Is grief a psychiatric disorder?

Maybe.

An interview with a patient who claims he "faked his way" into a psychiatric hospital

The patient, "Tony," was convicted, at age 17, of causing grevious bodily harm. (This was in Britain.) He started creating a new persona for himself by plagiarizing from any sources he could find — movies like A Clockwork Orange, a biography of Ted Bundy — so that he'd be sent to a psychiatric hospital instead of prison.

It worked. But Tony instantly regretted it and tried to get out.

In a new book called The Psychopath Test, Jon Ronson reports on his interview with Tony in the hospital:

It is an awful lot harder, Tony told me, to convince people you're sane than it is to convince them you're crazy.

"I know people are looking out for 'nonverbal clues' to my mental state," Tony continued. "Psychiatrists love 'nonverbal clues'. They love to analyse body movements. But that's really hard for the person who is trying to act sane. How do you sit in a sane way? How do you cross your legs in a sane way? . . ."

"[T]hey saw how well behaved I was and decided it meant I could behave well only in the environment of a psychiatric hospital and it proved I was mad."

I glanced suspiciously at Tony. I instinctively didn't believe him about this. It seemed too catch-22, too darkly-absurd-by-numbers. But later Tony sent me his files and, sure enough, it was right there. "Tony is cheerful and friendly," one report stated. "His detention in hospital is preventing deterioration of his condition."

I'm sure I'm not the only one who read this and thought of one of the greatest movies ever made:

Is there more or less stigma against a mental illness if people believe it's genetic?

This article looks at the question. The most striking finding: in a metastudy of 19 studies, "18 found that belief in a genetic or biological cause was associated with more negative attitudes to people with mental health problems. Just one found the opposite, that belief in a genetic or biological cause was associated with more positive attitudes."

The writer, Ben Goldacre, juxtaposes those psychological findings with this quote from a professor of neuropsychiatric genetics, responding to research that says ADHD is partly genetic:

"We hope that these findings will help overcome the stigma associated with ADHD . . . . Too often, people dismiss ADHD as being down to bad parenting or poor diet. As a clinician, it was clear to me that this was unlikely to be the case. Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children."

As Goldacre observes, anyone who's been campaigning against the stigmatization of mental health disorders seems have a severely mistaken assumption about people's attitudes toward mental health. If you believe someone's behavior comes from their genes, you won't necessarily be more inclined to forgive them. You might look down on them more: it's a problem with the whole person, not just a one-time decision they made. (That may be a very simplistic way to look at it. But I'm just describing how people in general might think; I'm not approving of these views.)

Do addicts have self-control?

This book review about "addiction and freedom" is worth reading, and it's a good companion to the book review about medicating children that I blogged recently. The book is Addiction: A Disorder of Choice by Gene M. Heyman, a Harvard psychologist. The reviewer is a psychiatrist, Sally Satel.

Both this review and the one about children illuminate the same fallacy, which I'd paraphrase like this:

1. A certain behavioral/mental problem -- call it "X" -- is associated with brain activity in ways that can be observed and predicted.  

2. Therefore, the solution to "X" must take the form of psychiatric/medical assistance; the solution cannot be individual free choice. (Indeed, even invoking that concept may be detrimental.)

There's a lot that could be said about why this is a fallacy and why it's so common. The question of free will lurks under the surface of the discussion, though Satel understandably sticks to talking about science, policy, and history, and hardly touches the philosophical problem. Here's what she says about the fallacy:

[M]uch of the public, and a dismaying number of psychiatrists, psychologists, and neuroscientists, mistakenly believe that if a behavior is influenced by genes or mediated by the brain then the actor cannot choose his actions. While every behavior has a biological correlate (and a genetic contribution) and every experience that changes behavior does so by changing the brain, the critical question, Heyman wisely says, is not whether brain changes occur (they do) but whether these changes block the influence of the factors that support self-control. . . .

Heyman uses the phenomenon of addiction to make a profound point about neuroscientific progress in general. "The implication is that as we learn more about a disorder," he writes, "the more likely it is to be thought of as a disease" -- and, consequently, as a condition whose course cannot be modified by its foreseeable consequences. Indeed, reconciling advances in brain science with their meaning for personal, legal, and civic notions of agency and responsibility will be one of our next major cultural projects.

Progress in brain science will also force a confrontation with the fact that the common interpretation of pathological behavior is often informed by a primitive form of dualism. If biological roots can be found, then we reflexively think “disease”—as in the obliteration of choice-making ability. The mechanical “brain disease” rhetoric is a symptom of the growing tendency to privilege neuroscientific explanations as the most authentic way of understanding human behavior.

