I read their book, before I gave it as a gift to my friend. I don't regret giving it. I think it is a sensible book. However, Im afraid it doesn't go far enough, in that as of the year 2009 (almost) we still don't know what the-F "genuine depressive disorder" is, or "endogenous depression", or whatever the hell you want to call it -- scientifically speaking.

Second, I think the books weakest point is that its not written by clinicians. In other words, it lacks what I think is a necessary piece of the picture required to understand the emptiness of the MDD label. Nemeroff himself published that most treatment resistant depressions have underpinnings in childhood trauma. They don't get into that too much, so they concede more than they should on that point.

It's amzing to me how many depressed people I meet who have gone through absolutely horrific circumstances and then deny any relationshop between their depression and their past (or present). I believe "endogenous" depression could arise acutely from organic reasons, and then, still wouldnt make a whole lot of sense to treat with the sloppy compounds we call SSRI's.

Ive been in the same position before. The majority of normal people arent introspective at all ( including myself), and depending on their circumstances, may or may not be given the impetus by some event or another to pause, and think about their life a little more integratively. I think it is the norm in America to discount, or totally ignore emotions, and the significance of parental, or societal sleights. Critical thinking skills aren't valued in the United States.

The usual sequence of events for people who claim no connection between past/present and their depression is always a little odd to me. We go to bed joyous one night, the sun rises, and we can't get out of bed???

Horowitz and Wakefield do a good job though in illustrating how diffuse and meaningless MDD category is. It is, in psychiatric terms, a true wastebasket diagnosis.

Posted by: JC at December 12, 2008 06:03 AM

Would it be a good thing if there were a pill that would take away all unhappiness, tiredness, and irritability? If we take away normal sadness what will that do to morality? I don't have much patience with people who think their sadness is a medical disease, much less with the "doctors" who create that belief. I think a society that requires the medicating of feelings is prohibiting feelings where as those who like the chemical model seem to feel that a society that doesn't require such medication is somehow belittling people who suffer from the disease of being human.

Posted by: Sally at December 12, 2008 11:43 AM

It was an interesting interview. I agree that physicians are too lenient with the symptoms leading to a diagnosis of MDD. That just invalidates MDD. There needs to be more digging on the part of doctors to ferret out what is going on: is it normal sadness or clinical depression. But that won't happen when most doctor visits only last under 15 minutes, just long enough to write a prescription and shove the patient out the door.

Posted by: Tony at December 12, 2008 12:40 PM

Confession time: I've been very sad lately. I moved to a new city a few months ago in a relationship that has fallen apart completely. I've also had some bad reactions to psychiatric medications which I've withdrawn from. But the biggest part of my past is some very intense grief over the past few years in my immediate family. This has largely gone unprocesses and has been covered over by drugs (prescribed and unprescribed if you know what I mean)

I went to the psychiatrist the other day but couldn't meet with my regular doctor so met with a very nice man who fit me into his schedule. We talked about my meds in the past and he had read over my history. I really WANTED him to give me SOMETHING to make the pain, lack of focus, dread, and tiredness go away. I was ready to take a stimulant even, anything to make me feel BETTER. He talked honestly about the limits of medications and said, bluntly, "you have a lot of reasons to be sad when I read over whats happened in your life recently."

Instead of pills he taught me breathing exercises and talked about some books about trauma and body-oriented recovery from it. He was saying he thought the trauma model of mental "illnesses" was going to be the next big thing.

I left feeling completely transformed and my mood has improved dramatically as well as my ability to focus. Just being HEARD and understood worked wonders. I'm glad I didn't get those pills I was after.

Posted by: David at December 12, 2008 11:21 PM

David thats great! Gosh, that's so nice to hear and it sounds like this new psychiatrist really knows his stuff. In my own struggles in the last few years I've come to find that just recognizing the interrelatedness of the past with my present "symptoms", has been half the battle, so to speak. And it sounds like you're there already too! I think you should be commended for taking a more thoughtful approach to your care. Hell, I know before, I've just accepted anything thrown at me by a doctor, simply because of my desperation.

I hear you. Just being understood and heard, genuinely, can have a real regulating effect. I know I've walked out of a therapy session completely free of the anxiety and depression that saddled me when I walked in. It's a more temporary solution, of course. But a profound one, even physiologically, and in the short term, it's just what I needed.

David, it seems like you've had some struggles in the relationship department. The psychologist Bruce Levine says that relationships are often a neglected factor and solution in depressions. All kinds of relationships. Big, small. Just thought I'd throw that out there. Knowledge is power.

It was uplifting to read your comment. I hope you stay well and take care of your self, you deserve it.

Take care,

JC

Posted by: JC at December 13, 2008 01:44 PM

Serotonin Enhancing Psychotropic Pharmaceuticals

In the 1930s, physicians approached the mental illness of depression a bit differently that we do today. While acknowledging a cause of depression is often due to some great misfortune, they seemed to focus on what is called a complex. A complex is disturbances of ideas and impulses that are the cause of consistent habitual patterns of thought, feelings, and behavior. An example of this state of mind of one who is depressed is one who experiences an exaggerated or obsessive concern or fear. And the etiology for this mental disorder was often undefined. In the 1930s, psychotherapy such as cognitive therapy was recommended for treating the depressed patient, and not pharmacological therapy. Also considered for the depressed patient was positive lifestyle changes that would lessen the pain that the depression was causing them.

Times have changed since then.

Presently, for the treatment of depression and other what some claim are other types of mental disorders that are may or may not exist, selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice by most prescribers today for a variety of mood disorders, including and primarily for the treatment of depressive disorders. The most severe of the depressive disorders is when one has a major depressive disorder, also called clinical depression or major depression. Symptoms of this type of depression, which is the most concerning due to its severity, include decreased or flat affect, decreased interest in activities once enjoyable, worthiness, guilt, regret, helplessness, and hopeless, to name a few of the diagnostic features that may be present with one who has such a major depressive disorder.

These SSRIs are known by some as third generation anti-depressants. Such drugs, drugs that affect the mind, are called psychotropic medications.

SSRIs also include a few drugs in this class that include the addition of a norepinephrine uptake inhibitor added to the SSRI, and these drugs are referred to as SNRI medications, which combined with SSRIs, are the number 1 top therapeutic class of prescriptions presently, it has been reported. While there are several available SSRIs presently, it is believed that only two SNRIs are available, which are Cymbalta and Effexor. Some consider these classes of meds the next generation mood enhancers- after the benzodiazepine hype decades ago. Furthermore, regarding SNRIs, adding the additional agent of norepinepherine is presumed to increase the effectiveness of SSRIs by some.

Some Definitions:

Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrist’s bible, which is known as the DSM, states that the definite etiology of depression remains a mystery and remains unknown with complete certainty. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected as a result of limited scientific evidence. In fact, diagnosing mental diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.

Norepinepherine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med, as suggested earlier.

And depression may be combined with related mood disorders that may exist with certain patients.

Anxiety usually exists with one who has a major depressive disorder. A objective diagnosis of these mental conditions lack complete accuracy, as they can only be defined conceptually, so the diagnosis or impression concluded by the patient’s doctor is dependent on subjective criteria, such as questionnaires and patient observation by the health care provider. Such questions come from what is known as a DSM book created by psychiatrists. Screening programs that have been used for identifying depressed patients have proven to be largely ineffective.

A social patient history is uncertain and tricky as well, some have said. There is no objective diagnostic testing for depression to validate as to whether or not the disease is present. A health care provider has to assess as to whether certain diagnostic features are present to offer the diagnosis of major depression. This is further complicated by the fact that the exact cause of major depression is unknown.

Yet the diagnosis of depression in patients has increased quite a bit over the past few decades. Some have asked themselves and others- actually how many people are really and actually depressed? What is believed is that if one is determined to be cognitively impaired from a mental paradigm, then it may be major depression. If this is determined by a health care provider, than pharmacological therapy is considered reasonable and necessary, as well as psychotherapy either used with or in place of medicinal therapy.

It has been reported that around 10 percent of the U.S. population will at some point be affected by a major depressive disorder. Due to such factors as the likeliness of others being depressed often being discussed recently in the media and medical literature, that may not be completely accurate or thorough, depression and the treatment and diagnosis of this disorder has increased remarkably in a short period of time in the United States. This depression issue is further encouraged by those pharmaceutical companies that market medications for major depressive disorders. So more people seek treatment now for what they believe is a major depressive disorder they are experiencing, when in fact it may be intense sadness, perhaps, due to a loss of some sort in their lives. There is a difference, and health care providers should have the appropriate tools and knowledge to discriminate between the two states of mental conditions. Sadness is not a medical problem.

Symptoms associated with an unfavorable mental state need to be excessive and chronic to be considered to have in fact the medical problem of a major depressive disorder, as stated by others.
In Time magazine’s June 16th 2008 cover story, it was reported that the military personnel in the Iraq war are pounding down SSRIs often. Every time there is a new war, there is a new drug, it seems. Yet the story may illustrate the frequent usage of these types of medications in a variety of different areas for different reasons. Some reasons may be valid and appropriate, yet others perhaps may not be reasonable for such medicinal therapy.

In regards to those pharmaceutical companies who make and market such psychotropic drugs in the manner that they do that largely is unknown to others, what is known is that the psychiatry specialty is the one specialty most paid to by certain pharmaceutical companies for ultimately and eventual support of their psychotropic meds that they currently promote to these doctors, as this aspect of the pharmaceutical industry clearly desires market growth of these psychoactive medications. Front groups to expand the market for these types of drugs have been known to occur as well, which have on occasion been developed if not supported by such companies.

Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders that may be suspected by a health care provider- regardless of their specialty. Yet these drugs discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related and suspected mental disease states or disorders. Patients should be aware of this fact as well as caregivers.

It has been estimated that over 30 million scripts of these types of meds that enhance serotonin saturation in the brain are written annually, and the franchise is around 20 billion dollars a year now, along with some of the meds costing over 3 dollars per tablet, it has been reported. There are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to be launched as a treatment for menopause. The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.

Furthermore, these meds have received upon request of their makers to the FDA additional indications besides depression for some really questionable conditions, such as social phobia and premenstrual syndrome. Also included with indications that now exist with these types of medications include both generalized and social anxiety disorders, Obsessive Compulsive Disorder, Panic Disorder, Agoraphobia, Post Traumatic Stress Disorder, Bulimia, and stress disorders in general. I understand they are seeking indications for pain management as well with these SSRI or SRNI pharmaceuticals. This may need further review before the use of these drugs are expanded into other conditions that have not been considered or thoroughly studied in the past, I believe.

With some of these indications for these classes of drugs, I question as to whether or not they are actual and treatable disease states or non-medical problems. Yet with additional indications for particular drugs in these classes o medications, one can be assured that the market for these drugs will continue to grow, as more are prescribed these particular classes of drugs, even though some have suggested that these types of drugs are effective in only about half who take them. And some of the indications granted to drugs in these classes of medications may be considered disease mongering to grow the market share for particular drugs of this type. This is combined with drug companies who make these types of meds either forming or creating front groups in order to have more diagnosed with various medical problems that may not exist so their medication can be utilized to a greater extent through such methods as screening others, or exaggerating the prevalence of a particular medical condition that their medication may be indicated for and authorized by the FDA.

Needless to say, such activities by pharmaceutical companies are deceptive, inappropriate, unreasonable, unnecessary, and clearly dangerous to others.

Perhaps of greater concern and danger with these particular psychotropics primarily involves the adverse effects associated with these types of drugs, which include suicidal thoughts and actions, violence, including acts of homicide, and aggression, to name a few, yet devastating, events that have occurred while one is taking a SSRI or SRNI. It has been reported that the makers of such drugs are suspected to have known about these toxic and dangerous effects of their drugs and did not share them with the public in a timely and critical manner. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others for understandable reasons, which have included those in the medical profession as well as citizen watchdog groups.

The reasons for this attention are due to the potential off-label use of these meds in this population of children, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, combined with the true decreased efficacy of SSRIs in general, which is believed to be only less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding of such important information- Elliot Spitzer specifically was the catalyst for this awareness, as I recall. Furthermore, that drug is in the spotlight once again years later. Some believe the drug maker knew about possible risk to the youth as early as 1991. Yet did not disclose such danger associated with their drug to the public or the FDA, and this was done with intent.

And there are very serious questions about the use of SSRIs in children and adolescents regarding the possible damaging effects of these meds on them. For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect would possibly cause harm rather than benefit a patient on such a drug? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their self identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring within their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist. It is observed in some who take such drugs, but not all who take these drugs.

Yet health care providers possibly should be much more aware of these possibilities, possibly, along with the black box warning now on SSRI prescribing information for the youth that has existed since 1994.

Finally, if SSRIs or SNRIs are discontinued by a patient rapidly and without medical supervision, withdrawals are believed to be quite brutal that follow soon after the drug is not taken anymore by a former patient of these types of drugs, and may be a catalyst for suicide in itself, as not only are these drugs habit forming, but discontinuing these meds abruptly, I understand, leaves the brain in a state of neurochemical instability, as the neurons need to recalibrate after existing in a brain over-saturated with serotonin. This occurs to some degree with any psychotropic medication, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs and SNRIs, it is believed. And this seems to concern many.

SSRIs and SRNIs have been claimed by doctors and patients to be extremely beneficial for the patient’s well -being regarding the patient’s mental issues where these types of meds are used, yet the risk factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug. Before these medications mentioned were developed, doctors praised trycyclics, another class of anti-depressants, in a similar manner some time ago.

Considering the lack of efficacy that has been demonstrated objectively with these newer psychotropics, along with the deadly adverse events with these SSRI and SSNI meds only recently brought to the attention of others, other pharmacological and non- pharmalogical treatment options should probably be considered, but that is up to the discretion of the prescriber. And the perception of the benefits derived by these types of drugs may be flawed, as there has been no decrease in incidences of suicide or remission of depression since these drugs have been available, many have concluded.

Furthermore, recent studies have suggested that the supplement, St. John’s Wart, has shown to be as effective as medicine for major depression.

It is my hope that such a prescriber rules out possible other etiologies for their patients’ mental conditions before they conclude that such a patient is suffering from true mental illness requiring the medications mentioned earlier, such as asking their patients about life stressors and other medications these patients have taken or are presently taking. Because at times, a doctor can in fact do harm without intent.

“I use to care, but now I take a pill for that.” --- Author unknown

Dan Abshear

Author’s note:
Addendum to this article based on the following link:

http://www.medicalnewstoday.com/articles/132005.php

There are greater than 60 symptoms associated with one who is or may be depressed, and there are different degrees of depression. The number of symptoms expressed by one who suffers from depression determines the severity of their depression.

The characteristics associated with depression are affective, cognitive, and somatic.

For example, affective symptoms are the core symptoms of a depressed mood, and the term that one has a flat affect is an indication that one may be suffering from depression. These symptoms may include sadness, dissatisfaction, crying episodes, irritability, as well as social withdrawal. It should be noted that many events could cause the expression of such symptoms besides depression in itself.

Cognitive symptoms associated with depression may include pessimism, a sense of failure as well as guilt, suicidal ideation, and dislike of self.

Somatic symptoms may include insomnia, fatigue, weight change, and loss of interests, such as sex or other activities engaged in historically with a depressed patient. It should be noted that stress can cause such symptoms as well, in my opinion,

Dan Abshear

Posted by: Dan at December 15, 2008 07:49 AM

Dan said, "So more people seek treatment now for what they believe is a major depressive disorder they are experiencing, when in fact it may be intense sadness, perhaps, due to a loss of some sort in their lives. There is a difference, and health care providers should have the appropriate tools and knowledge to discriminate between the two states of mental conditions. Sadness is not a medical problem."

It would be nice if doctors could tell the difference, but with 30 million scripts written annually I think it's pretty evident that they can't.

Posted by: Lisa at December 15, 2008 03:47 PM

Lisa:

Just wondering, but how do you tell the difference between ordinary sadness and major depression?

Posted by: dguller at December 15, 2008 07:24 PM

maybe there is no difference dguller.

Posted by: Gianna at December 15, 2008 08:26 PM

Gianna:

There is no difference between someone who is sad for a few weeks, but still able to work, and someone who is so devastated by sadness that they have been isolating themselves and unable to work for a few years and wants to die every day?

Posted by: dguller at December 16, 2008 04:52 AM

Gianna,
Please!
Come to your senses: antidepressants HELP!
Why do you all insist telling that these drugs cannot help? If SSRIs and SNRIs are of great help for those who are with major depression why not use them for those who are sad?
They will feel fine just like depressed people and will be jumping of joy even if they lost a relative, husband...
Can't you see that what is really important is:
PEOPLE HAVE TO BE HAPPY!
Why feel sadness when you can take a pill and feel fine?
Take me as an example:

I lost my job and broke up with my boyfriend.
Jesus! I was feeling so sad, so sad that I could not even brush my hair.
My GP prescribed me Paxil. I took it for 8 months.
After three days on the drug I felt GREAT! I was on top!
I've found a new job that have double my income and guess what?
I'll get married next April.
You see?
If it wasn't for Paxil I would never had done all of this.

"Heaven!
I'm in heaven!
And my heart beats so that I can't hardly breath!!!
.....
Together dancing cheek to cheek!"

Hope you take my advice and stop complaining.

WOW!!!!!!!!
I can't take it seriously any longer.
Arguments are pitiful.

Posted by: Ana at December 16, 2008 09:02 AM

Dguller,

You ask: "There is no difference between someone who is sad for a few weeks, but still able to work, and someone who is so devastated by sadness that they have been isolating themselves and unable to work for a few years and wants to die every day?"

The Last Psychiatrist has a blog entry addressing the rhetorical falsity you taunt Gianna with. Here are a few choice pieces of his response to your question:

"But dismissiveness isn't his real problem, it's his choice of analogies. Psychiatry isn't being accused of taking ordinary symptoms of cough and exaggerating them into pneumonia-- because then it could be easily unmasked. What psychiatry does is to call "cough" itself a major disorder. It makes this definitional, safely axiomatic, and thus irrefutable. Not, "he's much sicker than he seems," but "what he is, is sick."

and

"But hold on: the examples aren't preposterous, they are already pathologies. Ok, they're not disorders, but they are signs of disorders. Don't be fooled by the aliases. What Nasrallah doesn't realize (?) is that these "symptoms" signify, connote, a disorder, a process that cannot be undone. "He has mood swings" means he has bipolar, even if he doesn't. Even if 100 psychiatrists later agree he doesn't have bipolar, the diagnosis stays open: every aspect of his life will be forever measured against bipolar.

If the cough is a symptom of "Cough Disorder"-- who can protest?"

and

" He picks this as an example of hubris not being a disorder so that he can label the bankers as greedy. That's the purpose of this example. Someone else's greed-- say, a gambler's, or someone who does not offend him-- that could be pathology, that could be bipolar. So what he's showing you here is not the framework of normal vs. pathology, but how he gets to choose what to pathologize, and when."

and

"On the one hand psychiatry doesn't see normal sadness as pathology; on the other hand, psychiatry will intervene when someone else sees pathology. So when, ultimately, does normal sadness constitute a disorder? When someone says it does, that's when. Ipse dixit."http://thelastpsychiatrist.com/2008/12/should_hubris_be_in_the_dsm-v.html

Or to answer the question you posed to Gianna:

The fact that some sadness is more intense and enduring than other emotional distress is not relevant when determining whether sadness is a medical disease. The fact that you are the one that gets to choose when to pathologize the human emotional and intellectual experience concerns me.

Posted by: Sally at December 16, 2008 02:53 PM

Sally:

First, define "medical disease", please.

Second, do dementia, delirium and autism count as medical diseases? What are the objective tests and biological markers that can reliably identify them in a patient?

Third, does it really matter what you call it? Whether a medical illness, an existential crisis, or an emotional problem, perhaps the main issue is when does intervention become necessary, and what kinds of intervention are appropriate? When does supportive counselling become insufficient, and formal psychotherapy and (maybe) antidepressants become necessary?

Perhaps if we could explore these issues together, then we could find some common ground?

Posted by: dguller at December 16, 2008 04:49 PM

Sally:

Oh, and one more thing. To comment on the selections from Last Psychiatrist's post.

He makes the analogy between psychiatry's taking "sadness" and turning it into a major disorder as similar to taking "cough" and turning it into a major disorder. This is simply false. A cough, like sadness, is a sign. Nothing more. Nothing less. Depending on a variety of other factors, a clinical syndrome may or may not be present.

For example, a cough is insignificant, but when combined with a fever, productive sputum, chest pain, shortness of breath, and crackles on auscultation, then it becomes a possible presentation of pneumonia.

Similarly, feeling sad is insignificant, but when combined with a loss of interest in pleasurable activities, loss of appetite, inability to sleep properly, impaired concentration and memory, excessive guilt and regret, feelings of hopelessness about the future, lack of energy and motivation, as well as suicidal thoughts, all over an extended period of time that results in psychic pain or impairment in a person's premorbid level of function, then we consider an episode of major depression.

No-one confuses a sign or symptom with a full-blown illness. The entire clinical picture must be examined and it takes a constellation of signs and symptoms to declare a phenomenon a clinical illness.

So, I actually object to his portrayal of psychiatric diagnosis, which as imperfect as it may be, is certainly not the ridiculously absurd strawman that he constructs.

Posted by: dguller at December 16, 2008 05:02 PM

If you are willing to admit that depression is not a medical disease, we have some common ground. By medical disease, I mean a abnormal unpleasant condition caused by a physical abnormality of the body.

As for when intervention becomes necessary and what kinds of intervention are appropriate, I'd say the ways of dealing compassionately with human suffering should always be addressed on a case by case basis. Telling someone that their unhappiness is caused by chemicals in their brain instead of by circumstances of their lives is dishonest. Telling someone that their response to a loss is abnormal, is a judgment not a medical diagnosis.

What if antidepressants really worked, i.e. really stopped sadness, would you feel some need to judge when to prescribe them? For instance if a woman came to you extremely sad because her boyfriend had broken up with her, would you ask some questions and judge her before deciding to prescribe pills? If a man came to you sad because his mother had died, would you ask well how long ago and make a value judgment on his right to suffer, i.e. his right to be relieved? Are these judgments really practicing medicine or something else.

Perhaps psych drugs should be dispensed by experienced bar tenders some of whom know when to give a customer that extra drink because he lost his job and when to cut him off and call a cab.

Since psych drugs rarely work in relieving depression, or if they do work only work temporarily, do you agree that some information should be given to the client about the product s/he's buying in terms of side effects, addiction potential, etc?

As for medical disease - I'm using medical here as the art and science of healing and disease as a functional abnormality of the body.

As for dementia, delirium and autism, why do you feel it relevant to mention these conditions in a discussion of depression?

Posted by: Sally at December 16, 2008 05:34 PM

Sally:

First, you write: “By medical disease, I mean an abnormal unpleasant condition caused by a physical abnormality of the body.” Please define “abnormal unpleasant condition” and “physical abnormality”. Specifically, I would like to hear your thoughts on what counts as “abnormal”.

Second, the subjective experience of unhappiness is mediated by underlying neurobiological pathways, and thus it is reasonable to utilize treatments that can modify those pathways to alleviate the subjective feeling of distress. Opiates operate in a similar fashion to block the pain pathways in the central nervous system, but they do nothing to treat the underlying cause of the pain. I agree that in addition to using medications to alter one’s mood, a person must also face the underlying causes of their psychological distress, which could include a maladaptive coping style, interpersonal conflict, role transition, and other psychosocial factors.

Third, I mentioned dementia, delirium and autism, because they are all DSM-IV diagnoses. Since you claim that the DSM-IV is fraudulent and that its disease categories are not medical illnesses, then it follows that the three aforementioned conditions are also not medical conditions. If you disagree with this inference, then please explain what definitive biological processes are involved in those conditions, and what objective diagnostic tests are available to detect them.

Take care.

Posted by: dguller at December 16, 2008 09:23 PM

Dguller,

Your obtuseness is becoming more aggressive as your argument is proven more and more specious.

You write: "subjective experience of unhappiness is mediated by underlying neurobiological pathways." That's what I meant by depression is a medical disease and while you are not wrong, you miss that point. It seems logical to expect that "subjective experience of unhappiness is mediated by underlying neurobiological pathways" but as you know this hasn't been proven, and while it's an interesting theory that may help develop more successful happy pills, or, for that matter, unhappy pills, it misses the point which is that unhappiness is caused by the interaction of a human in her or his physical body in the external world, and while this includes the interaction of underlying neurobiological pathways with the external world, the point still holds that something external triggers the underlying neurobiological pathways to mediate subjective experience of unhappiness.

Your hostile tone frightens me but it's not abnormal considering your need to defend your obviously incorrect positions.

You request that I define “abnormal unpleasant condition” and “physical abnormality," specifically requesting my thoughts on what counts as

Anyway, do you agree that defining who is normal or abnormal is a contentious issue in abnormal psychology?

Abnormal means deviating from a standard. Having one leg is abnormal, as is having three, if you're human. Having one leg is a physical abnormality.

You seem to be arguing simultaneously that physical abnormalities of the body cause and control subjective experience of unhappiness.

I'm arguing that subjective experience of unhappiness is not abnormal though it may be unpleasant. I don't argue with efforts to palliate emotional pain, only with the idea that this pain is abnormal.

I'm not aware of claiming the DSM-IV was fraudulent. It's allegations that it's a science based book that are false. This doesn't mean dementia and delirium don't exist.

I'm not sure I think these conditions are medical diseases, in other words, I don't think, these conditions are abnormal, though they are often unpleasant. Think childbirth, both normal and extremely painful. I don't think it's wrong to get pain meds during labor, but I think it's harmful and dishonest to tell a woman her labor pains indicate an abnormal birth.

As for autism, it's a controversial condition, and the damage done in terms of overdiagnosis due to the dsm IV is hard to estimate, but possibly equal to that of the bogus child bipolar label (which I know hasn't been dsm'd yet).

Mental retardation is also in the DSM IV. Why didn't you ask me about that condition?

Posted by: Sally at December 17, 2008 09:50 AM

Sally:

First, I explicitly stated that the neurobiological underpinnings of subjective experience are secondary to a variety of psychosocial factors. You can see that when I wrote that “in addition to using medications to alter one’s mood, a person must also face the underlying causes of their psychological distress, which could include a maladaptive coping style, interpersonal conflict, role transition, and other psychosocial factors.” So I didn’t “miss the point” at all. I directly engaged with it.

