Friday, January 31, 2014

Lexicon of Madness -- Systematic Desensitization

Systematic Desensitization: An extremely effective behavioral treatment for phobias and other anxiety problems. Patients construct a "fear hierarchy" regarding the feared stimulus, ranging from activities they believe they could do right now (e.g., holding a magazine in which there is a picture of a snake) to activities they feel increasingly less comfortable with (e.g., handling a live snake). Relaxation training is an essential component of the treatment, which was developed by South African psychologist Joseph Wolpe. The treatment employs both graded exposure and counterconditioning, in which the patient experiences relaxation (or, at minimum, a significant diminishing of anxiety) in the presence of a feared stimulus. Wolpe also introduced the SUDS (Subjective Units of Distress Scale). Patients report their SUDS throughout the procedure (usually on a scale of 1, completely relaxed, to 100, extreme panic). Contrary to common belief, it is not necessary for a patient to become completely relaxed in the presence of one feared stimulus before moving on to the next item on the fear hierarchy. It is only necessary for the patient's SUDS to have diminished significantly, either through relaxation techniques or habituation. Systematic desensitization could involve either in vivo (real life) or imaginal exposure to feared stimuli. Exposures can be gradual ("graded exposure") or all-at-once ("flooding"). In flooding, there is a risk of the patient fleeing the feared stimulus prematurely, thereby reinforcing the existing avoidant response. Imaginal flooding therapy is sometimes called implosion therapy. Modeling (e.g., watching either a therapist or someone else of the same age and gender doing the feared activity) can also be very effective. Common phobias (e.g., dogs, snakes, elevators, flying, needles) can be treated successfully in a single session using this method. Systematic desensitization and similiar behavioral treatments have made it possible for people to live without being troubled by excessive or irrational fears.

Thursday, January 30, 2014

Lexicon of Madness: Rorschach Inkblot Test

Rorschach Inkblot Test: The "ROR-shock" consists of a standard set of 10 ambiguous, symetrical inkblots, some achromatic, some mostly achromatic and red, and some brightly colored. The inkblots were developed and chosen by Hermann Rorshach, a Swiss psychiatrist, over 100 years ago. The inkblots are presented to a patient in a pre-determined order, with the instruction, "What might this be?" The clinician writes down, verbatim, the entireity of the patient's response. After an inquiry phase ("Help me see it the way you did"), a complex scoring system is used to quantify the patient's responses. In experienced hands, the Rorschach can be a valuable instrument for assessing psychological functioning. At one level of interpretation, how you perceive the inkblots conveys important information about how you perceive the world. Obsessional people tend to focus more on detail. Conventional people tend to see what the average person sees. People who are hostile or who come from hostile backgrounds tend to see animals or people fighting, not cooperating. Psychotic people tend to see things that the clinician cannot readily perceive, or provide illogical explanations for their perceptions. Contrary to popular belief, many of the Rorschach variables have well-established empirical correlates. The test is very useful in identifying "low-grade" psychoticism (i.e., "deviant thinking"), oppositionalism/anger, and psychological dependency. Scores on the Rorschach Suicide Constellation (S-CON) has been found to predict suicide completion in samples of psychiatric inpatients. Among experienced administrators, scoring is acceptably reliable. The test has survived significant bouts of controversary, some of which reflects ill-founded contempt for any method that appears reminiscent of the psychodynamic approach. Projective techniques such as the Rorschach enable assessment psychologists to uncover significant data about a person that he may have be unable, or unwilling, to reveal himself.

Wednesday, January 29, 2014

Lexicon of Madness -- Quetiapine

Quetiapine: An antipsychotic medication sold under the brand name Seroquel. Quetapine is approved for use in the treatment of schizophrenia and bipolar disorder. It is a dopamine, serotonin, and adrenergic antagonist. Because of its sedating effects, it is sometimes prescribed for people with insomnia (at low doses, Seroquel functions as an antihistamine). It is also sometimes used, inappropriately, to manage the behaviors of delinquent children and agitated dementia patients. In 2010, AstraZeneca, the maker of the drug, agreed to pay $520 million to settle claims of inappropriate, aggressive "off-label" marketing of Seroquel. Somnolence (drowsiness) is one of the most common side effects, as is weight gain. Quetapine was approved by the FDA in 1997 and is considered an atypical antipsychotic. Compared to traditional antipsychotics (e.g., Thorazine, Haldol), atypicals appear less likely to cause serious side effects such as tardive dyskinesia (3.9% versus 5.5%). In clinical trials, however, patients discontinue use of atypicals at about the same rates as traditional antipsychotics. Despite initial hopes, atypical antipsychotics do not appear any more effective than traditional antipsychotics at reducing the negative symptoms of schizophrenia.

