Base Lewis-McChord, Wash., spoke during a press conference addressing the Army’s recent decision to discontinue the use of forensic psychiatry as part of its disability evaluation system.

After two weeks of following the Madigan Army Medical Center investigation, commander Col. Dallas Homas has been reinstated to his position. The investigation started mid-July after soldiers believed their Post Traumatic Stress Disorder (PTSD) diagnoses had been unfairly overturned by Madigan’s team of forensic psychiatrists and psychologists.

At an August 2nd press conference, the Army Vice Chief of Staff Gen. Lloyd Austin announced that forensic teams would no longer screen PTSD patients and reinstated Col. Dallas Homas to his position as commander, stating “he had not exerted any undue influence on the diagnostic process.”

In relation to our previous blog post “Military Psychiatrists Under Fire for Doing Their Jobs,” written by MCN’s Medical Director Brian Grant, MD, the Seattle Times featured him in an article last week. Here is an excerpt from the Seattle Times article “Reinstated Madigan Chief Happy to Be Back”:

Homas spoke to reporters along with Maj Gen. Richard Thomas, commander of the Western Regional Medical Command and Lt. Gen. Robert Brown, I Corps commander.

In his remarks, Homas confirmed before his removal he met with an ombudsman to discuss the forensic-screening team. At the time, Homas said he thought the forensic team was executing the accepted standard of care. “Now we have been given a new policy, and we’re going to execute that,” he said.

The Army’s decision to abandon the use of forensic screening has raised concerns among some doctors who practice forensic psychiatry. “I am baffled as to why making a psychiatric diagnosis in a military context should have different criteria from the civilian sector,” said Dr. Brian Grant, a Seattle-based forensic psychiatrist. “The matter deserves further study, hopefully including input from medical experts outside the military system.”

Read More…

The Causation Conundrum & Commentary On Who Should Perform Causation Analysis

by Brian L. Grant, MD

A core component on independent assessment and review is determination of causation. Such determinations should be evidence based. Evidence stands on its own merits. It is not a function of the degree of the expert or the opinion of a judge, legislator, advocate or journalist.

Examples abound of such errors in causation. These include Mild Traumatic Brain Injury (MTBI). Scientific evidence is lacking to prove a relationship between MTBI and permanent impairment. Similarly, legal and administrative pronouncements that presume a relationship between hypertension and law enforcement are unsupported by solid science. The media is awash with assumed links between military service and MTBI and PTSD at alarming rates, suggesting either a slippage of criteria, or a profound change in the nature of warriors or the nature of war. Just typing the prior sentence causes this writer anxiety, lest I be accused by advocates of demeaning military service.

Psychiatrists in Washington at Madigan Army Medical Center know all too well the dangers of exercising scrutiny in the politically fraught world or military PTSD. See the accompanying blog post that addresses this.

An expert expressing an opinion is just expressing an opinion – UNLESS the opinion is supported by solid evidence and scientific facts.

The book Guides to the Evaluation of Disease and Injury Causation addresses the challenge of causation determination in-depth as well as proper protocol to determine cause. Among other insights, it discusses the challenge of relatedness; that an event preceding a complaint does not establish causation but may, in the absence of specific evidence, constitute false reasoning.

The protocol to establish causation is a six step process:

1 – Definitely establishing a diagnosis

2 – Applying relevant findings from epidemiological science to the individual case

3 – Obtain and assess the evidence of exposure

4 – Consider other relevant factors

5 – Scrutinizing the Validity of the Evidence

6 – Evaluation of the results from all of the above steps, and generation of conclusions

The above points and much more are from a seminal article, “Determining Injury-Relatedness, Work-Relatedness, and Claim Relatedness” by Robert J Barth, Ph.D. (BarthRJ. Determining Injury-Relatedness, Work-Relatedness, and Claim Relatedness. AMA Guides Newsletter.May/June 2012: 1-10.) 

As of this writing, the issue of the newsletter is not yet listed on the AMA site, but presumably it will be soon and may be accessed by calling them at (800) 621-8335.

Barth is perhaps the foremost thinker and writer on this and many other related topics. The cited article is copyrighted and as such can’t be attached, but is well worth acquiring. In our opinion it is a must read and must own for anyone involved in medical or legal work involving medical causation.

We must quote another pearl from the above article that challenges the bias equation that is often applied to independent evaluators as opposed to treating clinicians:

“As is the case for any forensic work, a causation analysis should be conducted in an independent context. Treating clinicians face considerable financial and social conflicts of interest if they attempt to engage in any forensic activity (such as causation analysis) in regard to their patients. In contrast, independent evaluations minimize the evaluator’s conflicts of interest. Therefore, treating clinicians should refrain from engaging in any forensic work that involves their patients (including refraining from causation discussions).”

Clinicians not involved in the treatment of a particular claim may not be free of bias if they allow themselves to be swayed by requestors of their services. But in our experience the majority of those desiring evaluations are not overly invested in a particular outcome and more likely seek a realistic assessment of the truth, causation and related matters, in one of many cases they are managing at a given time. Contrast this to the considerable pressures that may be experienced in a treatment relationship where the emotional and economic stakes are very high for a patient, who may cause pressure to be felt by the treating clinician and impair objectivity as a result. Regardless of whether one is treating or evaluating, the same rigorous principles of causation analysis as well as other aspects of assessment, diagnosis and treatment must apply.