Second, I do agree that definitions of normality are problematic in any area of human inquiry, because the word “normal” has a variety of meanings, and each of those meanings has various connotations and implications. However, I never used the words “normal” or “abnormal”. You did, which is why I asked you to clarify what you meant, and you did. You said that “abnormal” meant “deviation from a standard”. Who sets your standard? Where did your standard come from? Are deviations from a standard problematic in all cases? If they are not, then what are the exceptions?

Third, I agree that the subjective experience of unhappiness is not abnormal. It is a normal firing on various neurological circuits in the brain, just like pain is a normal firing of certain pathways in the brain. However, we do not ignore pain just because there are natural neurobiological underpinnings to the experience of pain. We attempt to alleviate that subjective experience itself with pain killers, as well as address whatever underlying mechanisms are causing the pain in the first place. As I said earlier, that is my model for mental illness, especially for depression and anxiety disorders. I think that we are largely in agreement here. We only differ in whether antidepressants have a role in severe cases of distress to help alleviate some of the subjective distress.

Fourth, there are some problems with your comments about delirium and dementia. You state that they are not medical illnesses, because they are not abnormal. However, diabetes is a medical illness, because it is abnormal, right? What sense of “normal” are you applying to both cases? What standard are you using to measure deviation by?

If your standard is each bodily organ functionally performing its designed purpose, then diabetes is a medical illness, because the pancreatic cells that produce insulin no longer perform this function. However, what parts of the body have as their primary function the gradual deterioration of memory and cognitive function, as seen in dementia? What parts of the body have as their primary function the psychotic disorientation of delirium?

Or maybe the sense of “normal” is what is commonly seen in humanity? So, dementia is normal in the sense that it is seen in a large number of elderly people. However, we also see diabetes in a larger number of people, and so it should also be considered normal in that sense, and thus not a medical illness.

So, it appears that neither sense of “normal” is helpful here. Perhaps if you clarified what standard you are using, then things will become clearer.

Fifth, you are correct that autism could be over-diagnosed. Fair enough. But what about those cases where it is accurately diagnosed? In those cases, do you consider it a medical illness, or just a normal variation that should be respected and not interfered with? Oh, and I didn’t mention mental retardation, because I didn’t think of it.

Take care.

Posted by: dguller at December 17, 2008 08:34 PM

"Just wondering, but how do you tell the difference between ordinary sadness and major depression?"

dguller, I suppose it depends on who you see.

Posted by: Lisa at December 18, 2008 04:20 PM

Lisa:

Care to elaborate in a way that would be clinically useful? I appreciate Zen statements as much as the next guy, but I'd like something a little more practical, please.

Posted by: dguller at December 18, 2008 05:59 PM

Dguller,

You write:

"We attempt to alleviate that subjective experience itself with pain killers, as well as address whatever underlying mechanisms are causing the pain in the first place. As I said earlier, that is my model for mental illness, especially for depression and anxiety disorders. I think that we are largely in agreement here. We only differ in whether antidepressants have a role in severe cases of distress to help alleviate some of the subjective distress."

I think you really miss my point. What we differ about is whether underlying mechanisms cause depression, whether you should flatly lie to people who come to you and tell them they have a physical problem that is causing their unhappiness that can be corrected by drugs, falsely implying or flat out stating you have some knowledge that antidepressants, or whatever treatment you pushing is a medical cure for a physical illness.

I don't understand why, given truthful information about their efficacy, someone would choose to take antidepressants but I think if someone is given truth and chooses antidepressants for some reason, it's a fair choice.

It's when you lie and tell them depression is a medical disease with a medical cure that we get sideways. It's when you falsely tell them when the pills don't work that the problem is in their body's chemistry instead of being honest about the lack of efficacy of the drugs, when you tell them that their deepening distress is caused by their brain's diseased chemistry instead of the drug, when you fail to tell them that these drugs really don't work for many people, that their success would have been rare and push new diagnosis and pills on them, equally untested, and really think with that abusive (and to link from another thread nazi like) certainty that it's the patient that's failing to respond correctly to the drugs instead of the drugs just not working or more likely exacerbating whatever problems the patient may have had despite all evidence to the contrary that we disagree.

Of course the idea that severe distress is caused by some sort of "thought mistake" that a therapist can help the "diseased" change is also something we disagree about. Therapy is less successful even than pills and in some ways just as abusive. Compassion, decency, understanding are great but that's not what therapy is.

Unhappiness is a normal part of life. Reducing normal pain is great. What psychiatry does is analogous to telling someone who was innocently minding his own business when a boulder fell from the sky and broke his leg that he has a bone disease that caused the break or that it was his bad attitude. I have no problem with putting the dude in a cast.

As for my definitions of disease and abnormal, they're straight from Dorlands. Your beef with these definitions is a problem with the medical establishment, not with me, but then that's the relationship any psychiatrist has with the medical establishment.

You write:

"If your standard is each bodily organ functionally performing its designed purpose, then diabetes is a medical illness, because the pancreatic cells that produce insulin no longer perform this function. However, what parts of the body have as their primary function the gradual deterioration of memory and cognitive function, as seen in dementia? What parts of the body have as their primary function the psychotic disorientation of delirium?"

Again, go fight with real doctors. But first, give me your best argument that it's a proven fact that depression is a medical disease by anyone's definition.

Posted by: Sally at December 19, 2008 11:43 AM

Sally:

I actually agree with much of what you wrote. However, just to clarify a few things, I take it from what you wrote that you agree to the following:

(1) The subjective experience of mental states (e.g. depression) is directly caused by the activation of neurobiological pathways in the brain.

(2) Those pathways are activated by internal and external biopsychosocial triggers, which thus indirectly cause different mental states, such as depression.

(3) The subjective experience of mental states (e.g. depression) can be altered by modifying the underlying neurobiological pathways in the brain.

(4) The underlying neurobiological pathways in the brain can be modified by changing the internal and external biopsychosocial triggers that are activating them.

What you disagree with is whether there is a role for antidepressants in directly modifying the neurobiological pathways of depression. Fair enough. I feel that there is a limited role for them in severe cases, and I believe that the meta-analytic literature supports this, including the analyses by Arif Khan and Irving Kirsch. There are also interesting studies showing that antidepressant use improves neuroplasticity in key emotion-regulating areas of brain, such as the hippocampus (e.g. Novartis Found Symp. 2008; 289:152-60). However, the data is conflicting and the underlying mechanism remains unclear despite the clear superiority of antidepressants compared to placebo in severe depression.

You do raise good points that physicians should not oversell antidepressants and make claims about their efficacy that are not supported by the evidence. They should also not minimize the risks associated with them, but have a frank discussion with their patients and allow them to decide what treatment would be appropriate.

Moving on. You made the interesting analogy: “What psychiatry does is analogous to telling someone who was innocently minding his own business when a boulder fell from the sky and broke his leg that he has a bone disease that caused the break or that it was his bad attitude.” What if a pebble fell on his leg and it broke? Wouldn’t you look into an underlying vulnerability that predisposed his leg to break?

I mean, most people who have psychosocial stressors do not develop clinical depression, just as most people exposed to trauma or have panic attacks do not develop PTSD or panic disorder. What is your explanation for how these individuals develop a psychiatric condition when others who were exposed to the same stressor did not? It is quite obvious that they are vulnerable to responding to those stressors in ways that result in psychiatric illness. However, that vulnerability could be due to a variety of factors, including genetics, temperament, early childhood experience, trauma/abuse, maladaptive coping styles, medical problems, substance abuse, and so on. All of the underlying factors would have to be addressed to help them manage their difficulties.

Finally, you have often said that depression, for example, is not a medical illness, and then when I asked you to define “medical illness”, you gave a vague concept involving “normal” and “abnormal”, and then were unable to state what you meant by those crucial terms. If you have no idea about what is normal and abnormal, then you have no business discussing what is or is not a medical illness, because you literally do not know what you are talking about.

Take care.

Posted by: dguller at December 19, 2008 01:19 PM

DGuller, you said, "There are also interesting studies showing that antidepressant use improves neuroplasticity in key emotion-regulating areas of brain, such as the hippocampus (e.g. Novartis Found Symp. 2008; 289:152-60). However, the data is conflicting and the underlying mechanism remains unclear despite the clear superiority of antidepressants compared to placebo in severe depression."

I have posted a link on this site that shows that long term, SSRIS cause cognitive damage. A while back, on the Newsweek site, I posted several links when an idiot colleague of yours claimed that ADs didn't cause long term damage.

Due to severe insomnia which your colleagues downplay as a withdrawal symptoms, I am too exhausted to find the links. But I am sure you can find them on pub med.

Personally, I feel ADs have worsened my LD issues. A surgeon friend of someone I know who tragically lost her life to cancer, wasn't surprised at all to hear my story. If she understood what was happening, why do your colleagues not understand this issue. Even people who don't have LD report that SSRIS caused cognitive damage. But it is all due to our illness, right? Yes, I am being sarcastic.

Joseph Glenmullen, in his book, Prozac Backlash, had some evidence that SSRIS cause long term neurological damage.

To be blunt, I think it is malpractice to suggest that ADs cause neuroplasticity. You didn't do it but that is what your colleagues are suggesting.

Anyway, I couldn't let that pass.

Posted by: AA at December 19, 2008 02:46 PM

Dguller,

You write: "What you disagree with is whether there is a role for antidepressants in directly modifying the neurobiological pathways of depression."

That is not what I disagree with. I disagree with calling the current psych drugs, particularly here SSRIs and SSNRI's, antidepressants. Obviously chemical cures for emotional discomfort can work. At a post funeral wake, some of the folks drinking whiskey react in an appropriate drunken mournful sort of way, some become violent. Whiskey is administered in the same was as the drugs you call antidepressants and with caution and mixed results but no one calls it medical treatment.

You say I don't know what I'm talking about when I provide you with the standard definition of a disease, but you offer ad hom attacks instead of your own definition.

What about this, how can you claim that one drug is an antidepressant when you admit you can't even define depression.

Meanwhile, if there was a pill that caused the grief stricken instant and permanent happiness, it would have ethical and other issues, but it hasn't been invented. Quit pretending that it has.

As for your neuroplasticity docs from Novartis, the research a pharmaceutical co, novartis, does to try and find that it's drug does wonderful things, even if conclusive has certain conflict of interest issues, and yet this research by your own admission isn't conclusive.

You ask: "I mean, most people who have psychosocial stressors do not develop clinical depression, just as most people exposed to trauma or have panic attacks do not develop PTSD or panic disorder. What is your explanation for how these individuals develop a psychiatric condition when others who were exposed to the same stressor did not?"

First of all, how the h*ll do you know who develops depression since even you agree that you don't know what it is. Second, anyone who has a psychosocial stressor and subsequently goes to an MHP, gets labeled as having a psychiatric condition. People who don't go to mhp's, no matter how they respond, don't get labeled as having a psychiatric condition. After all, you can't diagnose depression in an autopsy, though I've no doubt some psychiatric expert may have tried to claim you can. So I'd say seeing the mental health expert causes the normal pain, understandable emotional injury if you will, to be pathologized into a "psychiatric condition," which would cause me to be labeled anti-psych in certain circles.

Posted by: Sally at December 19, 2008 03:43 PM

Sally:

First, you still have not been able to define what counts as "normal" and "abnormal" in terms of your conception of medical illness. If you cannot do so, then how can you say whether depression is a medical illness or not? I am not being facetious here. You are heavily invested in the idea that depression is not a medical illness. For it to not be a medical illness, you must be able to show how depression is in accordance with a predetermined standard. If you cannot identify that standard, then you cannot identify normality, and thus you cannot identify a medical illness. QED.

Second, I suppose that what counts as a medical treatment depends on the context. For example, I have seen alcohol prescribed in the ICU for a patient in extreme alcohol withdrawal. Perhaps medical treatment is anything that is prescribed by a physician. Having said that, there are better and worse forms of medical treatment in terms of degree of evidence of efficacy and safety, but I think that, in general, this definition holds. Regardless, I do not think that the focus should not be on what an intervention is called -- i.e. medical treatment or something else -- but on whether it works to treat a patient. It is similar to CAM. Once something in CAM is demonstrated to be effective, then traditional physicians will recommend it, and it is no longer CAM. All that matters is whether it is effective.

Third, you object to the fact that I have not provided my own definition of “medical illness”. I do not have to, because I am not claiming that depression is a medical illness. However, you are denying that it is, and thus the onus is upon you to provide the definition or else stop saying that it is not a medical illness.

But this is all very symbolic, in a way. You object to depression being called a medical illness, not because it fails to meet some definition of “medical illness”, but because of what it IMPLIES about a depressed person. What do you think the implications are if depression is a medical illness (loosely defined)? Perhaps this will help us both understand each other better.

Fourth, your point is well taken that I cannot give the necessary and sufficient conditions that define major depression. All definitions will lack the required precision, because of the multiple different forms that depression can take. Some people have sadness, others anhedonia, and others present with physical complaints. There is no mathematical equation that encompasses depression. However, there is no mathematical equation that encompasses many important concepts, including medical illness. :)

Fifth, let’s focus on the correlation between trauma and PTSD. The National Vietnam Veterans' Readjustment Study found that an estimated 15.2% of male and 8.5% of female Vietnam theatre veterans met criteria for current PTSD, and that those with high levels of war-zone exposure had significantly higher rates, with 35.8% of men and 17.5% of women meeting criteria for current PTSD. In other words, despite being in “high levels of war-zone exposure”, about 65% of males did not develop PTSD. What was it about them that made them resilient to PTSD? What was it about the former group that made them vulnerable to PTSD? Or, a better question: Do you reject the notion of vulnerability to mental illness (broadly defined) in total, or only the genetic-cum-biology version?

Take care, and thank you for your intriguing and intelligent comments. They are certainly giving me much food for thought. :)

Posted by: dguller at December 19, 2008 09:53 PM

AA:

Take your time, get some sleep, and post the citations when you can. I look forward to reading them. :)

Posted by: dguller at December 19, 2008 10:14 PM

Dguller,

You're the doctor, not me, and the fact that you can't explain why depression is a medical disease is the problem.

As for veterans and PTSD, again, what is the normal response to combat?

You write:

As for trauma and ptsd, we're just not in agreement about ptsd being a pathological response to trauma. It's the trauma, not the response to it that's indicative of human tragedy. I reject the idea of mental illness and the idea that mental differences such as combat era ptsd indicate inferiority in the person with ptsd.

As for the PTSD numbers you give, they're based on an inaccurate outdated study, National Vietnam Veterans Readjustment Study (NVVRS)

"Critics of the National Vietnam Veterans Readjustment Study (NVVRS) suspect that the NVVRS overestimated the prevalence of posttraumatic stress disorder (PTSD) among Vietnam veterans. Dohrenwend et al. (2006) confirmed this suspicion. Dohrenwend et al.'s reanalysis of the NVVRS data resulted in a prevalence estimate 40% lower than the original NVVRS estimate. Furthermore, had they required clinically significant functional impairment, the prevalence rate would have been 65% lower than the original NVVRS rate. That is, the current (late 1980s) prevalence estimates for PTSD are 15.2% (original NVVRS), 9.1% (Dohrenwend et al.), and 5.4% (clinically significant functional impairment)."

Posted by: Sally at December 20, 2008 12:40 AM

Sally:

First, I never said that depression was a medical illness, and thus I do not see why I have to define what “medical illness” is. You, on the other hand, are conclusively stating that it is not, and thus the onus is upon you to come up with a definition, not me. Again, if you cannot, then how can you say -- with the utter certainty that you do -- that something is not an X, when you cannot tell me what X even is?

Second, my point still stands that even if you cannot define “medical illness” properly, then I think it is still important to explore what you think depression being a medical illness IMPLIES. So, what do you believe the implications are if depression is, in fact, a medical illness? I think that your explanation would shed a great deal of light upon these issues.

Third, why do you equate vulnerability with inferiority? I spend much of my time with my patients trying to help them see that vulnerability is not weakness and inferiority. Why would it be? Without vulnerability, there is no love or human connection, but just controlling relationships that never allow anyone to be close. So, again, why do you feel that if someone has a variety of risk factors that make them vulnerable for a certain condition that they are somehow inferior? I certainly don’t think so.

Fourth, you write that one’s response to trauma is not the problem, but rather the trauma itself is the tragedy. Look at two scenarios:

(1) One person is exposed to a traumatic incident, and they are able to draw upon their inner resilience and move on with their lives.

(2) Another person exposed to a similar traumatic incident, and becomes trapped reliving the past in a fearful and apprehensive present in which they spend their lives avoiding and distracting themselves from their pain.

According to your analysis, these situations are equally tragic, because they both share the traumatic incident. The fact that (2)’s life has ground to a halt and they are in a constant state of distress is equivalent to (1)’s absence of these problems. That strikes be as unreasonable. Wouldn’t you agree that (1) and (2) have responded to the trauma differently, and that it is in their responses that the problem ultimately lies?

Fifth, your point about the veterans’ study I cited is well taken and the criticism is well received. However, I’m afraid that if the incidence of PTSD in the Vietnam veterans who were exposed to high degrees of violence and trauma are even lower than I cited, then that shows that trauma does not automatically lead to PTSD. Again, why do some people develop PTSD and others do not? What is it about their response to trauma that leads most people to move on without much difficulty, and others to become paralyzed? Help me understand why you believe they do.

Take care.

Posted by: dguller at December 20, 2008 07:05 AM

dguller, "Care to elaborate in a way that would be clinically useful? I appreciate Zen statements as much as the next guy, but I'd like something a little more practical, please."

I thought what I said was pretty clear. When I saw a psychiatrist I was given the label of treatment resistant recurrent major depression. When I saw a therapist who wasn't that interested in coming up with a pathological diagnosis I was a person suffering from some pretty shitty life experiences. Thus, my statement - it depends on who you see.

Posted by: Lisa at December 20, 2008 09:14 AM

Lisa:

Sorry, I misunderstood what you had written.

Posted by: dguller at December 20, 2008 11:19 AM

DGuller, here are the citations:

1. http://tinyurl.com/9sgt68 - A cross-sectional study of the prevalence of cognitive and physical symptoms during long-term antidepressant treatment.

Since I know you are going to mention this, the study felt that the cognitive symptoms could also be due to residual symptoms from the depression.

Frankly, to be blunt, that is a bunch of BS. As one whose word finding problems from LD worsened on Wellbutrin, that has nothing to do with depression.

2. http://www.annals-general-psychiatry.../1/7/abstract/ - Selective serotonin reuptake inhibitor use associates with apathy among depressed elderly: a case-control study

Conclusion

Even though depression was improved in elderly patients receiving antidepressants, apathy appeared to be greater in patients who were treated with SSRI than that found in patients who were not. Frontal lobe dysfunction due to alteration of serotonin is considered to be one of the possibilities.

3. http://www.ncbi.nlm.nih.gov/pubmed/9640489
Selective serotonin-reuptake inhibitor-induced movement disorders

Finally, one study I would like to see that will never happen is when you put people on antidepressants is to do a full battery of neuropsych testing. Do it 1 year out and then 5 years out and 10 years out. I suspect there would be improvement initially and then a deterioration the longer people were on the meds. It would greatly eliminate the biases of blaming everything on the illness although it wouldn't completely erase them.

Posted by: AA at December 20, 2008 02:29 PM

AA:

Let’s look at the studies that you cited.

1. J Clin Psychiatry. 2006;67(11):1754-9.

As you pointed out, because this study did not include a control group, it is impossible to know if the subjects who reported cognitive and physical impairment were due to the antidepressants or residual symptoms of depression. The authors conclude that it is likely a combination of both (p. 1757), and they are probably right. Another interesting note is that 30.8% were taking benzodiazepines with their antidepressants (p. 1756), which would definitely contribute to cognitive impairment, and thus confounding the results. So, not an impressive study.

2. Ann Gen Psychiatry. 2007 Feb 21;6:7.

You are correct that the study found that SSRI’s had higher apathy scores than non-SSRI’s. However, you failed to mention that the conclusion also stated that both SSRI’s and non-SSRI’s had apathy scores at discharge that “were less than at admission. Therefore, both SSRI’s and non-SSRI’s appeared to be efficacious in treating the apathy of depression”. In other words, both classes of antidepressants reduced apathy scores in depressed patients, but non-SSRI’s were better at it. Also, not an impressive study for your position.

3. Ann Pharmacother. 1998 Jun;32(6):692-8.

I was unable to access this article, but the abstract indicated a number of case reports of EPS associated with the use of SSRI’s. Most of the evidence consists of case reports, but there are a few studies around that have looked at this issue.

For example, in the International Journal of Psychopharmacology (2002; 17(2):75-9), they looked at the Netherlands Pharmacovigilance Foundation Lareb in the period 1985-99, and tracked down 2,476 cases of antidepressant-related adverse reactions. They found 61 cases of EPS, 41 with SSRI’s and 14 with non-SSRI’s. However, 5 patients were also using antipsychotics, which reduces the number of cases to 56, and thus the crude incidence of EPS in antidepressants is 2.3%, according to this study, but the rate is likely higher due to under-reporting.

The bottom line is that there is a small chance of EPS being induced by SSRI’s, and patients should be warned about this possible adverse effect.

So, to conclude, the first two studies do not demonstrate at all that SSRI’s cause cognitive impairment, and the second one actually shows that they are HELPFUL for apathy. The third study does show that SSRI’s rarely cause EPS in patients, and thus they should be warned and monitored closely.

You originally cited these studies to refute my citation of other studies that show that SSRI efficacy in some subjects is due to improved neuroplasticity. You have failed to do so, but I an open to the possibility that SSRI’s can result in lasting cognitive impairment in some patients, likely those who do not have the improved neuroplasticity seen in those who show clinical improvement. However, I am unaware of any studies that have looked into this matter.

Take care.

Posted by: dguller at December 20, 2008 08:19 PM

AA said, "Finally, one study I would like to see that will never happen is when you put people on antidepressants is to do a full battery of neuropsych testing. Do it 1 year out and then 5 years out and 10 years out. I suspect there would be improvement initially and then a deterioration the longer people were on the meds."

They really should do this, although I suspect some will still find a way to blame it on worsening mental illness rather than the drugs. It would also be interesting to see a sleep study prior to patients being placed on these drugs & after.

They did a sleep study on me AFTER the drugs were initiated & subsequently, I was diagnosed with periodic limb movement syndrome which was interferring w/ my sleep (of course, this led to even more drugs). I find it odd that a psychiatrist would order a sleep study after putting patients on antidepressants, because all the results are going to tell is the person's sleep pattern while on drugs. Just one more diagnosis to add to my long list. Now that I'm off all those drugs, I would be interested to know if my PLMS cleared right up too. I suspect it did.

Posted by: Lisa at December 21, 2008 11:43 AM

DGuller, if there is no control group, how can the authors decide that cognitive impairment is due to the depression, especially if they have been on meds long term?

Please explain how word finding difficulty is due to depression? How do they decide that? As one with LD who finds that psychiatrists are clueless about cognitive issues, I would love to hear how they are knowledgeable enough to make that distinction?

And if antidepressants are as effective as you and your colleagues claim they are, why are you claiming these cognitive problems are due to residual symptoms of depression? You can't have it both ways.

I also find it interesting that you admit that benzos cause cognitive impairment but you deny that antidepressants do when cognitive issues are listed as side effects for many ADS. Hmm, let's see, neuroleptics cause brain shrinkage, benzos cause cognitive impairment but antidepressants result in neuroplasticity. Anyone besides me see the fallacy of this argument?

And where are the long term studies that show improved scores on neuropsych testing if you feel my studies aren't valid which I disagree with.

By the way, you ignored my point about neuropsych testing being really the most valid instrument that would truly determine if these drugs don't cause cognitive impairment. Of course, you would have to account for certain variables but it is better than using researchers who don't have a clue about cognitive issues.

AA

Posted by: AA at December 21, 2008 12:07 PM

AA:

First, you are right that without a control group, the authors cannot conclude that the cognitive impairment is due to the illness itself and not the medications. However, they also cannot conclude that the cognitive impairment is due to the medications, and not the illness. That is the point. The study sheds no light upon this issue, because there is no control group. It is USELESS in this discussion.

Second, where did I deny that antidepressants can cause cognitive impairment? I explicitly stated that “The authors conclude that [the cognitive impairment] is likely a combination of both (p. 1757), and they are probably right.” However, the study is of no use to this issue, because it did not include a control group.

Third, I never said that your studies weren’t valid. They were perfectly valid, but limited in terms of what we can conclude from them. I especially liked the second one which actually found the exact opposite of what you claimed it found. I also enjoyed the fact that you didn’t include any acknowledgement of this fact in your post.

Fourth, I didn’t comment about your suggestion to use formal cognitive testing, because I happen to agree with you. That would be a great study to perform. No disagreement here.

So, again, you found two studies that purported to show that SSRI’s cause lasting cognitive impairment, and neither of them did so. That doesn’t mean that SSRI’s are innocent of this adverse effect, but only that your studies are useless to this issue. Find better studies, please.

Take care.

Posted by: dguller at December 21, 2008 04:48 PM

Dgueller,

You write,

"I never said that depression was a medical illness, and thus I do not see why I have to define what “medical illness” is."

If you're willing to admit depression is not a disease, we're making progress, but I doubt that's the case.

Why did you switch out the terms disease and illness? If you don't think depression is a medical disease or medical illness, I'm curious about why you think it a condition that needs treatment by a medical doctor. At it's most basic, an illness or disease is something that requires treatment by a doctor.

You ask:

"that something is not an X, when you cannot tell me what X even is?"

Bingo, since you can't tell me what x is, I don't need to tell you what it isn't, as it's pretty much impossible to say how something that doesn't exist would be if it did. It's a hollow old tactic in psychiatric.

You write:

"Second, my point still stands that even if you cannot define “medical illness” properly, then I think it is still important to explore what you think depression being a medical illness IMPLIES. So, what do you believe the implications are if depression is, in fact, a medical illness? I think that your explanation would shed a great deal of light upon these issues."

If I can't define "medical disease properly," perhaps you, the medical doctor could provide a definition. So far you've either not been able to or refused. Medical illness implies the need for treatment from a doctor often involving medication implying that a problem is caused by the physical body.

You write:

"Fifth, your point about the veterans’ study I cited is well taken and the criticism is well received. However, I’m afraid that if the incidence of PTSD in the Vietnam veterans who were exposed to high degrees of violence and trauma are even lower than I cited, then that shows that trauma does not automatically lead to PTSD. Again, why do some people develop PTSD and others do not? What is it about their response to trauma that leads most people to move on without much difficulty, and others to become paralyzed? Help me understand why you believe they do."

Help me to understand why you intentionally posted a misleading study. As for why some people respond differently to trauma than others, let's look at your previous comment to me.

