Behavior and Law: Mike Nova: American Psychiatry At The Crossroads
Thursday, 8:23 AM 5/13/2012
Mike Nova: American Psychiatry At The Crossroads
Mike Nova: American Psychiatry At The Crossroads
Last Update: 8:55 AM 5/11/2012
"It should broaden its theoretical and conceptual outlook... it should assume its rightful leadership role in World Psychiatry... by discarding the outdated stereotypes, not reinforcing them" |
Thank you, Dr. Frances; for your previous work and for your courageous and independent stand now. |
James Phillips: "Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations." |
Did American Psychiatry sell its soul to profit-hungry (Psycho)Pharmaceutical Industry for a couple of their logo pens? Is it not the time to stop all this "DSM-s In Perpetuity" madness? And not to spend another $25 or more ml. for the next round of controversies and wide-spread public scepticism and criticism?" |
"Empirical explanation and treatment repeatedly fail for psychiatric diagnoses. Diagnosis is mired in conceptual confusion that is illuminated by Ludwig Wittgenstein's later critique of philosophy (Philosophical Investigations).
A diagnosis is a sort of concept that cannot be located in or explained by a mental process. Conclusion: A diagnosis is an exercise in language and its usage changes according to the context and the needs it addresses."
Psychiatric diagnoses are not mental p... [Aust N Z J Psychiatry. 2012] - PubMed - NCBI
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"Much less clear, even in the US, is whether
the approach is commonly used by clinicians in ordinary
practice, thus really resulting in an increase of the reliability
of psychiatric diagnosis in clinical settings. It has been, for
instance, reported that several US clinicians have difficulties
to recall the DSM-IV criteria for major depressive disorder
and rarely use them in their practice (e.g., 2). Furthermore,
some of the DSM-IV cut-offs and time frames have been
found not to have a solid empirical basis (e.g., 3) and to
generate a high proportion of sub-threshold and “not otherwise
specified” cases (e.g., 4).
The spontaneous clinical process does not
involve checking in a given patient whether each of a series
of symptoms is present or not, and basing the diagnosis on
the number of symptoms which are present. It rather involves
checking whether the characteristics of the patient
match one of the templates of mental disorders that the clinician
has built up in his/her mind through his/her training
and clinical experience."
Mario Maj
President, World Psychiatric Association
Psychiatric diagnosis: pros and cons of prototypes...
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Drug companies like Pfizer are accused of pressuring doctors into over-prescribing medications to patients in order to increase profits - GALLO/GETTY
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American Psychiatry should broaden its theoretical and conceptual outlook beyond the narrow professional concerns about diagnostic systems and classifications (at this time, with all the enormous importance of these issues, we are not ready for the true scientific approach towards resolving them; and the practical problems with "reimbursements" and "parities" should be left for actuaries and medical records departments to resolve). Recent controversies about DSM-5 indicate that the whole conceptual direction of improving and perfecting diagnostic pseudonosological labeling system (and the professional and social power of labeling that comes with it) hit a roadblock and is in "no exit" blind alley. How can we introduce a true, medically scientific and evidence based classification system for mental disorders if we still know so little about their nature and origins? The attempts to codify the current clinical labels are methodologically and epistemologically dangerous because they reinforce the current clinical belief system with its multitude of misconceptions. The history of science and medicine in particular is replete with these kind of errors. Preoccupation with improving the reliability by forced agreement (which by itself proved to be impractical and next to impossible) does not affect the much more important issues of validity of psychiatric diagnosis, and, if anything, leads to their neglect and displacement (not only in psychodynamic, but real sense) from our area of interests and scientific horizons, almost relegating these issues to the province of "conspiracy of silence". How can we agree on something, if we don't really know what this "something" is or if it even really and "truly scientifically" exists? And why should we agree on this "unknown something?"