Tuesday, January 28, 2014

Lexicon of Madness -- Psychopathy

Psychopathy: A chronic, pervasive personality pathology characterized by impulsivity, irresponsible behavior, egocentricity, callousness, and empathy deficits. The estimated prevalance of psychopathy in the general population is 1%. About half of all law enforcement officers killed in the line of dury are murdered by people with psychopathic personalities. The term "antisocial personality" captures the psychopath's stance against society, but risks painting all habitual criminals as psychopaths. The term "sociopath" suggests that early social influences alone caused or influenced the adult deviant behavior. There are constitutional, biological, and genetic contributors underlying psychopathic traits, but psychopathy cannot be said to be genetically determined. David Lykken's low fear hypothesis suggests that psychopaths behave as they do, in part, because they do not fear the consequences of violating social norms as much as other people do. They are outgoing and have low social fear, which can help them to be charming con men. Under laboratory conditions, they are less likely to exhibit anticipatory anxiety in the face of punishment, and less likely to correct their behaviors after being punished. Failure to learn from punishment could explain why psychopathy is the best predictor of violent recidivism. Psychopaths are not psychotic, and they are not necessarily sexually sadistic serial killers. Psychopathic traits are more likely to be found among bank robbers and special forces operators.

Monday, January 27, 2014

Lexicon of Madness -- Obsessive Compulsive Personality Disorder

Obsessive Compulsive Personality Disorder: Often confused with Obsessive Compulsive Disorder (OCD), which is a far more severe disorder. People with OCPD are rigid and perfectionistic. They are obsessed with order and routine, and are distressed by spontaneity and the unexpected. Interpersonally, they are rather stiff and formal and usually have few friends. They show a marked preference for work over pleasure. OCPD is seen more frequently in males than in females. They like having rules to follow, and don't mind enforcing them. People with OCPD are sticklers for the "letter of the law," and may utterly fail to comprehend the law's "spirit." They often have strict codes of moral conduct and can be condemning of those who fail to conform accordingly. Their perfectionism often gets them into trouble because they take far too long to complete even routine tasks. They may procrastinate before starting work or not turn in work that others would have considered finished. They are intolerant of what they see as other people's sloppiness or unpredictability. They take life very seriously and don't experience much joy. Often, they experienced very harsh upbringings marked by severe punishments for minor infractions. They have internalized the unrealistically high standards set by their parents. At best, they are "oversocialized," and at worst they are terrified, even paralyzed, by life. Their dedication to work, saving money, and minimizing waste represents an attempt to erect a barrier against chaos.

Sunday, January 26, 2014

Ian McKellen reads Book I of The Odyssey

Well, this is awesome.

I'm kind of a Richard Lattimore snob, but Homer's greatness comes through in nearly any translation.

You might be familiar with Ian McKellen as Gandalf the Grey:

But he was also Richard III:

Friday, January 24, 2014

Lexicon of Madness -- Narcissistic Personality Disorder

Narcissistic Personality Disorder: A chronic, pervasive personality pathology marked by grandiose self-concept, excessive need for admiration, and empathy deficits. The narcissist feels himself to be superior to other people, deserving of special treatment, and entitled to use other people as objects to further his own ends. The nicest thing one could say about a narcissist is that he has supreme self-confidence, even if his belief in his abilities and status is not necessarily commensurate to reality. Narcissists can be surprisingly thin-skinned. The success of other people, praise directed at others, or even the mildest criticism can all be deeply wounding to them. They manage negative feelings by becoming irritable or even enraged. Belittling others, especially in a condescending manner, is a hallmark of narcissists. Because they can never fully realize their fantasies of unlimited wealth and power, stratospheric social status, and universal admiration, feelings of self-loathing are never far from the surface. Much has been said about a "narcissism epidemic" unfolding over the past few decades. However, one must be very careful to differentiate narcissism from unwarranted "high self-esteem." The egocentricity of the narcissist renders him unable to adopt the perspective of others, to feel empathy for their suffering, or to put any other person's interests ahead of his own.

