More DSM-5 controversy from across the pond

According to this article in The Guardian, tomorrow the British Psychological Society’s Division of Clinical Psychology (DCP) will be releasing a statement calling for a “paradigm shift” in how mental health is understood. They are expressing concerns about the diagnostic assumptions being made by the DSM.

What’s fascinating is that the DCP’s problem with the DSM-5 is the opposite of the issue that the NIMH cited (and I wrote about last week).  According to Dr. Lucy Johnstone, who helped draft the DCP statement, a chief concern was the focus on biological causality:

On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse.

I think most medical anthropologists would agree, without denying the interaction of biology:  chemical interactions with the environment, diet and nutrition, genetics and epigenetics, etc.

That groups are taking such diametrically opposed views in criticizing the same publication makes me wonder if the DSM-5 is being used as a scapegoat for long-held resentments and a catalyst for change.  I don’t see the DSM as either particularly biological or sociocultural, but neither is it a moderate middle ground between two extreme views.  It seems that each side is interpreting the DSM to create a foil for its goals.

NIMH rejects the DSM-5

In a letter on the National Institute of Mental Health website, Director Thomas Insel announced that NIMH will be “re-orienting its research away from DSM categories.” He comments that the DSM has had reliability but not validity:

In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

I had a moment of hope, that perhaps they would be looking beyond reported symptoms to cultural and structural as well as biological factors. Instead, NIMH is launching the Research Domain Criteria (RDoc) project to develop a classification system of its own. NIMH support in the future will be for research that cuts across DSM categories and fits the assumptions of RDoC (the emphasis is mine):

  • A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
  • Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
  • Each level of analysis needs to be understood across a dimension of function,
  • Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment

I’m not a doctor and I do believe that many illnesses that we see as “mental disorders” have a basis in chemical imbalances or biological disease. However, this sort of institutional bioreductionism worries me. It seems like a quest for magic bullet solutions rather than an understanding of the complex factors inside and outside the patient that contribute to what he or she is experiencing.

A prison, an asylum, or both?

Why are there so many homeless people in the US, so often suffering from mental illness? Because we closed the asylums, of course! That Q&A has become canon. But what would happen if we opened large psychiatric institutions again?

Fort Lyon. Photo (c) The Pueblo Chieftan

NPR has a piece on such a proposal: Colorado Weighs Reopening Psychiatric Hospitals for Homeless (including a short audio segment from All Things Considered). Though much of the impetus seemed to come from creating jobs and reusing an existing campus — Fort Lyon, which was once a veterans’ psychiatric hospital and then a prison — the plan would bus up to 300 of Colorado’s homeless people to the Fort, which would serve as a rehabilitation and transitional housing facility. At the end of the week, the bill to make this happen was shot down, but it will be added as an amendment to another bill.

Improving the plight of mentally ill homeless people should just be a matter of balancing cost/benefit of allowing things to continue as they are or bringing back the institutions, right?  The solution is not a simple binary (and neither was the problem, I’d argue, though that has become the prevalent discourse). Even if we imagine a Utopian care and rehabilitation facility and not a dumping ground like Vita, is the best option to remove homeless people from the community, sweep them out of sight, and hope that budget priorities don’t empty them onto the streets en masse again?

Sam Tsemberis of Pathways to Housing is quoted in the NPR piece. “Having someone in transitional housing teaches people how to manage living in transitional housing.”  I’ve heard a bit about the Pathways to Housing model in the past: it provides housing first — immediately taking homelessness out of the situation — and then adds needed counseling and treatment. (The website is very broken in Chrome; I didn’t check other browsers.) PBS NOW did a half-hour piece about the success of this approach, despite the obvious concerns it raises. [Watch video.]

The head of Colorado’s Coalition for the Homeless, John Parvensky, sees a need for both approaches to reach the range of people who find themselves long-term homeless.

“It’s not really a question of either-or: Should the state support community-based options or should they support Fort Lyon?” says Parvensky. “They really should be doing both, but historically they’ve been doing neither.”

