May 13, 2013 · 1:54 PM

Revolution: NIMH turns away from the DSM

dr-insel-2011

Thomas R. Insel, MD, director of the NIMH

Two weeks ago, National Institute of Mental Health director Thomas R. Insel, MD announced a revolution. The world’s largest mental-health research organization will no longer fund studies based solely on Diagnostic & Statistical Manual (DSM) diagnoses.  If, “NIMH will be re-orienting its research away from DSM categories,” sounds less subversive than, “Give me liberty or give me death,” pay attention.  The whole system of diagnosis may be upended.

The Golden Rule: Those with the gold make the rules.

When insurers began to require a DSM diagnosis,  the American Psychiatric Association (APA) cornered the market in mental health nosology. No other U.S. group has had the money, staff and interest to create a competing system.  Ambitious alternatives such as the Psychodynamic Diagnostic Manual settled for expanding on the existing design. The APA, which has earned an estimated 100 million dollars from the DSM, flaunts their monopoly in  DSM-5′s $133 cover price. By comparison, Thomas Pynchon’s “Against the Day“  is 112 pages longer,  1/10th the cost and exponentially better-written.

Forbes’s Matthew Herper believes DSM’s diagnostic weaknesses have led to failed drug trials, and so is one reason for Big Pharma’s shift from developing new psychiatric medications.  The NIMH’s 2013 budget totals nearly 1.5 billion dollars. Insel’s ready to spend some of that towards more valid diagnoses.

Reliability vs. Validity.

The last time the DSM was reformed, rather than revised, Robert Spitzer was chair and reliability was weak. Psychiatrists could only agree on a diagnosis  20% to 40% of the time.  Spitzer’s goal was for different assessors to reach the same diagnosis from the same facts as consistently as possible. He chaired contentious meetings of obstinate psychiatrists, and condensed the best opinions down to abstraction-free criteria of what a clinician could see and a client could report.  Reliability improved – some.

One offers valid insights into the human condition. The other is required by insurance companies.

One offers valid insights into the human condition.
The other is required by insurance companies.

Validity improved less. As the book defines Antisocial Personality Disorder, only three of seven criteria must be met for a diagnosis. It’s hard to argue this diagnosis describes an actual mental health disorder when it could fit two bad actors with nothing in common.   As Maria Konnikova points out, Spitzer’s subjective-observation-and report-only approach meant the APA bet everything on the least empirical source of data available.   While other fields of medicine have developed biological, physiological and genetic studies of physical diseases, the APA hasn’t kept up. Noted DSM critic Gary Greenberg tells the tale of how the DSM-5 committee rejected a proposed reinstatement of melancholia, in part because there was biochemical evidence it should be defined separately from depression.

RDoC: a system to break free of systems.

Also subversive and clever; an Omaha, NE punk band have named themselves "DSM-5".

Also subversive and clever; an Omaha, NE punk band have named themselves “DSM-5″.

To NIMH and many others,  the validity issue makes controversies over DSM-5′s changes as superficial and irrelevant as complaints about Bernie Madoff’s office décor.  In 2011, Insel announced the Research Domain Criteria (RDoC) project. This new approach defines disorders on multiple levels of data. Constructs such as negative affect, positive affect, cognitive processing and social-process systems would be tracked across dimensions of behavior, self-report, cells, genes and physiology.  Clients’ symptoms would be placed along a range from normal to abnormal, instead of being forced into discrete categories. If new influences on emotions and behavior are discovered, new layers of information can be incorporated into the model. Research projects involving DSM diagnoses will still be accepted, but researchers will be expected to think in broader terms than subjective assessment of symptom clusters.

Insel denies that RDoC is meant to replace the DSM-5. The NIMH is already developing “walk-across” list to align DSM and RDoC diagnoses. Given that RDoC 1.0 is probably years from public release, even critics as sharp-tongued as Allen Frances concur that the DSM is the best system of diagnosis clinicians have now.  None of that changes the existential threat to the APA’s subjective-observation-only model. If RDoC rebuilds diagnosis’ operating system and obtains  more-valid results, will insurers’ money stay with the DSM?