Medicine and psychiatry are empirical and "practical sciences"; we are not just "talkers" and "labellers"; we are "doers": our task is to ease mental pain and suffering (of which this world is aplenty) for individuals, groups and societies. We do it in the dark, our knowledge is still limited and trues are hidden. We should not reinforce these limitations, presenting "blind spots" as medical facts, but should accept them, be aware of them and work further, relentlessly, and completely with an open mind to resolve them. Narrow professional concerns with "parities and reimbursements" or any business interests of any kind (including the profits from publishing a manual - APA is not just a publishing house) should not be a consideration and should not stand in the way of scientific research and progress in modern psychiatry. This probably was the "primal and original sin" which lead the whole DSM improvement effort astray.
American Psychiatry should assume its rightful leadership role in World Psychiatry with its bold and broad, open and independent minded, scientifically eclectic stance, discarding the outdated stereotypes, not reinforcing them; the stance worthy of this great nation and its spirit.
References and Links:
Mike Nova: Breivik Trial and The Crisis Of Psychia...
Thursday, April 19, 2012
Mike Nova: Breivik Trial and The Crisis Of Psychiatry As A Science
Mike Nova
Breivik Trial and The Crisis Of Psychiatry As A Science
Breivik is not the only one who is on this trial. Psychiatry as a science is on this trial also, just like on many other trials where forensic psychiatric involvement is sought. This is highlighted by the two contradictory psychiatric assessments of the accused, with their directly opposing diagnostic impressions and directly conflicting main general conclusions. The first forensic psychiatric evaluation, completed on November 29, 2011 by the psychiatrists Torgeir Husby and Synne Sørheim found Breivik to be "paranoid schizophrenic" and "psychotic" at the time of the alleged crime and presently and therefore legally "insane". A leaked copy of the initial psychiatric examination described his crusader fantasy as a product of the "bizarre, grandiose delusions" of a sick mind.
The second evaluation, about 300 pages long, made by the psychiatrists Terje Toerrissen and Agnar Aspaas on a request from the court after widespread criticism of the first one, was completed on April 10, 2012, just six days before the trial, but was not released, and according to the leaked information, found him afflicted with "narcissistic personality disorder" with "grandiose self" and not psychotic at the time of the alleged crime and presently and therefore legally "sane".
The latest psychiatric report was confidential, but national broadcaster NRK and other Norwegian media who claimed to have seen its conclusions said it described Breivik as narcissistic but not psychotic.
Torgensen gets the impression that Breivik found an ideal place to nourish his delusions of grandeur in the anti-Islamic scene full of crusader fantasies. “This was coupled with an extremely sadistic disorder,” Torgensen says. “This disastrous combination could explain the scale of his violence.”
The new report from forensic psychiatrists Terje Tørrissen and Agnar Aspaas concludes that he did not have “significantly weakened capacity for realistic evaluation of his relations with the outside world, and did not act under severely impaired consciousness”.
"Our conclusion is that he (was) not psychotic at the time of the actions of terrorism and he is not psychotic now," Terje Toerrissen, one of the psychiatrists who examined Breivik in prison, told The Associated Press.
Thus, as it almost always happens in complex forensic psychiatric cases, it was left for the infinite wisdom and common sense of the court, unburdened by the "sophisticated" and empty psychiatric jargon, to decide by itself, and rightly so, the "main questions" of the accused's mental illness or mental health and his "sanity" or "insanity" and to make its own, judicial decision regarding the issue of legal responsibility. Both mutually conflicting (but not mutually exclusive) forensic psychiatric evaluations, which, no doubt, were performed in good faith and with utmost professional diligence, will be taken into account by the court, but were rendered almost irrelevant by their contradictions. Once again, psychiatry, pretending to be a medical discipline and a science, was humiliated and reduced to the position of a laughing stock for the public and the media.
Mr. Breivik's skillful and astute lead defense lawyer, Mr. Geri Lippestad, treating his client with respect and at the same time with appropriate professional distance and apparently convinced of his client's mental illness and "insanity", chose a strategy of presenting Mr. Breivik to the court and to the public "as is", letting him to reveal himself and his presumed mental illness fully as the engine of alleged criminal behavior, apparently counting that it will be convincing enough for both the judges and for the court of public opinion.
