Thud

I was too dilatory to blog this story ("Into the Cuckoo's Nest") while it was still up at the Guardian, but fortunately it's been archived by the Alternative News Network. Its major entertainment value is the detailed description of one of everyone's favorite psychology studies, David Rosenhan's "On Being Sane in Insane Places." Briefly, in 1972 Rosenhan and a bunch of his friends presented themselves at various psychiatric hospitals claiming to hear a voice saying "empty," "hollow," and "thud." All were hospitalized, at which point they stopped claiming to hear the voices and began to act completely normally. No one but their fellow patients ever noticed. Rosenhan's original paper can be found here, and is *well* worth reading for its chilling descriptions of how dehumanizing psychiatric treatment was in the 1970s, and how the most normal of behaviors were pathologized by staff members who thought they were observing crazy people.

The Guardian article is by a psychologist, Lauren Slater, who decided to replicate Rosenhan's experiment. Sort of. No one gets hospitalized just for hearing voices these days, and indeed, she wasn't. She went to various emergency rooms and told her story of the voice that said "thud," and each time she was diagnosed with psychotic depression or some variation thereof, and given prescriptions for antipsychotic and antidepressant drugs. She tries to spin this as evidence that psychiatry hasn't changed much in the thirty-odd years since Rosenhan, but I'm not buying it. The key element of Rosenhan's findings was not that the pseudopatients were admitted - they were, after all, faking auditory hallucinations - but that they were still judged to be ill even after they had reverted to totally normal behavior. Slater was never admitted, so the psych professionals never saw her behaving normally. They're guilty of being fooled by her lies, but they're not guilty of pathologizing normal behavior. The other key feature of Rosenhan's findings was the dreadful, dehumanizing treatment received by the pseudopatients and their fellows; Slater says she was treated with uniform kindness. (Enough so that she started to feel guilty.) So this partial attempt at replication makes a nice dramatic story, but I don't think it proves much of anything in particular.

Another point: Rosenhan and all of his fellow pseudopatients were psychologically healthy. Slater, I find in a review of one of her books, has a history of "[psychiatric] hospitalizations, suicide attempts, anorexia, and self-mutilation resulting from a variety of mental illnesses, obsessive-compulsive disorder the most recent among them." And yet we're supposed to be disturbed that the ER psychiatrists thought there was something mentally wrong with her - given her assertion in the article that "really, I'm fine now." Maybe she is fine now, but a history of severe mental illness certainly does tend to leave marks - physical and otherwise.

Some minor annoying things leap out at me upon re-reading the article now - things that Slater, as a psychologist, should've known better than to say. For example, she makes a point of saying that nowhere in psychiatric literature are there valid reports of voices saying "thud" - as if it's the content of hallucinations that matters, rather than the basic fact of hearing voices that aren't really there. (Even more annoyingly, she makes a snide comment about a patient who heard voices repeatedly saying "It's okay," saying that the symptom sounded "okay" to her. Again, as if the content of the hallucination makes it innocuous. Actual people who hallucinate tend to be disturbed by the fact that there's, you know, a voice in their head - regardless of what it's saying.) Or, for example, here:

"When will I get out?" we can imagine Rosenhan asked, his voice perhaps rising now, some panic here - what had he done, my God.

"When you are well," a doctor answered, or something to this effect. But he was well: 110 over 80, a pulse of 72, a temperature that hovered in the mid-zone of moderate, homeostatic, a machine well greased. It didn't matter. He was diagnosed with paranoid schizophrenia and kept for many days.

Lauren Slater's a psychologist, so she's got to know that blood pressure, pulse, and temperature have not a damn thing to do with whether a person has paranoid schizophrenia or not. It's like saying, "he was nondepressed and his judgment and memory were intact, but it didn't matter. He was diagnosed with pneumonia and kept for many days." Non sequitur as counter-evidence.

If I sound really pissed at Slater, that's probably because, in my experience, it's vastly more common these days to have trouble getting people in to the hospital than it is to get them out again. I've had to coach some of my clients - suicidal folks who wanted to be admitted for their own safety - on what to tell the ER doc to be sure they wouldn't just be sent home with a prescription. People hearing voices that say a lot scarier things than "thud" wind up living on the streets because there's no place for them in the system. Slater's story is sensationalistic and not really to the point, but because it's so compellingly written it deflects attention from real problems with emergency psychiatric care.

