January 7, 2012 · 3:33 PM

PTSD is overdiagnosed – unless maybe it’s not

Salon.com ran an interview with Stephen Joseph, professor of psychology, health and social care at the University of Nottingham,U.K., and author of, “What Doesn’t Kill Us: The New Psychology of Posttraumatic Growth”. The headline? “How PTSD took over America”.  The subtitle? “The diagnosis is now being applied to everything from muggings to childbirth. An expert explains why it’s bad news.”  Interviewer Alice Karekesi asks questions like, “Do you believe that PTSD is over-diagnosed?”, “Is the emotional pain overblown in such cases?” and “Are there some cultures that are more prone to post-traumatic growth?”  One quick scan and I was ready to ask Dr. Joseph blistering questions such as, “How long does a client need to suffer before they can skip the ‘growth’ and actually get some help?”

Until I re-read his answers. And noticed that Salon and Joseph were talking about different things. Joseph doesn’t claim post-traumatic stress disorder is over-diagnosed. He explains the definition of PTSD has expanded, but doesn’t argue that’s a bad thing. He notes some say the DSM over-medicalizes the human experience, but doesn’t take a stand on whether it does or not.  The only “bad news” he explains in the interview?  People who have a normal reaction to an upsetting event may believe they have PTSD.

I’ll be reading Joseph’s book in the near future. Blurbs for the book suggest it’s not about diagnosis, but the way one can grow during recovery from trauma, and emerge stronger and healthier than before. If there are meaty chapters claiming that PTSD is over-diagnosed, you’ll read the full update here.

Political observers note media coverage is often driven by pre-established narratives – storylines and stereotypes that journalists (overworked, underpaid, overstressed and under-respected, by definition) fall into. Why did Candidate X get labeled as a flip-flopper when Candidate Y changed positions, too? Because it fit a storyline, including people’s perceptions of X’s character. The narrative here seems to be that if you say you have PTSD (or any other DSM diagnosis), it’s more likely you’ve inflated mild symptoms into a mental disorder because you’re weak.

DSM-V comes out next year. Watch for more of this narrative as May, 2013 approaches.

@ 2012 Jonathan Miller All Rights Reserved

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December 28, 2011 · 10:09 AM

Bill Maher illustrates the ‘Bias Blindspot’

In the subtitle of his new book, provocative HBO commentator Bill Maher illustrates an interesting cognitive trap. Princeton University’s  Emily Pronin, Daniel Lin and Lee Ross talked with their study subjects and explained cognitive biases such as the better-than-average effect, the halo effect, and the self-serving bias. Everybody got the idea quickly – everybody thought they were less prone to these biases than the average person.  A tip of the hat to Mr. Maher, who at least seems aware of his bias blindspot.

@ 2011-2012 Jonathan Miller All Rights Reserved

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December 24, 2011 · 6:29 PM

Logging cognitions: Not “what” but “when”

@ 2011 Lynn Cummings, http://www.lynncummings.com . All Rights ReservedIn cognitive-behavioral therapy, it’s hard to get clients to write down their automatic thoughts.  It’s easy to forget one’s pen and pad, and easier to feel self-conscious about jotting private thoughts in public. Even those who cope with those obstacles, still often wonder, “What am I supposed to write down?” It’s not that the therapist didn’t explain carefully, or that the client didn’t get the concept. Often, they hesitate because most automatic thoughts are about as profound as, “I wish this place had Wi-Fi.”

As David D. Burns, M.D.’s “downward arrow” exercise shows, thoughts that seem insignificant can grow from deeply-held beliefs. “I wish this place had Wi-Fi,” might imply a deeper fear of, “I can’t get what I need to do this report properly,  which might imply, “My report isn’t going to be good enough for the presentation,” which might imply, “I’m going to be fired.” The chain could lead to a core cognition of, “I’m a total incompetent doomed to financial ruination and abandonment by my family and friends.” A wish for an internet link wouldn’t seem worth reframing, but the fear your life will be ruined certainly does.

Clients can feel more comfortable about noting automatic thoughts if they compare them to sea spume. These tiny bubbles are no more than a few seconds’ worth of salt water and air, but they are created by powerful ocean waves. Those waves are made by winds, which blow because of the atmosphere’s heating and cooling; and by the tides, which are created by the gravitational pull of the moon.   Like automatic thoughts, sea spume is insubstantial froth that links directly back to massive forces.