“This whole case indicated that he is insane,” Geir Lippestad told reporters. “He looks upon himself as a warrior. He starts this war and takes some kind of pride in that,” Lippestad said. Lippestad said Breivik had used “some kind of drugs” before the crime to keep strong and awake, and was surprised he had not been killed during the attacks or en route to Monday’s court hearing.
Lippestad, a member of the Labour party whose youth wing had been the target of Friday’s shooting rampage, said he would quit if Breivik did not agree to psychological tests.
Geir Lippestad said the new report means Breivik's testimony will be crucial "when the judges decide whether he is insane or not." The trial started on April 16 and is scheduled to last 10 weeks.
Mr. Breivik declared himself undoubtedly and completely "sane" and consistently, if somewhat eerily out of place and time, painted a self-portrait as a model and self-sacrificing ideological warrior, taking as an insult any, albeit "professional" opinions otherwise and dismissed them with anger and indignation.
“On this day,” he said, “I was waging a one-man war against all the regimes of Western Europe. I felt traumatized every second that blood and brains were spurting out. War is hell.”
"Breivik told the court that "ridiculous" lies had been told about him, rattling off a list which accused him of being a narcissist who was obsessed with the red jumper he wore to his first court hearing, of having a "bacterial phobia", "an incestuous relationship with my mother", "of being a child killer despite no one who died on Utoya being under 14".
He was not insane, he repeated many times. He claimed it was Norway's politicians who should be locked up in the sort of mental institution he can expect to spend the rest of his days if the court declares him criminally insane at the end of the ten-week trial. He said: "They expect us to applaud our ethnic and cultural doom... They should be characterised as insane, not me. Why is this the real insanity? This is the real insanity because it is not rational to work to deconstruct ones own ethnic group, culture and religion."
All this is fine and dandy, and, no doubt, the aforementioned infinite wisdom of Scandinavian level headed justice (embodied in a stern but motherly demeanor of the presiding Judge Wenche Elisabeth Arntzen) will eventually emanate from its somewhat obscure, slowly but surely turning and unstoppable wheels, hopefully to almost every one's satisfaction. And eventually, this horrendous crime, the purp and the trial will be almost forgotten and placed into archives for further studies.
But the nagging questions remain and will remain for some, and probably a long time: is psychiatry really a science? Or is it just a collection of "professional" opinions, mixed with convenient labels and outdated jargon? What is "sane" and what is "insane"? And how far should the justice go in its modern "humane" stance?
"Grete Faremo, Norway’s justice minister, has said that it plans to establish a committee to examine the role of forensic psychiatrists. She told Norwegian daily Aftenposten on April 13 the committee would have a “broad mandate” that would examine three key questions: What is sanity? What is the role of the forensic psychiatrist? And how do we take care of security when an insane man is sentenced?
“Much suggests that the medical principle is inadequate,” said Faremo. “It is a historic step we are now taking. It is an important step in light of the terrible incident and the trial we face and in consideration of people's sense of justice.”
“This is a big thing,” says Abrahamsen. “If it hadn’t been for Breivik, we wouldn’t have discussed this.”
References and Links
Psychiatry May Also Face Scrutiny at Norway Killer's Trial - NYTimes.com
Breivik trial: Norwegians rethink role of psychiatry in courts - CSMonitor.com
Breivik Trial and The Crisis Of Psychiatry As Science - Links
Psychiatry May Also Face Scrutiny at Norway Killer's Trial - NYTimes.com
Breivik trial: Norwegians rethink role of psychiatry in courts - CSMonitor.com
Breivik Trial and The Crisis Of Psychiatry As Science - Links
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Friday, April 27, 2012
Response to Dr. Wessely
Response to Dr. Wessely
Normality or psychopathology of belief or belief system is determined first of all by the intrinsic qualities of belief in question. It is not determined by the fact that belief is shared or not shared: "Delusions are beliefs that are not only wrong, in the sense of not corresponding to the world as we know it, but they must also not be shared with others of the same cultural background."There are many delusional beliefs that are or were shared, and some of them on a rather large scale. For example, the ancient Maya believed, that for the sun to rise they had to offer human sacrifices (of their best and brightest) every day, otherwise all kind of life on earth would come to a halt. This belief was shared very widely in precolumbian Maya culture, which does not make it less delusional.