You write:

"What was it about them that made them resilient to PTSD? What was it about the former group that made them vulnerable to PTSD? Or, a better question: Do you reject the notion of vulnerability to mental illness (broadly defined) in total, or only the genetic-cum-biology version?"

I reject the idea of mental problems being termed an illness, being treated by doctors as a medical problem. As for me thinking vulnerability implies inferiority, that's your bag, but to help you along a bit, think about this, if PTSD is an illness and certain people are resilient, i.e. don't get the illness, and certain are vulnerable, i.e. do get the illness, then the vulnerable are from a medical standpoint inferior to those who aren't vulnerable. To say that people who respond in a way that causes them for some reason to being labeled as having ptsd doesn't make them inferior is to agree with me.

Again, I don't in mental illness. I don't believe ptsd is a mental illness and I believe that when psychiatrists ask questions like why do people respond differently to trauma and think the only answer could be biological brain processes unrelated to experience they're being stupid.

Posted by: Sally at December 21, 2008 06:52 PM

Sally:

Oh Lord. This is actually getting quite ridiculous. Let me summarize where we are at.

You emphatically stated that major depression is not a medical illness. I asked you what you meant by a medical illness. You defined it using the concepts “normal” and “abnormal”, and when I asked you what your standard of normality was, you suddenly realized that you really didn’t have one, and so you changed your tactics. Instead of offering a definition of medical illness yourself, you now demand that I have to provide one! When I told you that the onus is upon you, because I never stated that major depression is a medical illness, you asserted that my use of the word “illness” and “disease” automatically implied that they were MEDICAL in nature, and thus demanded, once again, that I define “medical illness” for you, mainly because you still have no idea about that standard of normality that you yourself cited earlier.

So, let us continue our discussion.

First, Buddhism describes the suffering that human beings endure in their lives as secondary to a form of sickness, illness and/or disease of the mind and/or self in a variety of works. Are they all implying that all people have to treated by a medical doctor? Of course not! Therefore, the terms “illness” and “disease” do not automatically imply ones that are medical in nature. Rather, they refer to some form of affliction that results in human suffering, sometimes requiring medical intervention and sometimes requiring other forms of intervention, and sometimes requiring both.

Second, you state that “Medical illness implies the need for treatment from a doctor often involving medication implying that a problem is caused by the physical body.” So your problem with the possibility that major depression is a medical illness is that it implies a biological cause that may require medications to treat it? Why is major depression having a biological cause so problematic? All our mental states ultimately have biological causes -- i.e. neurological circuits activated in different parts of the brain -- and so why is this so unpalatable to you? Or is the problem that medications may be needed in some cases? If so, then what is the problem with using medications? I suspect that we are getting closer to your real objection to the medical illness model here.

Third, you write that “the vulnerable are from a medical standpoint inferior to those who aren't vulnerable”. I would love to read your evidence for this position, and so please do provide it. Also, in what sense of “superior” and “inferior” are you referring to here? There is the specific sense of someone having better skills than another being superior to them in that particular respect, and then there is the general sense. For example, someone can have better basketball skills than another, which makes them superior in that specific respect, but that does not imply that they are superior to them in general as a human being, nor does it imply that the other person is defective in some way. So, please help clarify what you mean here.

Fourth, you state that psychiatrists who “think the only answer could be biological brain processes unrelated to experience they're being stupid”. I wouldn’t use the word “stupid”, but rather “ignorant”. However, we are in general agreement here, because biological processes do not exist in a vacuum, and are highly correlated to the biopsychosocial context in which they are enmeshed, and thus they are highly related to experience. But the issue here is not the experience part, because we agree, but rather the biological part. Do you agree that our subjective experience has an important neurobiological component?

Take care.

Posted by: dguller at December 22, 2008 04:33 AM

Dguller,

You ask:

"Do you agree that our subjective experience has an important neurobiological component?"

Once again, it would seem likely that neurobiology is an intermediary between subjective events and the experience of them.

Again, what are you talking about when you mention the medical illness model?

You write:

"So your problem with the possibility that major depression is a medical illness is that it implies a biological cause that may require medications to treat it? Why is major depression having a biological cause so problematic? All our mental states ultimately have biological causes -- i.e. neurological circuits activated in different parts of the brain -- and so why is this so unpalatable to you? Or is the problem that medications may be needed in some cases? If so, then what is the problem with using medications? I suspect that we are getting closer to your real objection to the medical illness model here."

I'm tired of answering this question. Drugs can change feelings but the brain does not cause feelings spontaneously. I reject the idea that when a person behaves in a way you feel deviates from your subjective experience of what the norm is (and you are no more capable than I of defining that norm), that the chemistry of that person's brain is wrong. Taking a drug to change mood is neither always a good choice nor a bad choice. Telling someone that their feelings are caused by biology and are abnormal (a word you can't even define), that his brain is sick, is false and wrong.

As in the PTSD example, here what is sick is the society that sends a person to a doctor so the doctor can judge whether that person's grief response is healthy or unheathly. What is it that makes you think a doctor is the one best situated to treat conditions you think of as mental illnesses?

Posted by: Sally at December 22, 2008 09:16 AM

Sally:

First, you state that neurobiology is an intermediary between “subjective events” and “the experience of them”. I agree with you about the subjective experience part, but I am unclear about the “subjective events”. When I subjectively perceive a red apple, is the red apple a “subjective event”? I don’t think so. It is a real object in the world that has impacted my sensory neurocircuits in such a way that I have a subjective experience of the red apple as a percept. Please help me understand what you mean by “subjective events”. Perhaps a better term would be biopsychosocial triggers that activate the neurobiological pathways that lead to subjective experience? At least, that’s how I understand it.

Second, I did not mention the “medical illness model”. Please cite where I mentioned such a thing.

Third, you state that in some cases, taking medications to alter one’s subjective state of mind is appropriate. Excellent! We are in agreement here.

Fourth, you state that it is never appropriate to tell someone that their feelings and thoughts are “abnormal”, because their “brain is sick” and the “chemistry of that person’s brain is wrong”. Really? Never appropriate? So, if an elderly lady with no prior psychiatric history comes into the hospital for a surgical procedure, and suddenly develops a delirium in which they believe that the staff are trying to poison them and they become aggressive and agitated, then this is perfectly normal, and their brain is perfectly fine? I don’t think so.

It follows that it is SOMETIMES appropriate to describe someone’s feelings and thoughts as abnormal and ascribe them to a brain that is malfunctioning in some way. Or perhaps you have a better explanation for delirium? Oh, and if it is appropriate to use that description for delirium, then why is it inappropriate to use it for depression, schizophrenia, and so on?

Fifth, you agree that drugs can change feelings, which means that they are having a physical impact on the brain in some way. This implies that feelings are due to an underlying biological component that can be altered with medications. Excellent! We are in agreement here, which dovetails nicely into your comment that sometimes taking medications to alter one’s subjective experience can be appropriate. I think we are finding common ground here. :)

Sixth, it appears that your difficulty with psychiatry is that you believe that when someone is diagnosed with a psychiatric illness that the implication is that they are somehow defective or flawed, and thus to be rejected by society in some way. This goes to the heart of the stigma of mental illness, and it is certainly a problem. However, it has been a problem for thousands of years in human history, even before the discipline of psychiatry existed. In other words, human beings tend to avoid those they perceive as different from that culture’s accepted norms and standards. In the past, such behaviour was ascribed to demonic possession or some kind of personal flaw.

Psychiatry’s attempt to provide a scientific foundation for the manifestation of mental illness was supposed to remove this type of thinking that stated that the individual was somehow to blame for their condition due to moral failure, spiritual weakness, and so on. Rather, their mental status was secondary to a variety of factors completely outside their control and thus not their responsibility, such as genetics, early childhood experience, parenting style, trauma/abuse, medical illness, maladaptive coping style, and so on.

Letting go of self-blame for psychological distress is essential to opening up mental space to learning new ways of being in the world that are more in keeping with one’s underlying needs and values. The biopsychosocial approach was intended to facilitate this process. However, the public at large continues to be enthralled with the notion that individuals with mental illness are somehow defective, and thus to be shunned. Psychiatrists have failed their patients by not advocating on their behalf in the public forum to decrease such stigmas.

You are correct that we do not understand mental illness as we understand diabetes, for example, and thus the analogy is highly imperfect. However, it is clear that those aforementioned factors that contribute to mental illness have all been demonstrated to have an impact on the human brain, and the best hypothesis around states that mental illness must therefore reside in the neurobiological pathways of the brain functioning in a way that in combination and interaction with a particular psychosocial context, results in emotional suffering. This does not imply that they are somehow defective or flawed, but only suffering and in need of help, which can come in a variety of forms: medication, mindfulness practices, emotional education, supportive counselling, psychotherapy, skills training, and so on.

I see nothing defective about that description, but I do see something defective in thinking that by eliminating the scientific theory of the biological underpinnings of mental illness that stigma will be banished and those struggling with psychological distress will suddenly lead productive lives. I am afraid that this will not occur. Stigma of “abnormal” people has existed throughout human history, and will remain no matter the dominant belief paradigm, whether biological or otherwise.

Only education about mental illness and exposure to those who are different will remove the barriers that stand between human beings, help us realize our deep interconnections to one another, and bring us closer together. However, even if the stigma of mental illness is eliminated and we all can feel a deep kinship with those suffering from psychological distress as fellow brothers and sisters, that does not change the fact that people will continue to experience pain in their lives due to a variety of biopsychosocial factors that are endemic to the human condition. Those people will require all our compassion and support, and the utilization of whatever we have to offer that is effective at alleviating their distress.

I know that this comment has been long, but I thought it important for you to understand where I am coming from. These are my beliefs about mental illness, and if you disagree with any of the above, then I welcome your feedback. However, I wanted to make it clear that I never associated mental illness with someone being defective in any way, just as I never associated physical pain with someone being flawed as a human being. They are human beings in distress, nothing more, nothing less, and they need help, as we all do from time to time. I do my best to help with the tools that are available to me, as imperfect as they are.

Take care.

Posted by: dguller at December 22, 2008 01:17 PM

Dguller,

You write:
"When I subjectively perceive a red apple, is the red apple a “subjective event”?

It's your perception of the apple that's subjective event. It's your brain that tells you, whatever you is, that you are seeing a red apple.

You write:

"Second, I did not mention the “medical illness model”. Please cite where I mentioned such a thing."

Here goes, dguller at December 22, 2008 04:33 AM wrote:

"I suspect that we are getting closer to your real objection to the medical illness model here."

Maybe your brain was sick when your wrote that and you're psychotic and need a relative to take charge of your finances, or else you're just a normal human who forget. What's the difference - the psychiatrist who convicts, er labels you.

You write:

"if an elderly lady with no prior psychiatric history comes into the hospital for a surgical procedure, and suddenly develops a delirium in which they believe that the staff are trying to poison them and they become aggressive and agitated, then this is perfectly normal, and their brain is perfectly fine? I don’t think so."

Actually I do think that it is entirely reasonable for an elderly lady (pejorative sexist term there man) to be frightened and not trust the staff and fear the staff is trying to poison her. I don't think this constitutes delirium or that her brain is malfunctioning.

Too much, I'll look at the rest later. Gotta take the dog to the park before dark.

Posted by: Sally at December 22, 2008 01:51 PM

Sally:

First, I still do not understand what you mean by “subjective event”. According to you, the following holds true:

Subjective event  Neurobiological changes  Subjective experience.

I do not understand the first part. What does it consist of?

Second, you are correct that I did refer to the “medical model of illness” during one of my posts. I did forget, and I apologize.

However, I believe that my point still stands. You were the one who first mentioned this medical model in this thread. You wrote about it on December 12, 2008 at 11:43 am, and all our subsequent dialogue was in reference to this comment and what you were referring to when you mentioned it. When I said, “I suspect that we are getting closer to your real objection to the medical illness model here”, I was referencing your comments about the medical model from December 21, 2008 at 6:52 pm. I thought that it would be more productive to focus on what you thought the implications of depression being a medical illness – whatever that means to you – rather than get you to define the concept itself.

For example, you tell me that there is no way in hell that you are an X, and I ask you what X is. You are unable to tell me what X is, because there are various shades of meaning involved, and so rather than focus on what X is, I want to focus on what it means to you to be an X. If you tell me that being an X means that you are inferior, then I better understand your fears, because it is terrible to feel inferior, and thus one would legitimately be afraid. Then we can focus on whether it is legitimate for someone who is X to be inferior, and if we can agree that there is nothing in X’s various meanings that implies inferiority, then that should take the sting out of it, no?

The definition of “medical illness” is vague, I agree, but it is not meaningless. I wanted to get a sense of what the definition means to YOU, because whether your definition was true or not, it is true for YOU, and that is all I wanted to know, because then we can explore what it is about your conception of medical illness that causes you to despise classifying depression, for example, as a medical illness.

Is that a reasonable approach, or do you have a better alternative?

Third, you honestly believe that an elderly lady – no negative connotations implied – with no prior history of paranoia or suspicion who suddenly becomes convinced beyond all doubt that the hospital staff are trying to poison her and is acting violent towards her nurses and physicians and uttering abusive obscenities towards a co-patient occupying the room, is acting normally? Are you being serious? You wouldn’t order any medical investigations to identify the potential causal factors contributing to this sudden change in her mental status? You would do nothing, but sit with her and be compassionate, while an easily treated urinary tract infection, for example, goes unaddressed and continues to cause her paranoia? And you accuse ME of malpractice and harming patients? Wow.

I look forward to your further comments, and I hope you had a pleasant walk with your dog. :)

Take care.

Posted by: dguller at December 22, 2008 04:09 PM

Dguller,

All that and still you didn't answer this question, what exactly is it that you think a doctor can do for someone you believe to be mentally ill?

We believe differently. I don't believe mental problems are medical diseases. You can't even explain what a medical disease is but you believe mental problems are medical diseases. You can believe anything you want but your theories are unproven. And your diagnosis change lives more than real medical diagnoses.

Posted by: Sally at December 22, 2008 04:40 PM

Sally:

First, I believe that a physician can rule out medical illnesses or other medications that could be contributing to psychiatric symptoms, can prescribe medications when they are necessary, and can perform psychotherapy if properly trained, among other things.

Second, I truly wonder why you continue to avoid discussions what you believe the negative implications are if major depression, for example, is a medical illness, broadly defined. I’ll even agree with your original definition of “medical illness”, if it will move the dialogue forward. There, we agree on the definition. Please help me understand why it is so negative if major depression is an “abnormal unpleasant condition caused by a physical abnormality of the body”?

Does it imply that the person struggling with depression is somehow abnormal, i.e. defective, and thus should be disregarded by the public as a pariah? If that is true, then those in physical pain should equally be regarded as outcasts, because pain also fits that definition, and yet I doubt that you would agree with the implication I mentioned.

Does it imply that all forms of sadness are to be treated aggressively with psychotropic medications without any other kinds of therapeutic interventions? If that is true, then do all the guidelines state that psychotherapy is an essential modality of treatment of all forms of depression? Medications are only essential for very severe forms of depression, and even then, psychotherapy and other supportive measures are also recommended to optimize treatment.

Does it imply anything else?

I am not trying to be annoying here to press this point, because I read it often here on this blog. Many people who despise psychiatry do so from the standpoint of despising biological psychiatry due to its conceptualization of mental illness as a medical disease. I hope that your answer to the above questions will help to shed light on the issue, and I truly look forward to them.

Take care.

Posted by: dguller at December 22, 2008 06:57 PM

dguller,

You write:

"Please help me understand why it is so negative if major depression is an “abnormal unpleasant condition caused by a physical abnormality of the body”?"

Major depression is not definable, but even severe unhappiness is caused by an external event, not by a physical abnormality of the body. The fact that someone as obtuse, passive aggressive (take care - do not think I doubt your great concern brother pshrink), and defensive as you gets to randomly label certain behavior normal and certain abnormal is absurd and horrific.

You write:

"Second, I truly wonder why you continue to avoid discussions what you believe the negative implications are if major depression, for example, is a medical illness, broadly defined. I’ll even agree with your original definition of “medical illness”, if it will move the dialogue forward."

So finally after all of the verbal abuse and sarcasm you agree with my definition of medical illness, though I didn't define medical illness, but instead disease. "Continue to avoid" nope dude, that's what we've been doing.

you write:

"Many people who despise psychiatry do so from the standpoint of despising biological psychiatry due to its conceptualization of mental illness as a medical disease."

One reason to despise psychiatry is this. You push these purported diseases as real medical diseases (I know dude you can't prove they are I can't prove they're not) that you can prove are real medical diseases, somehow, hell I don't know how, and then it turns out asking for proof is a symptom of the disease. And now you admit that you have no proof of any biology of mental illness, that's just how you conceptualize mental illness.

So you tell people who are unhappy that their brain chemistry is wrong. You're lying.

You really believe that adhd exists and brand children with this bogus condition and kill them with amphetamines.

Your medical treatments don't work and you are patronizing and abusive. And yes, if no one can prove your conceptualization, you shouldn't be out there assigning bullshit dsm codes to human beings.

To paraphrase Vedantam, Widiger, and Sankis, the very construct of "mental disorder" is in fact culture-bound. Different societies, cultures, and even persons within a particular culture may disagree as to what constitutes optimal or pathological biological and psychological functioning, and indeed research has demonstrated variation across cultures in the relative importance placed on, for example, happiness, autonomy, or social relationships for pleasure. Likewise, the fact that a behavior pattern is valued, accepted, encouraged, or even statistically normative within a particular culture does not necessarily mean it is conducive to optimal psychological functioning. There may be a tendency to overstate or misinterpret neurophysiological findings and to understate the scientific importance of social-psychological variables,and the cultural and ethnic diversity of individuals is often discounted by researchers and services providers.Rather than indicating a disorder from within, distress and disability may be seen as an indicator of emotional struggle and the need to address social and structural problems.

As Fromm wrote:

"Yet many psychiatrists and psychologists refuse to entertain the idea that society as a whole may be lacking in sanity. They hold that the problem of mental health in a society is only that of the number of 'unadjusted' individuals, and not of a possible unadjustment of the culture itself."

What you're doing is wrong, just plain wrong.

Posted by: Sally at December 23, 2008 02:22 AM

Sally:

First, you have some nerve to complain to me about “verbal abuse and sarcasm”. Since we have begun our recent dialogue, you have called me a Nazi, obtuse, hostile, a liar, sick, passive-aggressive, and sexist, among other things. I would love to hear you cite me calling you equivalent terms of abuse, please.

Second, perhaps we should avoid this talk of normality, because it is extremely unhelpful and divisive. That is why I have tried to avoid using those terms in our discussion, and having focused on what I hoped we could agree upon; namely, that people with depression are suffering, and their suffering is a byproduct of the interaction between their neurobiology and their biopsychosocial context. The question is what to do about their suffering, whether normal or abnormal.

You have agreed that medications can have a role, because they can directly alter a person’s neurobiology, and thus their mood, energy, and so on. I happen to agree with you that there is a limited role for antidepressants in severe cases. I also agree with you that any form of treatment that ignores the biopsychosocial context that triggered the depressive symptomatology in the first place is foolish. Thus, it should be a priority to address the underlying biological, psychological and social factors that are precipitated and perpetuate the depression.

Again, this is how I conceptualize mental illness, and I hope that you can agree that there is nothing particularly sick or deceptive about it. As always, I look forward to your feedback.

Take care.

Posted by: dguller at December 23, 2008 11:08 AM

Sally:

And one more thing. I'm not too sure if you read an important portion of a comment I made above. I'd like to repost it here, and hopefully you will provide me with some constructive criticism, if possible.

Here it is:

"... it appears that your difficulty with psychiatry is that you believe that when someone is diagnosed with a psychiatric illness that the implication is that they are somehow defective or flawed, and thus to be rejected by society in some way. This goes to the heart of the stigma of mental illness, and it is certainly a problem. However, it has been a problem for thousands of years in human history, even before the discipline of psychiatry existed. In other words, human beings tend to avoid those they perceive as different from that culture’s accepted norms and standards. In the past, such behaviour was ascribed to demonic possession or some kind of personal flaw.

Psychiatry’s attempt to provide a scientific foundation for the manifestation of mental illness was supposed to remove this type of thinking that stated that the individual was somehow to blame for their condition due to moral failure, spiritual weakness, and so on. Rather, their mental status was secondary to a variety of factors completely outside their control and thus not their responsibility, such as genetics, early childhood experience, parenting style, trauma/abuse, medical illness, maladaptive coping style, and so on.

Letting go of self-blame for psychological distress is essential to opening up mental space to learning new ways of being in the world that are more in keeping with one’s underlying needs and values. The biopsychosocial approach was intended to facilitate this process. However, the public at large continues to be enthralled with the notion that individuals with mental illness are somehow defective, and thus to be shunned. Psychiatrists have failed their patients by not advocating on their behalf in the public forum to decrease such stigmas.

You are correct that we do not understand mental illness as we understand diabetes, for example, and thus the analogy is highly imperfect. However, it is clear that those aforementioned factors that contribute to mental illness have all been demonstrated to have an impact on the human brain, and the best hypothesis around states that mental illness must therefore reside in the neurobiological pathways of the brain functioning in a way that in combination and interaction with a particular psychosocial context, results in emotional suffering. This does not imply that they are somehow defective or flawed, but only suffering and in need of help, which can come in a variety of forms: medication, mindfulness practices, emotional education, supportive counselling, psychotherapy, skills training, and so on.

I see nothing defective about that description, but I do see something defective in thinking that by eliminating the scientific theory of the biological underpinnings of mental illness that stigma will be banished and those struggling with psychological distress will suddenly lead productive lives. I am afraid that this will not occur. Stigma of “abnormal” people has existed throughout human history, and will remain no matter the dominant belief paradigm, whether biological or otherwise.

Only education about mental illness and exposure to those who are different will remove the barriers that stand between human beings, help us realize our deep interconnections to one another, and bring us closer together. However, even if the stigma of mental illness is eliminated and we all can feel a deep kinship with those suffering from psychological distress as fellow brothers and sisters, that does not change the fact that people will continue to experience pain in their lives due to a variety of biopsychosocial factors that are endemic to the human condition. Those people will require all our compassion and support, and the utilization of whatever we have to offer that is effective at alleviating their distress.

I know that this comment has been long, but I thought it important for you to understand where I am coming from. These are my beliefs about mental illness, and if you disagree with any of the above, then I welcome your feedback. However, I wanted to make it clear that I never associated mental illness with someone being defective in any way, just as I never associated physical pain with someone being flawed as a human being. They are human beings in distress, nothing more, nothing less, and they need help, as we all do from time to time. I do my best to help with the tools that are available to me, as imperfect as they are."

Let me know what you think about this.

Take care.

Posted by: dguller at December 24, 2008 07:35 AM

Dguller,

I think you're on the right track here and I'll respond at length when I have time but right now I'm busy cat sitting, attempting to make basset hound shaped ginger bread cookies, and such.

I guess my first question would be this, if you know your tools are imperfect, how can you be comfortable using them to legally label people for life as it's the label that removes the legal right to a life, i.e. a career, control of finances and of course liberty from a person labeled schizophrenic, bipolar, borderline, autistic...? Don't you know institutionalization means these folks are often locked in filthy institutions with windows that don't even open to allow in fresh air for most of their lives because of psych labels. I just barely eluded that fate myself.

Posted by: Sally at December 27, 2008 07:07 AM

Sally:

So, you are concerned about the imperfect labeling of individuals that can result in irreparable harm to their well-being. Fair enough. I suppose that you are equally concerned about Americans who are the victims of identity fraud, who have lost their homes due to errors in computer databases, who have innocently been sent to prison, who have processed the wrong orders in a hospital leading to deaths due to medical errors, and millions of other people who have suffered, because of “imperfect labeling”.

In short, if your position is that the only types of labeling are those that are impervious to error, then we should not be labeling or categorizing anyone or anything. That is because all our labeling systems are flawed to one extent or another, and have led to the ruination of people’s lives. Are you truly stating that we should do away with labeling in total? How could we function without the capacity to classify and categorize, even if imperfectly? Or do you only object to psychiatric labeling, and if so, why is the harm due to mislabeling in psychiatry objectionable to the exclusion of all other types of mislabeling?

Take care.

Posted by: dguller at December 27, 2008 06:56 PM

Sorry to interrupt what seems like a breakthrough but I've been waiting a week now for someone to say it, and this is as close as we've come. Well said Sally, I think we're getting there!

The fact that ... you get to randomly label certain behavior normal and certain behavior abnormal is absurd and horrific.

But this is Szasz and his followers w/r/t the medical model; the objection is with authority, expertise, and hierarchy.

Szasz, a psychoanalyst, has the common, childish but understandable animosity toward psychiatrists, professional envy steeped in careerism. That is all his campaign against psychiatry is, and all it has ever been, his narcissistic injury run riot. It is sad to see his ideological offspring use his talking points without understanding they are carrying the water of a malignant egotist, pissed about the fact that as a psychoanalyst his own heft is negligible compared to that of a psychiatrist.

Sally, it appears your own allegiance falls on the side of anti-intellectualism, woo, entrenched identity and the politics thereto. This has been established in your own words in years of discussion on the internet, but never with anyone so forbearing as what we see playing out before us. On the other hand, you do enlighten, as in this common accusation made by anti-psychiatry propagandists:

and then it turns out asking for proof is a symptom of the disease

Asking for proof could be nothing more than a symptom of not understanding how science works, which does not deal in proof. When given the basics in the scientific method http://www.youtube.com/watch?v=zcavPAFiG14
and the Sallies of the world not only ignore it but simply re-state their antipsychiatry woo with the customary spittle-dribble seen above, what would you call that if not mental phenomena of some sort?

The fact that ... you get to randomly label certain behavior normal and certain behavior abnormal is absurd and horrific.

It's not just dguller, it's not random, not everything is normal, and the abnormal is not wrong. Show me the data that says otherwise.

Posted by: flawedplan at December 28, 2008 06:28 AM

dguller, you can't be serious in drawing parallels between these examples. Psychiatry is a whole system built upon an often flawed labeling system that robs people of their identities and the unique stories of their lives and places them into categories from which they can rarely escape and that often become self perpetuating. That is a far different cry than an error in labeling medications in a hospital that is a true mistake or identity fraud which is stealing a "label." In the case of psychiatry we are talking about "labels" that, through their use, can actually create illness rather than define it. This is a system built upon using labels to control people and make them sick when they otherwise might not be. It's defining people by their "illnesses" instead of by their own stories.

Posted by: Sara at December 28, 2008 08:17 AM

Sara:

What about Americans who are imprisoned for crimes they did not commit, or with unreasonably harsh penalties (e.g. marijuana possession), in "a whole system built upon an often flawed labeling system that robs people of their identities and the unique stories of their lives and places them into categories from which they can rarely escape and that often become self perpetuating".