Reading a number of Colorado news articles, it quickly became clear that what’s being debated is not the question of what’s best for homeless people. It’s about budget and jobs and veterans (an earlier proposal had Fort Lyon as transitional housing explicitly for homeless veterans). It’s about the corollary to the American Dream that says that everyone should pull himself up by his bootstraps and take personal responsibility for improving his life.

I’m not convinced that large inpatient institutions are the solution — my personal opinion is that they cause new problems without solving anything but how to hide inconvenient people — but it’s hard to argue that ignoring the problem is better for anyone involved. On my future reading pile: a list of psychology/psychiatry and social work studies on the Housing First approach (anyone have a good anthropological study to recommend on this?) The claimed cost savings of it soothe my fiscal conservative side, while a humanistic method that treats those on the streets as people first — not as junkies or crazies — appeals to my inner anthropologist. The phenomenological experience of being treated worthy of shelter must be so different than that of trying to get clean, find work, or stay on a psychiatric regimen while homeless in order to be considered for a housing program.

Another DSM-5 critique

DSM-5* launches on the 22nd of this month and the ripples of its drop could be tsunami-sized for some communities. We’ve written previously about DSM-5 controversy here and here.  The Wired article that we linked to was written by psychotherapist Gary Greenberg, who offers a harsh critique of the new DSM — and any DSM and psychiatry as a whole — in his new work The Book of Woe: The DSM and the Unmaking of Psychiatry. I haven’t read the book yet, but The Atlantic has an interview with Greenberg: The Real Problems with Psychiatry. It’s worth a critical read, along with the comments on the interview.

I agree with several of Greenberg’s points, perhaps the ones in which he’s most in sync with Allen Frances, but on others his approach is so antithetical to medical anthropology that I was arguing aloud as I read them. Consider his lack of distinction between illness, disease, and disorder and sentences like, “If they don’t have real diseases, they don’t belong in real medicine.” If he’s so opposed to the APA being the judge of psychiatric diagnostic criteria, I wonder whom he would appoint to be the arbiter distinguishing real from non-real diseases or even real from non-real medicine.

As I read the piece, I wondered if perhaps Greenberg was just not a good interviewee. Though other things he’s written have a cynical edge, the tone seemed off and there were inconsistencies. According to Greenberg’s website, he didn’t know that the format of the Atlantic piece was going to be Q&A with verbatim quotes, and he admits that he “said some pretty intemperate things… but only a couple are embarrassing.”  Ah, that makes more sense. I’ll have to take a look at the book to get a better understanding of his arguments.

*  The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition.

Patient dumping: from Greyhound buses to private planes

Last night’s Colbert Report did a “The Word” segment about “medical leave”. No, not when you take time off from work for illness, but what people are calling medical repatriation. I’d only known that phrase as part of the travel insurance I buy when heading out of the country, to get me home in case I fall ill or am injured. Colbert’s segment is talking about something else, less euphemistically known as patient dumping. [Watch the video.]

The first example in the video is that of two undocumented workers in Iowa who were comatose after an automobile accident. They had insurance (which is rather remarkable and kudos to the unnamed agricultural firm that employed them), but it wasn’t clear to the hospital if long-term care would be covered. So, after less than two weeks, the hospital flew the unconscious men to Mexico and put them into a hospital in Veracruz.  There’s a more complete summary from the Des Moines Register.

Fiscal responsibility is certainly important for hospitals, but patient care is supposed to be their raison d’etre.  Medical repatriation is just one example of where those two purposes conflict. Writing in The American Journal of Bioethics last year*, Mark Kuczewski proposed that medical repatriation could be ethical (legality is a separate issue) if particular conditions are met:

(1) Transfer must be able to be seen by a reasonable person as being in the patient’s best interests aside from the issue of reimbursement. (2) The hospital must exercise due diligence regarding the medical support available at the patient’s destination. (3) The patient or appropriate surrogate must give fully informed consent to being returned to another country. (Kuczewski 2012:1)

There are some excellent peer commentary essays that critique his approach as well as a response from Kuczewski. Even if we accept his initial three requirements, it seems that the Iowa case falls far short. And, that was just one case.  A recent report states that there have been more than 800 cases of attempted or successful medical repatriation from the US in the past six years.