Thursday, January 23, 2014

Lexicon of Madness -- MMPI

Minnesota Multiphasic Personality Inventory, 2nd edition (MMPI-2): The MMPI is perhaps the most widely used psychological test in the world. It was originally developed in the 1930s by Starke Hathaway and J.C. McKinley. The current version of the test consists of 567 True or False items. A tremendous amount of research involving the MMPI has been produced over the years; consequently, there are well-established clinical correlates for the various scores a patient might produce. In essence, after a patient has completed the MMPI, it is possible to compare the way she responded to the test items to the way that tens of thousands of prior patients responded. The clinician can identify a subgroup of prior patients that responded to the items in a way similiar to how the new patient did. What is known about that prior patient subgroup (e.g., symptoms, diagnoses, responses to various treatments, prognosis, social and development history) can then be used to enhance the assessment and treatment of the new patient. Items were originally selected for inclusion using an "empirical keying" method. A group of patients known to have a specific disorder (e.g., psychopathy, schizophrenia, major depression, hypomania) completed a set of candidate items, and their answers were contrasted with the normative sample (non-patient "normals"). Only items that differentiated the criterion (patient) group from the normative group were included on that Clinical Scale. One advantage of this item selection method is that the MMPI Clinical Scales contain some items that, on the face of it, do not appear to measure the domain of interest; this makes "faking ill" or "faking well" more difficult (as do the various Validity Scales embedded in the test). For example, an item that asks whether or not you tease animals is may actually be assessing depressed mood. What is important is whether, during the item selection process, depressed patients consistently responded to that item differently than "normals" did. The two highest Clinical Scales combine to form a patient's MMPI Codetype. A "4-9" represents elevations on the scales for Psychopathic Deviancy and Hypomania. This code is common among people with Antisocial Personality Disorder and others with criminal histories. A "2-7" represents elevations on the scales for Depression and Psychasthenia. these patients are anxious, depressed, tense, and guilty. They constitute the "bread and butter" clientele for psychotherapists. A "6-8" codetype is the most common scale configuration among persons with paranoid schizophrenia.

Wednesday, January 22, 2014

Lexicon of Madness -- Learned Helplessness

Learned Helplessness: Beginning in 1967, psychologist Martin Seligman and colleagues conducted a series of an experiments in which they exposed dogs to a series of uncontrollable, and painful, electrical shocks. When later placed in a shuttle-box and exposed to shocks from which they could easily escape by crossing a small barrier, these dogs instead laid down and whimpered. (Dogs from a control group, which had not been previously exposed to uncontrollable shocks, easily learned the escape-avoidance behavior.) Seligman's first reaction when he observed this phenomenon was that the scientific supply company must have sold him a batch of "dud" dogs. His second reaction was that these "helpless" and passive dogs looked to him like depressed human patients. Could it be, he wondered, that some depressed patients fail to take even the rudimentary steps that could improve their lives (getting out of bed, combing their hair, paying their bills, eating a healthy meal) because they had previously been exposed to uncontrollable and painful "shocks"? Much of what we know about the risk factors for mental illness does seem consistent with Seligman's learned helplessness theory of depression. For example, men who had suffered physical abuse in childhood were more likely than their non-abused peers to develop Posttraumatic Stress Disorder (PTSD) after experiencing combat in Vietnam (26% versus 7%; Bremner et al., 1993).

Tuesday, January 21, 2014

Lexicon of Madness -- Kleptomania

Kleptomania: The recurrent failure to resist the urge to steal. The kleptomaniac steals items that she doesn't need or even want; she might throw them away or even surreptitiously return them after the theft. They usually have the money needed to purchase the stolen item. A woman might steal a pair of mens' gloves from a department store and then leave them on a bench outside the store. There is an intolerable increase in tension immediately prior to the act, and then a significant reduction in tension after the theft. Thefts are impulsive and because they are not carefully planned, may result in arrest. Kleptomaniacs often feel guilt, anxiety, or depression as a consequence of their acts. Stealing unneeded items is usually their only form of antisocial behavior. Kleptomania is sometimes comorbid with bulimia nervosa, another disorder marked by impaired impulse control. Some psychodynamic theorists have suggested that kleptomania could represent a covert act of aggression, or serve as a substitute for sexual behavior (which is a different form of tension relief).

Monday, January 20, 2014

Lexicon of Madness -- Jung

Jung, Carl Gustav (1875-1961): Swiss psychiatrist, founder of Analytical Psychology. Prior to his break with Freud, Jung was considered "the crown prince" or heir apparent of psychoanalysis. Jung is a controversial figure, primarily due to the mystical and even occult flavor of some of his writings. His efforts to deal meaningfully with human religious experience and his period of "creative illness" after his break from Freud, during which he has a "confrontation with the unconscious" (i.e., saw visions/became psychotic), have caused him to be dismissed by most academic psychologists. Jung developed the Word Association Test ("I'll say a word and then you say the first thing that comes to mind..."), which he used to identify unconscious complexes. His personality theory introduced the terms Extrovert and Introvert and was later adopted by the creators of the Myers-Briggs Type Indicator.  Jung's theory of archetypes (innate, ancestral psychic remnants of our shared human and pre-human history) is not entirely inconsistent with modern evolutionary psychology. In Jungian dream interpretation, a dream is an important message sent by the unconscious about the dreamer's current life situation. Jung felt that a person should seek to integrate his all aspects of his personality, and in the process become his true Self (as opposed to his persona, or mask). After successfully achieving the central tasks of life --separating from one's parents, marrying and raising a family, and become an effective contributor in one's field of endeavor -- Jung thought that a person should attempt the process of individuation. A man should embrace the feminine aspects of his personality (his anima), a introvert should employ more of the active and engaged aspects of his personality, a rational and controlled person should explore his unconscious, the irrational, the spontaneous.  Jung asserted that the psychotic symptoms of schizophrenics were symbolic communications that could be interpreted much in the same manner as dreams. Even if we ignore all the rest of Jung's contributions, we should always remember that it is as important to attend to the content of psychotic hallucinations as it is to note that the patient is hallucinating.