Breivik's ultra nationalist anti-immigrant ideology is shared by great many people of various cultural backgrounds. The goal of his forensic psychiatric evaluation is to assess his own particular belief system, with all its peculiarities and idiosyncrasies, in order to determine its nature, qualities and psychopathological aspects, regardless of other similar beliefs. In the end, it was him, not others, who took these ideas to their logical (or rather illogical and "sick") extreme, although the (possibly facilitating) role of "significant others" in his case still has to be determined.
Neither the "monstrosity" and "grievous consequences" of his actions nor "popular misconceptions" should cloud the picture. The most important factor in his forensic psychiatric assessment is the presence or absence of identifiable and diagnosable mental illness and the degree of its causal relationship with the crime. In my opinion, whatever it is worth, psychopathological qualities of Breivic's beliefs: their highly systematised, structured, all embracing "world view" quality, along with their unshakable, messianic conviction and "call for action", indicate with high degree of probability the presence of Delusional Disorder, mixed, persecutory-paranoid type, and the direct and overwhelming causal connection of his psychopathology with the criminal act.
The cognitive aspect in psychopathology of Delusional Disorders (abnormalities and/or dysfunctions in concept selection, elimination and confirmation), indicating possible subtle but decisive organic involvement is much under-researched area, probably due to our neglect or inattention to biological aspects of these disorders and overestimation of its psychodynamic aspects. Delusional jealousy, secondary to chronic alcoholism (a very discrete and specific syndrome) is the case in point.
"The... misconception... that the purpose of psychiatry is to “get people off”" might be as wide spread as any other misconception, which does not make it any less of a misconception. The historically formed legal concept of "NGRI: not guilty by reason of insanity" is a witness to humanity and rationality on a part of a society; not to mention other, less important but present factors, such as political and social convenience, expediency and cultural traditions. (E.g.: Disraeli to Queen Victoria: "Only a madman can think about assassinating your Majesty..."). Modern psychiatry, very likely, was born out of the M'Naghten rules, as some psychiatric historians suppose.
And last, but certainly not least, is the difficult and complex subject of "Schizophrenia", its clinical concept (and/or misconcept) and diagnosis (and/or misdiagnosis). The diagnostic label of "Schizophrenia" became so wide spread and all encompassing (because it is so easy to apply, and is applied almost indiscriminately), as to loose its meaning and clinical value. In our rush to nosological (and reimbursement) parity with the rest of medicine we jumped over our heads too soon, introducing the (man made) diagnostic criteria based "nosological" system, which leads to premature ossification and codification of clinical concepts and experience, impeding the independent minded research greatly and precluding the normal development (albeit slow and lagging) of psychiatry as a medical science. Is it not more correct and probably clinically more productive, especially in the field of psychopharmacology, to return to syndromologically based classification system and to try to define, refine and research these historically formed clinical syndromes further, before rushing to judgements about their pseudonosological "pigeon holes"?
This is what Breivic trial, along with other issues, brings to the front. And these issues deserve a deep and long thought.
Michael Novakhov, M.D.
References and Links
Anders Breivik, the public, and psychiatry : The Lancet
Anders Breivik, the public, and psychiatry : The Lancet
The Lancet, Volume 379, Issue 9826, Pages 1563 - 1564, 28 April 2012
doi:10.1016/S0140-6736(12)60655-2
Cite or Link Using DOI
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sane society - Google Search
Erich Fromm - From Wikipedia, the free encyclopedia
Cite or Link Using DOI __________________________________________________________
Sanity -
Wikipedia, the free encyclopedia
In The Sane Society, published in 1955, psychologist Erich Fromm proposed that, not just individuals, but entire societies "may be lacking in sanity". Fromm argued that one of the most deceptive features of social life involves "consensual validation."[3]:
In The Sane Society, published in 1955, psychologist Erich Fromm proposed that, not just individuals, but entire societies "may be lacking in sanity". Fromm argued that one of the most deceptive features of social life involves "consensual validation."[3]:
| “ | It is naively assumed that the fact that the majority of people share
certain ideas or feelings proves the validity of these ideas and feelings.