Should we then do away with the criminal justice system? Or should we be reasonable and attempt to repair the flaws in the system instead of jettisoning the whole thing?

I only mentioned them, becuase your objection to psychatric diagnoses was that they are "imperfect labeling" that leads to significant harm in some cases. If you problem is with "imperfect labeling", then there are many other forms of it that lead to harm. If your problem is with "imperfect labeling", plus some other factors, then please be more precise and complete in your descriptions.

Take care.

Posted by: dguller at December 28, 2008 12:35 PM

Dguller,

I've been away from the computer for some time and will be again soon but you write:

"So, you are concerned about the imperfect labeling of individuals that can result in irreparable harm to their well-being. Fair enough. I suppose that you are equally concerned about Americans who are the victims of identity fraud, who have lost their homes due to errors in computer databases, who have innocently been sent to prison, who have processed the wrong orders in a hospital leading to deaths due to medical errors, and millions of other people who have suffered, because of “imperfect labeling”.

In short, if your position is that the only types of labeling are those that are impervious to error, then we should not be labeling or categorizing anyone or anything."

In short, my position is that psychiatric labeling on its face is always erroneous and harmful. Always. I still haven't had time to respond to your previous comment but I think eventually you'll get to where you see the light on this.

When you admit that psychiatric diseases are not really medical diseases, that you falsely tell clients and their families and the justice system and insurance companies, etc., that these diseases are real and not just metaphors, I don't get how you can fail to see that what you are doing is all erroneous. Your tactic of suggesting that it isn't just psychiatry that's bad but lots of other things too is odd. I'm very concerned about the issues you mentioned too, but psychiatric abuse is the one that happened to me, though certainly I give money to the Innocence Project and in fact almost went to law school at Cardozo. I'm certainly opposed to Hippa and a national database of medical records. It's interesting that all of your examples are issues that, as well as psychiatric abuse, I'm actively concerned about, even to the point of participating in an anti predatory lending task force.

Perhaps you and FP can listen to some old Laurie Anderson records together and play like everything in psychiatry is just super cool and activism is unhip.

Posted by: Sally at December 28, 2008 03:05 PM

dguller, I am not Sally and did not make the point about "imperfect labeling" to which you are referring. Please keep the commenters to whom you are replying straight. I have never said I am jettisoning all of psychiatry either. Please do not put words in commenter's mouths. The parallels with psychiatry and the criminal justice system which you draw are very apt.

Posted by: Sara at December 28, 2008 05:08 PM

Sara:

You are correct that you never explicitly stated that psychiatry must be jettisoned. I apologize for ascribing views to you that you reject.

Take care.

Posted by: dguller at December 28, 2008 08:20 PM

activism is unhip.

Nice try, but my volunteer work is with the Texas Civil Rights Project, where our disability caseload buckles with disenfranchised riffraff who are denied psychiatric services and seeking legal advocacy to force their guardians to provide mental health services. Posted by: flawedplan at December 28, 2008 08:22 PM

Dguller,

Imperfect labeling is indeed a bad thing and the criminal justice system does need to be overhauled.

Psychiatry is different though with labeling being one of the main problems which is I think always wrong and contributes in part to the stigma you discuss. Is there really a permanent chemical difference in the brain of a child labeled adhd and one labeled bipolar that will predict all future behavior of that child? When someone becomes psychotic, do you really have any evidence that this is because of some problem in their brain that will cause them to always be this way? No, you don't, and yet you give them the predictive labels of psychiatry.

I just finished a long legal battle in which I had both my involuntary commitment and my psych labels voided. Had I not recently finished law school before bringing the suit, I wouldn't have known how to do it. I think FP's weird world view is largely because she has a brother who commited crimes and got locked up in the whole NGRI (not guilty by reason of insanity) thing. I think it's always a disservice to use the ngri defense, that a person with money, like say OJ, goes with a mitigating circumstances defense instead, same facts, no stigma, no b*lls*it psychiatric experts.

The fact that our criminal justice system is too harsh and that there are not nearly enough public defenders, is a contributing factor to the sick, disgusting, immoral, unscientific proliferation of "psychiatric" and "psychological" experts.

In the other erroneous labeling situations you mention, such as wrongful criminal conviction, at least there's a process for exoneration. And the problems of crime and punishment and psychiatry are related.

The unreasonably harsh penalties dealt out in the criminal justice system have lead to a boom in the for profit drug and alcohol rehab business, one of the few real growth industries these days.

Marijuana, and all drugs for that matter, should be legalized, but since there are such harsh penalties for drug abuse, every teenage kid who gets busted with a joint pleads addict and tries to get treatment instead of jail which you can't blame him for, it's the lesser of two evils, but then the kid is branded for life as an addict, which these days as you know is a symptom of "bipolar disorder" which he'll also get labeled with, and then, while taking the drugs foisted on him for the bogus non existent bipolar condition, drugs which make him dangerous as opposed to marijuana which would not, he will commit a crime and end up in jail with lawyers trying to argue the insanity defense to lessen his sentence. And Fuller Torrey will be hooping and hollering that every kid who gets caught smoking marijuana is bipolar and needs AOT so our jails won't become mental hospitals.

The unreasonable trend towards trying children and teenagers as adults is probably related to the rise in psych diagnosis in kids. It's thought to be better to have your kid labeled adhd and sent to a teen "behavior mod" treatment center for rolling the neighbors yard than to be sent to prison as an adult for years. It's horrible that we humans have placed ourselves in a situation where those are the only two options for normal boys.

The false science of psychiatry is intimately connected with the problems in the criminal justice system. It's not the sole cause, but it's a huge problem. It's good that you see that.

Posted by: Sally at December 29, 2008 06:55 AM

Dguller,

You write:

" we all can feel a deep kinship with those suffering from psychological distress as fellow brothers and sisters, that does not change the fact that people will continue to experience pain in their lives due to a variety of biopsychosocial factors that are endemic to the human condition. Those people will require all our compassion and support, and the utilization of whatever we have to offer that is effective at alleviating their distress."

Them and those people buddy, it's all humans. The idea that there are some people who go their entire lives without suffering psychological distress is nonsense. It's one of the first false premises upon which psychiatry is built, it's a real stigma reinforcer, because as you correctly write:

"Stigma of “abnormal” people has existed throughout human history, and will remain no matter the dominant belief paradigm, whether biological or otherwise."

Psychiatry increases this stigma by falsely promoting the idea that differences in personality and/or behavior, whether biological or otherwise, are sicknesses that can be treated and changed rather than treating intolerance of the abnormal which is the real flaw in humanity.

It's certainly true that sometimes behavior, normal or abnormal, crosses a line and becomes criminal behavior, like murder. Psychiatry falsely puts out the theory that abnormal behavior is more likely to lead to crime than normal behavior. Let's not forget that being a Nazi was in it's time normal, that it's the person who refused to join to the movement who you would have diagnosed as mentally ill.

You write:

"They are human beings in distress, nothing more, nothing less, and they need help, as we all do from time to time. I do my best to help with the tools that are available to me, as imperfect as they are."

If you had written we are human beings all of whom at times are in distress...., I would have been in agreement with you though we still would have likely disagreed about the definition of "help," but it's that theying and othering of psychiatry that feeds and promotes stigma, that harms not just individuals but all of society. Until we all recognize our capacity to become nazis, those sorts of horrible atrocities will continue to be committed by us, we, me, you, the human race. Psychiatry is one of those atrocities and I hope you can make the cognitive lead out of your desire to "help them" into the idea that we are all equally human.

Posted by: Sally at December 29, 2008 07:27 AM

Sally,

If you're so inclined, I'd really like to hear you tell us how you succeeded in voiding a psychiatric label. I haven't heard many accounts where this has been accomplished so I'm rather impressed.

Many thanks,
Paul

Posted by: Paul at December 29, 2008 11:19 AM

Paul,

Actually psychiatric labels are essentially voided all of the time in social security disability hearings where a psychiatric expert, so deemed by SSA, goes over the psych records and testimony of a person applying for disability (claimant) and states that the symptoms and other arcana listed and described do not meet the dsm criteria for whatever purported psych disability the person is applying for.

Also, when someone tries to use the not guilty by reason of insanity defense to avoid prosecution for a crime, you'll see lots of psych labels voided by purported psych experts.

Ironically however, due to the punitive nature of psychiatry, much like how the person who begs to stay in the psych hospital is kicked out and the one who begs to leave held against their will, however, the claimant or accused is unhappy about having their psych label voided.

In my case, I wanted my label voided and got it voided which is pretty damned unusual, but I did have years of psych records and behavior none of which met the criteria for the psych labels I was wrongly convicted of having, i.e. "diagnosed with," hence I had the diagnosis declared void by a judge. Of course the criteria are so subjective and vague that had I not in the course of my career sat in on 100's of social security disability hearings and been to law school, as well as having had a brilliant lawyer (who doesn't share my radical views about psychiatry), loving, devoted friends to stand by me (and wonderful dog and cats), I would have never accomplished the near impossible task of voiding a psych label.

It took 5 years and a lot of time and money but it was worth it.

Posted by: Sally at December 29, 2008 01:36 PM

Sally:

First, I never stated that there are people who never feel distress in their lives. We all do from time to time, but some of us are unable to recover and require help. That help sometimes comes from psychiatrists, but often does not.

Second, you state that rather than treat severe psychological distress as a type of illness, we should improve tolerance of abnormality. Again, you seem to have a problem with the notion of human suffering being a type of illness. I suppose you also oppose Buddhists who look upon human suffering as due to an illness of the mind that is delusional and unable to appreciate the non-duality of human existence. Or is their labeling of psychic distress an illness and disease somehow appropriate?

Third, I did not identify those with mental illness as somehow Other. That is why I explicitly stated that they need help, “as we all do from time to time”.

Fourth, you claim that psychiatry contributes to stigma by labeling people with psychiatric diagnoses. You failed to answer my point that stigma existed long before psychiatry, and will continue to exist long after psychiatry disappears (if it does). You also failed to answer how stating that some people suffer from mental illness due to the interaction between their neurobiology and a particular biopsychosocial context that activates psychological distress contributes to stigma.

Take care.

Posted by: dguller at December 29, 2008 07:41 PM

Sally I have to break character here and put aside our semantical differences for just one minute to congratulate your work in getting that done. It's worth clapping when someone is able to remove an albatross from around the neck whatever guise it takes. Letting go, moving forward with a sense of liberation and renewed possibility, who isn't inspired by that?

Posted by: flawedplan at December 29, 2008 11:59 PM

Dguller,

You write:

"Third, I did not identify those with mental illness as somehow Other. That is why I explicitly stated that they need help, “as we all do from time to time”.

They need help. I rest my case.

"Fourth, you claim that psychiatry contributes to stigma by labeling people with psychiatric diagnoses. You failed to answer my point that stigma existed long before psychiatry, and will continue to exist long after psychiatry disappears (if it does). You also failed to answer how stating that some people suffer from mental illness due to the interaction between their neurobiology and a particular biopsychosocial context that activates psychological distress contributes to stigma."

I've been responding to you over and over again. Reread my previous posts.

Posted by: Sally at December 30, 2008 10:10 AM

Sally:

First, are you really unable to see where I included all of us in the category of those who suffer and need help? See: "as we all do from time to time"?

Second, I have reread your posts. You simply assert -- "over and over again" -- that identifying someone with a "chemical imbalance" that is the cause of mental illness is dehumanizing and contributes to stigma. You also objected to characterizing those in psychological distress as having ANY type of disease or illness, because this also contributes to stigmatizing them and alienating them. You never explained HOW this is so. Please, refer me to where you did so in the form of an argument.

My own arguments are that Buddhists refer to psychological distress and suffering as secondary to a disease, sickness and illness of the mind, but you do not object to that characterization. Therefore, it is not the notion that mental illness is a disease that is the problem, but the TYPE of disease that it is that you object to; namely, a BIOLOGICAL illness.

I asked you repeatedly to tell me what the implications of a person's psychiatric symptoms being secondary to biological illness are with regards to their status as an allegedly defective human being. You never did so. My contention is that determining a biological component -- and it is a part of the picture -- actually removes blame and provides a measure of relief to patients, because they can recognize that their vulnerability is not entirely their fault.

Perhaps your position is that declaring a biological underpinning of mental illness in whatever form is utterly false and thus the problem is in LYING to patients. However, we have agreed -- I thought -- that mental illness is secondary to the activation of neurobiological pathways of the human brain due to a biopsychosocial context. There IS a biological component, unless you are willing to argue that our mental states are independent of our brain's circuitry, which is essentially biological in nature? So, there is no falsehood here, but you are correct that the "chemical imbalance" theory was very simplistic and left out many other important pieces of the puzzle.

Perhaps you position is that having a biological vulnerability implies defectiveness, because vulnerability itself is defective? Perhaps you equate vulnerable with weakness? I also disagree with this position, because without vulnerability, meaningful human relationships wouldn't be possible to begin with. Vulnerability is essential to the human condition, because we are all capable of being hurt and injured, and any position in denial of this fact is unhealthy.

Please help me understand your train of thought that relates "biological illness" with "defective human being".

Take care.

Posted by: dguller at December 30, 2008 06:07 PM

Dguller,

You write:

"You also failed to answer how stating that some people suffer from mental illness due to the interaction between their neurobiology and a particular biopsychosocial context that activates psychological distress contributes to stigma."

I don't like being falsely accused of failing to answer. I did address this concern when I wrote:

"Psychiatry increases this stigma by falsely promoting the idea that differences in personality and/or behavior, whether biological or otherwise, are sicknesses that can be treated and changed rather than treating intolerance of the abnormal which is the real flaw in humanity."

Your response to me was this:

"My own arguments are that Buddhists refer to psychological distress and suffering as secondary to a disease, sickness and illness of the mind, but you do not object to that characterization. Therefore, it is not the notion that mental illness is a disease that is the problem, but the TYPE of disease that it is that you object to; namely, a BIOLOGICAL illness."

Oh, biopsychiatry is cool and scientific because of Buddhism. Thanks for clearing that up. Where do you get the idea that "it is not the notion that mental illness is a disease that is the problem, but the TYPE of disease that it is that you object to; namely, a BIOLOGICAL illness."

You write:

"Perhaps you position is that having a biological vulnerability implies defectiveness, because vulnerability itself is defective? Perhaps you equate vulnerable with weakness?"

No, this is not my position. Once again, I'll quote Bruce Levine:

"Labeling depression as a disease gives some people relief, but such labeling creates grief for others. I have met many people who have been failed by antidepressants and electroshock. They talk about the adverse physiological effects of their treatments, but they also talk about something else. By becoming compliant patients to a medical authority, they describe losing control over their lives. Depression is an experience of helplessness and hopelessness, and for these people, accepting depression as a disease makes them feel even more helpless and hopeless.

Instead of labeling depression as weakness or illness, we might better decrease depression by understanding it as a normal, albeit painful, human reaction. When we label a part of ourselves as either "weak" or "sick," we alienate ourselves from a part of who we are, and this can create even more pain. In contrast, when we accept the whole of our humanity, we are more likely to be freed up to resolve and heal the source of our pains.http://www.huffingtonpost.com/bruce-e-levine/why-i-dont-disease-dep_b_74369.html"

You write:

"However, we have agreed -- I thought -- that mental illness is secondary to the activation of neurobiological pathways of the human brain due to a biopsychosocial context."

Nope, we didn't agree about that. Neurobiological pathways are activated secondary to human experience. This activation does not constitute mental illness but a normal human response to external conditions.

You write:

"There IS a biological component, unless you are willing to argue that our mental states are independent of our brain's circuitry, which is essentially biological in nature?"

You miss the entire point. The fact that there's a biological component to mental states does not imply that mental states are diseases, it implies the opposite.

You write:

"So, there is no falsehood here, but you are correct that the "chemical imbalance" theory was very simplistic and left out many other important pieces of the puzzle."

Yes there is a falsehood. And the chemical imbalance theory is currently alive and well in spite of the fact that it's false.

Posted by: Sally at January 2, 2009 05:54 AM

Sally:

First, do you object to Buddhists declaring that human suffering is secondary to diseases of the mind?

Second, I think I better understand your position. You feel that depression should not be described as a disease, because it is a normal response to significant losses, and thus by pathologizing it, we are alienating an important part of our humanity. I would agree with this construct if it referred primarily to feelings, which are always valid and to be accepted. However, our reactions to our feelings are often the source of the prolonged suffering of emotional disorders, in particular.

For example, it is normal to feel sadness when we lose something or someone important in our lives, and part of that sadness involves a temporary withdrawal from our lives in order to regroup and incorporate that loss into the new narrative of our lives, as well as to use our tears as signals to others that we are in distress and require support. However, when someone has responded to their sadness with cognitive and behavioural patterns that serve to perpetuate that sadness – e.g. isolating themselves, rejecting their sadness as an unwanted emotion, believing themselves to be failures and without hope of improvement, putting value-based living on hold until all the sadness disappears – and their lives are completely stalled due to it, then I would say that their distress could benefit from some intervention. I don’t think that it would particularly help the latter person to say that what they are enduring is “normal”, especially if it has dragged on for months or even years without any resolution.

That would be the equivalent of someone being in physical pain, and rather than dealing with the cause of the pain, they contort themselves into a position that exacerbates and perpetuates the pain. Rather than addressing the pain and its causes, you would advise that they simply be told that “pain is a normal part of the human condition”. I agree that telling them that fact is necessary, but it is not sufficient, because they must also be helped to see how they are contorting themselves in a way that makes the pain worse.

Whether you want to call the contorted response that perpetuates the distress an illness, a disease, or whatever, the point is that these people are suffering and stuck and don’t know what to do to get unstuck. I actually no longer tell my patients that they have an illness, but rather that their behaviours are counterproductive, and that it is time for something new, because doing the same thing results in the same outcome. There are a variety of interventions that could be helpful at this point, whether supportive counselling, psychotherapy, medications, or whatever else, but simply normalizing their feelings is “half the battle” to quote the illustrious G.I. Joe.

My thinking about this subject has been highly influenced by Emotion-Focused Therapy (EFT) by Leslie Greenberg, and Acceptance and Commitment Therapy (ACT) by Stephen Hayes. I think that anyone struggling with depression or anxiety would really benefit from these approaches, and would especially enjoy the Mindfulness and Acceptance Workbook for Depression (2008), and for Anxiety (2007), that have come out recently.

Third, you wrote that “The fact that there's a biological component to mental states does not imply that mental states are diseases, it implies the opposite.” I think that your assumption is that if a physical component can be traced for a subjective phenomenon, then that physical component is perfectly normal. I would question this, because we can identify organic causes to mental status changes for a variety of conditions, such as temporal lobe epilepsy, brain tumours, brain infections, and so on. All those conditions have a “biological component to mental states”, but they certainly are not the “opposite” of disease.

However, this argument is less important than our agreement that ALL mental states – both positive and negative – are due to the activation of neurobiological pathways by biopsychosocial triggers. I think that I contributed to our misunderstanding by saying that “mental illness” was due to this construction, rather than all of our states of mind. I actually do not believe that this is especially controversial, but rather the controversy is in claiming that when some neurobiological pathways – e.g. of depression, anxiety – are activated in such a fashion that they are leading to severe debilitation of a person’s life, then a biopsychosocial intervention is likely appropriate, which would include addressing the biological, psychological and social factors contributing to the destructive emotional state.

I think that we are getting closer to agreement here. :)

Take care.

Posted by: dguller at January 2, 2009 04:23 PM

Dguller,

You write:

"However, this argument is less important than our agreement that ALL mental states – both positive and negative – are due to the activation of neurobiological pathways by biopsychosocial triggers."

Nah, I don't recall agreeing to anything.

I'll agree to disagree but I'm neither comfortable with you declaring what I agree to nor what is important.

That word, biopsychosocial, I guess it's one you like. It's redundant, misleading and troubling. Which parts of human social and/or psychological functioning don't have their roots in biology?

By biopsychosocial, I assume you mean drugs which are generally not effective and psychotherapy which has a bad track record too. Oh and there's the social, hmmm, what exactly does that encompass in your world view? Bringing in the family? Halfway houses? Biopsychosocial, a trendy word. What're you establishment pshrinks hiding behind it?

Oddly, what we seem to agree on is that it's okay to take drugs to change mood, even okay for a doctor to prescribe them, but we split on the efficacy of the drugs and what the drugs are doing I think, and of course the talk therapy has a bad record too but at least if it's anonymous it's not likely to do that much harm, still pshrinks shouldn't be doing it, though of course if you are going to prescribe drugs and/or some of other course of treatment you have a duty to talk to your patients about what's going on and monitor their response to treatment, but that's not therapy that's practicing medicine.

Posted by: Sally at January 3, 2009 02:56 AM

Sally, thanks for the great Levine quote. Levine - "Depression is an experience of helplessness and hopelessness, and for these people, accepting depression as a disease makes them feel even more helpless and hopeless." I'm not sure where I stand on depression as a disease or not, but I do know that focusing on it as a disease did nothing to improve my well being.

I also liked what the Candid Psychiatrist had to say about depression. It's been a while since I read his essays, so I don't know if they're still available online or not.

Posted by: Lisa at January 3, 2009 08:46 AM

Sally:

First, you still haven’t answered my question about Buddhism’s account of mental suffering as a disease and illness of the mind. Do you object to this account?

Second, you wrote “Neurobiological pathways are activated secondary to human experience. This activation does not constitute mental illness but a normal human response to external conditions.” So, we agree that mental states are secondary to the activation of neurobiological pathways in the brain. Good. We also agree that they are activated by internal and external factors: your “human experience” and “external conditions”. I think that the only difference between us here is that I use the term “biopsychosocial factors” as an all-encompassing term that accounts for what activates the neurobiological circuits in the brain.

Let me elaborate a little to bring some clarification here.

The “bio” part consists of organic etiologies that alter the brain, and thus mental states. These include family history (i.e. genetics), comorbid medical illnesses, medications being used, street drugs being abused, and so on. All of these biological factors can contribute to our mental life. You appeared to believe that the addition of the “bio” component was redundant, because ALL mental activity is ultimately biological, which is true. However, I was using it to refer to the triggers that I listed above, and not just the redundant aspect, as you mentioned.

The “psycho” part consists of acquired maladaptive schemas, internal working models and core themes (e.g. fear of abandonment, being a failure, being defective, need for control, etc.) from past experiences; attachment style; coping strategies and defense mechanisms; automatic thoughts and cognitive distortions; and behavioural reinforcements that contribute to a mental state. It also includes the current psychological stressors that activate any of the above maladaptive schemas. These aspects are best addressed through supportive counselling and psychotherapy.

The “social” part consists of their key relationships (e.g. family, romantic partner, friends), education, work history, housing issues, financial issues, legal issues, access to healthcare, and so on. Naturally, if any of these areas contributes to mental distress, then they must be given support in those areas. For example, if someone has just lost their job and they have core beliefs of being a failure, then managing their subsequent depression would have to include helping them find new work, as well as accessing employment insurance and disability pensions to help them support themselves until they can find work, for starters. Another example: if a person’s anxiety and depression are secondary to a turbulent marriage, then marital counselling and support groups would be appropriate.

A proper psychiatric formulation must take into account the biopsychosocial factors that are contributing to someone’s psychological distress, and must include an examination of the aspects that I mentioned above. I don’t think that I’m hiding behind this model, and if you object to taking into consideration whatever factors are contributing to someone’s distress in order to help address them, then I would like to hear your alternative. Or do you object to the fact that psychiatrists often fail to do a good formulation involving all the factors I listed above? If they aren’t, then they should be doing so.

Third, you state that you do not object to psychotropic medications and psychotherapy, but believe that they lack efficacy. Fair enough. What approaches do you endorse as effective? You mentioned validating emotions as authentic human responses to various stressors. I agreed that this is necessary, but not sufficient. What else would you say needs to be done? And please be detailed, if possible.

Fourth, why do you find it so objectionable that we agree on certain key ideas?

Take care.

Posted by: dguller at January 3, 2009 12:26 PM

Dguller,

You ask:

"Fourth, why do you find it so objectionable that we agree on certain key ideas?"

I find your characterization of us as agreeing on certain key ideas offensive. It makes me feel violated. You are harming people and to use one of psychiatry's catch phrases, you're in denial about it.

But first a digression, on your bizarre and abusive attempt to connect in criticism of psychiatry with a rejection of Buddhism...you write:

"First, you still haven’t answered my question about Buddhism’s account of mental suffering as a disease and illness of the mind. Do you object to this account?"

I need some original text here. Where in Buddhism does it say that? Are you a psychiatrist as an outgrowth of your personal practice of Buddhism?

As always we're fighting over the implications of the terms disease and illness. If are suggesting that the goal of mental health like the goal of Buddhism (which I could be wrong about) is to eradicate all human suffering because it's an aberration, I'd bet you're vastly oversimplifying Buddhism too, and of course confusing science with religion as is typical of psychiatry. If you want to have a religious belief that all mental suffering is a disease, I'm not joining your religion but I'll defend your right to practice it. It's when you start passing your religion off as science that I get p*ssed.

A concrete example: Back when I worked with injured workers, I always liked getting the Jehovah's Witnesses because they didn't believe in blood transfusions and would drive the workers comp system crazy with their refusal to have surgery that might require blood transfusions. I talked on end with Jehovah's Witness clients about their religion and found it fascinating but never was tempted to join their religion. I supported their legal right to refuse surgery on a religious basis and keep their workers comp benefits and with specific patients admired their principled and courageous refusal to have surgery.

But if a hospital in town had been taken over by Jehovah's Witnesses and thus the entire medical hierarchy from doctor to orderly and every social worker and nurse in between began telling people that blood transfusions would no longer be available because scientific studies indicated that blood transfusions were cannibalism and caused an afterlife of eternal damnation, and people I loved died from not having blood transfusions, not for principled religious reasons but because they had been lied to by people who falsely covered up adverse data and lied saying there was a consensus among all science that blood transfusions were harmful, I'd challenge the moral and legal right of the hospital to do such.

I can think of so many specific examples of people who went to see a psychiatrist because of extreme sadness after a horrible loss, who were told they had a medical disease and thus years later keep switching from drug to drug in a debilitating journey of misery. Of course to give specific details would violate confidentiality, still I suspect you have seem such people to as you write in another thread: "I do not believe that I did anyone any harm in my brief time as their treating physician, but by prescribing medications more frequently than I currently do, I certainly increased the possibility of an adverse event due to side effects."