Sunday, January 19, 2014

Suicide -- Alvaro de Campos (Fernando Pessoa)

Warning: This is a really grim poem. Don't listen to the reading if you don't feel like being depressed for the next few hours or if you aren't emotionally stable. If you are feeling suicidal, call 1-800-SUICIDE, or go to the nearest hospital emergency room.

Saturday, January 18, 2014

It was a very good year -- Frank Sinatra (in studio, 1965)

"The biggest complaint I have about a lot of the kids who sing today is that I can't understand what they're saying. If I could only understand some of the words, I might be more interested in what they're doing, but I can't -- there's no enunciation, no clarity of diction."

-- Frank Sinatra

Friday, January 17, 2014

Lexicon of Madness -- Insomnia


Insomnia: Difficulty initiating or maintaining sleep. Insomnia is a symptom of both depression and anxiety and is common during periods of high stress, although some patients may report no specific stressors or subjective anxiety. Patients should be reassured that they are probably getting more sleep than they realize, and that sleeping for less than 6 hours a day does not have any long-term negative effects. They must practice good sleep hygiene: 1) the sleeping environment must be quiet, dark, and cool; 2) they must rise at the same time each morning, no matter how much sleep they got during the night; 3) they must absolutely avoid any daytime napping; 4) if they fail to fall asleep within 10 minutes of getting into bed, they should rise and perform some boring activity (e.g., folding laundry) until they are tired enough to sleep; 5) the bedroom must be used only for sleeping and sex; 6) there should be no television in the bedroom, and the patient should not engage in any screentime (t.v., texting, computer, etc.) in the hour before bedtime; 7) they should perform a relaxing pre-bedtime ritual (e.g., taking a warm bath, reading, or progressive muscle relaxation); 8) they should avoid "sleeping in" on weekends, instead rising at the same time as during the work week; 9) they should avoid strenuous exercise within 4 hours of bedtime; and, 10) they should avoid caffeine (in all forms, including chocolate), within 6 hours of bedtime. Satisfying sexual activity can help induce sleep, particularly in men. Many cases of insomnia are precipitated by anxiety over uncompleted tasks -- that report you need to write, or that difficult phone call you have been putting off. Completing the unfinished business in your life will help you sleep better. Other cases of insomnia appear to be self-inflicted punishment (sleep deprivation happens to be one of the most common methods of torture). Patients feel guilty about something they have done (or failed to do). They should considering making amends, or if that is not possible, confessing their transgression to a trustworthy, neutral person. If medications such as benzodiazapines or Ambien are prescribed, they should be used for no more than two weeks, because of the risk of tolerance and dependence. "Rebound insomnia" should be expected when these medications are discontinued.

Thursday, January 16, 2014

Lexicon of Madness -- Hypervigilance

Hypervigilance: A psychiatric symptom of Posttraumatic Stress Disorder (PTSD) or paranoia. May also be seen in survivors of childhood abuse or neglect. The patient constantly scans his environment for signs of threat. The energy expended in this effort is disproportionate to the actual level of threat. A recently returned veteran examines the people around him at a shopping mall for signs that they might be carrying a concealed firearm or wearing a suicide bomb vest. In a restaurant he might always sit against a wall, facing the front entrance, so that he can scruntinize entering patrons. Hypervigilant behaviors may have been adaptive (i.e., promoted survival) under combat conditions, but cause dysfunction in civilian life.