 

@ 2013 Jonathan Miller All Rights Reserved

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May 2, 2013 · 9:04 PM

Hippocrates on Social Anxiety Disorder

Hippocrates of Kos (c. 460 BCE – c. 370 BCE)

Hippocrates of Kos (c. 460 BCE – c. 370 BCE)

I’m catching on that many Anxiety Disorder NOS diagnoses may be Social Phobia. To quote the Father of Medicine:

“(this man) … through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him.”

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April 14, 2013 · 11:34 AM

Stress Management Blogging #5

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April 9, 2013 · 10:22 PM

Invalidation at the Multiplex

... and invalidation won't actually toughen up your kid.

… and invalidation won’t actually toughen up your kid.

This week, I spotted ads for the upcoming After Earth at the local movie theater. Between the tensed faces of Will and Jaden Smith, the poster blurbs, “Danger is Real. Fear is a Choice.“

Oh, Hollywood. So much sex. So much violence. So little psychological accuracy. Any $275-per-hour L.A. psychologist could have told you: emotions aren’t a rational choice, any more than logic is an emotional impulse. To tell people otherwise is invalidating.

Invalidation happens any time clients get the message their emotions or beliefs are flawed, wrong or unimportant. It is more than just negativity: “You failed the test,” states a fact. “Don’t tell me you studied when you bring home an F,” invalidates all of the student’s effort.

Everyone can handle a little. What kid has never heard, “You can’t be hungry, you just ate”? Repeated invalidation leaves people in doubt about their emotions and themselves. It’s associated with poor social skills in children,  self-harm in teen-agers, psychological distress in adulthood and worsened rheumatoid arthritis in sufferers of all ages.  In cognitive-behavioral therapy, it takes a delicate touch to challenge clients’ beliefs without invalidating them as people. When people hear enough repetitions of, “You put the pressure on yourself,” “Let’s hold a pity party,” or “Stop being so dramatic,” they’ll start invalidating themselves.

New, hesitant clients often say, “Maybe I should just get over it.”  They’ve absorbed the idea they can fix their emotional issues by choosing not to have them. The trouble is, emotions are like pets and children. We’re each responsible for our own, but we control them indirectly at best.  If you start by believing anxiety means you are weak and self-indulgent, you can wind up certain you are a failure when it doesn’t go away.

C’mon, Tinseltown! How about a tag line like,

“Danger is real.

Fear is a normal, healthy emotion everyone experiences.

You can manage it effectively with  mindful acceptance and self-validation.”

That would be much more accurate, and only cut ticket sales by half.

n.b.: . Steve Hein, of EQI.org has a .pdf on invalidation for parents of teen-agers here. Worth a read.

@ 2013 Jonathan Miller All Rights Reserved

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March 25, 2013 · 8:07 PM

Hearts, Darkness and Chinua Achebe

The Nigerian novelist, Chinua Achebe,  died last week. Besides being, “one of the greatest writers of the 20th century,”  he was also a publisher, professor, deputy vice-president of a Nigerian political party and a stalwart champion for third-world writers. I studied under Achebe in undergrad.  In one class, he taught something invaluable for therapy practice.

Chinua_Achebe_- resized

RIP Chinua Achebe: November 16, 1930 – March 21, 2013

This day, we asked Professor Achebe about his famous critique of Joseph Conrad’s Heart of Darkness. First, we took deep breaths. The professor always spoke with quiet, measured dignity; so much so, it took courage once to tell him he was teaching next week’s book. Pulses calmed, we asked: was it fair to call Conrad’s masterwork racist? Didn’t  Kurtz’s character show it was Europeans who disgusted the author?