An adverse event! Let's see, I know someone miserable on a zyprexa prozac because her psychiatrist tells her she suffers from a medical disease called depression and if she stops taking the drugs she'll commit suicide so she won't quit taking them because as miserable as she is, she doesn't want to commit suicide. But wait, there's no evidence she has a medical disease and there is evidence that no matter what has happened to them, people taking zyprexa or prozac, not to mention the combo, have a higher suicide rate than people not taking these drugs. And my friend continues on saying things like, "I feel like a zombie, before this medication I used to have interests but my doctor says I'm better on the drugs. I'm like a diabetic who needs her insulin."

And you say oh the psychiatric isn't lying, he's just using a metaphor. I'm not sure about the if it's a metaphor it's not a lie rule, but I do know your religion, by masquerading as science is killing people.

As an ex member of your religion my reaction is pretty vehement. Yours as a defender of it is too, in the polite, passive aggressive way of psychiatry but now I'm struck by the irony of the fact that this thread is in response to article posted about a book. I think we should both read that book before continuing this discussion. What do you think?

Posted by: Sally at January 4, 2009 07:53 AM

dguller,

You mentioned the importance of helping a person with depression get on disability to help support themselves until they find a job. I think this is a bad idea. The last thing a person with depression needs is reinforcement to stay isolated in their home & once on disability where is the incentive to look for a job?

What message do you think is sent by putting a person with depression on disability? You are telling them yes, you're right you are too sick to work. This is the same beef I have with psych hospitals - I think they encourage pathology by telling patients see, this is all you're capable of. All you are capable of is sitting in a stupid little group coloring pictures & cutting & pasting. Is this really the message you want to send to patients who already feel helpless & hopeless?

Posted by: Lisa at January 4, 2009 12:59 PM

Sally:

First, you ask where Buddhism describes mental afflictions as secondary to a disease or illness of the mind. The Buddha told his monks:

“Monks, there are to be seen beings who can admit freedom from suffering from bodily disease for one year, for two years, for three, four, five, ten, twenty … who can admit freedom from bodily disease for even a hundred years. But, monks, those beings are hard to find in the world who can admit freedom from mental DISEASE even for one moment, save only those in whom the afflictions are destroyed”.

And here is Lama Yeshe:

“Too much concern for your own comfort and pleasure driven by the exaggerations of attachment automatically leads to feelings of hatred for others. Those two incompatible feelings—attachment and hatred—naturally clash in your mind and, from the Buddhist point of view, a mind in this kind of conflict is SICK and unbalanced in nature” (http://www.lamayeshe.com/index.php?sect=article&id=46).

I can find more quotes if you like, but the fact remains that Buddhism looks upon most human beings as having diseased minds rooted in delusion, craving and aversion, which are all ultimately due to our identification with an independent and substantial self.

Just to remind you, you wrote above:

“Psychiatry increases this stigma by falsely promoting the idea that differences in personality and/or behavior, whether biological or otherwise, are sicknesses that can be treated and changed rather than treating intolerance of the abnormal which is the real flaw in humanity.”

So, my question remains: do you despise Buddhism as you despise psychiatry? Does Buddhism contribute to stigmatizing those suffering from mental affliction? Both utilize a model of illness and disease for emotional suffering, after all.

Second, I have already ordered the book and look forward to reading it. :)

Third, I would like to hear your thoughts about my statement that all mental states are due to the activation of neurobiological pathways by biopsychosocial triggers. Do you agree or disagree, and if the latter, then why?

Fourth, why does our agreement on some key issues “violate” you? Is everything that I believe and do tainted and disgusting? If you agreement with me on something, then does that imply that you have been tainted by it? Do you see me as a person with multiple dimensions, or have you successfully dehumanized me in your mind as a diabolical entity who wreaks death and destruction everywhere I go? Is not that dehumanizing caricature of my complexity as a human being the very crime that you accuse psychiatrists of routinely committing?

Take care.

Posted by: dguller at January 4, 2009 01:57 PM

Lisa:

Yes, you are correct that helping depressed patients get on disability is a two-edged sword that must be carefully balanced. The idea is that they take enough time to recover and implement the necessary changes in their lives without the burden of worrying about returning to work prematurely. I have had some patients who returned to work too soon, and were unable to perform adequately, thus adding their failure at work to the other stressors that were contributing to their depression. Ultimately, the patient must make their own decision about how to proceed, but I often recommend taking a few months to recuperate, and an early return to work, if possible.

I also think it is important to clarify that they are not recommended to stay at home and do nothing for weeks and months. There is usually a plan in place where they attend support groups; meet with a therapist; engage in activities designed to modify their cognitive distortions, activate them behaviourally, and mindfully accept their feelings in a compassionate way that is in keeping with their values; and meet with their psychiatrist (if necessary).

You make valid points about going on disability possibly reinforcing their hopelessness, but that is not the only way to frame the issue. I try to frame it as a matter of recovery, which requires time and effort, and that they have the capacity to get well and return to their life with a renewed sense of vitality.

Take care.

Posted by: dguller at January 4, 2009 02:11 PM

Dguller,

You ask:

"So, my question remains: do you despise Buddhism as you despise psychiatry? Does Buddhism contribute to stigmatizing those suffering from mental affliction? Both utilize a model of illness and disease for emotional suffering, after all."

Nah dude that's the first time you asked that question. Do you do this to your patients too? Utilizing the concept of disease as a metaphor is not wrong. It's the pretense that something else is happening in psychiatry that is wrong.

Your comparison of psychiatry to Buddhism is off of the mark as Buddhists would consider mental suffering a normal part of the spiritual journey of everyone. A developmental journey. Also, Buddhism is not the state religion in the US as psychiatry essentially is. If psychiatry weren't the de facto state religion here in the US, I wouldn't find it as objectionable as say Scientology, another religion with which it has much in common.

You write:

"Third, I would like to hear your thoughts about my statement that all mental states are due to the activation of neurobiological pathways by biopsychosocial triggers. Do you agree or disagree, and if the latter, then why?"

The concept of triggers troubles me, reducing as it does all life to a biopsychosocial trigger. Furthermore, when people use a big word to dress up a simple concept it's absurd. Psychiatry loves to restate the obvious in complex terms and pretend this is proof. As I lawyer, I understand this practice;0 still, I agree that the brain seems to channel the human's reactions to outside stimuli. This proves nothing but I do agree. This does not mean that in the context of this argument we agree about "many things."

As Niall McLaren writes:

"Since the collapse of the 19th century models (psychoanalysis, biologism and behaviourism), psychiatrists have been in search of a model which integrates the psyche and the soma. So keen has been their search that they embraced the so-called 'biopsychosocial model' without ever bothering to check its details. If, at any time over the last three decades, they had done so, they would have found it had none. This would have forced them into the embarrassing position of having to acknowledge that modern psychiatry is operating in a theoretical vacuum."

and you write:

"Fourth, why does our agreement on some key issues “violate” you?"

It's your false characterization of our agreement that violates me.

you write:

"Is everything that I believe and do tainted and disgusting?"

I don't know, I'm not aware of everything you do.

you write:

"If you agreement with me on something, then does that imply that you have been tainted by it?"

Your declaration that I agree with you is different from an actual agreement. Tainted, really.

you ask:

"Do you see me as a person with multiple dimensions, or have you successfully dehumanized me in your mind as a diabolical entity who wreaks death and destruction everywhere I go?"

I feel sorry for you but I obviously only know you as a blog commenter. I see you as one of those sad characters who is slowly realizing their profession is completely wrong, you're on the right path but still wrecking havoc. Back to the Nazi metaphor, you're like a Nazi upon whom it's slowly dawning that the holocaust is wrong, but you're at the phase of this awakening where you're still killing Jews. I hope for you and your "patients" you get past this stage quickly. Your delving into Buddhism seems a good thing as the Buddhists in the quotes you mentioned and in my limited understanding of their religion, think that suffering is normal for all humans.

Is not that dehumanizing caricature of my complexity as a human being the very crime that you accuse psychiatrists of routinely committing?"

You ask questions of me, pretend I've answered, and then go on to challenge my imaged response. If you want to communicate, I'd recommend that you stop doing that.

Show me some evidence of a dehumanizing caricature? No, that's not the crime I accuse psychiatrists of committing, it's more the philosophical underpinning for such crimes.

And I await the book too.

Posted by: Sally at January 5, 2009 05:59 AM

dguller,

It occurs to me that I might mention that I think that you are well intentioned, as are most in the mental health industry. Ironically that makes you that much more dangerous.

S

Posted by: Sally at January 5, 2009 06:56 AM

Sally:

First, you have dodged the question, once again.

You claim that any institution or belief system that describes any element of human psychology as a form of sickness or disease is contributing to the stigmatization of a vulnerable part of society, which results in their oppression and alienation. You also claim that a better approach would be the validation and normalization of their “abnormal” mental states rather than informing them that they are sick and require treatment.

I have quoted reputable Buddhists who describe the human condition as generally one of mental sickness and disease, which contributes to human suffering (the first and second Noble Truths), and that requires treatment in order to alleviate the illness and bring mental peace (the third and fourth Noble Truths). They explicitly state that suffering can be alleviated in the state of Nirvana through the rigorous training of mindfulness and meditation. They do not view suffering as something to be normalized and left alone as a valid form of human experience, but rather have developed a complicated system to eliminate it from their lives altogether in a state of joy and equanimity.

Your earlier comments have the implication that Buddhism also contributes to stigmatization and alienation by describing afflictive mental states as diseased and requiring treatment. However, instead of simply accepting this logical inference, you are now dodging the issue by introducing other factors, because you obviously do not want to put Buddhism in the same category as psychiatry. So, you now speak of “state religion”. I suppose that this implies that in countries where Buddhism is the state religion, you would agree that it alienates and harms people by stigmatizing them there? Why does it matter where an ideology is dominant in terms of its validity and effectiveness?

Perhaps the issue is not whether a doctrine labels mental states as diseased, but rather the consequences of that label in terms of coercive treatment. I suspect that you have no problem with Buddhism’s labelling of afflictive mental states as diseased, because it does not mandate treatment, and rather insists that the training exercises that it recommends must be undertaken in a voluntary fashion.

So, can we agree that it really does not matter so much whether a mental state that results in significant suffering is labelled an illness or not, and rather the issue is whether someone can be forced to be treated against their will? Can we agree that your real problem with psychiatry is not its diagnosis of patients as having illnesses, but rather that those diagnostic labels can lead to the violation of patients’ human rights in the cases of involuntary treatment? Is this ultimately about the power differential between psychiatry and society?

Second, you object to my notion of a biopsychosocial trigger that activates neurobiological pathways, which results in the generation of mental states. Your objections are basically that I am needlessly complicating an “obvious” and “simple concept”, and that my conception somehow “reduces all life”, and thus “troubles” you. So, on the one hand, you agree with my formulation as quite intuitive and obvious, and on the other hand, you are distressed by its implications. It appears that you have conflicted emotions about this model, but generally agree with it, albeit with different terminology: “I agree that the brain seems to channel the human’s reactions to outside stimuli”. Fair enough.

Third, you quote Niall McLaren from his 2006 paper in Medical Hypotheses (66:1165-1173) as a critic of the biopsychosocial model. He does not actually offer any critique of that model in that paper, but references his 1998 paper from the Australian and New Zealand Journal of Psychiatry (32:86-92) in it. Since you cited him as an authority, can you please elaborate precisely what his objections are to the biopsychosocial model that I described in an earlier post?

Fourth, you felt “violated” by the possibility that we agreed upon certain key issues. That was your word, not mine. I was trying to understand why you felt defiled and abused, which are the implications of “violated”, by our potential agreement. Rather than assume that I comprehend your rationale, I would rather just put it to you, especially since you never answered my original question. So, why do you feel “violated” by our potential agreement on certain issues? What is it about those issues that particularly disgusts you?

Take care.

Posted by: dguller at January 5, 2009 11:59 AM

Sally,

It's perfectly logical and reasonable to reject Psychiatry's labelling but not Buddhism's because the underlying premise is false. Buddhism and Psychiatry are concerned with very different things. The comparison being made is invalid.

It matters not that both belief systems have doctrinal concepts for "mental illness" that involve a label. What matters is that Buddhism's locus is the betterment of oneself to help others whilst Psychiatry's locus is power, force, and fraud to help other people.

A psychiatric label is a weaponized tool; it's but a descriptor in Buddhism.

Paul

Posted by: Paul at January 5, 2009 02:24 PM

Dguller,

You write:

"You claim that any institution or belief system that describes any element of human psychology as a form of sickness or disease is contributing to the stigmatization of a vulnerable part of society, which results in their oppression and alienation."

Uh, where exactly did I make that claim?

This putting of "violated" in quotes is odd.
You write:

"Third, you quote Niall McLaren from his 2006 paper in Medical Hypotheses (66:1165-1173) as a critic of the biopsychosocial model. He does not actually offer any critique of that model in that paper, but references his 1998 paper from the Australian and New Zealand Journal of Psychiatry (32:86-92) in it. Since you cited him as an authority, can you please elaborate precisely what his objections are to the biopsychosocial model that I described in an earlier post?"

Dguller, I'm not your research assistant, look it up yourself.

You write:

"I was trying to understand why you felt defiled and abused, which are the implications of “violated”, by our potential agreement."

You never respond directly to me, but you counter by falsely attributing statements to me. And then I feel forced to correct you, but I don't have time for it anymore. No more from me in this thread.

Posted by: Sally at January 5, 2009 02:44 PM

Sally:

First, I put “violated” in quotes, because I was QUOTING you. There is nothing insidious going on here. Sorry to disappoint. :)

Second, you’re STILL ducking my question about whether you reject Buddhism due to its emphasis on human beings having a form of sickness or illness of the mind.

Third, I have both of McLaren’s papers that I cited, and have read them. They are very interesting, and I am well aware of his arguments against the biopsychosocial model. I only asked you about his arguments, because I wondered if you actually read his work that you cited, or just lifted it from the Wikipedia page on “Biopsychosocial Model”. I guess I know that answer to that question now.

Fourth, you must be a very effective lawyer, and I commend you for your skills of avoiding directly answering a question. Instead, you criticize my misinterpretations of your words without actually CLARIFYING what you meant. Very impressive! :)

Take care.

Posted by: dguller at January 5, 2009 03:40 PM

Paul:

First, thank you for clarifying the main issue here.

It is not about labelling people with an illness per se, but about what follows from having such a label. In both our countries, labelling someone with a psychiatric illness has legal ramifications that could result in violating some of a patient’s human rights, especially in the case of involuntary hospitalization and treatment. Since it is an extremely serious issue, the Canadian legal system contains various safeguards to ensure that the patient’s rights are protected as much as possible. However, no such system is foolproof and it is certain that some patients have been involuntarily treated without just cause, which is just as certainly a tragedy.

Second, could you please elaborate on the following comment: “Buddhism's locus is the betterment of oneself to help others whilst Psychiatry's locus is power, force, and fraud to help other people”? I agree that there are elements of psychiatry that involve the use of power and force in the course of involuntary treatment in an inpatient setting, and that there has been a history of fraudulent research practices and deception on the part of drug companies and clinicians (e.g. “chemical imbalance” theory). However, I disagree that you can make such a global statement about ALL of psychiatry.

I am currently working in an outpatient clinic, and deal mainly with patients who have depressive and anxiety disorders. I do not use force or power in my regular sessions with them, and I do not engage in fraud, either. I mainly engage in psychotherapy in the form of CBT, ACT and EFT, depending on the case. I rarely use medications, but when I feel that medications could be helpful, I am open about the fact that they have been shown in studies to be superior to placebo, but that there is no guarantee that they will work in my patient, and I explain the possible side effects and adverse events, as well.

If your position is true, and “power, force and fraud” are essential to all aspects of psychiatry, then the implication is that I am also engaging in such activities. Would you say that my form of practice utilizes “power, force and fraud”?

Third, you might be happy to learn that there is a movement in psychiatry to incorporate mindfulness practices from Buddhism in a “third wave” of psychotherapy. It is mainly concerned with helping patients identify their deepest needs and values, engage in behavioural change to live their lives in a value-based and meaningful fashion, and to use mindfulness techniques to better accept difficult emotions that are present in their lives, rather than struggle against them. If this is an area of interest of yours, then you can read about Dialectical-Behavioural Therapy (DBT) by Marsha Linehan and Acceptance and Commitment Therapy (ACT) by Stephen Hayes. Their approach is absolutely fascinating, and I have incorporated their theory and treatment strategies into my personal practice.

Fourth, I am back from visiting my family, and so I promise to read your posts much more carefully to avoid confusion. :)

Take care.

Posted by: dguller at January 5, 2009 04:12 PM

"Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concentration.

These problems can become chronic or recurrent, substantially impairing an individual’s ability to cope with daily life. At its most severe, depression can lead to suicide. Most cases of depression can be treated with medication or psychotherapy.

By the year 2020, depression is projected to reach 2nd place of the ranking of DALYs calcuated for all ages, both sexes. Today, depression is already the 2nd cause of DALYs in the age category 15-44 years for both sexes combined."
Source: WHO

WOW
According to WHO we should start considering search for help immediately.
Is it panic-mongering or what?

Posted by: Ana at January 5, 2009 04:14 PM

"Depression can be reliably diagnosed in primary care. Antidepressant medications and brief, structured forms of psychotherapy are effective for 60-80 % of those affected and can be delivered in primary care. However, fewer than 25 % of those affected (in some countries fewer than 10 %) receive such treatments. Barriers to effective care include the lack of resources, lack of trained providers, and the social stigma associated with mental disorders including depression."

Source: WHO

I hope the Pharmas hurry up and start selling antidepressants to these countries!
Dear Lord! If these people don't receive treatment can you imagine how serious the economy will be affected?
We need to take care!

Posted by: Ana at January 5, 2009 04:22 PM

It is about labelling people with an illness in Psychiatry; it isn't in Buddhism.

If labelling is innocuous or immaterial then it doesn't matter per se. If labelling is used for a material purpose (pos or neg) then it matters. The greater or more central the purpose, the more it matters. Labelling mental illness is essential to Psychiatry as presently practiced. It is not essential to practice Buddhism. This doesn't mean that every psychiatrist is committed to labelling - some won't do it at all, but Psychiatry is and has expanded them with every DSM iteration.

The aspects and practices of Buddhism are centered around the betterment of oneself so as to be able to better help others - that is its locus. Psychiatry also lays claim to help others as well. However, its locus is centered about power/control over others, through the use of force, and through fraud. This is how it achieves its ends and legitimacy. Take these away and Psychiatry would be banished to a small corner - remember the 70s?. These aspects are central, significant, and form a discrete locus.

The first two are fairly self-explanatory. So, where is the fraud? It's in the deliberate misrepresentation of itself (Psychiatry) and its practices. Treating based on perpetuation of the serotonin hypothesis, for example, is fraud. The involuntary commitment process is replete with fraud. The research is riddled with fraud (compromised KOLs, absurd efficacy measures, selective reporting of positive trials, corruption of CMEs by pharma monies, and so on).

Buddhism and Psychiatry are the topic and context here, not individual Buddhists or psychiatrists or you.

Don't try to justify Psychiatry by pointing to other belief systems. Psychiatry's use of labels should be defensible on it's own without resorting to logical constructs with faulty premises. Debate the validity and beneficence of psychiatric labels on their own merits.

DBT? It's very trendy East/West fusion. It reminds me of mail order black belt programs. You can't just skim off the good or useful parts of eastern philosophical systems and weave them into western practices - it's just bad sushi in the end. Eastern thought is very context sensitive which is graphically orthogonal to western content richness. The master-student relationship is central to teaching. Mindfulness in an eastern sense is a very different experience than in the west or in a DBT context. "The Unfettered Mind" is a good read as is "The Book of Five Rings", but some much is lost in translation because east and west are so contextually disparate. Still, if one finds it useful, it is a far better approach than psychotropics in that at least it attempts to deliberately train the mind to identify and separate emotional from rational thinking and develop strategies to manage crisis situations.

This is just a big diversion and distraction from the question of the over-diagnosis of depression. What did we learn? You can't compare apples and oranges. Wait. We already did this before. Deja Vu all over again...

Paul

Posted by: Paul at January 5, 2009 08:32 PM

Paul:

First, I think that we should clarify why this discussion about illness has been going on. I understood Sally to argue earlier that any ideology that labels the emotions that people experience as a type of illness, instead of simply validating them as authentic and perfectly normal, is to be opposed. That is why I mentioned Buddhism, because it does not validate and normalize afflictive emotions, but rather views them as manifestations of a sick mind that needs to be cured of its delusions, aversions and attachments, which are the root causes of suffering. I just wanted to demonstrate that labelling a mental state as an illness is neither necessary nor sufficient to reject that ideology, because that would require the rejection of Buddhism, which is absurd. Your position that it is not the labels, but rather what they are USED FOR that is important is absolutely true, and I agree with you on this score.

Second, I believe that you are incorrect about labelling not being central to Buddhism. In their scriptures, they have identified 84,000 afflictive emotional states, which they have painstakingly labelled in varying amounts of detail. One of their central aspects is the thorough study of the human mind, the labelling of its myriad mental states, the identification of which are productive and which are destructive, and deriving antidotes to the latter, afflictive emotions. So, they are also about diagnosis and treatment. So, there are similarities between psychiatry and Buddhism, but there are also many, many differences. :)

Third, I wonder why you did not state whether you felt that my way of practicing psychiatry involved “power, force and fraud”. You made a general statement about ALL of psychiatry being involved in “power, force and fraud”, and that implies that I am equally utilizing them. There is no need to hide behind generalities here. If you believe that your general principle is true and valid, then follow the conclusion into my practice and tell me if I am currently utilizing “power, force and fraud” when treating my patients.

Fourth, I can bring in other belief systems into the discussion of the validity of psychiatry, because the criticisms offered here of my field are based upon general principles, which have implications that might affect other ideologies. That is why I bring in Buddhism in a discussion of the validity of identifying mental states as diseased, and why I bring in the Catholic Church in a discussion in which the offences of a few key opinion leaders imply that their entire field is fraudulent and should be dismantled. If someone rejects the conclusion that is logically implied by the premises of a valid argument, then the premises must be reconsidered. I think that this is a perfectly legitimate form of reasoning.

Fifth, you state that “You can't just skim off the good or useful parts of eastern philosophical systems and weave them into western practices - it's just bad sushi in the end.” The researchers that I mentioned as part of the “third wave” of psychotherapy are simply following the lead of the Dalai Lama, and his followers, who have attempted to bring Tibetan Buddhism to the West in an accessible and universal fashion that does not necessarily require the intricacies of the Tibetan culture. He has collaborated with Western scientists for many decades (see, the Mind and Life Institute) in the hopes of unifying Buddhism with Western science, and has even said that if Western science contradicts Buddhism, then that tenet of Buddhism must be rejected. So, it appears that a form of fusion is certainly possible, and actually has led to some intriguing avenues of research and changes in practice.

Take care.

Posted by: dguller at January 6, 2009 05:31 AM

Paul:

Oh, and one more thing. That was a great pick-up that you mentioned earlier about the paranoia secondary to adrenal deficiency. Are you in endocrinology, by any chance? Internal medicine? Emergency medicine?

Also, in your specialty, what is your relationship to psychiatry? Do you ever refer patients to psychiatry or consult psychiatry at all in your practice?

Just wondering. :)

Posted by: dguller at January 6, 2009 07:28 AM

Nicely done, dguller.

http://en.wikipedia.org/wiki/Fisking

"savaging an argument and scattering the tattered remnants to the four corners of the internet."

Because staying on topic works to her disadvantage, Abused Innocence retreats to nourish her grievance, after getting publicly PWND by someone who actually knows what he's talking about and who undeniably practices the humanistic psychiatry Abused Innocence demands psychiatrists practice, but don't, because she says they don't! Strawman, lawyer, you might look that up.

Cluestick: Dguller's "third force" approach is synonymous with "humanistic"-- which is to say the trippy experiential school extolled by a living breathing practicing pshrink leaves Sally with no recourse but to stamp her feet and Paul to denounce in an encyclopedic critique as trendy, impure and derivative, man. A distraction, kick it over!

"Be careful what you ask for because you just might get it." Or out yourselves as blatant nihilists who's cognitive dissonance would be painful to watch if not for the endless and harmless LULZ it produces. Y'all are fucking priceless, here we are now, entertain us.

Posted by: flawedplan at January 6, 2009 10:55 AM

The point remains that labels are essential to Psychiatry but not to Buddhism. Everything else is a distraction, an attempt to divert.

Accepting the validity of Buddhism's use of labels in no way logically compels one to accept Psychiatry's. It is perfect reasonable and logical to reject Psychiatry's use of label, but not Buddhism's since they are fundamentally different things.

Secondly, I did not imply anything about you or any individual psychiatrist. My argument is with Psychiatry (not psychiatry) as an institution, not you. Just because a thing tastes awful doesn't mean all the ingredients taste awful or are wrong. Must we revisit this as well?

"Third Way" is not following the Dalai Lama or his example. It is selectively pruning what concepts or ideas it wants - not unlike cafeteria Catholics. DBT's Buddhism connection is rather superficial. You'd be better off learning T'ai Chi to develop mindfulness. You'd learn some other important things on living as well if you practiced long enough.

DBT, in principle, is not useless, but let's not get all gushy over it's Eastern flavors. Believe me there is a difference between a curry in Mumbai, one in London, and the one you just picked up from the market. Once you have a proper curry you won't mistake the other form.

Paul

Posted by: Paul at January 6, 2009 12:18 PM

Paul:

First, can you please elaborate on how labels are not important to Buddhism, especially since I told you that they have labelled 84,000 mental states in their literature. To me, that degree of classification implies a healthy importance with labelling.

Second, I agree that accepting Buddhism’s labelling does not imply accepting psychiatry’s. That is not the issue at all. At issue is the major premise in the following argument:

(1) If an ideology labels human emotions as a product of illness, disease or sickness, then it must be rejected.
(2) Psychiatry labels human emotions as a product of illness, disease or sickness.
(3) Therefore, psychiatry must be rejected.
(4) Buddhism labels human emotions as a product of illness, disease or sickness.
(5) Therefore, Buddhism must be rejected.

By rejecting (5), we have to reject either (1) or (4) as false. I choose to reject (1) as false, because I think we can agree that (4) is true. Without (1), we cannot conclude that (3) is true within the context of this argument with (1) as the major premise. However, this does not imply that (3) is false, because that would make the logical fallacy of denying the antecedent. In other words, not-(1) does not imply not-(3), which is why accepting Buddhism’s labels does not imply accepting psychiatry’s labels. It only means that you cannot REJECT psychiatry’s labels on the basis of (1), and an inability to reject a proposition on the basis of one premise does not preclude rejecting it on the basis of another one.