Military Psychiatrists Under Fire for Doing Their Jobs

by Brian L. Grant, MD

In recent months, forensic psychiatrists in Washington State have been pummeled in the media for taking on the task of reviewing PTSD diagnoses. Based upon media accounts rather than any specific knowledge of individual cases, purported statements implying bias by psychiatrists as well as reversal of some prior PTSD diagnoses, have landed some clinicians and the work of the unit in political hot water. The alleged statements were a common sense remark that claims of PTSD cost money and should be evaluated carefully. This is obvious and acknowledging the cost of such claims does not imply bias against proper diagnoses, but merely places it in a social context by the person making the comment. Diagnoses should be evidence based and any clinician who has familiarity with PTSD may be quite aware that the diagnosis can be made in a sloppy and inaccurate manner by those who lack expertise or possess strong biases. Washington’s Senator Patty Murray has perhaps been the loudest in her criticism of the forensic unit. We attach two articles from the Tacoma News Tribune that address the controversy. The long investigative piece does a nice job of laying out the many issues. We look forward to learning more about the outcome of the investigation and the outcome of the careers of the clinicians under fire. Those who dare to challenge popular wisdom do so at their peril.

Madigan Psychiatrists Who Made PTSD Calls Had National Renown
Senator Murray Begins Investigation into Hospitals’ PTSD Designations

Brain Calisthenics for Abstract Ideas

For years school curriculums have emphasized top-down instruction, especially for topics like math and science. Learn the rules first — the theorems, the order of operations, Newton’s laws — then make a run at the problem list at the end of the chapter. Yet recent research has found that true experts have something at least as valuable as a mastery of the rules: gut instinct, an instantaneous grasp of the type of problem they’re up against. Like the ballplayer who can “read” pitches early, or the chess master who “sees” the best move, they’ve developed a great eye.

Now, as reported in this New York Times article, a small group of cognitive scientists is arguing that schools and students could take far more advantage of this same bottom-up ability, called perceptual learning. The brain is a pattern-recognition machine, after all, and when focused properly, it can quickly deepen a person’s grasp of a principle, new studies suggest. Better yet, perceptual knowledge builds automatically: There’s no reason someone with a good eye for fashion or wordplay cannot develop an intuition for classifying rocks or mammals or algebraic equations, given a little interest or motivation.

“When facing problems in real-life situations, the first question is always, ‘What am I looking at? What kind of problem is this?’ ” said Philip J. Kellman, a psychologist at the University of California, Los Angeles. “Any theory of how we learn presupposes perceptual knowledge — that we know which facts are relevant, that we know what to look for.”

The challenge for education, Dr. Kellman added, “is what do we need to do to make this happen efficiently?” Read more…

Mental Illness Hit 1 in 5 U.S. Adults in Past Year

Per this Bloomberg article, a new survey finds that 20 percent of U.S. adults—over 45 million people— experienced mental illness in the past year. The survey, which included 67,500 adults nationwide, was released by the Substance Abuse and Mental Health Services Administration (SAMHSA).

“The consequences for individuals, families and communities can be devastating. If left untreated mental illnesses can result in disability, substance abuse, suicides, lost productivity, and family discord. Through health care reform and the Mental Health Parity and Addiction Equity Act we can help far more people get needed treatment for behavioral health problems,” noted SAMHSA Administrator Pamela S. Hyde. Read more…

We sense…a debunking in the future

As per this New York Times article, one of psychology’s most respected journals has agreed to publish a paper presenting what its author describes as strong evidence for extrasensory perception, the ability to sense future events. The decision may delight believers in so-called paranormal events, but it is already mortifying scientists.

Advance copies of the paper, to be published this year in The Journal of Personality and Social Psychology, have circulated widely among psychological researchers in recent weeks and have generated a mixture of amusement and scorn—and some discussion of scientific process, which be a useful by-product of the debate.

We have a premonition, a extrasensory sense if you will, that upon further review this research will be debunked and the authors discredited. Read more…

Should You Be Snuggling With Your Cell phone?

The possible harmful effects of cell phone use have been widely debated: one  research professor of bioengineering at the University of Washington maintains a database of 400 scientific papers on possible biological effects of radiation from wireless communication.

As noted in this New York Times article, a new book by University of Pittsburg epidemiologist Devra Davis, Disconnect, notes that the question is not at all resolved, and the nation’s 292 million wireless users may be exposing themselves to harm.

Ms. Davis cites laboratory research  suggesting mechanisms by which low-energy radiation could damage cells, possibly leading to cancer. The F.C.C. concurs about the best way to avoid exposure, issuing guidelines on the safety threshold of a cell phone’s specific absorption rates (SAR) and advising consumers to hold their cell phones “away from the head or body.”

Cell phone manufacturers (the wireless industry generates $109 billion revenues annually) do issue warnings about the proper distance for holding a cell phone away from the body, but is this enough? Ms. Davis, citing unsettling findings from research in Israel, France, Sweden, and Finland, said, “I do think I’m looking at an epidemic in slow motion.”

Magnetic Brain Stimulation Fights Depression (for now)

When weighing electroshock treatment, one’s mind typically drifts to practices seen in popular films rather than curing depression, but studies going on right now are looking to change that. While all parties may not agree regarding the ethics of such treatments, the facts are in: 14% of patients recovered from depressions in the first trial and 30% in the second.

The big question is what to do next. Doctors can’t agree on how long treatment should last or what sorts of drugs to pair with treatment.