Wednesday, January 15, 2014

Lexicon of Madness -- Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD): Persons suffering from GAD worry excessively about a broad range of events, e.g., What if there is a terrorist attack at my kids' elementary school? What if the economy heads south and my company starts to lose money and my boss decides to fire me? What if I took four aspirins instead of the two I intended? I wonder if that mole on my back is cancer? What if the garbage doesn't get picked up tomorrow? They feel unable to control their worrying, and the worrying causes dysfunction in their lives. GAD was formerly called "free-floating anxiety." Unsurprisingly, people with GAD often have difficulty sleeping. The sleeplessness and feeling of being "on edge" all the time can make them irritable. Constant muscle tension and the inability to relax can lead to feelings of restlessness, fatigue, and "shakiness."  They often report headaches, stomach problems, excessive sweating, or heart palpitations. Most patients with GAD report that they have been like this "all my life," which suggests a possible biological etiology. They may have been born with a nervous temperament, i.e., a nervous system that is more sensitive to potential environmental threats and which recovers more slowly from shocks. People with GAD should avoid caffeine. A serious danger is the potential for dependence on alcohol or benzodiazapines (e.g., Ativan, Xanax, Klonopin, Valium). With these patients, benzodiazapines should be used for a maximum of two months (inclusive of a two week tapering period). Sympathetic and concerned listening can be beneficial, as can relaxation training and biofeedback. It is always interesting to consider what use a patient's symptoms might be serving, i.e., What does having these symptoms do for you? In the case of some people with GAD, it might be that worrying about many small or unlikely things could be a way of avoiding thinking about a few, certain things, e.g., that you will fail to live up to your highest ideals and values, and the expectations of your parents; or, the fact of your mortality and the mortality of your loved ones.

Tuesday, January 14, 2014

Lexicon of Madness -- Five-Factor Model

Five-Factor Model: A trait model of personality, more commonly known as the "Big 5." Through a statistical process called factor analysis, five factors, or traits, have been consistently identified as important descriptors of human behavioral tendencies: 1) Extroversion, a measure of one's engagement with the external world, of stimulus-seeking; 2) Agreeableness, a measure of cooperativeness, consideration for others, and trustingness; 3) Neuroticism, a measure of how sensitive one is to the pain of living, and to others' pain; 4) Conscientiousness, a measure of impulse-control, and the desire to do things right the first time, every time; and, 5) Openness to Experience, a measure of imaginative thinking, tolerance of ambiguity, and tolerance of alternative perspectives. After adulthood, these traits tend to be remarkable stable, and are therefore predictive of important outcomes. Conscientiousness, for example, is the best predictor of job performance in any job position. (Cognitive ability is an even better predictor of job performance than Conscientiousness, but intelligence is not a personality trait.) Of particular interest are how extreme levels of "normal" traits map onto DSM personality disorders. For example, persons with Antisocial Personality Disorder (e.g., habitual criminals with empathy deficits and impulsive natures) tend to score low on Agreeableness (they are distrustful and do not respect the rights of others), low on Conscientiousness (they live moment by moment and are impulsive pleasure seekers), and high on Extroversion (they are active and energetic and not socially inhibited). Persons with Narcissistic Personality Disorder also have empathy deficits and can be equally manipulative and exploitative of others; they differ from Antisocials only in their higher Conscientiousness scores. This explains why Narcissists, annoyingly, often rise to positions of social prominence, and why criminals, thankfully, are often easy to catch and always easy to convict. Histrionic Personality Disorder, which is marked by extreme fluctuations of shallowly felt emotions and a strong desire to be in the spotlight ("Look at me!") might be conceived of as a disorder of extreme Extroversion, whereas Schizoid Personality Disorder, which is marked by a lack of desire for interpersonal relationships, might be conceived of as a disorder of extreme Introversion. The Five-Factor "misery triad" consists of High Neuroticism, Low Introversion, and Low Conscientiousness. These people derive little pleasure from life, have low social support, and are inefficient in their approach to tasks that could improve their situation.

Monday, January 13, 2014

Lexicon of Madness -- Electroconvulsive Therapy

 A vintage electroconvulsive therapy (ECT) unit at the HCMC History Museum in Minneapolis, MN.

Electroconvulsive Therapy (ECT): A safe and effective, even life-saving, treatment for severe depression, mania, and acute schizophrenia. It is unfortunately underutilized and many patients are thus denied a treatment that could have provided rapid relief from serious psychiatric symptoms, including psychosis and acute suicidality. Because ECT employs electricity to produce a seizure, the procedure is frightening to the uninformed. It doesn't help that in ECT "the mechanism of action is unclear," i.e., no one really knows why producing a seizure helps or what exactly happens in the brains of patients during and after treatment. The Academy Award winning film One Flew Over the Cuckoo's Nest (1975) did much to discredit ECT in the eyes of both laypersons and clinicians, as did unsubstantiated claims that ECT causes brain damage. In 1938 in Rome, Italy, Ugo Cerletti and Lucio Bini administered the first "electroshock" treatment. The administration of muscle relaxants prior to seizure-production has eliminated the severe, full body contractions and bone fractures that plagued the earlier form of the treatment. Modern ECT is a remarkably uninteresting procedure to observe. Ladislas von Meduna had introduced Metrazol convulsive therapy in 1934, basing his actions partly on the (erroneous) observation that schizophrenia and epilepsy are never comorbid (i.e., there is no such thing as an epileptic schizophrenic). Metrazol treatment had drawbacks, including feelings of intense dread in patients during the period between administration and effect. Metrozol therapy was superior to Manfred Sakel's Insulin Coma Therapy (1933), however, in that the latter had a death rate of up to 10% (putting people in and out of hypoglycemic comas 40 or 50 times during the course of a single treatment was a risky endeavor). The mortality rate for modern ECT compares favorably to those of childbirth or general anesthesia. The most important question is: How many psychiatric patients have died by suicide because they did not have access to ECT?