The second example in Colbert’s piece is about a Las Vegas hospital accused of putting psychiatric patients onto Greyhound buses and sending them to other states without a support system in place at the destination. This practice came to light through a March story and a follow-up investigative report in April by The Sacramento Bee. The Nevada Department of Health and Human Services investigated and found that of 1,500 patients discharged from Rawson-Neal Psychiatric Hospital since 2008, ten had been bused off into the abyss without any support.

During the five-year period reviewed, Rawson-Neal maintained an aggressive practice of discharging patients to the Greyhound terminal in Las Vegas, sending them off, unaccompanied, with Ensure nutritional supplements and a limited supply of medications.

The second Sacramento Bee article notes that funding for mental health care in Nevada has been slashed in recent years, and that from 2009 to 2012, the number of discharged patients bused out of state from southern Nevada increased 66%. Or as Colbert puts it, “In America, we don’t turn a blind eye to the needs of our fellow man. So we need to send them someplace we can’t see them at all.”

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* Kuczewski, Mark. 2012. “Can Medical Repatriation be Ethical? Establishing Best Practices”. The American Journal of Bioethics 12(9): 1-5.

Controversial DSM-5 approved for publication in May

The National Psychologist, January/February 2013 issue page 6, publishes 2 articles: 1) about Psychiatric association approval of DSM-5 publication in spite of complaints from the professional field and 2) how Psychologist organizations react to DSM-5. Both are scanned in one document.

It is worth considering how construction of diagnosis is interrelated with political biomedical authority. The process might not necessarily benefit the individual but it leads to creation of compliant body and collectively a member of Foucalian society.

Munchausen by Internet

While following a trail of links from an article about Manti Te’o’s imaginary girlfriend, I rediscovered this excellent article from The Stranger (a weekly newspaper in Seattle) about people — mostly women — who lie about illnesses online. It’s a terribly interesting read.

“Munchausen by Internet” is not considered a unique illness, though that was debated for the DSM-V, but is a form of Munchausen Syndrome in which a person fakes his/her own illnesses.  (There is also Munchausen by proxy, the most common example of which is a mother who exploits exaggerated or imaginary illnesses in her child.)

It’s easy to say that these illness fabricators are pathetic or predatory, emotional vampires who feed on the sympathy of others.  However, I find myself thinking about Ong’s work with Malaysian factory workers, Nichter’s “Idioms of Distress”, or accounts of spirit possessions (mostly of women) in various cultures.  Should we consider this an individual psychiatric disorder when the condition centers around relationships with others?  Why is it largely a female phenomenon?  Is this a culture bound syndrome?

The homeless guy in the apartment next door

by Jonathan Bartlett for LA Weekly

William had been homeless for about 20 years when he received a $200,000 legal settlement. One of his first actions was to do what many would applaud: he got off the streets and out of the broken-down hotels of Los Angeles and rented an apartment.  What he did not do was bathe, wash his hair, change his clothing, wear shoes, or alter his lifestyle of keeping all of his possessions in shopping bags.

The very day he moved in, the leasing agent left soap, shampoo, towels, and a change of clothing in his apartment.  William was insulted and disgusted that his home had been “contaminated.”  By the next week, neighbors were making complaints about the foul odor they said was seeping from his unit.  A veritable battlefield of potpourri and deodorizers was laid out between his door and the next and eviction threats began.