Gently, he explained we had missed his point entirely.

heartofdarknessAchebe told us about childhood in a Nigeria that was part of the British empire; where his schoolbooks taught the story of, “we Britons,” and the few Africans in storybooks were savages.  To him, it wasn’t the spears or loincloths that made these fictional natives sub-human.  He himself wrote a book in which tribesmen kill and eat a man, chatting casually over their meal. His point was speech. The only natives who speak aloud in Heart of Darkness, he said, are those under the ‘civilizing influence’ Conrad viewed with irony and despair.  The professor, a master of many languages, opined Conrad dehumanizes his natives because he limits them to animalistic shrieks and war whoops. At least Achebe let his cannibals talk.

In our first counseling class, we’re taught we should speak 30% of the time and listen 70%.  In session, we fight the urge to interrupt our clients and tell them how to fix their problems. A psychology professor told me in his years as a therapist, the lesson he’d re-learned the most was, “Shut up and listen.” Professor Achebe would have appreciated his effort. Clients often come to us because no one else will hear. Letting people talk can give back their humanity.

@ 2013 Jonathan Miller All Rights Reserved

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February 22, 2013 · 7:12 PM

Mindfulness vs. PTSD

The Washington Post reported this week on new studies addressing Post-Traumatic Stress Disorder with mindfulness. Research has already found regular practice may help those with PTSD recover faster. New findings suggest it may do even more.

Elizabeth A. Stanley, PhD, of Georgetown University

Elizabeth A. Stanley, PhD, of Georgetown University

Elizabeth A. Stanley, Ph.D is professor of security studies at Georgetown University. She’s not a psychologist, but she ‘s among those who’ve found regular mindfulness practice significantly eased their post-traumatic symptoms.  Per the Post’s article, Stanley’s new study tracked 320 marines through simulated combat training. The results showed those schooled in mindfulness weren’t just calmer during the exercises, they also responded faster to new threats.

This is crucial, says Tom Minor, a University of California at San Diego neuroscientist who was one of the researchers. “That was one thing we worried about: ‘Are we going to take a bunch of Marines and turn them into chanting monks who couldn’t generate a stress response?’ But they didn’t get too relaxed.”

“Too relaxed,” is a fear for many traumatized people. With a constant perception of danger, it can be unnerving to think one might be lackadaisical about threats. Clinical evidence that mindfulness reduces response time can be a major selling point to the hypervigilant.

Opens with the titular Vietnam vet practicing mindfulness in a Buddhist monastery. Discuss.

In the “Baba Rum Raisin” days of the late 1960s and early 1970s, meditation was peddled as a cure for everything. Skepticism bordered on cynicism. This article cites peer-reviewed, clinically-validated studies such as  Thomas F. Minor‘s research, which indicates meditation boosts the hormones that repair stress-related damage and decreases the chemicals that cause it. It also mentions Martin M. Paulus’ work that shows mindfulness boosts activity in areas of the brain devoted to awareness and control of emotions.  The sample sizes are too small and the results need to be reproduced a few more times,  but the findings on mindfulness and PTSD have started to verge on Maharishi-esque territory.

Of all the goodies in the Post article, the most tantalizing (and least empirically-supported) is the suggestion that mindfulness practice may reduce the risk of developing post-traumatic symptoms:

(Marine medic Del) Cochran says he believes meditation helped him stay much calmer during his second tour in Iraq. “The first tour, I was freaked out all the time,” he says. “There was so much static. With meditation, you’re much more in tune — what is a target, what is not a target. You are much more focused on what you are doing.”

Meta-analyses of studies of traumatized children shows pre-existing anxiety may increase one’s vulnerability to PTSD. Who wants to fund a study comparing PTSD rates among veterans from countries with a cultural tradition of mindfulness practice and those without?

Citations:

Kohn, David (2013, February 18) Mindfulness and meditation training could ease PTSD symptoms, researchers say. The Washington Post. Retrieved on February 22, 2013.

Examining the protective effects of mindfulness training on working memory capacity and affective experience. By Jha, Amishi P.; Stanley, Elizabeth A.; Kiyonaga, Anastasia; Wong, Ling; Gelfand, Lois
Emotion, Vol 10(1), Feb 2010, 54-64.
 