Sunday, January 12, 2014

When You Are Old -- William Butler Yeats

WHEN you are old and grey and full of sleep,
And nodding by the fire, take down this book,
And slowly read, and dream of the soft look
Your eyes had once, and of their shadows deep;
How many loved your moments of glad grace,
And loved your beauty with love false or true,
But one man loved the pilgrim Soul in you,
And loved the sorrows of your changing face;
And bending down beside the glowing bars,
Murmur, a little sadly, how Love fled
And paced upon the mountains overhead
And hid his face amid a crowd of stars.      

Friday, January 10, 2014

Lexicon of Madness -- Delusion

Delusion: A fixed, false belief, typically not shared by others, that is not the result of ignorance or cultural influences, but rather a misinterpretation of reality. Delusional people cannot be talked out of their delusional beliefs. Presentation of contrary evidence is not persuasive ("How do I know that those are really my x-rays? Maybe you don't want me to know that I have a radio transmitter in my stomach"). A common positive symptom of schizophrenia, but also observed in psychotic depression. Delusions can be bizarre (e.g., "Aliens have replaced my blood with typing correction fluid") or non-bizarre (e.g., "My wife is poisoning me"). Non-bizarre delusions, while perhaps very unlikely, could conceivably occur in reality (e.g., "The CIA and mafia are trying to kill me"). Delusions can be mood-congruent (e.g., a severely depressed patient believes that he is the cause of a deadly tsunami halfway across the world). Somatic delusions involve the false belief that one's body is malfunctioning (e.g., a patient asks for his healthy arm to be amputated because it is "sick, gangrenous, rotting -- I can't stand the smell"). Paranoid delusions place the patient at the center of a web of harassment, ridicule, or persecution. Sufferers may arm themselves or use violence to protect themselves from their "persecutors." For some people, paranoid delusions might serve to defend against feelings of utter insignificance (i.e., it is preferable to feel followed, spied upon, harassed, and plotted against than to feel disregarded, ignored, or overlooked). Delusions of grandeur involve the exaggeration of one's own importance or powers, or the belief that one is a special person (e.g., Jesus Christ's younger brother). Delusions of reference involve the belief that other people are talking about you or otherwise doing things with you in mind (e.g., a news announcer wears a blue tie one evening in order to signal you to go to the beach). Delusional jealousy involves the false belief (again, invulnerable to exculpatory evidence) that one's partner is unfaithful. (This is sometimes called "Othello syndrome," even though Othello was misled, not delusional.) Erotomania (de Clerambault's syndrome) involves the delusion that a famous or powerful person is in love with you and won't leave you alone. Antipsychotic medications can be effective in the treatment of delusions.

Thursday, January 9, 2014

Lexicon of Madness -- Conversion Disorder

Conversion Disorder: The conversion of psychological distress into physical symptoms, such as blindness or paralysis. The process of conversion is unconscious, i.e., patients are not "faking it" and are not willfully producing their symptoms. Often, however, they seem strangely unconcerned about their physical symptoms ("la belle indifference"). Conversion symptoms were frequently found among Sigmund Freud's patients, and were observed in abundance in military personnel during the world wars (e.g., a front-line soldier is "struck blind" or becomes unable to walk, and thus has to be evacuated to a safer position). According to Freud, the conversion symptom is a "compromise formation" that provides a (less than ideal) solution to an unconscious conflict (e.g., the desire to flee from danger versus the desire to do one's duty). Conversion symptoms seem to have become more rare, but it is possible that they have simply become more subtle, and thus more difficult to detect. A large number of seizure patients evaluated in neurological clinics don't actually have epilepsy but rather demonstrate pseudoseizures. (Interestingly, these patients tend not to get hurt during their seizure episodes; similarly, patients who have been "struck blind" tend not to collide into walls or tumble down stairs). It has been suggested that the epidemic of chronic pain cases in the Western world actually represents an outbreak of conversion disorder, in which pain itself is the conversion symptom. Pain constitutes the perfect conversion symptom, because it cannot be objectively measured or evaluated. Telling conversion patients that their symptoms are "all in their head" can cause an exacerbation of symptoms. Symptoms usually resolve spontaneously in a few days, especially if the patient feels cared for, sympathized with, and understood.

