Hentor the Barbarian:
Not claiming definitive proof (notice use of the word “apparently”) but I didn’t pull it out of my ass:
http://www.academicarmageddon.co.uk/library/kirk.htm
http://www.sonoma.edu/psychology/os2db/barbetti1.html
http://members.bellatlantic.net/~adhdah/psych_inmates_libfront/vol_1/Hill/Hill_InadeqData.html (old stuff)
DSeid, to TVAA:
Without trying to put words in TVAA’s mouth, I must say I’m under the same impression. For years I’ve heard about how schizophrenia is a brain-based genetically-borne ailment in which neurotransmitter reuptake inhibitor chemistry is all messed up. Now it turns out it may be a symptom of infection borne by kitty litter? Cite; Cite; Cite; Cite.
Hey, I’m a respecter of the kind of science where, as (I believe) Isaac Asimov once said the greatest discoveries are not punctuated by a shout of “Eureka!” but instead the phrase, “…that’s funny?!”. I do not expect medicine to be perfect or doctors to refrain from practice until it is. So why (you may ask) are we holding psychiatry to a standard of perfection and absence of major mistakes and uncertainties?
Because of forced treatment. If you’re going to force treatment on someone you’d damn well better know what you’re doing, and why, and those reasons had better justify the imposition of force.
And because, in light of the need to defend forced treatment, the field and its defenders have claimed expertise and certainty that does not hold up to scrutiny.
Ultimately the problem with the medieval witch-burners was not that they did not have the same degree of supportive evidence that psychiatry has to support involuntary psychiatric treatment. The problem with medieval witch-burners was that they imposed what they did on people for their own good without their consent, and that they were wrong.
I have no problem with psychiatric practice on a voluntary basis (as long as fully informed consent is the order of the day), but as long as we’re discussing treatments which modify the way the mind/brain works and which are imposed on people without their consent, I don’t think the burden of providing cites and supportive studies rests with those of us who think these treatments are bad for people. It is those who advocate forced treatment who should demonstrate why it is OK for them to proceed.
I remain unconvinced and will do everything in my power to remove this authority from the profession.
That’s it. I’ve run out of adjectives to describe how insane this debate has become.
Do you have any idea what it means for a phenomenon to be called ‘diagnostic’? We’ve already discussed the fact that the DSM criteria are not what are actually used in real-life diagnosis and treatment, primarily because they’re so vague, secondarily because reimbursement isn’t allowed without a DSM label so the categories are applied as broadly as possible. We’ve already discussed how the DSM is a definition of conditions, not a clinical description of how they present. The definition (valid or otherwise) of a disease rarely has anything to do with how it’s detected. What makes you think you could find a description of a purely clinical practice in the formal definition of the condition?!
The criteria for ADD are so vague that the school behaviors of supposedly sick children are essentially indistinguishable from those of unchallenged gifted children. That’s why they had to specify that ADD must occur across several different environments and surroundings, because teachers and doctors were labeling smart kids who were bored with their repetitive and tedious schoolwork as sick!
Do it; and the next time a man punches his sixty year old father in the face for “speaking the word of the devil” after being off his risperdal for three weeks, then tell us how to intervene.
-true story, the guy thought his dad was speaking the word of the devil, hit him, was promptly taken to the local mental health hospital and given a shot of haldol. Then he was kept in seclusion till he took his risperdal. Not ODD, but (IME) people aren’t forced into treatment because of a disorder, it’s more about behavior.
Same way you intervene when a man punches his sixty year old father in the face just for the fuck of it. You charge the sonofabitch with assault, give the old man an order of protection, and if recidivism occurs you jail him longer for violating the OOP. But you don’t force drugs on him.
A person’s alleged “mental illness” is totally irrelevant here. A delusional paranoid does not commit a greater crime than a sane asshole. Equal protection under the law, got it?
I knew it! TV, magazines, and a website, the extent of your expertise.
Maybe, just maybe, they seem arbitrary to you because you really don’t know much about them. Kinda like the other day when I cracked open my VCR and looked at all the arbitrary little wires and things in there. They don’t correspond to anything in my reality, so they must be arbitrary, right?
Insanity defense, got it? No court would convict him even if he was charged. The court system seems to think that “a delusional paranoid” commits a different crime somehow, I happen to agree.
You really think this guy could fully appreciate the fact that his dad isn’t channeling the devil?
He loves his dad (apologized profusely for weeks after he got home).
He’s actually a nice guy, not a sonofabitch at all. See how quickly a lay person jumps to such a conclusion?
labeling him a criminal and a sonofabitch is ok, but heaven forbid we should force a treatment on him that has proven helpful to him in the past, right? Definitely we shouldn’t pathologize him with schizophrenia.
You really think a couple of months in jail is preferrable to being forced to take haldol? (cause he sure didn’t)
So he gets to jail, then what? Does he just disappear after that? Problem solved?