Read the full story on the LA Weekly site: The Man Who Smelled Too Much

I couldn’t help think of a piece by Bourgeois (From Jibaro to Crack Dealer: Confronting the Restructuring of Capitalism in El Barrio) that we read in Anthropology Theory this week.  The “common sense” of the other residents of the nice apartment building is foreign to William.  If the problem is the odor leaving his home, then fine: he squirts some peppermint soap under the door and calls it good.  His neighbors, the building management, and the eventual jury he faces can’t comprehend why he doesn’t simply bathe, put on shoes, and change his clothes.  The foreman is baffled why William won’t cut his hair, since “it grows back.”  There is some victim-blaming going on, but what about the rights of his neighbors?  The comments on the article make for an interesting read, as well.

Envision conference at OU, October 19

Seems that information like this never reaches other departments in time, but it should still be possible to register for this interesting conference to be held in Rochester next month. Student registrations are free but limited; I haven’t gotten a response to my registration request yet, but it’s worth a try if you want to go. (Update: I was able to get a student seat for the conference, but it sounds like space is tight.)

This conference will explore the question: Do mental health issues manifest into chronic physical problems, or does the chronic illness create significant and long-lasting impairment of an individual’s mental health? Participants will learn how nurses and mental health professionals can better understand the magnitude of this issue and collaborate to provide patients timely, appropriate and effective services while safeguarding basic human rights. Additionally, participants will learn how they can decrease their own depression, compassion fatigue and improve job satisfaction through mindfulness, laughter and other alternative techniques.

Approximately 25% of the general population (adults) have diagnosed mental health disorders (though this is most likely grossly underestimated because of the stigma often associated with mental illness) while about 58% of the general adult population have been diagnosed with at least one medical condition. (Robert Wood Johnson, Synthesis Project)

When it comes to the complexity of health care, the line often blurs between physical and mental health. Today, the interaction between physical and mental illnesses is a necessity not an exception. This results in an increased need for health care workers to gain a broader understanding of working with patients who suffer from co-existing physical and mental illnesses. This year’s Envision Conference will offer a broader understanding in “THE COMPLEXITY OF CO-MORBIDITY: CONNECTING WITH OTHERS THROUGH THE SYNTHESIS OF MIND, BODY AND SPIRIT” taking place on October 19th at the Royal Park Hotel in Rochester, MI.

SPEAKER TOPICS:

  • Complexity of Comorbidity and its Implications: Sharon Freeman, PhD, Freeman Institute for Cognitive Therapy
  • Mindfulness in Care (for Caregiver and Patient): Bup Chon Sunim (Brent Eastman), Buddhist Monk
  • Relationship-Based Care: Kathleen Van Wagoner, Chief Nursing Officer, Crittenton Hospital Medical Center
  • Spirituality, Suffering and Illness: Lessons Learned from Research, Clinical Families and Living Life: Lorraine Wright, International Lecturer and Professor Emeritus of Nursing, University of Calgary
  • with a mini lunch demonstration on the Power of Laughter: Paul McGhee, PhD, Lecturer

Location:Royal Park Hotel
600 East University Drive
Rochester, MI 48307

Cost: $125 per person. Register here.
Students are free! (Student space is limited and you must pre-register!)

Students – please do not register online. Pre-register by contacting Cynthia Rutledge at carutled@oakland.edu or at 248-370-3799 to be added as an attendee. Whether you’re a student at Oakland University or another institution, you must provide a valid student ID to be admitted to the conference.

An ongoing Asperger’s narrative

There’s a common theme in much of the writing I enjoy: personal narratives from smart, introspective, odd people.  That’s why I can’t resist Penelope Trunk.  Penelope founded three start-up companies, wrote a bestselling career advice book, and she’s now homeschooling her children and making goat cheese.  She also has Asperger’s Syndrome and she speaks about her mental processes and challenges in clear, explicit posts like “Why I’m difficult in meetings” and “What it’s like to have sex with someone with Asperger’s“.

Penelope Trunk

Penelope can be controversial and shocking in her directness, and her blog mixes career advice, trendspotting, and her personal life.  It also provides a chance to see the world through the eyes of someone whose perspective may be very different from most of ours, described vividly and intelligently.  Worth a look.