Wednesday, January 8, 2014

Lexicon of Madness -- Bipolar Disorder

Bipolar Disorder: Short for Bipolar I Disorder, formerly known as manic-depressive illness. As the older name implies, the course of the illness is marked by alternating episodes of mania and major depression, followed by periods of relatively unimpaired functioning. A manic episode can feature elevated mood, agitation, restlessness, decreased need for sleep, increased talkativeness ("pressured speech" -- as if the words are coming out of a fire hose), financial profligacy (e.g., spending sprees or extreme generosity), grandiosity (including delusions of having special powers or a divinely-ordained mission), increased goal-directed behavior, and psychosis. A person experiencing mania might act like a "maniac" -- abusing substances, being sexually promiscuous, driving 100 mph, and assaulting others if he feels that they are constraining him. He might spend his life savings on lumber and start building a ten-storey observation tower in his backyard. The symptoms of mania must persist for at least a week for the diagnostic criteria to be met. Following the law of "what goes up must come down," manic episodes are usually followed by a depressive episode of at least two weeks duration. This disorder is almost as rare as schizophrenia, and can be just as severe. (The U.S. Secret Service has more contacts with people who are bipolar than with people who are schizophrenic.) People suffering from bipolar disorder require medications such as lithium to stabilize their moods and usually have histories of psychiatric hospitalization, contacts with law enforcement, or suicidal behavior. Most people who describe themselves as "bipolar" are actually not. Usually, they are better described as moody, irritable, immature, and as having poor impulse control. Displaying a tendency to get disproportionately angry or upset over minor frustrations does not mean that someone is bipolar. Many people who have been diagnosed as bipolar actually have Borderline Personality Disorder, which is marked by extreme mood reactivity and instability of mood, but the mood states do not persist nearly as long as they do in bipolar disorder. Bipolar II Disorder features discrete episodes of depression and hypomania (which is essentially a shorter-duration, low-grade mania that won't land you in a psychiatric hospital or jail cell).

Tuesday, January 7, 2014

Lexicon of Madness -- Anhedonia

Anhedonia: Diminished hedonic capacity, i.e., a reduced ability to experience pleasure. A loss of interest in activities that previously had been considered pleasurable. Most commonly associated with Major Depressive Disorder (clinical depression) but also a symptom of Posttraumatic Stress Disorder (PTSD). Also a common Negative Symptom of Schizophrenia. A depressed man finds that he no longer enjoys golfing with friends or watching sports on television. For many people, eating is a primary source of pleasure. For the anhedonic person, even favorite foods can taste "like wet clay, or like ashes in my mouth." Loss of such a central source of pleasure can quickly lead to hopelessness and thoughts of suicide.

Monday, January 6, 2014

Easy A's at Harvard

The Atlantic
“The median grade in Harvard College is indeed an A-,” the school’s dean of education said today, according to the student newspaper. Even more stunning: “The most frequently awarded grade in Harvard College is actually a straight A.”
That ought to dispel any notion that Harvard is tough on its students. Grade inflation may be a victimless crime, but what is the point of having a range of grades if half of them are A- or higher?
Accusations of grade inflation flare up frequently at Harvard and other college campuses. Harvard, in particular, has been accused of grading more softly than some of its rivals in the Ivy League.
Larry Summers, the former US Treasury secretary, was highly critical of the practice while he was president of the university. After he stepped down, he told an interviewer: “Ninety percent of Harvard graduates graduated with honors when I started. The most unique honor you could graduate with was none.”
There are clear incentives to inflate grades. For professors, it makes life easier to just give everybody an A. Nobody complains about getting an undeserved A. For institutions, your graduates are more competitive in graduate school admissions if they have "perfect" transcripts. What if Harvard suddenly decided that all professors had to make their mean grade a 75, with a standard deviation of 10? Then the top law schools, med schools, and business schools would be full of Yale, Princeton, and Stanford grads.

The problem is that these grades are meaningless to the student. If you get an A, you tend to think that you mastered the subject at hand. But what if everyone in the class got an A? Does that mean that everyone mastered the subject equally well? Of course not.

Even at Harvard, there is significant variation among students with regard to talent and effort and it irks the psychometrician in me that letter grades are not differentiating the more talented and harder working from their counterparts. The simplest solution would be to abandon letter grades and to issue grades on a 60 to 100 scale. Those 90 to 100 scores would all still be As and A minuses, but there could be a big difference between a 91 and a 98.

A class ranking system would be far superior than traditional letter grades in most courses. Give everybody As, sure -- but make sure that each student is clear that his A means that he was, for example, 17th best out of 34 students.


Sunday, January 5, 2014

Because I could not stop for Death -- Emily Dickinson

Because I could not stop for Death –
He kindly stopped for me –
The Carriage held but just Ourselves –
And Immortality.