Just so you know, I base (1) on Sally’s comment above: “Psychiatry increases this stigma by falsely promoting the idea that differences in personality and/or behavior, whether biological or otherwise, are sicknesses that can be treated and changed rather than treating intolerance of the abnormal which is the real flaw in humanity”. Perhaps I am misunderstanding the thrust of this statement, but to me, it clearly implies that psychiatry must be rejected, because it “falsely” declares that our “differences in personality and/or behaviour” are due to “sicknesses that can be treated and changed”, which “increases” “stigma”, rather than accepting those differences as perfectly normal and acceptable.

Third, you state that you have no problem with individual psychiatrists, but reserve your criticisms for Psychiatry as an institution. You then use a clever analogy where a final product contains qualities that the individual parts fail to have, which is true. I would use a different analogy: If the source of a stream is poisoned, then the stream is poisoned. In other words, all psychiatrists participate in Psychiatry and derive their identity and practices from Psychiatry. If Psychiatry is tainted, then the psychiatrists must also be tainted.

You wrote earlier that psychiatry contains “unsupportable premises and questionable practices” that are analogous to the Nazi movement. These despicable elements are “ideological and woven into the basic substrate”. I understood you as saying that these rogue Nazi constituents within Psychiatry were part of your objection to Psychiatry. To carry this line of reasoning further, your argument implies that individual Nazis are innocent of blame and criticism, but that the institution of Nazism is the real locus of your bile. That is certainly absurd, and so your critique must also involve the daily practices of all individual psychiatrists, and thus I ask you again: given my description of my practice, do you believe that I engage in “power, force and fraud”?

Fourth, what aspects of DBT do you find “superficial”? What ideas and concepts of Buddhism are being “selectively prun[ed]” by the “third wave” of psychotherapy? I had no idea that you had an in-depth understanding of DBT, ACT and Buddhism, and I look forward to reading your comments about these fascinating areas of human knowledge. :)

Fifth, you may have missed my comment where I asked you what form of medicine you practice and whether you ever refer patients to psychiatry or consult psychiatrists where you work. I am eager to hear your answers. :)

Take care.

Posted by: dguller at January 6, 2009 02:33 PM

flawedplan:

Your loquacious and elaborate rhetorical style oft strikes my cerebrum in a humorous manner. :)

Posted by: dguller at January 6, 2009 03:04 PM

M. Guller,

Obviously, I'm a chef. I wasn't able to get into FP's secular humanist school for very clever girls. Apparently, my blatant nihilism and cognitive dissonance proved too great a barrier for admission.

Posted by: Paul at January 6, 2009 06:37 PM

"Mental illness"

does it really matter what you call it? .... Says D Gulller ...

OF COURSE IT MATTERS ..

Words are powerful , you know that more than most people...

To imply "mental illness" is to evoke the image of a sick and diseased brain ...

Most mental illnesses are emotional and psycho-spiritual in nature....

There is no sick and diseased brain in depression, Post traumatic stress or Bi-polar ...

Why don't you begin to listen to what these people on here are talking about D Guller? Have you got ADHD? Your ability to respond to our questions seems quite inept... Maybe you need some drugs yourself to fix this "character flaw"?

Get off your arrogant psychiatric pedestal and start listening to the people who have gone through it!!! listen to the survivors of SSRI's and the psychiatric system!

That's where the evidence , truth and knowledge is!

It's not in some obscure pseudo-scientific medical journal sponsored by the pharmaceutical industry !
(which is where I suspect you obtain most of your deluded information)

Posted by: truthman30 at January 7, 2009 01:35 AM

Hi Sally

Well done for getting your psych label Voided!
I have always wondered is that possible..
I myself would like to get mine voided , I was diagnosed 10 years ago with depression (they said it was caused by a chemical imbalance, all the while dismissing the environmental factors)

I think getting people to void their psychiatric diagnoses could start real change!!!

Lets all do it...

Put the fascist drug pushing ego-maniacs out of business once and for all....

Posted by: truthman30 at January 7, 2009 01:53 AM

Truthman30:

First, if by “mental illness”, you are implying an illness or disease of the mind, then I disagree that this automatically implies a diseased brain. If that were true, then Buddhism would also be arguing that the brain is diseased, because it equally identified emotional difficulties as sicknesses of the mind, but they do not make such a claim. Of course, the brain is involved, because all mental states are generated by the activation of various neurobiological pathways in the brain, but it does not follow that they are necessarily diseased.

Second, I do listen to what people here say quite closely. However, validating someone’s tragic experiences with psychiatry does not imply that I must agree with their understanding of psychiatry, especially when they conception of it is so harsh, unyielding and derogatory.

Third, you write: “To imply "mental illness" is to evoke the image of a sick and diseased brain”. In other words, anyone who uses words that mean that the mind is somehow ill or diseased is automatically implying brain that is diseased. Well, on a previous thread you wrote: “I never said I didn't believe in "mental illness"” (Jim Carrey thread, December 28, 2008 at 6:18 pm), and now write: “Most mental illnesses are emotional and psycho-spiritual in nature”. So, did you also “evoke the image of a sick and diseased brain”? You are correct that “words are powerful”. You know what else is powerful? Consistency.

Take care.

Posted by: dguller at January 7, 2009 05:33 AM

Paul:

That was clever sarcasm. :)

I look forward to reading your real response to my points above.

Take care.

Posted by: dguller at January 7, 2009 05:41 AM

D Guller..

I shall waste no more of my time conversing with you...
You are a master of deflection (must be a trick you learn in Psych-pharma college..

good luck..

(oh and I sincerely hope that you never experience a debilitating emotion like depression in your life time, because I don't think you would handle it very well, but then again there's always medication right?)

Posted by: truthman30 at January 7, 2009 01:01 PM

M. Guller,

I don't think any further elucidation on my part will further this discussion. As much as I enjoy providing some degree of entertainment for Stephany, I'd prefer to deny this to FP - call it cognitive dissonance if you must.

I picked that particular analogy because it represents how I view Psychiatry and psychiatrists. I don't agree that because Psychiatry is flawed that infers all psychiatrists are so because of the original sin. Again, this is a waste of time as I've already said this on numerous occasions. In my experience you are an anomaly, or hold a junior position. Now, if you had operational responsibility for an in-patient unit or out-patient program, and you were able to influence other physician's practices, I'd take you a bit more seriously.

If you can't see the differences between Psychiatry's foundational need for labels and labelling people versus Buddhism's lack of this foundational need, then I continue waste my time. Without its ability to label, Psychiatry would lose power to control, to force treatment, and to perpetuate fraud. Labels are descriptors (repeating myself again) in Buddhism, nothing more. A Buddhist would be able to better him or herself sans these labels. 84,000 labels does not imply the necessity of these labels to the practice of Buddhism. You have to look at what their relevance is to practice, to the ends, and the means to achieving those ends. These differences form a chasm-like gulf between P. and B.

I already told you I was done with Nazis. You've, again, misinterpreted and misconstrued what I said. I just can't be bothered to fisk you one more time.

Premise (1) is not what Sally said either. Sally is saying (paraphrasing) that psychiatry increases stigma by falsely promoting differences as a biological or other sickness to be treated/changed versus expansion of tolerance of what society views as "normal" behaviour. What premise (1) should say is:

1) If an ideology labels human emotions as a product of illness, disease or sickness that results in sufficiently negative, unnecessary, stigmatization, then that ideology should reject the use of labels.

We can then debate whether Psychiatry does this or not, and to what extent. We don't need to throw nihilists out with the bathwater now do we?

I know more than my fair share about DBT and Buddhism, though I can't comment on ACT with any authority. DBT's link with Buddhism is akin to learning karate from a book. Sure you can learn the moves, but you miss the essential essence of what it is - something that can only be experienced firsthand by learning from a highly trained Sensei for many years. I have nothing further to add here.

My own professional training will have to remain irrelevant for now as I wouldn't want it to confer any strength or weakness to my views. However, my formal training spans a number of scientific and non-scientific fields. I don't have the hubris to be a humanist, but that doesn't prevent me from indulging in arrogance, vanity, or self-righteousness. I don't believe the creator is especially nit-picky about the foods we eat, the people/things we fuck, the clothes we wear or don't wear, or is a particularly good listener.

Paul

Posted by: Paul at January 7, 2009 01:35 PM

"I'm arguing that subjective experience of unhappiness is not abnormal though it may be unpleasant. I don't argue with efforts to palliate emotional pain, only with the idea that this pain is abnormal" (Sally)

I've just been reading some of your posts here Sally, and I have to say, I think you have great insight and you write with great eloquence and articulation

Mr Guller is no match for you...

:)

Keep it up Sally, He is losing his argument , and he is failing in Spades..

Nice to see others actually get it, well done Sally..

Mr Guller..

My advice to you would be to quit while you are "behind", you are digging your own hole, get your head out of the DSM for a while, remove your ego from your ass and start listening... The people here know what they are talking about, psychiatry is bullshit, and the internet will make more and more people aware of that fact...

Posted by: truthman30 at January 7, 2009 03:12 PM

Paul:

First, I never used to term “cognitive dissonance”. Sorry.

Second, you argue using an analogy where the sum has properties that the parts lack that although the institution of Psychiatry it inherent flawed due to its utilization of “power, force and fraud” that individual psychiatrists are not tainted by this institutional flaw, and thus should not be criticized on this score. I think your analogy is misplaced here, and I used Nazism as an example. If your analogy held true, then it would logically imply that one could condemn Nazism as utter barbarism, but hold individual Nazis are innocent of blame.

However, the analogy is misplaced here, because you confuse essential and accidental properties, to use Aristotelian language. Your example was of ingredients of food that combine to form a meal, which possesses a flavour that is different from the smaller ingredients. The specific flavour is an accidental property that can change with culinary manipulation, but the essential property is being a piece of food that has a taste. That property is shared by both the ingredients and the final meal, which is why it is essential and not accidental.

To return to Psychiatry, if one of its essential qualities was the use of “power, force and fraud”, then in order to be a member of Psychiatry, one must also embody those essential qualities, just as in order to be part of a meal an ingredient must be a piece of food with taste. That is why your argument breaks down with the Nazi case, as well, and why – despite your argument – we can easily criticize individual Nazis, because by virtue of being a Nazi, they embody the essential features of Nazism, which are monstrous. Therefore, if you claim that it is an essential feature of Psychiatry to utilize “power, force and fraud” then in order to be considered a psychiatrist at all, one must also use them.

So, I put the question to you again: hearing how I practice, do you feel that I use “power, force and fraud” in my practice? Or, are you willing to revise your statement that they are part of the essence of Psychiatry?

Third, I do hold a “junior position”, being a psychiatry resident. What does that have to do with the CONTENT of my arguments? Ad hominem fallacy anyone?

Fourth, you still tenaciously cling to the notion that labelling is essential to psychiatry, but not in Buddhism. Deny it all you want, but it is a foundational need of Buddhism to accurately describe and label the various cognitive and emotional states that human beings experience in order to identify antidotes to those that result in human suffering. It is precisely because they realize that they have to be very precise in their labels of human experience in order to recommend the appropriate antidotes that they have painstakingly plumbed the human psyche and identified 84,000 different mental states.

You argue that this complicated labelling process is not important and that they are able to better themselves without such a complex system of classification. You are correct that even with a rudimentary and basic understanding of the root causes of affliction – delusion, attachment and aversion – one can probably find some measure of peace and relief. But, to use your earlier analogy, one can find decent curry in any restaurant, but the genuine cuisine can best be tasted in India by those who have perfected their culinary technique. It is for the sake of such perfection that Buddhists find it essential to carefully label the full spectrum of human psychological states, and not to approach it in a haphazard fashion. So, I will have to continue to disagree with your contention that labelling is not important to Buddhism, because it clearly is.

Fifth, you are misconstruing what Sally wrote. Her objection to psychiatry was that it contributed to stigma (which is the main criticism in her statement). How does it do this? By labelling people with having illnesses that require treatment instead of just validating their thoughts, feelings and behaviour as normal and appropriate. You’ve converted a conditional statement into a conjunction, which is a different logical category. In other words, you’ve taken:

(1) If an ideology labels people as having illnesses that require treatment rather than validating their experience as normal, then it contributes to stigma;

(2) If an ideology contributes to stigma, then it must be rejected.

and turned it into:

(3) If an ideology labels people as having illnesses that require treatment rather than validating their experience as normal AND contributes to stigma, then it must be rejected.

(1)-(2) and (3) are TOTALLY DIFFERENT in terms of their logical implications, and only the former are in keeping with Sally’s actual words. If she agrees to change her mind and agree with (3) instead of (1)-(2) as the major premises of her argument, then we will have a totally different type of argument, which is actually stronger for you and her. However, rather than just revise even a single opinion that is obviously incorrect, you continue to persist in defending Sally's statement in this futile line of reasoning when language and logic are against you. Why not just admit that Sally is wrong about this matter?

Sixth, I am happy to know that your knowledge of DBT and Buddhism is substantial, and I hope we can have a productive dialogue in this area. Now, you say that the “essential essence” – a bit of overkill, no? – that DBT misses is the absence of a trained master to guide the novice through the stages of enlightenment. That would be a good criticism if the goal of DBT was enlightenment, but fortunately it is not. The goal is to foster an attitude of non-judgemental acceptance of one’s thoughts and feelings in a mindful and gentle fashion rather than become fused and identified with them in a rigid and harmful way. That is possible without having a master, and is why many reputable Buddhist practitioners endorse the utilization of mindfulness techniques in Western psychotherapy even in the absence of a recognized master. Of course, it is best to have a guide along this path to attain one’s maximum potential, but a great deal of benefit can be derived from learning these techniques “from a book”.

Seventh, I agree with your comments about a creator. Funny! :)

Eighth, I would still like to know how you and your colleagues interact with psychiatry where you practice. Do you make referrals to psychiatry or consult with psychiatry when your patients have psychiatric symptoms but a negative organic work-up?

Take care.

Posted by: dguller at January 7, 2009 05:44 PM

truthman30:

First, I AGREED with you that mental illness does not imply a diseased brain.

Second, I just pointed out the inconsistency in what you have posted here. Don't get mad at me. Just accept that you contradicted yourself, pick a position that is consistent, and we can move on.

There's no problem, we all contradict ourselves from time to time, myself included. But there's no need to get upset at me for just pointing it out using your own words. :)

Take care.

Posted by: dguller at January 7, 2009 05:48 PM

Truthman30 and Paul,

Thanks for your comments.

Posted by: Sally at January 7, 2009 07:20 PM

"There's no problem, we all contradict ourselves from time to time, myself included. But there's no need to get upset at me for just pointing it out using your own words. :)

Take care.

Posted by: dguller at January 7, 2009 05:48 PM

Sarcasm with a smile D Guller?..
How very telling of you ..

First of all I did not address the "contradiction" that you refer to because quite simply I did not contradict myself in the first place..
But if you could be so kind and point out to me where exactly I was "inconsistent" in my argument I would be more than willing to address it..

Inconsistency is the hallmark of your trade so I am sure it will be quite easy for you to drag it up again..

You are doing yourself no favors here Mr. Guller..
The anti-psychiatric sentiment runs high on this site for good reason...

Oh and you never addressed any of my points in the last thread , and you continue to ignore everybody else's on here too...

You smear any kind of challenge with pseudo-intellectual crap talk ... Is there something pathological in that perhaps? ..

And one last thing, you don't have a clue about buddhism , and mentioning it alongside psychiatry is an insult to that belief system..

Buddhism has genuine good intent , psychiatry does not..
I can see your ego has an insatiable appetite...
You think you have knowledge? ..
You can waffle in scholarly tones, but that doesn't mean you have wisdom my friend...
The downfall of all corrupt ideologies and beliefs is always audacious arrogance.. Maybe psychiatry should be aware of that?

http://www.crystalinks.com/socrates.html

Socrates' life as the "gadfly" of Athens began when his friend Chaerephon asked the oracle at Delphi if anyone was wiser than Socrates; the Oracle responded negatively.

Socrates, interpreting this as a riddle, set out to find men who were wiser than him. He questioned the men of Athens about their knowledge of good, beauty, and virtue. Finding that they knew nothing and yet believing themselves to know much, Socrates came to the conclusion that he was wise only in so far as he knew he knew nothing. The others only falsely thought they had knowledge."

Posted by: truthman30 at January 7, 2009 07:30 PM

Dguller,

Why have you decided to be a psychiatrist?

Posted by: Ana at January 7, 2009 07:47 PM

I guess this thread is done, too...

Posted by: Paul at January 7, 2009 08:07 PM

Truthman30:

You wrote: (1) “To imply “mental illness” is to evoke the image of a sick and diseased brain”.

You also wrote: (2) “I never said I didn’t believe in “mental illness”” and (3) “Most mental illnesses are emotional and psycho-spiritual in nature”.

Then you wrote: (4) “There is no sick and diseased brain in depression, Post traumatic stress and Bi-polar …”

Here’s the contradiction:

When you wrote (2) and (3), by using the term “mental illness”, you implied “the image of a sick and diseased brain” (by (1)), and thus tacitly endorse mental illness being due to a “sick and diseased brain”. However, you then wrote (4), which denies that mental illness is due to a “sick and diseased brain”.

So, by (1), (2) and (3), you appear to endorse mental illness being due to a “sick and diseased brain”, which you then reject in (4), thus resulting in a contradiction, because you both endorse and reject the proposition “mental illness is due to a sick and diseased brain”. Q.E.D.

The best solution is to reject (1), which I would actually agree with, as I mentioned in my previous post. :)

Take care.

Posted by: dguller at January 7, 2009 08:35 PM

Ana:

Because I enjoy interacting with people, getting to know the complexity of their histories and life stories, and helping them be flexible enough to let go of unhelpful ways of being in the world that bring them emotional suffering. I find that I can mostly do this with psychotherapy, but have also found benefit to using medications in severe cases. I also enjoy neuroscience and understanding the human brain and how it generates our experiences of life.

Take care.

Posted by: dguller at January 7, 2009 08:52 PM

Paul:

You can ignore most of my post above, if you like. I mean, it WAS kind of long! ;)

But, I would really appreciate if you could answer my eighth point about how you, as a physician, interact with psychiatry in your practice. Do you and your colleagues refer to or consult psychiatry when a patient with psychiatric symptoms has a negative organic work-up?

Thanks, and take care.

Posted by: dguller at January 7, 2009 09:23 PM

M. Guller,

Sorry if the "junior position" quip rubbed you the wrong way. It wasn't intended to be derogatory, but rather a measure of your organizational influence as a surrogate for your ability to affect change in Psychiatry. I can understand how it may have been interpreted otherwise. My apologies. Everyone has a boss! Sometimes everyone is your boss...

The length of your comments does not dissuade me. However, it is entirely too time consuming to constantly correct your misstatements of my comments. I feel as though I am correcting term papers again or have somehow been cast in a Seinfeld episode. It's tedious and frankly boring.

I think I'll just stick to my gin and tonic instead of responding to you any further.

Indian tonic, of course, for the taste and the anti-malarial qualities.

Paul

Posted by: Paul at January 7, 2009 10:49 PM

There is no inconsistency in my comments that you quoted Mr Guller..

I did say , that to imply mental illness is to evoke the image of a sick and diseased brain, and that was in the context of the words "mental illness" , words which I have always disagreed with .. (it was also in a separate thread , and different context)

I did also say that I did not say I believed in mental illness as in I do not believe in the "sick brain model" , to put it simply, I do believe that these "states of being" exist, I just think that the connotation and wording of the banner "mental illness" only serves to perpetuate the "sick and diseased biological model"..

And when you apply this phrasing to peoples emotional states , in many cases it doesn't fit..

While it looks like I contradicted myself, I actually did not..
You are just trying to find flaws in my argument and that is not surprising because it is a hallmark of the callous way in which your profession uses misinformation and wording as weapons against the individual...

Posted by: truthman30 at January 8, 2009 02:38 AM

Truthman30:

You wrote: “I did not say I believed in mental illness as in I do not believe in the "sick brain model"”. That is total bullshit, because you previously wrote: “I never said I didn't believe in "mental illness"” (Jim Carrey thread, December 28, 2008 at 6:18 pm) and that was in direct response to my questioning whether you believed in mental illness at all!

And if you are saying that, when YOU use the words “mental illness”, YOU do not imply a “sick and diseased brain”, then that means that your claim that ANYONE who uses the words “mental illness” AUTOMATICALLY implies a “sick and diseased brain”, is false. (I base this upon your statement: “To imply "mental illness" is to evoke the image of a sick and diseased brain”.) Either the words ALWAYS imply the “sick brain model”, or they SOMETIMES do (or they never do, but that is silly). You cannot have it both ways, because you end up in a contradiction.

Let me further show you how:

(1) All X’s are Y –- (All uses of the words “mental illness” imply a “sick brain”)

(2) This X is not-Y –- (My use of the words “mental illness” does not imply a “sick brain”)

(3) But X must be a Y (by (1))

(4) Therefore, X is both Y and not-Y -– (the contradiction)

What is most stupid about this discussion is that I actually AGREE with your claim that using the words “mental illness” does not imply a diseased brain. I just disagreed with ONE statement of yours, because it led to a contradiction, but rather than just saying that you over-generalized with your statement -- “To imply "mental illness" is to evoke the image of a sick and diseased brain” -- you prefer to attack me for pointing out your inappropriate use of a universal statement that we actually both agree is false. You are either doing this in bad faith, because you despise me so much that you cannot even agree with my points on anything, or you are doing this because you are simply too stupid to even understand the implications of your own language and the logical structure of propositions.

Why not just admit that you did not mean to say that all uses of the words "mental illness" imply a "sick and diseased brain"? That would be honest, understandable and legitimate. However, this current line of discussion is none of the three, unfortunately, and I am afraid that you only appear sillier and sillier as we continue.

Take care.

Posted by: dguller at January 8, 2009 03:48 AM

Paul:

Apology accepted. :)

I hope that you enjoy your INDIAN (!) gin and tonic, but I would still appreciate an answer to the single point that I raised in my last post to you. I do not believe that it would consume too much of your time, and it would really better my understanding to your approach to mental illness.

Thanks, and take care.

Posted by: dguller at January 8, 2009 03:51 AM

Hmph, so it's hubris to believe humans are naturally good, healthy and self-correcting organisms deserving of unconditional positive regard. Are you defending the faith Paul, original sin and the Fall from grace? Balls to that.

In mental health a "humanistic" practitioner is doing existentialism, that's philosophy, not religion, and the two are not mutually exclusive.
Let's not confuse "secular" humanism with humanistic psychology; things are complicated enough on their own.

http://www.ahpweb.org/rowan_bibliography/chapter2.html

one of the characteristics of humanistic psychology, which distinguishes it very sharply from secular humanism, that it has a place for the spiritual.

What we talk about when we talk about dguller:

http://www.intropsych.com/ch01_psychology_and_science/third_force.html

Humanistic or Third Force psychology focuses on inner needs, fulfillment, the search for identity, and other distinctly human concerns. It is less concerned with doing research on human behavior than with describing its meaning and purpose

That's why this school has lost ground; humanism rests on QUALITATIVE research methods (aka leftwing hippy shit) in an age of neurobabble and neat little measurable chemical formulas.

Academic psychiatrists have lost the plot, but to call humanism irrelevant is absurd on its face. Humanism is what they need to get back to; the clinical virtues extolled by our whipping boy dguller.

http://webspace.ship.edu/cgboer/genpsyhumanists.html

Like Existentialism, Humanism is a broad collection of theories and theorists that are sometimes hard to pin down. But the best known and most influential person among them has to be Carl Rogers.

You say dguller has a minority position? Perhaps you missed Columbia University's 2007 "Recent Trends" poll that asked clinicians:

"Over the last 25 years, which figures have most influenced your practice?"

http://www.psychotherapynetworker.org/component/content/article/81-2007-marchapril/219-the-top-10

According to 2,598 respondents:

the single most influential psychotherapist—by a landslide—was Carl Rogers. In other words, the therapist who became famous for his leisurely, nondirective, open-ended, soft-focus form of therapy 50 years ago remains a major role model today, even with the explosion of brief, "evidence-based" clinical models, a psychopharmacological revolution that often makes medications the intervention du jour, and a radically altered system of insurance reimbursement that simply won't pay for the kind of therapy Rogers did.

With this knowledge you can walk into a psychiatrist's office holding their feet to the fire. When the disciplines of psychology and psychiatry compete with each other back psychology. Name names, arm yourself, use your weapons.

HTH.

Posted by: flawedplan at January 8, 2009 09:20 AM

Listen Guller..

You took what I said out of context in order to discredit me , I could do the same if I could be bothered, but to be honest I have better things to do than search the whole of furious seasons and look for threads where I might find inconsistencies in your discussions... (and also you took two completely different arguments from different threads which is quite ridiculous and petty if you ask me)

Anyhow, no, I do not despise you, your arrogance causes me bemusement more than anything. I think you do believe what you are saying, and that itself is worrying, but also you don't engage in actual discussion, you tend to veer every thread into an abyss of confusion, but maybe that is your intention? is it?

Oh and on the subject of being stupid, I would hardly be studying in one of the top 50 universities in the world if I was stupid would I? I mean, they tend not to let stupid people into those kind of places, at least in the case of where I study, I know the application process in most thorough... Then again I wouldn't be much informed on whether they let stupid people in to study psychiatry. I must ask in the faculty , next time I happen to pass... actually maybe not, the mere thought that they actually teach that stuff in my university makes me want to vomit..

Posted by: truthman30 at January 8, 2009 10:24 AM

FP,

Interesting comments, but you also seem to suffer from Guller's affliction of misquoting... No worries, I won't fisk you.

Yes, I think Humanism implies a certain hubris to exclude the possibility of the supernatural. How you go from that and my other quip to "defender of the the faith" is a leap. I do find the Kalam cosmological argument rather persuasive, but I find it difficult to extrapolate it to what we have today in terms of organized religion. This position hardly places me in the camp of apologetics. Still, I do find their logic compelling too.

Show were I said Humanism was irrelevant. Perhaps you were referring to "third wave"? I didn't say that was irrelevant either. I agree that humanist psychology does draw a distinction with Humanism. Too bad they couldn't find a better term because, as you say, it does create needless confusion. I've see the term Holistic used in some practices, but that also carries some "new Age" pablum connotations. It seems more marketing than a difference in practice from humanistic psychology. Regardless of coinage, there are many positive aspects to this approach. Anytime you treat another person as a human deserving of respect, you're on the right path.