In addition to logically explaining why that's a fallacy, Satel also says that the people who came up with the idea that addiction is a disease and is incompatible with self-control were motivated by political and financial concerns (and probably emotional impulses):

In fairness, the scientists who forged the brain disease concept had good intentions. By placing addiction on equal footing with more conventional medical disorders, they sought to create an image of the addict as a hapless victim of his own wayward neurochemistry. They hoped this would inspire companies and politicians to allocate more funding for treatment. Also, by emphasizing dramatic scientific advances, such as brain imaging techniques, and applying them to addiction, they hoped researchers might reap more financial support for their work. Finally, promoting the idea of addiction as a brain disease would rehabilitate the addict’s public image from that of a criminal who deserves punishment into a sympathetic figure who deserves treatment.

Those concerns may be admirable. But having good intentions behind your account of reality hardly ensures that your account will be accurate.

Finally, I had never heard of this incident (which begins the review), and I'm surprised it isn't better-known:

In 1970, high-grade heroin and opium flooded Southeast Asia. Military physicians in Vietnam estimated that between 10 percent and 25 percent of enlisted Army men were addicted to narcotics. Deaths from overdosing soared. In May 1971, the crisis exploded on the front page of The New York Times: “G.I. Heroin Addiction Epidemic in Vietnam.” Spurred by fears that newly discharged veterans would ignite an outbreak of heroin use in American cities, President Richard Nixon commanded the military to begin drug testing. In June, the White House announced that no soldier would be allowed to board the plane home unless he passed a urine test. Those who failed could go to an Army-sponsored detoxification program before they were re-tested.

The plan worked. Most GIs stopped using narcotics as word of the new directive spread and the vast minority who were detained produced clean samples when given a second chance. More startlingly, only 12 percent of soldiers who were dependent on opiate narcotics in Vietnam became re-addicted to heroin at some point in the three years after their return to the states. “This surprising rate of recovery even when re-exposed to narcotic drugs,” said the epidemiologist who collected the data, “ran counter to the conventional wisdom that heroin is a drug which causes addicts to suffer intolerable craving that rapidly leads to re-addiction if re-exposed to the drug.”

Satel says our ignorance of this real-life experiment represents a case of "generational amnesia." It's easy to keep believing in a dogma if you don't look at any of the evidence that goes against it.

(Photo by Daniel Modell, a.k.a. dM.nyc.)

Should children be medicated to deal with their psychological issues?

In this book review that's probably a more worthwhile read than the book, Alison Gopnik writes:

Within the past few years more and more children have been given powerful brain-altering drugs to deal with a wide range of problems. . . .

You can sympathize with the impulse of parents to do something, anything at all, to help their children. But that doesn't alter the fact that the scientific evidence just isn't clear about what to do. On balance, though, the evidence suggests that we should be conservative about prescribing drugs to children, and much more conservative than we actually are. Even the scientists who advocate some use of drugs acknowledge that they are overprescribed and badly managed. Brains are complex enough, children's developing brains are even more complex, and determining the long-term effects of drugs that alter those brains is especially difficult. Children are different from adults, often in radical ways, and many childhood problems resolve just as part of development.

On top of that, each generation of doctors discovers that the last generation was disastrously misguided in its medical interventions, from lobotomies to estrogen replacement, at the same time that they assure the patients that this time is different.

I'm also glad to see that the review highlights the importance of compatible "levels of description":

[Judith] Warner's book [We've Got Issues] also reflects a common confusion in popular writing about psychology. She writes as if there are just two kinds of explanations for human behavior. Either the everyday narratives are right—so that children are unhappy because their parents don't care about them, or they fail at school because they are lazy. Or else the right answer is that the children's problems are the result of "something in their brains." Warner's logic seems to be that since the parents do care about their kids, the problem must be in the children's brains and therefore drugs will fix it.

But everything about human beings, cultural or individual, innate or learned, is in our brains. Loss and humiliation change our serotonin levels, education transforms our brain connections, social support affects our cortisol. Neurological and psychological and social processes are inextricable. The work of psychological science is to identify causes at many levels of description—social, cultural, individual, and neurological.

There was a very insightful blog post (on Psychology Today's website) that makes a similar point about evolutionary psychology: "Is it evolutionary, or is it . . . ?" (That post speaks of "levels of causation," which is the same thing as the "levels of description" in the above block quote.) I've also blogged this concept before: "Can you give a neurological or evolutionary explanation of love without debunking the whole idea of love?"

By the way, that book review has several points that could be added to my list of ways blogs are better than books. The bias in favor of conclusions that come from riveting stories is huge.