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Psychiatry

Emotional Support, with Fur

Pocket, the author's pet, aka emotional support animal.

Pocket, the author’s pet, aka emotional support animal.

That a dog provides comfort to owners is a given. That’s why we call them pets. But now, under the guise of subjective criteria of any physician or licensed therapist and the perceived needs of certain individuals, some are claimed as a necessity that others must tolerate in the public sphere.

Some are claiming and demanding that their pets have therapeutic impact and address an emotional disability and must accompany them on planes, at work, in restaurants, and in pet-free housing. Others claim their animals can retrieve dropped items that they can’t stoop down for, or have the uncanny and improbable talent of detecting and stopping seizures.

Please note that highly trained service animals such as seeing eye dogs actually DO something and deserve respect and access to any setting. But a clear line must be drawn when it comes to animals whose sole talent is BEING. By all means, enjoy your pet, dress it up in silly costumes, feed it from the table, and pay for its chemotherapy. But someone else’s pet provides zero social good to society at large. It will never pay taxes, teach our kids, or shovel the snow off your walk out of altruism. They have earned no dispensation or right to privilege or sacrifice from the rest of us. As one commenter queried, she derives comfort from their husband — can he fly free and sit at her feet on a plane? One’s perceived needs and wishes need not be indulged by society, or endorsed with misguided and abused rules.

The Costly Marketing Budget for Antipsychotic Drugs

By Brian L. Grant, MD

At the American Psychological Association Conference, the pharmaceutical industry has a large marketing presence.

The New York Times article, “A Call for Caution in the Use of Antipsychotic Drugs,” was alarming but not surprising to me as a psychiatrist. The numbers are staggering though. The advertising budget alone, at 2.4 billion dollars for the new antipsychotic drugs equates to about $57,000 per US psychiatrist (about 42,000 total)!

This marketing budget total alone just approximates the entire market for non-Federal IME’s and medical reviews. If spread across the U.S. population evenly, each of us would have consumed about 58 dollars worth of antipsychotic drugs in the past year! The use of such medications is clearly concentrated to a small portion of the population and are prescribed in large amounts by a small portion of psychiatrists and other licensed practitioners.

Anyone who has been to a major psychiatric conference would not be surprised at the massive booths from the drug purveyors manned by sharp men and women hawking the wares, with various enticements to visit their booths. The incentives to over-prescribe is clear, given the money involved.

The fact that a number of medical lightweights fail to understand how they are being used as gatekeepers to these drugs is sad and costly, not only for payers, but for patients who are often given these costly drugs with very real side effects, when less costly alternatives with equal or better outcomes exist. To deny the positive impact of these medications in select patients is wrong. But common sense combined with available science should lead to the obvious conclusion that this is not right.

Label creep, where a good drug is advocated for the wrong reasons, is not unique to psychiatry. Articles like this by Dr. Friedman does little to bring pride to my profession. Similar scrutiny is warranted for so-called ADHD (attention deficit hyperactivity disorder) in adults, fibromyalgia and any other malady that is largely associated with profitable, or abused drugs and often direct to consumer advertising to create a wider market.

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.

The Release of the D.S.M – 5

The coming months will see the release of the D.S.M – 5. This 5th edition of the diagnostic and statistical manual is getting lots of news. Originally a useful tool for mental health professionals, allowing us to agree on who may or may not warrant a particular diagnosis, the manual has been co-opted and hijacked by many others for a variety of less noble purposes. We have attached two of many articles appearing in recent months. More will certainly come.

The hazards and dangers of the D.S.M are many. A main theme includes the medicalization and pathologizing of normal life. Grieve a loved one: Bereavement disorder. A bit strange? Autistic Spectrum Disorder; Crave Food or Alcohol: Addiction disorder; Easily Distracted: Attention Deficit Disorder. The list goes on. To the degree labels help treat problems they can be useful. To the degree that they confer entitlements, exculpation of responsibility, mandated health benefits, employment accommodation, legal responsibility or lack of responsibility – the benefits are far less clear and capacity for mischief and abuse quite evident.

 The following cautionary statement appears in the preface of the D.S.M. – 4: (emphasis added)

 Cautionary Statement
The specified diagnostic criteria for each mental disorder are offered as guidelines for making diagnoses, because it has been demonstrated that the use of such criteria enhances agreement among clinicians and investigators. The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills.

These diagnostic criteria and the DSM-IV Classification of mental disorders reflect a consensus of current formulations of evolving knowledge in our field. They do not encompass, however, all the conditions for which people may be treated or that may be appropriate topics for research efforts.

The purpose of DSM-IV is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders. It is to be understood that inclusion here, for clinical and research purposes, of a diagnostic category such as Pathological Gambling or does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability. The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, determination, and competency.

Hopefully this statement or similar variant will remain in the upcoming edition. We should add: “Insurance coverage, employment and school accommodation, and denial or impact of individual choice or responsibility.