I'm not sure how relevant a poll of the most influential psychotherapist is in the context of psychiatric practice. Far too many psychiatrists are crap psychotherapists, if they do it at all. Substitute any of the current KOLs in the headlines for Rogers and compare answers. Roger's influence can't explain the explosion on ADD/ADHD or bipolar diagnoses or diagnoses in general. Roger's influence may still permeate psychotherapy, but Psychiatry has clearly moved on to pharmacological intervention. This doesn't make him irrelevant, but it shows where the money goes.

Yep, I'd also back psychology over psychiatry unless it also gains the power to prescribe. I think psychology has been far more progressive and patient focused than psychiatry - by miles.

Lastly, are you suggesting M. Guller practices anything other than traditional psychiatry? I've seen no specific evidence other than an academic interests in a variety of things including curries and poisoned water sources. He's said he has changed his prescribing habits. OK. Can he influence his peers, or his boss, or his boss' boss? He's hardly the site whipping boy. Other psychiatrists and psychologists manage to post and discuss things without resorting to Guller's tactics. If anything it's self-inflicted.

Your prose are excellent FP! I don't always follow your thoughts, but I do enjoy reading them.

Fond regards,
Paul

Posted by: Paul at January 8, 2009 11:21 AM

Truthman30:

First, how did I take what you said out of context? In one context, I specifically asked you if you believed in mental illness, and you said that you did. In another context, you said that anyone who uses the words “mental illness” automatically implies the “sick brain model”. Since you believe in mental illness, you must believe in the “sick brain model”, according to the principle that you laid down.

On the other hand, perhaps you are using the words “mental illness” to mean different things in the different contexts, which would be a good strategy to dissolve the contradiction. So, were you using the term in two different meanings, and if so, then what are the two different senses of the words “mental illness” that you were using?

Of course, it doesn’t help much when you decry the use of the words “mental illness” as endorsing the “sick brain model”, and then USE THOSE VERY WORDS in the NEXT SENTENCE! Please see your post on January 7, 2009 at 1:35 am. But I suppose that you were using the words “mental illness” in DIFFERENT CONTEXTS from one sentence to another! Right?

Second, just because you go to one of the top 50 universities in the United States does not mean that you cannot be an utterly hopeless moron. George W. Bush attended Yale and Harvard, which are probably better universities than the one that you attend – otherwise you would have said that you were in the top 10 and not the top 50 – and yet he is a total idiot. So, that argument is no good.

Oh, and just to clarify matters, I never said that your idiocy was represented in all your cognitive domains, because you are probably very bright in the areas that you are currently studying. What I actually said was that you lacked the intellect to follow the logical implications of the sentences that you were using in our argument. That certainly does not imply that you are mentally retarded in a global sense, but only that your rational insight is deficient in this particular area of logical argumentation.

Take care.

Posted by: dguller at January 8, 2009 11:41 AM

I don't live in the United States Mr Guller..
(and I'm pretty happy about that)

Bush probably bought his way in to Yale, I earned my place through a series of hard work, interviews, past grades and aptitude tests, also also my socio economic background is what you might call of the "lower class". Your Bush/Yale analogy couldn't be anymore ridiculous.

The only reason I told you about my studies was to highlight the fact that you are not the only one who has an education, and because sometimes you I feel you tend to patronize people with academic language on this site and personally I find it extremely off putting. I would be more than able to engage in it, but I think it is completely unnecessary given the context of most of the discussions here.

A perfect example of your condescending and patronizing tone can be found in this quote from you :

"What I actually said was that you lacked the intellect to follow the logical implications of the sentences that you were using in our argument. That certainly does not imply that you are mentally retarded in a global sense, but only that your rational insight is deficient in this particular area of logical argumentation.

I do not lack intellect in any sense Mr Guller, you took what I said out of context, I have already explained that and it is tiresome to go over it again, but if I have to put it to rest once and for all then I will. Also I find it interesting that you allude to those of a lower intellect as "mentally retarded" , to me that implies somewhere in your psychiatric psyche you have delusions of grandeur, how would you perceive that Mr Guller? Would I be correct in making that assumption?

Anyhow,

On the subject of what I said and what I didn't say about mental illness. I believe what I actually said was, "I never said I didn't believe that mental illness doesn't exist". In the context of the thread, what I meant was, yes of course people manifest the symptoms of what is commonly referred to as "mental illness". Conditions such as depression, anxiety and bi-polar are commonly filed under that category. But that doesn't automatically mean that they are "mentally ill".

What I also said (in a different thread, and a different context of argument) was I did not like the terminology of the term "mental illness" and what it implies. What it implies being an illness of the mind or a "Sick brain". The reasons why I do not like the words "mental illness" is because I feel they have a negative and often unfounded connotation when applied to most conditions. Take for example someone who is depressed. To say someone who is depressed and suicidal is mentally ill is in fact a falsehood. Who are we to judge them as somehow "sick" or "ill". In most cases of depression and suicide the individual in question is usually in a lot of emotional and spiritual pain. To deem them as just "mentally ill" is to be blase and convenient about their actual suffering. The biological "sick brain" model of psychiatry is defective reasoning. It uses categories, words and definitions which do not serve the individual suffering under psychiatric care, but rather it is a system by which psychiatry can operate and of course dominate the discourse. This is very wrong and also very dangerous.

Psychiatry reminds me of the catholic church and other institutions of similar doctrines. Unquestioned power is always dangerous. That is why I question psychiatry and that is why I question you. It seems to me that you are very much frustrated with peoples views on here about psychiatry, and what bothers you most is their attack on your belief system. If, as you say, you actually cared about people suffering from "mental illness" (there's those words again) then you would be compassionate and try to understand why we are so furious with your profession. But you don't do that. I think you are more frustrated in having your authority and ego undermined here than anything else.

Posted by: truthman30 at January 8, 2009 12:36 PM

Truthman30:

First, I apologize for implying that you were attending an American university. I missed that part of your post. I also highly commend and admire you for your hard work and diligence in terms of getting into a good university. However, your argument was that NO-ONE who attends a top university could POSSIBLY be stupid, and I provided you with a counterexample in the excremental form of George W. Bush. Perhaps if you had said that MOST who attend the top universities are not stupid, then I would wholeheartedly agree with you, but it is your tendency to make universal and general statements that I often find fault with. Perhaps if you were more nuanced in your posts, then we would avoid such confusion in the future.

Second, I actually agree with you that psychiatric labels, like all labels, are hopelessly incapable to capture the essential complexity of any human being, and that any reduction of a person to a single label is a gross injustice.

Third, I continue to be utterly shocked at your inability to understand the logical implications of what you write. You cannot damn anyone who uses the term “mental illness” as endorsing the “sick brain model” and then use it in the very next sentence while denying that you endorse the “sick brain model”! That would be like saying, “Anyone who uses the word ‘shit’ is a total shithead” and then say, “Shit! Oh, but I’m not a shithead”.

The obvious implication is that rather than ANYONE, you should say SOME PEOPLE. In other words, instead of saying that ANYONE who uses the term “mental illness” implies a “sick brain model”, why not say that SOME PEOPLE who use the term “mental illness” imply a “sick brain model”? The latter has the benefit of being both true and saving your from an inconsistency. Also, you can go further with the latter statement and add that those people who do so are wrong. That would actually strengthen your argument substantially! Again, my objection is to your inappropriate use of universal and general statements rather than being more circumspect and nuanced. That’s all.

Fourth, I wholeheartedly welcome your criticisms, and I can promise you that my profession will be better by taking them into consideration. I am certainly not bothered by the criticisms I read on this website about psychiatry, because much of it is valid and I agree with it. However, I do disagree with some more extreme views that are based on invalid generalizations and unwarranted premises, and so I offer my arguments against them.

You seem to believe that my persistence on some points of disagreement implies that I reject the general idea that psychiatry contains numerous flaws that must be corrected in order for it to become a viable form of medicine in the future. I do not reject that idea at all. However, I do not believe in throwing the baby out with the bathwater, especially when unnecessary. So, let’s just get rid of the bathwater instead, and keep the baby! :)

Fifth, regarding my "authority and ego", I certainly lack the former and am unimpressed with the latter. :)

Take care.

Posted by: dguller at January 8, 2009 01:16 PM

Paul:

Since you are such a stickler about my “affliction of misquoting”, I would love for you to justify your claim that I have “academic interests” in “curries and poisoned water sources”, Mr. Mumbai-curry-is-better-than-London-which-is-better-than-one-in-the-market.

Also, I still note that you have not answered whether you, as a practicing physician, consult psychiatry when you have a patient with psychiatric symptoms, but a negative organic work-up. It’s been a few days now, and I’m starting to wonder why you are avoiding this issue.

Take care.

Posted by: dguller at January 8, 2009 01:40 PM

truthman30:

Oh, and when I used the term "mentally retarded", I was referring to those with an IQ of less than 70. Unfortunately, that term has negative cultural connotations, but I was using it in its strictest definition. No "delusions of grandeur", I'm afraid.

Take care.

Posted by: dguller at January 8, 2009 01:42 PM

Thanks Paul, I appreciate your comments too, with apologies for interpreting your remarks as an attack on humanistic practices. My baggage from years of fighting the CBT overlords.

I just want to restate, for those of us who are in the VOLUNTARY mental health milieu, going in with knowledge of humanistic psychology is a weapon against the pricks, though finding treaters who work it can be frustrating in community mental health clinics, what a psychiatrist can't say is "oh you're just making shit up now." That's when you hit 'em with the books (and evidence of how you apply the principles to your own well-being and recovery).

I've found "medication-management" psychiatrists in free mental health clinics have been amenable to their humble position in my treatment hierarchy --ahead of the nurse but behind the psychotherapist, and just above the neighborhood psychic who reads palms at 10 bucks a throw.

Maybe it's about not being passive in the face of psychiatry but being on a "path", working within a framework where a different, legitimate mental health dogma holds rank. Make that the starting place and you'll command respect from psychiatrists, but you have to walk the walk. For this reason we must preserve humanistic psychology -- without it we are well and truly fuct.

Of course there are alternatives to taking charge of your own treatment course, but ish.

Posted by: flawedplan at January 8, 2009 05:12 PM

FP,

I was being cheeky. No need to apologise.

Physicians should be treated like used cars. Use carfax and buyer beware. You're absolutely right about arming yourself with as much knowledge as possible. I'd also add that if you aren't happy with how a physician treats you or your knowledge of treatment then walk out and get someone you can work with. This is problematic when treatment is involuntary. You need a very different strategy. I've found subterfuge sometimes necessary until you can gain your freedom to make free choices. It's a difficult balance to strongly advocate for yourself without becoming labelled as a problem patient.

Paul

Posted by: Paul at January 8, 2009 08:22 PM

Hell is here. I'm back in this thread.

Recommending that "patients" advocate for themselves is pretty dangerous as the patient that advocates for herself will be seen as a problem patient as once you voluntarily submit to treatment you are essentially stating that the doctor's judgment is better than yours. Sure shopping around you might find a better therapist but there's always the notes from the ones that didn't like you.

You can never take that power back and any attempt at advocacy is symptom. That's why it's better to avoid the system entirely. If you end up in it involuntarily, well so much the worse for you.

Posted by: Sally at January 9, 2009 05:19 AM

Dear dguller,
I often wonder, and marvel at, what system you work in. It certainly bears no resemblence to any mental health entity I've ever seen. Is Canadian medicine really so advanced that your pdocs actually provide the information their counterparts routinely withhold in the US? Are you all so enlightened up there that your patients--unlike ours--are actually able to advocate for themselves without fear of retaliation in the form of lies, punitive drugging, innuendos and false diagnoses on their Permanent Record?

To be honest, I really don't believe it. It always seems to me that you're either being disengenuous (which I'm sure I've spelled wrong) or out of touch with the reality your patients face, if not from you then from the majority of your colleagues. I don't think you're flat-out lying, which is more slack than I cut most psychiatrists most days.

I wish you'd start listening and hearing instead of focussing on nit-picking the details of this or that semantic shading or research study. That seems to be your comfort zone.

Trust me, you have no way of knowing what goes on behind closed doors. We do. Sadly, it's obvious you'd prefer to continue sticking your head in the sand. Too bad.

Respectfully yours,
Sherry

Posted by: Sherry at January 9, 2009 11:21 AM

Sherry:

No, the Canadian system is not a utopian panacea, and I have seen the type of behaviour that you protest in the American system occur here, as well. That is why I only described how I try to practice, which is also imperfect and always has room for improvement, rather than making global statements about Canadian mental health, which is also flawed (like all human institutions, in general).

My "nit picking" is only about minor details that I think either misrepresent a finding in a study or overgeneralize some point in an unreasonable fashion. I don't think one needs to go beyond the evidence to make one's argument. That's all.

No need for exaggeration or overreach, because the facts are actually quite supportive of a need for a large reform of the mental health system. It is disengenuous -- why is this word so hard to spell?! -- to critize researchers for misrepresent their study findings, and then go on to misrepresent the findings of other studies. Let's all just stick to the facts. We'd all be better off.

Also, I think that you miss the forest for the trees. Yes, I do get into detailed discussions about a few points in which I disagree with some posters, but do not lose sight of the fact that I have listened to the people here and the articles that Philip posts, and have modified my practice accordingly. Hell, I even gave a recent case study rounds on the PLACEBO EFFECT in relation to antidepressants, which I don't think made many staff too happy! ;)

So, although I can never know the true extent of your pain and frustration with psychiatry, I can still sympathize with your plight and try to learn from it in order to better the lives of my patients. :)

Take care.

Posted by: dguller at January 9, 2009 01:52 PM

Actually, if a psychiatrist adjusted their practice by listening to us, then they would QUIT THEIR JOB.

Posted by: Stephany at January 9, 2009 03:12 PM

Stephany:

Well, fortunately, the visitors to this blog do not represent a monolithic block, and thus you have to specify which "us" you are referring to.

There are basically two large groups, from what I can tell: (1) those who see psychiatry as intrinsically and hopelessly evil, and thus to be rejected altogether and ultimately dismantled and abolished; and (2) those who see psychiatry as flawed, but not fatally so, and thus in need of reform, which can come in a variety of flavours, including the emphasis on empathic and therapeutic relationships and a de-emphasis of medications, except in severe cases where the scientific literature is supportive. That is how I choose practice.

I don't think there is anyone who thinks that things are just fine the way they are. I know that I don't know anyone that I've ever worked with that hasn't offered harsh criticisms of the way mental health is provided.

I suppose that you are part of (1), and thus feel that psychiatry is irredeemable and inherently compromised without any hope of reform. I wonder why you believe this. Could you please offer your rationale for such a position, and why reform is impossible?

Thanks, and take care.

Posted by: dguller at January 9, 2009 04:58 PM

oops! us wasn't meant to include anyone but myself!

Posted by: Stephany at January 9, 2009 08:02 PM

PS-- Guller you appear to think that my comment was directed toward you, and if you read my comment it had no name listed.

You aren't the only psychiatrist in this world, and I'm not here to answer your questions.

Posted by: Stephany at January 9, 2009 08:05 PM

wow talk about stats! 51 comments in this thread by dguller!

Posted by: Stephany at January 9, 2009 08:09 PM

LOL. Thanks for counting Stephany. Now I know to skip this one. :-)

Posted by: Becky at January 9, 2009 11:48 PM

Stephany:

First, I think that I am free to reply that anyone’s comments, including those that aren’t specifically addressed to me, as you do on this website, as well.

Second, feel free to not answer my questions. You are under no obligation to do so, but it would be helpful to understand your position better. For example, do you believe that psychiatry is intrinsically evil, because it endorses the use of psychotropic medications?

Third, I have commented a lot on this thread, but it was in response to Sally’s 26 comments, Paul’s 6 comments, truthman30’s 8 comments, and a few other comments. But that is what happens when people engage in a dialogue, and in this case, the posts became very numerous. By the way, what is the appropriate number of comments that people are permitted on this thread?

Take care.

Posted by: dguller at January 10, 2009 05:49 AM

Paul said, "It's a difficult balance to strongly advocate for yourself without becoming labelled as a problem patient."

Yes, it's pretty much impossible to stand up for yourself when in-patient. My medical records say, "Patient is too astute for group therapy." This because I refused to sit in a circle and pretend to be an animal in a circus. Refusing to participate in such nonsense should have been viewed as a sign of mental wellness, instead, it got me labelled as a problem patient.

I also rebelled against the suggestion that I stand in front of a mirror & say positive things to my reflection. This was supposed to improve my self esteem. All I could think of was Stuart Smalley sitting in front of a mirror in the Saturday Night Live skit.

So, I go in for depression & come out with a huge bill for treatment that did nothing but make me feel like a complete freak. To think they save anyone from suicide with this nonsense is delusional at best.

There should be some standards for what passes as mental health care, but unfortunately there isn't.

Posted by: Lisa at January 10, 2009 10:04 AM

Lisa,

My inpatient records say "patient continues to perseverate that she was entitled to a hearing before commitment" and, my favorite, "patient denies previous diagnosis of bipolar disorder."

I had to take the f*ckers to court to prove that in fact I was entitled to a hearing before commitment, had there been a hearing I would not have been committed, and furthermore I had never been labeled (i.e. diagnosed) as bipolar. The hospital could have easily proved these things with a couple of phone calls. Apparently they don't do that sort of thing.

Luckily, I didn't take the meds, cheeked them instead, otherwise, from side effects I really would have seemed mentally incapacitated.

Then there was the fact that the hospital, at 1000 at day, didn't provide sanitary napkins, tampons, or shampoo, and then wrote folks up for poor hygiene, a conclusive symptom of everything from schizophrenia to bipolar to depression which are the only three you get locked up for, the felony convictions of "mental illness." Luckily I had a friend to bring supplies, and let one poor woman, who hadn't had access to shampoo in months, use mine. I'm glad you survived. Keep speaking out.

Posted by: Sally at January 10, 2009 12:33 PM

I'm curious about people who throw bombs on internet blogs. Bomb-throwing= fuck everything, no discussion, burn it down, fuck all you serious motherfuckers, fuck everything.

Sometimes there are valid Joey Ramone reasons for throwing bombs, I just don't get the point of it on discussion forums. What is the objective? Self-expression? Great, then what? Where does it go from there?

Posted by: flawedplan at January 10, 2009 12:35 PM

Just having some fun with ya guller, nothing more, nothing less.

Posted by: Stephany at January 10, 2009 02:14 PM

Dang it! Was that a wild and amazing Femi-Nazi Bomb I just read? Or is this the same as a psycho pot calling the crazy kettle black?

"F-everything" must be the cheerful motto of the week, as I gather from this post!

I can't help but find the laughing filled humor in how off the deep end some will actually go.

Please keep up this thoughtful and hope filled work here in the comment section.

Thanks

Posted by: LOL at January 10, 2009 02:27 PM

FP,

Has a bomb been thrown? Your pal, the lap you're snuggling in, dguller, is still on it and will get the last word if only he's got the time for the last comment.

Where's the bomb?

Posted by: Sally at January 10, 2009 05:02 PM

I have long been of the belief that psychiatrists themselves harbor many of the "disorders" that they brand their patients with...

I wonder..

Does Mr Guller have "Disruptive disorder"?
And if so, does "Disruptive disorder" exist in adults?

• Always disagreeing, arguing and making small situations seem bigger than they really are.Children with disruptive disorder often want to have the last word

http://209.85.229.132/search?q=cache:48qyRLXwWCMJ:www.health.nsw.gov.au/mhcs/publication_pdfs/6435/DOH-6435-ENG.pdf+disruptive+disorder+the+last+word&hl=en&ct=clnk&cd=1&gl=ie

Posted by: truthman30 at January 10, 2009 06:12 PM

Stephany,
Include me in your us.

And we'll have a record on Monday!
It will be this thread birthday!
It only stopped December 14, 25 and 31.

Posted by: Ana at January 10, 2009 07:29 PM

Lisa,

The only purpose of in-patient activities is to monitor your behaviour. No one cares about the pretty pictures your draw or other arts and crafts projects. All they do is to measure behavioural content to measure compliance - meaning are you drugged enuff...

Posted by: Paul at January 10, 2009 08:13 PM

Sally,

Cheeking should be a required subject for all students - kindergarten (or whatever age kids are being drugged at these days is) and above...

Posted by: Paul at January 10, 2009 08:15 PM

Truthman30:

I wrote above that “my objection is to your inappropriate use of universal and general statements rather than being more circumspect and nuanced”. You just keep repeating your mistakes, again and again. You just implied that I may have “disruptive disorder”. What do you base your diagnosis upon? Well, the fact that I am “Always disagreeing, arguing and making small situations seem bigger than they really are”. ALWAYS DISAGREEING? Are you kidding me?

Let’s look at how I ALWAYS DISAGREE by just looking at my comments on this thread:

“I agree that in addition to using medications to alter one’s mood, a person must also face the underlying causes of their psychological distress, which could include a maladaptive coping style, interpersonal conflict, role transition, and other psychosocial factors” (December 16, 2008 09:23 PM).

“I do agree that definitions of normality are problematic in any area of human inquiry, because the word “normal” has a variety of meanings, and each of those meanings has various connotations and implications” (December 17, 2008 08:34 PM).

“I agree that the subjective experience of unhappiness is not abnormal” (December 17, 2008 08:34 PM).

“I didn’t comment about your suggestion to use formal cognitive testing, because I happen to agree with you” (December 21, 2008 04:48 PM).

“I happen to agree with you that there is a limited role for antidepressants in severe cases. I also agree with you that any form of treatment that ignores the biopsychosocial context that triggered the depressive symptomatology in the first place is foolish” (December 23, 2008 11:08 AM).

“I agree that there are elements of psychiatry that involve the use of power and force in the course of involuntary treatment in an inpatient setting, and that there has been a history of fraudulent research practices and deception on the part of drug companies and clinicians (e.g. “chemical imbalance” theory).” (January 5, 2009 04:12 PM).

“I agree that accepting Buddhism’s labelling does not imply accepting psychiatry’s” (January 6, 2009 02:33 PM).

“I actually agree with you that psychiatric labels, like all labels, are hopelessly incapable to capture the essential complexity of any human being, and that any reduction of a person to a single label is a gross injustice” (January 8, 2009 01:16 PM).

But you are probably right. I ALWAYS DISAGREE, and I am absolutely wrong that you use universal and general statements inappropriately.

Take care.

Posted by: dguller at January 10, 2009 10:00 PM

Paul:

It’s been three days since I posted this, and I’d appreciate a reply:

“Since you are such a stickler about my “affliction of misquoting”, I would love for you to justify your claim that I have “academic interests” in “curries and poisoned water sources”, Mr. Mumbai-curry-is-better-than-London-which-is-better-than-one-in-the-market.

“Also, I still note that you have not answered whether you, as a practicing physician, consult psychiatry when you have a patient with psychiatric symptoms, but a negative organic work-up. It’s been a few days now, and I’m starting to wonder why you are avoiding this issue.”

Take care.

Posted by: dguller at January 10, 2009 10:03 PM

Give your ego a break Guller , it might do you good...
I was referring more to your obsession with having the last word..
"Defiance" does not equate as "superior knowledge"..

;)

Posted by: truthman30 at January 11, 2009 06:09 AM

DGuller,

Why are you hounding Paul about not answering the question of consults? It is obvious he isn't going to answer and besides, just because someone has a negative organic workup, doesn't mean that nothing isn't wrong medically.

.

I wish I had a nickle for every horror story I have heard about people who were told nothing was wrong and were told to see a psychiatrist only to find out later, that they had something wrong and many times, it was very serious. This happened to a co-worker.

Anyway, if someone doesn't answer a question after you have asked them 2 or 3 times (I am not a good counter like the rest of you:)), in my opinion, it is time to stop asking.

AA

Posted by: AA at January 11, 2009 07:36 AM

Subjective experience of unhappiness is not abnormal.

I wonder what is objective experience of unhappiness means.

Posted by: Ana at January 11, 2009 07:50 AM

Paul:

Oh, and one more thing, and this has to do with your demand to exactitude and your harsh criticism of misrepresentation on this website. You have stated that you refuse to engage with me in a discussion, because “it is entirely too time consuming to constantly correct your misstatements of my comments”. That is very interesting, because I actually reviewed our recent discussions, and found something very intriguing.

You explicitly corrected a misinterpretation of mine of your comments three times in the “Charles Nemeroff Agrees …” thread (December 28, 2008 09:24 PM; December 30, 2008 07:55 AM; December 30, 2008 11:34 PM) and once here (January 7, 2009 01:35 PM), meaning that you have explicitly corrected my misinterpretations of you FOUR TIMES. How many comments have I addressed to you? SEVENTEEN. How many comments have you addressed to me? Seven from the “Nemeroff” thread, and five here, making a total of TWELVE.

Therefore, you have corrected my misquoting your comments in exactly 25% of your posts (4 out of 12), and I have misquoted you in exactly 23% of my comments directed to you (4 out of 17). The numbers are actually even lower, because most of what we both wrote in our posts had nothing to do with the few sentences that I misinterpreted of yours and that you corrected in your comments.

CONSTANTLY CORRECTING my misstatements, eh? How bad of a misrepresentation and exaggeration is THAT? I suppose you made your remark in “a foolish manner”, and that “you must be daft or is English not your native language?” I suppose “you just made that up out of whole cloth. You misquoted me and added a complete fabrication of your own” and have “misinterpreted and misconstrued” what was said. Those were the snide and insulting remarks that you made about my mistakes. I wonder if you will describe your conduct in a similar fashion?

Take care.

Posted by: dguller at January 11, 2009 08:21 AM

If I had not already decided (due to 14 yrs of damage) never to see a psychiatrist again, the comments FROM psychiatrists on this website would have clinched it. I would be thoroughly scared to death with their sociopathic ways. I would not take the chance of seeking help knowing it could be someone like this.

If the intent was to bring balance to the points discussed on here; it has utterly failed.

This specific thread is giving me flashbacks to my marriage (13 yrs ago) to an emotionally & verbally abusive alcoholic; although, he wasn’t as dangerous because he didn’t disguise himself with a suit and an M.D behind his name.

Posted by: Becky at January 11, 2009 08:42 AM

truthman30:

Again, just be a little more careful with what you write here, because you might mean one thing, but the words you choose may have other meanings that you may not intend.

This is not about my ego, but about language. You yourself stated above that "words are powerful", and thus we must all be careful about which words we choose to use. When you imply that I have a disorder based upon some diagnostic criteria, then you better be sure that I have actually acted in a way commensurate with that criteria. You can be sure that I will point out to you if I have not.

And as for my need for the "last word", I reserve my right to reply to any comments that I believe contain falsehoods, just as you are free to do the same.