@ 2013 Jonathan Miller All Rights Reserved

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February 18, 2013 · 10:10 PM

Grief: Stages, Waves and Tasks

Clare Bidwell Smith has written a worthy essay on grief and anxiety, one that challenges Elizabeth Kübler-Ross‘s ‘bargaining’ stage:

Many of my clients immediately begin to assess their current state in terms of where they are with denial, anger, bargaining, depression, and acceptance. But while the stages were meant to be helpful, this is often where people begin to get confused. I don’t think I’m following the stages correctly, they’ll admit in a worried tone.

I don’t understand the bargaining part. I’ve been depressed for too long. I skipped the anger stage—is that okay? I don’t know where my anxiety fits in. These are the kinds of things I hear over and over again. In fact, I’ve heard them so often that I’ve now come to believe that when the five stages are applied to grief, bargaining should be replaced with anxiety.

Contemplating © 2013 by Anders Engelbøl

Not every mourner gets a soothing vista to grieve by.

Smith deserves kudos for drawing attention to anxiety’s role in grief. The loss of a loved one is a hole in our safety net. It reminds us of our own mortality. How does one not feel anxious about that? Her suggestion we make anxiety a stage of grief, on the other hand, propagates long-standing problems with the model.

For all of its cultural dominance, Kübler-Ross’s magnum opus has taken heavy fire. Bonnano, Wortman, et al (1)  found grief might take five different paths, including one of resilient recovery.  Maciejewski, Zhang et al (2) found symptoms of grief such as yearning, anger and depression rose and fell along overlapping curves, while acceptance rose along a steady upward slope.  Kübler-Ross herself freely admitted not everyone will experience each stage, the stages may not come in order, and that stages might recur once they’ve faded.  So, why describe grief in such terms?

A figure from Maciejewski and Zhang's research. While each psychological response peaks about a month apart, they all begin within three weeks of the loss and remain present throughout the process.

A figure from Maciejewski and Zhang’s research. While the first four ‘stages’ peak about a month apart, all begin within three weeks of the loss and continue nearly to the end. (see complete figure at the link)

James William Worden’s ‘task’ model drops the view of grief as a commuter ride on the Dysphoria Local.  Worden, professor at Biola University’s Rosemead School of Psychology, frames mourning as a set of chores:

  1. Accept the reality of the loss. Completely.
  2. Work through all of the emotions tied to the loss. All of them.
  3. Make all the adjustments needed to function without that person – inside and out.
  4. Find a way to maintain a link to the loved one, while you move on with your life.

Each task can be worked on a bit at a time. They don’t need to be completed in order. Anxiety, yearning, anger, depression? Each fits each task. No one needs to wonder why they still feel angry after being depressed for so long.  Worden’s model empowers our clients, because it makes grief a mission to complete, not a storm to be weathered.

The flaw in Smith’s plan to substitute ‘anxiety’ for ‘bargaining’ is the same that undermines Kübler-Ross’ model.  Symptoms like anger and anxiety rise and fall, but they don’t come in stages. They pervade the process. Let’s reassure our clients the loss of a loved one can be terrifying. Let’s not shoehorn that anxiety into an misfired concept like ‘stage’.

Citations:

1: Resilience to loss and chronic grief: A prospective study from preloss to 18-months postloss. Bonanno, George A.; Wortman, Camille B.; Lehman, Darrin R.; Tweed, Roger G.; Haring, Michelle; Sonnega, John; Carr, Deborah; Nesse, Randolph M. Journal of Personality and Social Psychology, Vol 83(5), Nov 2002, 1150-1164. doi: 10.1037/0022-3514.83.5.1150

2: Maciejewski PK, Zhang B, Block SD, Prigerson HG. An Empirical Examination of the Stage Theory of Grief. JAMA. 2007;297(7):716-723. doi:10.1001/jama.297.7.716.

@ 2013 Jonathan Miller All Rights Reserved

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