Performance versus Ability Another Issue Frequently Ignored in Psychiatry Research

In previous posts, I have discussed some bizarre assumptions made in psychiatry research papers when the data is analyzed. I wrote about how, for example, differences in brain area size and functioning between different groups on fMRI scans are automatically interpreted as abnormalities.

Nassir Ghaemi, a blogger on Medscape with whom I have had some strong disagreements about borderline personality disorder and bipolar disorder, nonetheless had a great quote on this with which I wholeheartedly agree:
             

"All things biological are not disease, even though we can define disease in such a way that all diseases are biological. This matter is obvious once pointed out. A few assumptions,  which seem either patently true or very likely: all human psychological experience is mediated by the brain; each person only has one brain; therefore the brain will always be biologically changing as we have psychological experiences. Reading a blog post about the brain is a psychological experience. Having delusions from schizophrenia is a psychological experience. The first brain change does not reflect disease; the second does. So showing MRI changes with adult ADHD or borderline personality does nothing to demonstrate that those conditions are diseases. If you watch TV and play video games inordinately, you will have changes in your brain, and you might also develop clinical symptoms of ADHD. If you are repeatedly sexually abused, you will have changes in the brain, and you might also develop clinical symptoms of borderline personality. But those changes in the brain do not have the same causal role as the neuronal atrophy that happens with trisomy 21, or with schizophrenia, or bipolar illness..."

Another major nonsensical assumption that litters the psychiatric literature (the literature littering alliteration?) is that one can totally disregard the motivations of research subjects as well their past experiences and the environmental context in which they live when evaluating their performance on psychological tests. 

I mentioned an example of how this is utter nonsense in a previous post: The performance of African-Americans on IQ tests just might be related to the fact that for several generations Blacks who looked too smart were at high risk of being lynched. Do you think they are just as motivated as other folks to want to look smart on an IQ test which is being administered by White researchers?

What I have seen more and more lately, particular in the personality disorders literature, are studies that look at differences between various diagnostic groups on such issues as how much "impulsive aggression" they show, or how and how well they read the emotional state of ambiguous faces of strangers in photographs. When differences are found, once again the "lower" performing groups are just assumed to be "impaired" or "abnormal."

This, of course, confuses performance with ability. Without knowing anything about what the subjects in the experiments are motivated to do in their daily lives on any particular dimension for whatever reason, or what environmental contingencies they are worried about that may relate to the task at hand, it is literally impossible to say for sure whether any difference in their performance is related to what they would be able to do if those other issues were not operative.

Patients with borderline personality disorder, for example, grow up in families in which double messages are flying in all directions, and with parents who can switch from being over-involved to neglectful at the drop of hat. They are bound to have a higher index of suspicion about what facial expressions on strangers might mean than someone who grew up in a more consistent and predictable environment. If they did not, they would be morons.

Another major issue ignored in the literature is the difference between a research subject's real self versus their persona or false self in certain social situations. We all present different "faces" to the outside world depending on social context. Researchers who do not consider this must think that men, for example, present themselves exactly the same way around their children, their bosses, and their mistresses. Really?

With personality disorders, as I described in several previous posts, people play social roles designed to stabilize family homeostasis. These roles are merely a much more pervasive version of the different roles played by the above "normal" man interacting with different people. So someone with antisocial tendencies, for example, which are part of the role of avenger, are motivated to show more impulsive aggression than other people - on purpose - and have literally trained themselves to be like that. They do so habitually, automatically, and without thinking. Of course they will show more impulsive aggression in the experiment! Why wouldn't they? 

In fact, showing a lot of impulsive aggression might be considered to be part of the definition of antisocial behavior. The experiments therefore do nothing more than prove that anti-social people act habitually in an anti-social manner. Like, duh!

These types of results in no way indicate any "deficits," "deficiencies," or "abnormalities." One wonders how people who make these ludicrous assumptions ever manage to get through medical or graduate school.

Anti Psychiatry Civil Rights Activists Drop the Ball

There is a fairly large and vocal contingency of people who protest the involuntary commitment and involuntary treatment of people who doctors label with the diagnoses of schizophrenia or other psychotic disorders. They think this practice is a gross violation of the civil rights of these patients, who are, they claim, being persecuted by society merely because they are different and do not fit in.  Such patients should have the right to, say, walk uninvited into their neighbor's house in the nude, or live in cardboard boxes on Skid Row if they so choose.