Hi There!

Welcome to all of you who have just found me through the kind words of Electrolite and Tapped. I'm a little bit stunned by the twenty-fold increase in my daily hit count, but I hope to rise to the occasion and offer you some things worth sticking around for.

(And to my older readers who are wondering: yes, I'm planning to come back to the euthanasia series. Those posts just take a lot of time to get right, and I need to be in a pretty cheerful mood to go there.)

The Flynn Effect

Crooked Timber has a post up about the Flynn effect, a subject I've always found interesting. Flynn found massive gains in IQ across time, with average children's performance increasing as much as a standard deviation in one generation. This is a shocking blow to the few remaining people who think that IQ is all about genetics, but it also raises questions about the general relations between IQ and intelligence. Clearly, the argument goes, if intelligence were rising at the rate of one SD per generation, we'd be in the middle of an intellectual Renaissance the likes of which the world has never seen.

I think the Flynn effect can be attributed to a number of things - improved nutrition, more widespread education, the spread of mass communications (there used to be a big rural-urban difference in mean IQ, which has subsequently disappeared within the U.S.), and increased opportunity for people in general to become familiar and comfortable with test-taking situations. Moreover, the kinds of tasks that appear on children's IQ tests have trickled down into the culture. Fifty years ago, a young child taking the Wechsler Intelligence Scale for Children (WISC) might be faced with solving a maze for the first time. Today, you find mazes on the backs of cereal boxes.

I don't think it's coincidental that nonverbal, puzzle-like components of IQ tests have shown much larger Flynn effect gains across time than more academically-rooted components like vocabulary and arithmetic. If the Flynn effect is driven by increased exposure to testlike elements in the general culture, you'd expect to see smaller gains on elements people have been exposed to for a very long time (like arithmetic) and larger gains on elements that have only become commonly encountered in the last generation or so (like complex pattern-matching games).

(As a sidenote: I could practically have written 75% of the Crooked Timber post's comments section without reading it first, just based on prior online arguments. No matter what opinion most people have of IQ, a lot of the things they're sure they know about IQ tests just aren't so... but that's a rant for another time.)

More Breast Issues Exposed

Sisyphus Shrugged has news of the inevitable class-action lawsuit, filed by a Tennessee woman who complains she suffered "outrage, anger, embarrassment and serious injury" from the brief sight of Janet Jackson's tit, sufficient to require three years' worth of the total revenues of CBS, MTV, and Viacom in order to assuage her pain. Heaven help her if she ever accidentally stumbles into a meeting of the La Leche League.

Skimble points out that the nipple plaintiffs are suing for considerably more money than would be offered, under Bush's tort reform plan, for the pain and suffering of a woman who received and unnecessary double mastectomy.

Wonkette provides a useful translation of Peggy Noonan's hand-wringing editorial somehow linking Boobgate to 9/11.

See? Crystal clear. You're the frog, I'm the water, Justin Timberlake is the hand that turns the flame on. . . Are you with me? [...] OK, let me explain again. Our culture is a frog. Janet Jackson is the pot and Justin Timberlake is the water. The nipple is the flame. No, wait. . . The nipple is the water, Janet is the flame and Whitney Houston is the frog. Hold on, I'm almost getting it. . .

My previous post on this issue is garnering lots of party invitations, which is nice. One hopes that they're all from people who understand that my breasts generally stay inside my clothing.

Hell Freezes Over; Otters Defend Big Pharma

I've done my fair share of bashing the pharmaceutical industry. And at first glance, this article in the New York Times seems to provide fodder for more of the same.

To sell medicines that treat schizophrenia, [drug] companies focus on a much smaller group of customers: state officials who oversee treatment for many people with serious mental illness. Those patients - in mental hospitals, at mental health clinics and on Medicaid - make states among the largest buyers of antipsychotic drugs. [...]

Since the mid-1990's, a group of drug companies, led by Johnson & Johnson, has campaigned to convince state officials that a new generation of drugs - with names like Risperdal, Zyprexa and Seroquel - is superior to older and much cheaper antipsychotics like Haldol. The campaign has led a dozen states to adopt guidelines for treating schizophrenia that make it hard for doctors to prescribe anything but the new drugs. That, in turn, has helped transform the new medicines into blockbusters.