Probably he punches another devil, gets the shit beat out of him, maybe gets put in solitary confinement, maybe gets killed, maybe can’t handle it and kills himself, maybe he learns the error of his ways, cause people really get rehabilitated in prison :rolleyes:
There are plenty of operational definitions in the research studies from which the DSM was compiled.
Hint: you’re not going to find them in “People” nor on an episode of “law and order”
The standards for insane in a court of law are substantially different from those used to force medications on someone. In my opinion there should be a unified standard and it should be the same standard as the one used to determine whether or not you are in any condition to make out a will or sign a contract.
Hell yeah. Haldol is serious assault if you don’t want it.
AHunter,
The issue of treatment without consent is really unrelated to most of the rest of this. Minors are subject to parental decision making on their behalf with great latitude. Adults are allowed to make their own decisions unless they are deemed of great harm to themselves and others. If a schizophrenic wants to not take meds and prefers to roam homeless muttering to the voices that he alone hears, then he is usually allowed to do so. Where that line should be drawn has little to do with the scientific validity of DSM labels. I understand your concern and acknowledge that the line is not always drwn where you would prefer it placed.
As to the heterogenous etiology of many mental illnesses and neurologic conditions. I know that you know enough to know that many genes and many nongene factors contrinbute to schizophrenia. There is a strong genetic component but no one knows exactly which or how many genes. There are nongenetic factors as well. More interesting is understanding why the complex network has this state as a stable state, why this functions as an attractor basin. I’d refer you to Steven Grossberg’s work on the dynamics of the neural networks involved for a wonderful model.
Zenster,
OTOH, we do know the potential consequences of not intervening can be devastating on occassion and often at least significant impediments to quality of life. Caution is warranted where big pharma is involved but one can proceed while proceeding with caution.
TVAA,
The research community is not what People says it is. Most researchers have an appreciation for how little is really known. True there is some hubris. And some who fail to appreciate how little we really know so far and function with simplistic models as truth. But more who are working to make the small steps to better understanding.
The DSM is the measuring device for a complex set of measurements. I am not thrilled with it. It has bits that aree as bad as you claim. Reactive attachment disorder? I could go on, including comments about tics to Tourette’s, but it is a good faith effort and scientific in the main because it is a work in progress.
** I’m afraid my expertise extends far beyond that. Nice try, though.
Those are obviously the only kinds of sources you have available to you. It would be rather pointless to reference texts you could only find in a university library if you don’t have access, wouldn’t it?
Those sources are more than enough to prove the point I was making: that the information available to the the layperson emphasizes the claim that various mental illnesses are physical diseases with physical cures.
Note: available to the layperson.
TVAA,
You keep claiming vast expertise and vast amounts of knowledge about science and scientific philosophy far exceeded any of the rest of our small uneducated minds, yet you have yet to provide any basis for such claims. Or maybe we are just too ignorant to understand that we should bow before you. Or maybe your expertise extends to USA Today articles and no farther? You may not know how to access scholarly sources but lots of lay people have figured out how to use the web to get to source information if they are curious enough.
But now your point is … what now?
That the layperson relies on the media for information and if such is distorted such that the media claims that researchers say things that they do not that it is the research community’s responsibilty?
Or that mental disorders do not have biologic contributors or even are in some cases primarily of biologic origin?
You have made neither of these points and both are fallacious anyway.
no, in fact it wouldn’t since you have to date made exactly 1 point verifiable by any means (and quite off our topic I might add, since you have no grounds for making the claim that ritalin is used to treat ODD).
You being the non mental health professional in this interaction (unless you’re a mental health professional playing exceedingly dumb), doesn’t that make YOU the layperson?
But I’ll tell ya what: point me to the magazine article, the tv show, and where the NAMI website states that mental illnesses are physical diseases with physical cures. Specifically ODD if you can (good luck). Name it, I’ll find it.
If anyone is interested in a nonlinear neural networks approach to mental conditions and normal brain function, the best is the work by Steve Grossberg available here: http://cns-web.bu.edu/Profiles/Grossberg.html
Specifically the model as applied to schizophrenia is here:
http://www.cns.bu.edu/Profiles/Grossberg/Gro.BioPsy2000.html
http://www.cns.bu.edu/Profiles/Grossberg/Gro99.hall.html
(I’ve been working with him applying his model to autism for a while now and hope to get it published soon.)
AHunter3, I want to say thanks very much for attempting to support an assertion with some referent. I do appreciate it and find it very much more beneficial to furthering an actual discussion.
Previously, you asserted this:
You then provided three references for this, which you did appropriately qualify.
Your first link is to a paper written by Kirk and Kutchins (1994). It is interesting, but does not really support the notion that reliability “kind of sucks,” depending on what the definition of “sucks” is. More specifically, it suggests that reliability sucks for some disorders and is good for others. It particularly seems like a straw man, since your original argument was that interrater reliability is good for Alzheimer’s disease and not good for all (other) psychiatric disorders (presumably excluding Alzheimer’s, since it is included in the DSM as a psychiatric disorder).