Nothing is further from the truth... Just as there is a folie à deux there is a folie à
millions. The fact that millions of people share the same vices does not make these vices virtues, the
fact that they share so many errors does not make the errors to be truths, and
the fact that millions of people share the same form of mental pathology does
not make these people sane.[4] Fromm, Erich. The Sane Society, Routledge, 1955, pp.14–15. |
sane society - Google Search
Erich Fromm - From Wikipedia, the free encyclopedia
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Mike Nova: American Psychiatry At The Crossroads
Sunday, May 13, 2012
Mike Nova: I support Dr. Frances' idea about founding some new... interdisciplinary body for establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis
Last Update: 9:20 AM
5/13/2012
Mike Nova: I support Dr. Frances' idea about founding some new, superpsychiatric (possibly under combined umbrella of all the appropriate agencies that he mentioned) interdisciplinary body for
Establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis,
which should include efficient participation of philosophers, neuroscientists, geneticists, biologists, psychologists, sociologists, specialists in forensic behavioral sciences and lawyers.
Maybe, with a little help from our friends the "heavenly gate" to a new, broader scientific paradigm in psychiatry will crack open; a little.
And this might lead to true and real (not imaginary, as a product of the wishful thinking), scientifically revolutionary "paradigm shift". Any new paradigm in psychiatry (just like in any other scientifically oriented ideational activity, according to Kuhn) has to be significantly broader than the previous one, incorporating the new body of knowledge, disciplines and theories in a new conceptual framework, resolving the "anomalous contradictions" of the old paradigm which becomes conceptually inadequate to contain them.
This new paradigm must also fit into the larger current paradigmatic systems of scientific and cultural beliefs, and the present lively debate about the meanings and the essence of psychiatric diagnosis is one, and maybe the best indication that the old paradigm "does not fit", that it is scientifically (which is not synonymous with medical practice) - inadequate.
It is also interesting to observe that the battle for this new paradigm is waged in a mainstream media, which might also indicate "the revolutionary situation" expressed as a heightened public awareness and concerns which are absolutely justified, legitimate and significant.
Mike Nova: I support Dr. Frances' idea about founding some new, superpsychiatric (possibly under combined umbrella of all the appropriate agencies that he mentioned) interdisciplinary body for
Establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis,
which should include efficient participation of philosophers, neuroscientists, geneticists, biologists, psychologists, sociologists, specialists in forensic behavioral sciences and lawyers.
Maybe, with a little help from our friends the "heavenly gate" to a new, broader scientific paradigm in psychiatry will crack open; a little.
And this might lead to true and real (not imaginary, as a product of the wishful thinking), scientifically revolutionary "paradigm shift". Any new paradigm in psychiatry (just like in any other scientifically oriented ideational activity, according to Kuhn) has to be significantly broader than the previous one, incorporating the new body of knowledge, disciplines and theories in a new conceptual framework, resolving the "anomalous contradictions" of the old paradigm which becomes conceptually inadequate to contain them.
This new paradigm must also fit into the larger current paradigmatic systems of scientific and cultural beliefs, and the present lively debate about the meanings and the essence of psychiatric diagnosis is one, and maybe the best indication that the old paradigm "does not fit", that it is scientifically (which is not synonymous with medical practice) - inadequate.
It is also interesting to observe that the battle for this new paradigm is waged in a mainstream media, which might also indicate "the revolutionary situation" expressed as a heightened public awareness and concerns which are absolutely justified, legitimate and significant.
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