Psychiatry is not the only specialty guilty of misrepresenting science for politics, social justice and economic self-interest. But I fear we may be about to outperform in this capacity to the degree we use diagnoses to define not true disease, but normal human experience and variations. And to the degree others coattail on these diagnoses for goals other than improving emotional and mental states.

The DSM and categories of suffering

by Brian L. Grant, MD

This article in The New York Times importantly describes some of the many problems with the DSM in particular, and medical diagnoses in general. When diagnoses gain power to drive resources and funds, create obligations on the part of others, excuse or justify shortcomings in behaviors and habits, demand more time on tests, and generate billions in drug sales – mischief and misuse follows.

The DSM is a worthwhile effort and useful for psychiatrists in treating patients. But in the hands of the greater society it has become wildly distorted. The power of diagnoses are profound. But  psychiatric diagnoses in particular are highly reductionist. They are a cookbook that apply if a patient falls into particular boxes. They do nothing to explain the “why” of the human condition, nor does a particular diagnosis remove the unique humanity that makes each of us different. Pills may address particular symptoms and provide some relief. But they will never alter fundamental personality configurations,  eliminate personal choice and accountability, or substitute for self-examination and introspection.

Read more…

Teasing Out Policy Insight From a Character Profile

As noted in this New York Times article, for decades analysts at the Central Intelligence Agency and the Department of Defense have compiled psychological assessments of hostile leaders like Colonel Qaddafi of Libya and Kim Jong-il of North Korea, as well as allies, potential successors, and other prominent officials. (Many foreign governments do the same, of course.)

Diplomats, military strategists and even presidents have drawn on those profiles to inform their decisions—in some cases to their benefit, in other cases at a cost.

Given the volatile political situation in North Africa, an understanding of the personalities involved could be crucial. In a profile of Col. Muammar el-Qadaffi for Foreign Policy magazine, Dr. Jerrold Post (a psychiatrist who directs the political psychology program at George Washington University and founded the C.I.A. branch that does behavioral analysis) concludes that Qadaffi, while usually rational, is prone to delusional thinking when under pressure — “and right now, he is under the most stress he has been under since taking over the leadership of Libya.” Read more…

“Sidewalk Rage”: Seeking Insights on Anger’s Origins and Coping Techniques

You don’t need a car to get road rage.

For many people, few things are more infuriating than slow walkers—those seemingly inconsiderate people who clog up sidewalks, grocery aisles and airport hallways while others fume behind them.

Researchers say the concept of “sidewalk rage” is real. One scientist has even developed a Pedestrian Aggressiveness Syndrome Scale to map out how people express their fury. At its most extreme, sidewalk rage can signal a psychiatric condition known as “intermittent explosive disorder [as defined by the DSM-IV, or Diagnostic and Statistical Manual of Mental Disorders, psychiatry’s bible of diagnoses],” researchers say.

This Wall Street Journal article explores the condition further. Though the whole idea of people who become enraged because the person in front of them is perceived as walking more slowly than they ought may seem trivial (that’s an actual disorder? People just need to cope), the study could to shed some light into the much larger question—very real and very destructive—of anger control, what triggers sudden rages, and how this can be prevented.  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…

Service Dog Expansion Stretches Credibility

I have long had an interest in the expanded definition and use of service-dogs in US society. Historically these animals were used to extend capability to individuals with sensory deficits, primarily sight. Appropriate access laws and policies have been in place for some time with respect to these dogs.

The January 15 “Psychiatric News” of the American Psychiatric Association had a sympathetic article on the topic. I wrote a letter to the editor that was published on April 16 in response to this article.

I have been chagrined to see a trend towards creating a special class of animals to provide for the subjective comfort of their owners, to the degree that this imposes duties upon others to provide access and rights to the dog and their owners. For example right to be in workplaces, on public transportation, restaurants and other public accommodations that do not permit pets. At this point to my knowledge the issue has been addressed in the regulatory and not judicial sphere. A test case or two in the Federal courts would be illuminating and may soon be overdue.

While I can’t dispute the strongly held positions and  passions of others who feel the need for such accomodations for emotional issues, society at large has an equally compelling right to set limits on the obligations of others to participate or endorse these views.

It should also be noted that there is no meaningful credentialing of such service dogs or the claims of those who wish to use them. A web search will find any number of sites that will provide credentials for the animals and endorsement for their owners based upon self-report of need. See: http://www.servicedogsamerica.org/ and http://www.psychdog.org/index.html as a small sample of the many sites on the topic.

See http://www.pawnation.com/2009/05/21/service-animals-pets-helping-people/ and click on the slide show showing a number of ‘service animals’. Based upon the criteria that the animal do something and perform a service, which of them do you feel are legitimate in their function, and warrant the definition and rights of a service dog?

By the way, I have two dogs (King Charles Spaniels) and am rather fond of them, but they are pets, not therapists – regardless of he companionship and comfort that they may provide.