The intriguing critique of Kirk & Kutchins is that the improvement in reliability has not changed from DSM I days to DSM-III-R. While an important question, their method of answering it is not particularly good. They rely on work by Spitzer in 1975 and DSM III field trials around 1979. What they suggest is that considering all diagnoses, the reliability kappa’s did not meaningfully improve. They make the same point in transitioning from DSM-III to DSM-III-R by focusing on a paper detailing tests of the Structured Clinical Interview for DSM-III-R (Williams et al 1992). These are important points they raise regarding claims of reliability for the entire DSM, and ideally we will someday get to a point where all the diagnoses are 100% reliable. Taken on their face, the Kirk and Kutchins analyses put lie to the argument that Dseid (I am presuming) and I would put forth; that we are moving forward and improving our diagnostic tools.
However, there are two problems. First, regarding your assertion that the “overlap kind of sucks” for psychiatric disorders. The kappa statistic is a measure of agreement between two raters that removes chance association, meaning that a kappa of 0 implies association solely by chance, and a kappa of 1 perfect agreement. So a kappa of .50 is midway between those ends. Conventionally, kappa’s of .7 are regarded as acceptable levels of agreement. Kirk and Kutchins don’t provide the weighted mean of kappas for their DSM III data (although they do point out how bad the data they relied on sucked). What it says is that the whole DSM III (published in 1980 and replaced in 1987) averaged out somewhere around (from just eyeballing their graph) at a kappa of .60 - .65. This is not better than what they have presented for DSM II days, but it does mean that when you include all DSM III defined disorders (even the most shaky ones) interrater reliability is markedly better than chance, and is just slightly below the acceptable levels of agreement. To the point, it is a far cry from 10 different opinions from 10 different raters. While somewhat surprising, I wouldn’t jump up and down about it because the data they are using really isn’t all that good. To be fair, that is not exactly their fault – they are criticizing the “selling” of the DSM and using data that was apparently used by those doing the selling.
This leads me to point number two: A more fair comparison, both for them and for our purposes here would be to use good data and compare the improvement or worsening of interrater reliabilities for specific diagnoses. The questions should be: Which diagnoses show good reliability and which do not? What has been the improvement for both the good and the bad over revisions of the DSM? What are some possible explanations for any lack of improvement? What research is being done, and what should be done, to address areas of weakness?
The second paper appears to be a highly selective review paper that might have been written by a student at Duquesne University, just down the road. As such, it really only relies on the Kirk and Kutchins work and some others, and does not appear to add much empirically to the discussion on reliability. However, I skimmed it for discussion of reliability, and I could very well be missing something. The final paper appears only to discuss diagnostic reliability of schizophrenia prior to about 1970 or 1975 or so. Interesting history, but hard to really apply to the current discussion.
In general, I find the Kirk and Kutchins paper mildly useful. In part, it suffers from the same problems that many of the criticisms voiced in this thread display – it is overly broad without the empirical support to really back it up. On the other hand, it is useful because it does raise interesting questions (e.g. Can we take an overall kappa across the DSM as an indicator of a lack of progress?) and points out deficits in the literature.
I don’t think a full diagnostic interview is possible with someone trying to hit you. Hentor’s probably a much better diagnostician than I am, maybe he could pull it off.
I think you may be departing from the real world in your idealism here.
Either way, were quite off topic since ODD isn’t primarily treated with medication.
** When and where have I ever made the claim that ritalin is used to treat ODD?
** I take exception to the “exceedingly dumb” remark: to be perfectly frank, I don’t think you have any right to evaluate my statements until you figure out what they actually are.
You seem to have crafted quite a nice strawman there. When you’re finished shadowboxing with him, perhaps you and I could continue our argument.
I didn’t say you made the claim that ritalin was used to treat ODD, I said that your discussion of it was off topic, and your 1 valid cite was off topic.
Wouldn’t you have to be making that claim in order to include it in a discussion about ODD though?
Make that 2 valid cites:
The NAMI website does say that mental disorders are biologically based brain disorders. The context of that seems to be in the spirit of convincing people of past mistaken notions about mental illnesses though.
although if you’d bothered to look a little deeper you’d have seen the list of disorders:
http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/By_Illness/Default284.htm
Notice, the list doesn’t include ODD or conduct disorder. Maybe NAMI doesn’t claim it’s a brain disorder like it claims the others are.
Your statements actually are indicative that you have no real world context in which to put any research or Dateline special you might have read or watched. I can tell by the things you are writing that you don’t have much if any firsthand knowledge of what a mental illness looks like in an actual human being. Or, if you actually do you’re pretending not to, I only allow for that because you got upset when I stated outright that you don’t know anything, so that comes at your request.
In short:
Don’t you know anything about people with mental disorders?
There’s why, that and your unwillingness to qualify any of your assertions about people with mental illnesses or the illnesses themselves.
There’s no other way to quickly compare the behavior and mien of children both before and after treatment with stimulants, unless you can suggest soemthing better.