Thoughts are usually emotionally loaded when they arise at a time of strong emotions. When client’s ask, “What should I write down?” it’s useful to say, “Don’t worry about ‘what’. Think about ‘when’.”

@ 2011-2012 Jonathan Miller All Rights Reserved

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December 17, 2011 · 12:01 PM

Sylvia Plath on Electroconvulsive Therapy, Pt. 1

A description of ECT poorly applied in the mid-1950s, from The Bell Jar, pg. 143: [i]

I tried to smile, but my skin had gone stiff, like parchment.

Doctor Gordon was fitting two metal plates on either side of my head. He buckled them into place with a strap that dented my forehead, and gave me a wire to bite.

I shut my eyes.

There was a brief silence, like an indrawn breath.

Then something bent down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant.

I wondered what terrible thing it was that I had done.

A note to clients: the use of ECT has really improved since then.

[i] Harper Perennial Modern Classics edition, ASIN B004N8X6LK

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December 12, 2011 · 8:15 PM

Why mindfulness works – The behavioral view

Photo @2005-2011 Juanita de Paola - http://www.juanita.it/

Experts have known since 500 BCE that mindfulness practice can lead to greater feelings of equanimity and contentment.  Mindfulness- based therapies have been part of western psychology at least since 1979, when Jon Kabat-Zinn opened the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School. Unlike many other “eastern” treatments, empirical studies have accumulated to support claims of effectiveness against depression[i] and anxiety disorders such as generalized anxiety disorder[ii], obsessive-compulsive disorder[iii], and even irritable bowel syndrome[iv].

What has been less well understood is how it works. Michael Treanor, of the University of Massachusetts published a meta-analysis[v] this February that suggests exposure is key. Since Joseph Wolpe’s time (and before), we’ve known if you expose yourself long enough to something that causes anxiety, your amygdala and sympathetic nervous system will (eventually) realize it’s not so dangerous. The difficulty has always been how to stay with the phobic object when every part of you wants to run. Treanor’s meta-analysis finds empirical support for the idea that mindfulness works as a conditioned inhibitor – meaning, in this case, it eases the urge to flee.

Treanor’s findings were anticipated in a 2005 article[vi] by Shapiro, Carlson et al. They defined mindfulness as choosing to focus one’s attention on the present moment, with an open, accepting attitude, and the intention of calming, exploring, or regulating oneself.  Marsha Linehan made it part of Dialectical Behavioral Therapy because it helped her chronically suicidal clients stay present with their emotions long enough to recognize and tolerate them.  For those overwhelmed by dysphoria, mindfulness can be like the difference between watching a football game from the 50-yard line, and being  tackled and trampled by players on the field.

Exposure, naturally, is the key intervention in Edna Foa’s prolonged exposure therapy, which is the U.S. military’s treatment of choice for Post-Traumatic Stress Disorder. This article tells how Sgt. Richard Low, a veteran of 280 combat missions in Iraq, recovered from PTSD symptoms with help from Sudarshan Kriya yoga:

When he came back from the service, he didn’t think his experience affected him in any major way. He had nightmares, and he startled easily, but he chalked that up to just something veterans live with.

Then he enrolled in a study he initially wrote off as “just some hippie thing,” where he learned about yoga breathing and meditation. A year later, Low, 30, sums up his experience with two words: “It works.”

Heads-up to tough guys of the world: Mindfulness is not just a hippie thing. It’s also a Shaolin Monk thing.

 

@ 2011 Jonathan Miller All Rights Reserved

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November 27, 2011 · 1:20 PM

Hypnagogia, misdiagnosis and Kermit the Frog

It’s a too-common newbie mistake: a therapist fresh out of grad school assesses a client who reports mild anxiety and maybe a little depression. Do they hear voices? Sure… every now and again. The poor client winds up misdiagnosed with Psychotic Disorder NOS, because the rookie assessor didn’t ask a crucial follow-up question: “When do you hear these voices?”

Hypnagogic  hallucinations are visual, auditory, or tactile hallucinations that occur while drifting off to sleep.  The term ‘hypnagogia’ is taken from the Greek for “inducing sleep”,  and was coined by Napoleon III’s librarian, Louis Ferdinand Alfred Maury. Bódizs, Sverteczki, et al [i] suggested that elements of REM sleep continue in the hypnagogic space between full wakefulness and true sleep. If they’re right (and follow-up EEG studies [ii] support the hypothesis), it would seem our dreams can briefly blend with our waking awareness, like a computer-generated movie monster matted in with the actors. Psychic researcher Frederic Myers noted something similar can happen when we wake, and termed this a hypnopompic state. The DSM says this part of the normal human experience, like the illusion of hearing someone call your name.  I won’t count any reports of hallucinations in bed as a sign of mental illness, even if the client insists they were wide awake at the time.