Finally, I wonder why you often are reduced to insulting my character and integrity in an ad hominem logical fallacy rather than simply admit that you may have been incorrect in your choice of words. I have often admitted when I am wrong and when I agree with people on this website. That is certainly not identical with pathological behaviour. I wouldn't even call your behaviour here pathological, only immature and silly.

Take care.

Posted by: dguller at January 11, 2009 11:29 AM

Becky,
I was just going to post in response to our friend Mr. Guller's last posting to Paul that he (guller) seems to have ridden off the rails at this point. But you said it so much better than I was going to. These people really ARE sick.

Wouldn't it be nice to put them all on a big ship, tell each one of them they're The Doctor and everyone else is The Patient, then tow them far out to sea and set them adrift? Not only would they no longer be able to hurt anyone, it would make for the world's greatest reality show!

By the way, dguller, I don't think "psychiatry is intrinsically evil, because it endorses the use of psychotropic medications". I think it's intrinsically evil because it endorses the notion that one person is entitled to have an inordinate amount of power over another. It amazes me that you have spent as much time on this site as you have, that you claim to "hear" us, and yet you still don't understand that it's the illegitimate power imbalance to which we object. The drugs are only part of the picture. If this were the 30's we'd be objecting to insulin shock, etc. It's the enforcement of illegitimate power that's the problem with your profession.

The fact these people who wield this power are no healthier than we are--you just have more socially acceptable pathology (oh, I forgot, you get to DEFINE the pathology)--makes your profession even more unacceptable to thoughtful persons who've been forced into complying with your professional "norms".

By the way, speaking of time spent... does your boss know how bloody much time you waste here arguing with people who'll never agree with you? That alone is pathological enough to raise my radar. I make no big claims to mental health or wise use of my time. But you do. And yet... you're still here, tilting at windmills. Wouldn't you rather be bowling?

Posted by: Sherry at January 11, 2009 11:32 AM

AA:

You raise good points, and this will probably be the last time I ask, but I can assure you that I had good reasons for persisting in that line of questioning.

Take care.

Ana:

That is a GREAT point.

"Subjective experience" is a little redundant, no? I guess what I was driving at was our individual experiences of private mental states as opposed to an "objective" experience of a shared physical object, e.g. several people watching a show. But ultimately, you are right, "objective" experiences in this sense are also irreducably subjective in each person's mind. :)

Posted by: dguller at January 11, 2009 11:35 AM

Becky:

Suppose someone argues that George W. Bush is a terrible president, because he has publicly strangled puppies. If another person argues that George W. Bush has not publicly strangled puppies, then it does not follow that they disagree that George W. Bush is a terrible president, but only that using the point that he has publicly strangled puppies is false and irrelevant to the discussion.

It is identical to what is happening here. I agree with most of the criticisms of psychiatry here, and have said so on numerous occasions. However, if someone argues against psychiatry using falsehoods and poor logic, then I will tell them so. It does not follow that I believe that psychiatry is pure and free of fault, but only that that particular line of argumentation is not valid in this discussion.

That's all.

I would have thought that those who are anti-psychiatry would be grateful for the weeding out of bad arguments, which would only leave better and stronger arguments for their position.

Take care.

Posted by: dguller at January 11, 2009 11:43 AM

Sally,

I know what you mean. I asked multiple times (to no avail) if I could have some toothpaste & a toothbrush. We had to make goals in Goals Group, so my goal was to obtain hygiene products. They told me I had to come up with a different goal. I guess they didn't want to write that down in my medical record.

Paul,

At least in the hospitals I was in they did care that we attended those idiotic groups. Those who refused to participate in the groups were labelled noncompliant with treatment. I think a lot of that had to do with the fact that they couldn't bill for the service if we didn't attend.

My shrink pretty much said what you did in that he only cared about the medication. He admitted that the groups were a complete waste of time & didn't care if I attended them or not. However, he didn't have to cajones to say that to the staff.

Needless to say I don't support in patient treatment for depression, because all they did was make a bad situation a shitload worse.

Posted by: Lisa at January 11, 2009 11:44 AM

"If I had not already decided (due to 14 yrs of damage) never to see a psychiatrist again, the comments FROM psychiatrists on this website would have clinched it."

Becky,

I feel the same. That's why it's good to keep on discussing, they keep on talking. lol
The only problem is that I don't believe that a potential patient will read it all and might read one sentence here and there.
The authoritative titles are amazing!
I'm also having flashbacks that's why I don't read it all.
I'm on the verge of having a real trauma.
Seriously, I'm becoming more and more afraid of psychiatrists.
Sometimes when I take a nap I wake up with the strange feeling that I was searching while how to explain all we are trying to explain here.
The anecdotal part of the thing:

"In medicine anecdotal evidence is also subject to placebo effects[12]: it is well-established that a patient's (or doctor's) expectation can genuinely change the outcome of treatment. Only double-blind randomized placebo-controlled clinical trials can confirm a hypothesis about the effectiveness of a treatment independently of expectations.

Sites devoted to rhetoric[13] often give explanations along these lines:

Anecdotal evidence, for example, is by definition less statistically reliable than other sorts of evidence, and explanations do not carry the weight of authority. But both anecdotal evidence and explanations may affect our understanding of a premise, and therefore influence our judgment. The relative strength of an explanation or an anecdote is usually a function of its clarity and applicability to the premise it is supporting. [1]

By contrast, in science and logic, the "relative strength of an explanation" is based upon its ability to be tested, proven to be due to the stated cause, and verified under neutral conditions in a manner that other researchers will agree has been performed competently, and can check for themselves."

This is at wikipedia. It was for a post I gave up writing.
I'm giving up.
Statistics made this way deals with quantity not quality.
I believe we should volunteer to one of these clinical trials where anecdotal evidence is being tested.
Is there any?

Unfortunately we cannot have Traci Johnson, Sarah Carlin, Candace Downing, Eric Harris, and so many anecdotal evidences.
That is amazing!
"Stories", not even statistics, the death of these children is called.

Posted by: Ana at January 11, 2009 01:44 PM

Lisa,

Ah yes, billing. How could I have misplaced that little tidbit. Higher functioning people have a very hard time with in-patient treatment as it is so infantile. I visit one unit where I found a copy of Catch-22 squirreled away on a shelf that served as a library. I made a point to carry it around with me that day and replaced before I left. I wonder if anyone appreciated the deepest irony of it all...

I once sat in a therapy session where the rn/therapist asked a person felt about just having lost a commitment hearing. He responded (paraphrasing): "what kinda stupid ass question is that you fucking moron? " It took every fibre not to laugh out loud with the rest of them. Unbelievable some people...

Posted by: Paul at January 11, 2009 04:15 PM

Being anti pharma lies and anti-buried data, and anti-pharam reps, and anti-drugging of children, etc doesn't make ppl antipsychiatry. There's a lot of ppl commenting here who have been to the bad ass side of psychiatry and back (I'm one of them) and are here reporting back what hell it was, and for some in withdrawals still is, and for these ppl, this forum is a place where we can gather and know we are not alone in this shitty world. I also wonder what possesses a doctor to spend so much time arguing with patients and other doctors here, it's not too professional looking and makes some doctors look like fools.

Posted by: Stephany at January 11, 2009 04:53 PM

Errata:
Sometimes when I take a nap I wake up with the strange feeling that I was searching while sleeping how to explain all we are trying to explain here.

Hi Stephany!
I came to see what you've written.

I'm glad you're better.
Hope Philip is better too.

Guess who is next?

Posted by: Ana at January 11, 2009 05:38 PM

Lisa, I have bead bracelets by the dozen from making them in "therapy" with my daughter in the psych wards and the costmetic kit was from Lilly! (you probably already know this)I've made ceremic tiles that now grace the halls of one ward, and Paul--unbelievable how there is no library worth reading in the wards, there were only bibles in one with my daughter and then psychiatrists would say the person was psychotic if they were reading it and quoting it. Hell it was the only thing to do besides TV!

Not to mention outside time was taken away if non medcompliant! I truly believe after a decade and experiencing several psych hospitals with my daughter that those places serve NO purpose other than shutting ppl up and drugging them into silence. Women were restrained and forcibly injected with Haldol...it's what I can't forget and why I won't stop speaking up.

Posted by: Stephany at January 11, 2009 06:10 PM

Sherry:

First, you state that psychiatry is intrinsically evil, because “it endorses the notion that one person is entitled to have an inordinate amount of power over another”. Do you object to all forms of human institutions where “one person is entitled to have an inordinate amount of power over another”? Or, is there something specific about psychiatry's power imbalance that you object to, and if so, then what is that "something specific"?

Second, you are correct that many practitioners in the mental health field are not beacons of mental health themselves, and thus it is a bit hypocritical for them to not practice what they preach. It would certainly boost their authority if this was not the case, but it does not decrease from the validity of what they are recommending. In other words, if a thief told you that it was wrong to steal, then he would certainly be called a hypocrite, but he would not be called a liar.

Third, I post here during my free time at work, and sometimes at home. I don’t think my boss would mind. :) Oh, and I don’t bowl. :)

Thanks, and take care.

Posted by: dguller at January 11, 2009 07:34 PM

Stephany,

It is peculiar that religious books would be placed in environs where increased religiosity is considered symptomatic.

I agree with your assessment. Patients aren't generally considered stable unless they are medicated. The only way to avoid medication seems to be cheeking or prevailing in court. I've never seen an exception to this - never. I've seen many who have tried to reject medication punished through curtailing of privileges, legal proceedings, and veiled threats, however.

Paul

Posted by: Paul at January 11, 2009 10:53 PM

Paul:

You wrote: "Patients aren't generally considered stable unless they are medicated. The only way to avoid medication seems to be cheeking or prevailing in court. I've never seen an exception to this - never. I've seen many who have tried to reject medication punished through curtailing of privileges, legal proceedings, and veiled threats, however."

I think that you have to specify what psychiatric conditions you are referring to. Yes, those who are acutely psychotic or manic are always treated with medications after an organic work-up is completed. That is what the guidelines say.

However, there are patients admitted to the inpatient unit who present with anxiety or depression due to concrete life stressors that are often not offered medications, if they stabilize on the unit. I've discharged several people who just needed crisis stabilization in a safe environment with validation of their plight, and outpatient referral to therapy, support groups and other community resources, but did not require medication while hospitalized, except maybe sedatives to help them sleep.

Just wanted to offer some clarification.

Take care.

Posted by: dguller at January 12, 2009 04:43 AM

Happy birthday to you...

........dear thread
Happy birthday to you!

Posted by: Ana at January 12, 2009 04:57 AM

Stephany:

First, I agree with you that being against the pernicious influence of drug companies upon physicians in general, and psychiatrists in particular, does not necessarily imply that one is anti-psychiatry. I was specifically replying to Becky who expressed her wish to put all psychiatrists onto a boat and send them all off to sea to they could not longer hurt anyone. That, to me, expresses an anti-psychiatry viewpoint, which I was responding to.

Second, instead of attacking my intentions, why not just answer my points? I agree with people most of the time here, and only dispute a few points that I believe are false. I do not invalidate the suffering of the people here who have been harmed by my profession, but I do not allow their suffering to justify their use of falsehood to slander me and my colleagues.

The problem is that there are some visitors to this website that view themselves in an all-out war with psychiatry, and feel that they cannot give any quarter, no matter the circumstances. So, when I attack one of their arguments or positions as false, they perceive me to be attacking a core belief of their perspective, and thus they must defend it at all costs, and feel that if they admit that I may be correct about anything, then their cause has somehow been compromised. That is manifestly untrue.

It is like being in a war and choosing to spend your resources defending land that is deserted, inhospitable and useless rather than those that are fertile and populated. Why not just get rid of the useless land (i.e the false facts and poor arguments) and focus on defending the rich land (i.e. the true facts and good arguments)? Why does this almost always have to be a zero-sum game? Why can’t people just admit that some of their facts are wrong and some of their arguments are not valid or sound? It does not imply that their entire position is false. Some of my facts were wrong and some of my arguments were pretty shitty, as was profitably pointed out to me on this website. I accepted this fact, and moved on to improved positions. That is what people who seek the truth do.

But to attack my intentions, my character, my integrity, and my psychological health (not necessarily by you, but certainly by others on this site)? That certainly should have no place in any discussion, because it reeks of fallacious reasoning.

Take care.

Posted by: dguller at January 12, 2009 05:02 AM

Lisa, Paul, Stephany, et al,

Cheeking was only possible for me because a)I possess an apparently unique talent, holding a pill under my tongue while swallowing a glass of water; b) my ex-husband's favorite movie was "One Flew Over the Cuckoo's Nest" - this place really was like that except that there were more than one Nurse Ratchett and that role wasn't always played by a woman or a nurse; and c) the first night I was there, after I realized my friends weren't coming with a lawyer that night (it took them a few days, it was late Friday night), I took the handful of pills I was given. Of course, among other things I was haldoled, and hence when I recovered decided never to take another pill again in that place. Meanwhile, I'd hate to think what kind of torture would be doled out there to someone caught cheeking. And this is all purportedly treatment for mental illness, this brutal torture.

Meanwhile, as I was begging for access to the internet to pay my bills and complaining that not only did I not consent to inpatient "treatment" but I was sure I couldn't pay for it, I was written up for "wanting to talk about non psychiatric problems."

As for group therapy, after I started cheeking, I won bingo ($700.00 an hour for Bingo, mostly billed to medicaid as everyone committed for 6 months automatically qualifies for ssdi or ssi). It was pretty obvious that the only reason I was winning Bingo was that I was not doped up like the other "patients," hence I stopped winning. Of course the prize for winning was an inspirational Christian book. I was written up for religious delusions of some sort, for reading that book I suppose.

I did make a scary clown painting in arts and crafts, a kind of paint by numbers thing, at $500.00 a day. These places aren't just concentration camps, they're also fraudulent billing factories. The psychiatrist that admitted me also worked at a nursing home where it was determined they were billing the government for dead patients.

And as Paul mentions, patients aren't generally considered stable unless they're medicated but, I add, they're medicated to the point that they're not lucid and thus not stable. These places don't want to cure that want doped up, compliant hostages for which they can bill.

These places are horrible, have absolutely no oversight because once you're labeled mentally ill you simply don't exist as a witness. Scary stuff.

And no, it's not the drugs I object to, it's the involuntary intoxication, the haldoling and then writing up flat affect as a symptom, etc.

Posted by: Sally at January 12, 2009 06:22 AM

And... they ask patients what day it is, with no calendar in sight! When I was visiting my daughter a patient asked me what day it was because he said he was going to court and if he didn't get the day right he wasn't going to be discharged. I made sure he knew the day of the week, the month, the year. All of it. He walked around with an enormous science text, the guy was brilliant. Another young man who played chess with my daughter demanded to be released, and said these poignant words to the doctor: "we are more than chemicals." I saw him a few months after that in Target store. He recognized me and asked where he knew me from. I said, "Art therapy", and he burst out laughing, we knew where that was....and he was thrilled to know my daughter was out and he was off drugs and doing fantastic.

Posted by: Stephany at January 12, 2009 09:50 AM

one more thing about the psych hospital topic and insurance: my daughter's private insurance ran out of lifetime inpatient stays (that is LIFETIME)and she, by age 18 has been on Medicaid. Which feels weird to me, like I couldn't provide for my child, and then because of a decade of medical bills and out of pocket for her care, I'm wiped out--bankrupt officially now. Just to get this care for my child, and she is not well! It's very frustrating, and she is living proof the drugs don't stop but actually I believe make psychosis worse.

Some days, the art therapy classes...I would sit there and see all of us (they wanted me to participate with my daughter because she did more artwork when I was with her)--I would sit there and wonder why I was seeing some of the same ppl over and over again,--revolving door patients--it's because the paradigm in place now does not work. simple as that.

Posted by: Stephany at January 12, 2009 09:56 AM

fallacious reasoning

Wow!

We have already heard that!
I love it!

For he's a jolly good fellow, for he's a jolly good fellow
For he's a jolly good feeeeellow......, which nobody can deny
Which nobody can deny, which nobody can deny
For he's a jolly good feeeeeellow......, which nobody can deny!
nobody can deny!

I'm still parting!
I'm so happy with this birthday!

Posted by: Ana at January 12, 2009 10:39 AM

Sally,

Great points. It's amazing what you can learn from in-patients veterans. That's how I learned of cheeking myself. It takes a little practice, but it's not too hard to do. I never saw anyone caught doing it, but I can tell you what the penalty would be: open mouth and lift tongue followed next time by injectable forms if need be - depending on (in)voluntary status, of course.

I have to admit, I am impressed that you were able to keep your wits and use them to your advantage. In-patient can be very scary and intimidating. It's hard to find a person you can trust in these situations, but sometimes you can find a veteran who can help you avoids mistakes. The problem is that few people would ever consider planning ahead in the event they find themselves in a psychiatric hospital.

I sense a book in the making...

Fond regards,
Paul

Posted by: Paul at January 12, 2009 03:45 PM

Stephany, I bet that was one expensive bracelet!

Paul, Catch 22 is the perfect book for inpatient psych treatment. Everything is ass backwards in a psych hospital. Common sense is not allowed. They really need to stop treating adults like children - it's creepy.

Dguller is correct in that meds are not given to every patient. My first experience in patient I was not given meds, but that is because I had no documented h/o mental illness. Chances are if a person admits to having seen a shrink before, they'll be getting meds.

Sally, $700 for bingo? I hope you at least won a nice prize? I had Blue Cross/Blue Shield at the time & they were billed $85 for 10 minutes of the board game Scattegories - I forget if that was the discounted amount or not.

Posted by: Lisa at January 12, 2009 03:58 PM

I must say that due to being inside all of the local psych wards where I live including private hospitals, wards inside medical hospitals, the county facility and the state institution: I would never, EVER check myself into one. Sadly, I know this from having seen the inside of them with my daughter. Learning from a child's experience, as a parent truly sucks.

Posted by: Stephany at January 12, 2009 04:51 PM

Guller..

Instead of nit picking every facet of every comment on the threads here, don't you think it would be more constructive and useful if maybe you tried to understand why the concept of "anti-psychiatry" exists? ..

Posted by: truthman30 at January 12, 2009 04:53 PM

Sally said, "And as Paul mentions, patients aren't generally considered stable unless they're medicated but, I add, they're medicated to the point that they're not lucid and thus not stable."

This is true. When I requested to leave the nurse scurried away to get a pill for me to swallow. I guess her plan was to medicate me so I would be unable to sign the AMA form & drive home. Sneaky bastards. But, I didn't take the pill.

Posted by: Lisa at January 12, 2009 04:58 PM

truthman30:

You wrote that I am "nit picking every facet of every comment on the threads here". Sigh. You really don't get it about overgeneralizations, do you? How can I take you seriously when you misrepresent the facts so egregiously? And as for my understanding anti-psychiatry better, why don't you help me understand it using a little logical fallacies as you can?

Take care.

Posted by: dguller at January 12, 2009 05:17 PM

Lisa,

I did win a prize in Bingo, which of course scared me as I thought I wasn't acting sedated enough. The 700.00 was just for me, one person in group.

It certainly appeared that everyone on my floor was getting meds, but I couldn't be sure.

Paul,

I was able to call friends before the sheriff's deputy took me away and I was between my second and third years of law school when this happened. I think my family assumed I would be so hysterical about being taken unexpectedly that I'd panic and really become hysterical. All over a property dispute - you know the probate judge both commits and handles deeds, scary how common what happened to me probably is.

My friends got me out on a Friday and I started the 3rd, i.e. final year of law school, the following Monday, no psych meds and graduated!

One of my favorite moments was when a particularly hostile, sadistic, incompetent psychiatric nurse came to get me in the TV room. My phone privileges had already been taken away because I received too many calls, even though I was admitted partly on my family's complaints that they were my only support system, so I was simultaneously held for not having friends and punished for having too many friends, but back to the point, the nurse said, "there's a man on the phone claiming to be one of your law professors." Damned if it wasn't. My friends had called the prof I told them it was okay to contact. Things moved a bit faster after that and my phone priviledges were restored.

Meanwhile, the other inmates of the ward weren't so lucky. Tragic.

Posted by: Sally at January 12, 2009 05:18 PM

Sally,

You are indeed blessed with good friends. It's very hard if you don't hard support from the outside. Staff views you as suspect or compromised, so it is so very critical to have persons on the outside you will strongly advocate for you. Again, no one plans for this eventuality so most people find themselves trapped and scared.

Later in life you consider living wills and such, but I should think anyone of legal age should secure some sort of advance directive to protect themselves should they run afoul of Psychiatry.

No one is immune.

Fond regards,
Paul

Posted by: Paul at January 12, 2009 06:41 PM

dguller,
Why do you want to be part of a discussion in which argumentation are fallacies and based on perspectives, not experiences?

I don't understand why you're here for two months.
I would like you to answer me what do you think of Philip's work and if you have voted for this blog.

Are you on vacations?

Posted by: Ana at January 12, 2009 07:17 PM

dguller,
I can tell you this: your argumentative, didactic communication style cuts off communication. And this is a really serious issue, considering your professed choice of occupation.

Case in point: I find myself second guessing the above, wondering with which verb or adjective you will find fault and rush to "correct". What flaw in my logic or speech pattern will you find next, you little nitpicker you?

Can you not see how detrimental this is to any hope of communication? The rest of us sure can.

Can you tell me why you find it necessary to correct our logical lapses, in the name of "helping" us to argue our case better--although no one here has ever asked for this "help" and many of us have asked you to PLEASE STOP? Has anyone here ever, even ONCE asked for this "help" you so blithely offer?

Are you really this unaware of or unconcerned about the effect your communication style has on your fellow human beings?

The longer you stay, the more you argue arcane points of law, the more mystifying your presence here becomes. You don't engage in conversation, you engage in debate--to an obdurate degree. It seems to be your only style of communication. Which wouldn't be a problem at all if you were an auto mechanic or graphic artist. But you're not, are you?

Posted by: Sherry at January 13, 2009 07:26 AM

I highly recommend the work of Mary Ellen Copeland. You can Google her. She's into teaching people how to make specific advanced directives for their mental health issues. She's also into relapse prevention utilizing good symptom management. It's actually very similar to relapse prevention I've seen in alcohol recovery. It worked very well for me, although it took me a year or two to really get the hang of it properly.

Now that I'm feeling much better I realize the legal danger I'm in due to the shopping bag of diagnoses on my psychiatric Permanent Record. None of them, of course, include my hypothyroidism or Vitamin D deficiency, which turned out to be the two main culprits (along with a bad gall bladder). Those are on my family doc's record. I've watched the pdocs rip him a new *sshole often enough to know where he stands on the totem pole. Nice guy, no power.

I, of course, have no power as a mental patient. Once I have that Magic Bracelet (hospital ID) on I'm someone to be discounted no matter what I say. It's amazing what a simple change from one side of the desk to the other does to one's credibility.

I'm thinking I need to do one of Mary Ellen's plans. I'm also thinking I need to find a lawyer who specializes in disability issues. One relapse into depression--and if my husband were to die, wouldn't that be a NORMAL reponse???--and I could end up on a locked ward with few civil rights very, very quickly. The skids are all greased, thanks to our little inept-in-diagnostic pals in the psychiatry profession.

Posted by: Sherry at January 13, 2009 07:53 AM

Ana:

First, I think Philip is doing wonderful and important work. My rare criticisms of some of his posts are about certain facts that he reports, particularly about study results. That's all. I think that it is important to present things properly in order to make the best case one can for one's position, which should exclude fallacious reasoning and falsehoods. I don't think that's an unreasonable position to take.

Second, I think that using one's personal experiences are perfectly legitimate, but that this approach contains problems, including those that plague anecdotal data. That is not to say that controlled trials are perfect, because they aren't, but well designed controlled trials are superior to anecdotes. I hope that helps answer your question. :)

Take care.

Posted by: dguller at January 13, 2009 07:58 AM

Here is Information on creating an Advance Psychiatric Directive from Bazelon Center for Mental Health.

"If you are concerned that you may be subject to involuntary psychiatric commitment or treatment at some future time, you can prepare a legal document in advance to express your choices about treatment. The document is called an advance directive for mental health decisionmaking."

Posted by: Stephany at January 13, 2009 12:17 PM

"well designed controlled trials are superior to anecdotes"

"Anecdotes" Mr Guller... are you calling our personal experience of psychiatric drugs mere anecdotes? How patronizing , particularly considering you don't take them yourself..

The studies you talk about are never objective Guller, they are designed to inflate the positives and suppress negatives ..

When independent studies are done and if they show adverse reactions and dangers with psychiatric drugs, your corrupt colleagues rally together with their pharmaceutical industry masters and attempt to discredit the findings!

WE ARE THE LONG TERM STUDY GULLER
AND WE ARE TELLING YOU THESE PSYCHIATRIC DRUGS ARE DANGEROUS !
WHEN WILL YOU START LISTENING!!!!!!!!!!!!!!!!?????????????

Posted by: truthman30 at January 13, 2009 02:28 PM

dguller,
Your answer, as always, doesn't have any effect on me.
Whenever I read something from you I don't see anything, it makes no difference.
I have nothing to say to you, you say nothing to me.
The only thing I notice is the way you write.

Joe Doe,

First,
Second,

blah blah blah... However.... blah blah...
Third,

Take care.

It's funny. I'm very sorry but I find it funny because I've seen people using this formula in my social networking life that have other issues. Without exception what they had to say didn't affect me.
I have seen the "Take care" advice expressed in many ways even as "God Bless you" - it was in Portuguese.

But keep on writing. You didn't answer all my questions but I understand.

Posted by: Ana at January 13, 2009 02:46 PM

"I can't believe I'm still talking about my weight."
Larry King reported Oprah's problem and someone has e-mailed him claiming that Oprah was depressed but in denial.
The most amazing was seeing

Oops!

Sorry!

I thought I was on the other blog.

Sorry Philip!

Posted by: Ana at January 13, 2009 02:51 PM

This thread has been going on on a daily basis for over a month. I don't think it has anything to do with the original post. I would like to recommend that everyone here stop addressing comments or responses to dguller and to disregard his logical contortions, nitpicking, and faith in scientific studies as published in medical journals. Let him keep on responding to Philip's posts or whatever turns him on but don't keep feeding this frenzy. It's really not constructive or healthy for anyone concerned. Just my two cents but I'm concerned at how aggressive the discussion is on both sides. It's very unpleasant from what little I see.

Posted by: Sara at January 13, 2009 03:45 PM

Sara,
Agreed. Thanks for your input.
Sherry

Posted by: Sherry at January 13, 2009 04:10 PM

Yeah, and I also agree with truthman that we are the long term studies.

Posted by: Stephany at January 13, 2009 04:59 PM

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