We slowly drove – He knew no haste
And I had put away
My labor and my leisure too,
For His Civility –

We passed the School, where Children strove
At Recess – in the Ring –
We passed the Fields of Gazing Grain –
We passed the Setting Sun –

Or rather – He passed Us –
The Dews drew quivering and Chill –
For only Gossamer, my Gown –
My Tippet – only Tulle –

We paused before a House that seemed
A Swelling of the Ground –
The Roof was scarcely visible –
The Cornice – in the Ground –

Since then – 'tis Centuries – and yet
Feels shorter than the Day
I first surmised the Horses' Heads
Were toward Eternity –

Friday, January 3, 2014

Sham Surgery for Knee Pain


A fake surgical procedure is just as good as real surgery at reducing pain and other symptoms in some patients suffering from torn knee cartilage, according to a new study that is likely to fuel debate over one of the most common orthopedic operations.
[R]esearchers in Finland who studied two sets of patients—one that received the surgery, and another that was led to believe that it had—observed no significant differences in improvement between the groups after one year.
"The implications are fairly profound," said Jeffrey Katz, a professor of medicine at Brigham and Women's Hospital in Boston who wasn't involved in the Finnish study. "There may be some relatively small advantages to meniscal surgery, but they're short-lived."
The study is likely to stir controversy over the minimally invasive procedure, known as partial meniscectomy, which can cost between $3,000 and $6,000. The study's authors estimated that it accounts for $4 billion in annual medical costs in the U.S.
Teppo L.N. Järvinen, one of the study's authors, said he was uncertain whether the research paper would change clinical practice. A previous study showed that physical therapy was just as effective as surgery for patients with both a meniscal tear and osteoarthritis, but many physicians have continued to recommend the procedures anyway, he said. "Doctors have a bad tendency to confuse what they believe with what they know," said Dr. Järvinen, an orthopedic resident and adjunct professor at Helsinki University Central Hospital.

Here's the abstract of the NEJM article. Of course, they should have had a third group of controls -- candidates for knee surgery who were put on a wait-list and their pain and functioning measured after one-year. If there was no difference between the wait-list controls and the surgery patients, then you would have a compelling case that the surgery is worthless. With the present study, all you have is yet another demonstration of the power of the placebo effect (i.e., people who think that they had an effective surgery do as well as people who had the actual surgery).

Thursday, January 2, 2014

Boston Globe on the Tsarnaev family

Boston Globe

Tamerlan Tsarnaev first heard the voice when he was a young man.
It came to him at unexpected times, an internal rambling that he alone could hear. Alarmed, he confided to his mother that the voice “felt like two people inside of me.”
As he got older, the voice became more authoritative, its bidding more insistent. Tamerlan confided in a close friend that the voice had begun to issue orders and to require him to perform certain acts, though he never told his friend specifically what those acts were.
“He was torn between those two people,” said Donald Larking, 67, who attended the mosque with Tamerlan for nearly two years. “He said that several times. And he did not like it.”
Federal investigators have suspected that Tamerlan, the 26-year-old boxer from southern Russia who is believed, along with his brother, to have set off the deadly Boston Marathon bombs in April, was motivated, if not deliberately directed, by real life jihadist revolutionaries on the other side of the globe. But an investigation by the Boston Globe suggests that Tamerlan was in the perilous grip of someone far more menacing: himself.
The Globe corroborated with several people who knew him just how plagued Tamerlan felt by the inner voices. Some family acquaintances feared for his mental health, among them a doctor concerned it could be schizophrenia. The Globe’s five-month investigation, with reporting in Russia, Kyrgyzstan, Canada, and the United States, also:
■ Fundamentally recasts the conventional public understanding of the brothers, showing them to be much more nearly coequals in failure, in growing desperation, and in conspiracy.
■ Establishes that the brothers were heirs to a pattern of violence and dysfunction running back several generations. Their father, Anzor, scarred by brutal assaults in Russia and later in Boston, often awoke screaming and tearful at night. Both parents sought psychiatric care shortly after arriving in the United States but apparently sought no help for Tamerlan even as his mental condition grew more obvious and worrisome.
■ Casts doubt on the claim by Russian security officials that Tamerlan made contact with or was recruited by Islamist radicals during his visit to his family homeland.
■ Raises questions about the Tsarnaevs’ claim that they came to this country as victims of persecution seeking asylum. More likely, they were on the run from elements of the Russian underworld whom Anzor had fallen afoul of. Or they were simply fleeing economic hardship.

Wednesday, January 1, 2014

Happy 2014!

Cease, Man, to mourn, to weep, to wail;
enjoy thy shining hour of sun;
We dance along Death's icy brink,

but is the dance less full of fun?

-- Captain Sir Richard Francis Burton