Necessary follow-up questions can fall victim to time pressures. In community mental health, the pressure can come from management less concerned about about  precise diagnosis than they are about meeting Medicaid timelines . In private practice, the pressure can come from clients impatient to move past formalities and start fixing their problems. A client’s eligibility to adopt a child or buy life insurance can hang on the question of, “Have you ever been diagnosed with…?” Misdiagnoses based on something as ordinary as hypnagogia can affect them long after their actual mental health problems are resolved.

How ordinary are hypnagogic hallucinations? Muppets have them:

Key lines come at the start of the third verse:

“Have you been half asleep, and have you heard voices?
I’ve heard them calling my name.”

@ 2011 Jonathan Miller All Rights Reserved

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November 24, 2011 · 4:46 PM

Can police peers prevent PTSD?

The DSM-IV-TR defines traumatic events (TE’s) as  “events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.” That’s a  fair description of  situations police officers might find themselves in every day. In Quebec, the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST) has found that police officers are less vulnerable to Post-Traumatic Stress Disorder than previously thought. Per the IRSST, they’re actually no more likely to develop PTSD than any one else.

The American Medical Network reports:

“Providing police officers with interventional support shortly after and in the weeks following a TE improves the chances of preventing PTSD,” explained André Marchand, lead author of the study, researcher at the Fernand-Seguin Research Centre of Louis-H. Lafontaine Hospital and Associate Professor at Université de Montréal’s.”

What is intriguing here is how much “interventional support” sounds  like Critical Incident Stress Management. With CISM,  emergency service personnel and accident victims meet mental-health professionals for information and support immediately after a traumatic event. It’s an intervention that seems logical, but can actually increase the risk of developing PTSD. So what’s the difference?

…  the police officers stated that talking to their colleagues, obtaining peer support and taking part in leisure activities are particularly helpful after a TE. “The police offers involved in this study even advise their colleagues who experience this kind of event to consult a psychologist and are themselves open to the idea of receiving psychological support if need be,” said Mélissa Martin, co-author and psychologist at the Trauma Study Centre at Louis-H. Lafontaine Hospital.

This is a tantalizing hint of two key differences:

  • support from friends and family, rather than a stranger with a psychology degree
  • choosing to meet with clinical staff, rather than being presented with them

The original study has not been translated into English. Man, I wish I spoke French.

@ 2011 Jonathan Miller All Rights Reserved

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November 20, 2011 · 10:15 PM

Why vodka is like depression

Photo by Rob Nova - robnova.wordpress.comEvery week, in some major city,  a bar, distillery or festival holds a vodka tasting.  This sparks skepticism among non-aficionados, because vodka is tasteless – literally. The USA’s code of federal regulations title 27, volume 1 defines “vodka” as “neutral spirits so distilled, or so treated after distillation with charcoal or other materials, as to be without distinctive character, aroma, taste, or color.”

Which makes it a lot like depression. Sip a screwdriver and it tastes just like orange juice, except for the ethanol kick. Depression can feel just like everyday life, only with a deadening lack of pleasure or motivation.

When a client says, “I didn’t really feel anything this week,” it helps to ask, “What has your appetite been like? How about your temper? How many hours have you slept? What all did you do this week?” Too often, the answers are, “Terrible,” “Terrible,” “Who knows,” and, “I got the kids off to school, then I went back to bed.”  Emotional numbness isn’t one of the DSM-IV-TR’s criteria, but it notes, “(with) individuals who complain of feeling ‘blah’, having no feelings or feeling anxious, the depressed mood can be inferred from the person’s facial expression and demeanor.”

Clients often assume depression always means sadness. They can know the dishes have piled up in the sink, or that formerly-reasonable family members are suddenly impossible, without recognizing these are signs that their mood has declined. They’re more alert to such shifts when they know depression can creep up in the form of a slow, steady, subtraction – the loss of energy, appetite,  interest, or hope.

Vodka is like ‘nothing’, with a kick. Depression can be a ‘nothing’ that hurts.

@ 2011 Jonathan Miller All Rights Reserved

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November 19, 2011 · 10:29 AM

Welcome to the ’Sphere!

“My analyst told me that I was right out of my head.
But I said, ‘Dear doctor, I think that it’s you instead’.”

 

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