After eleven paragraphs of marketing description, and at the bottom of the first page of the web story, we are told that the novel antipsychotics cost around $3,000 a year, compared to the $250 annual cost of an older antipsychotic. And yet states are mandating that the newer drugs be prescribed! This is obvious graft, right?

Wrong.

In the 19th paragraph there is a brief mention that "doctors widely prefer the new medications, saying that the older drugs cause a higher incidence of side effects like stiffness, trembling and uncontrollable jerks that can stigmatize patients and prompt them to stop taking the drugs." This is immediately countered by the claim, in the following paragraph, that the new drugs can increase the risk of obesity, diabetes, and high cholesterol - so comparatively, "stiffness and trembling" seem like minor complaints.

But what they're talking about when they say "trembling" is tardive dyskinesia, a form of irreversable nervous system damage. Tardive dyskinesia causes tics and twitches which may happen dozens of times an hour, which may be disfiguring, and which are almost always awkward and uncomfortable. Twenty percent of people with schizophrenia develop incurable neurological damage within five years of beginning traditional antipsychotics, and the risk increases with the duration of treatment. So in the old days, almost every chronic schizophrenic wound up with some symptoms of TD. With the new, expensive drugs, the risk of TD is ten times less.

The increased risk of diabetes with the new antipsychotics, which appears to have been included in the article for "balance," doesn't seem particularly comparable. There is a significantly greater relative risk of diabetes in people on the new antipsychotics - they're 1.17 times more likely to develop diabetes than people on the older versions. But the overall risk of diabetes in schizophrenics isn't particularly high - the incidence is only 2.5%. (Reference here; requires free registration.) So we're talking about moderately increased risk of a treatable, not-very-common side effect - compared to vastly increased risk of an incurable, common side effect, in the case of TD.

Now, the article appeared in the NYT's business section, not the medical section - so I suppose I can't expect the reporter to go through and figure out the business about relative risks and so forth. But it still seems to me that the article has an obvious slant. If you ask psychiatrists, nine out of ten will immediately tell you that the newer drugs are much better for the patient. But that doesn't come through in the article at all. Who'd the reporter talk to?

Shock, Horror

I don't normally like to do this, because I think it's a cheap shot. But you know, sometimes I'm driven to it.

I'm a psychologist in an HIV clinic. I meet people every day who have problems like, "I just found out I have HIV, and I'm seven months pregnant, and I don't have anywhere to live or enough money for food." I face common diagnostic questions like, "is this person just crazy, or has HIV irrevocably eaten away part of her brain?" I worry about things like, "Do I even want to know whether that psychotic guy brings a gun to the clinic?" 'Family values' problems in my world are things like, "Ever since I told my parents I have HIV, they make me eat off a paper plate when I visit."

I actually love my job. But it's spoiled me for modern living, because I come home from the clinic, log on to my computer and read things like this:

But strangely enough, I'm feeling another emotion besides anger. I feel overwhelmed by sadness at this most recent (and most prominent) example of the flush of our nation's cesspool we call prime-time entertainment. Sure, I was shocked and appalled by what these performers did. But I can't shake this pervasive feeling of sadness. So many people to feel sorry for, so much hurt and harm done by one tasteless, classless act on an international stage like halftime of the Super Bowl.

...and I don't know whether to laugh, cry, or go batshit crazy myself. "So much hurt and harm done." By a breast.

See, this is why people don't invite me to parties.

Anything Government Can Do, Industry Can Do Better

Halliburton-KBR has apparently vastly overcharged for meals served Iraq. They've discovered $16 million in overcharges at a single base, and are now extending the inquiry to KBR's other 50 dining facilities. The U.S. government was billed for 42,042 meals per day, but only 14,053 meals per day were served.

And what kind of food service are we paying so much extra money for?

The Pentagon repeatedly warned contractor Halliburton-KBR that the food it served to US troops in Iraq was "dirty," as were as the kitchens it was served in, NBC News reported [in mid-December]. The Pentagon reported finding "blood all over the floor," "dirty pans," "dirty grills," "dirty salad bars" and "rotting meats ... and vegetables" in four of the military messes the company operates in Iraq, NBC said, citing Pentagon documents.

Well. It's a good thing that food service in Iraq was outsourced to private corporations, instead of being left to the bloated, inefficient, incompetent public sector. Everyone knows that industry does everything government can do, but cheaper and better.