These activists also believe people who most of us would label as “psychotic” are merely misunderstood.  Delusions and hallucinations do not signify a brain disease, they say, because there are no gross anatomic lesions associated with them.  (You know, like early Parkinson’s Disease).  In fact, they really do not believe in brain diseases at all. 


So I have a bone to pick with them. I think they have really dropped the ball when it comes to people labeled by society with "Alzheimer's Disease." These unfortunate victims are often locked up in nursing homes and never, ever let out!  Ever! They too are often drugged against their will, just to keep them manageable and quiet for the comfort and safety of Hispanic and Filipina nurses aides who are taking care of them for minimum wage.


How can activists who claim to be so concerned about civil rights NOT come to their rescue? Why should these poor elderly defenseless individuals be persecuted just because they don't keep track of the date, or care much about what locations they find themselves in? Shouldn’t they have the freedom to wander wherever they want?  Should they be locked up just because their memories don't conform to societal norms?!?  This is outrageous!!


I must admit that I am  a little concerned that some people might get the mistaken impression that I am actually being serious here. In reality, it has been becoming more and more difficult to involuntarily commit, hospitalize, and treat the seriously and persistently mentally ill, and this has become an unmitigated disaster for many mentally ill individuals and their families.


And the results can be horrific. An excellent first person account of what misery can be created was recently published by the New York Times entitled, When My Crazy Father Actually Lost His Mind.    


I recommend reading the whole piece.  To just briefly summarize, the writer's father, a beloved family man with a solid employment record, had an episode of mania. He spent a long time acting crazy on the street.  He could not be committed because he was deemed to not be dangerous enough by the powers that be, even though he threatened to "haunt" his wife forever.  He was, however, sane enough to be arrested and nearly put in jail.  

The family in question

The author continues, "And so for weeks, we had been locked in a game of chicken: waiting for my father to do something clearly dangerous; praying like hell that it would not be his suicide or accidental death or the death of someone else." When the mania finally abated - on its own because he never did get treatment - he returned home.  He later "lamented the time lost with his family. 'Those are days I will never get back,' he said."

The increasing difficulty in committing seriously ill individuals has been largely due to two factors:  First, tight state budgets in the recession have led to the elimination of large numbers of psychiatric hospital beds, so there is often no place to send severely impaired mental patients. This trend actually started way before the recession. Chronically mentally ill people were supposed to be treated as outpatients by Community Mental Health Centers - but those were never funded adequately.

The second factor is the "patient's rights" movement mentioned above.  


Now, just so I am completely clear, this movement initially addressed some very real and reprehensible abuses by the states in the US, and by the psychiatric profession itself. The practice of locking up mental patients in "snake pits" and throwing away the key (and sometimes this happened to people who were not, in fact, mentally ill - at the impetus of family members who were, for example, trying to get their hands on some family money) was widespread and unchecked.


Stopping such practices was a very good thing indeed.  


But as usual, eventually the baby got thrown out with the bathwater.


The first major commitment law that stopped the abusive practices was California's Lanterman-Petris-Short Act.  The act went into full effect on July 1, 1972.  The law mandated only time-limited commitment of mental patients, at least until they were judged to be mentally incompetent to make treatment decisions by a court of law and placed on a conservatorship. 


The law also mandated judicial review for anyone who was held for more than 72 hours.  If a patient was to be committed, police or psychiatric professionals would have to fill out a "72 hour hold," also known as a 5150 for all of you Van Halen fans.

The grounds for commitment were, first, that the patient had to have a diagnosable mental illness (being suicidal was allowed to be presumptive evidence of mental illness for all practical purposes, even though one does not necessarily have to be mentally ill to be suicidal). Then, you had to either be a danger to yourself, a danger to others, or be something called gravely disabled - on the basis of said mental illness.


Grave disability was defined as the inability to provide for one's own food, clothing and shelter because of the mental disorder.


When the law was first implemented, there were plenty of psychiatric beds available, and the patients rights advocates seemed satisfied with how the law was being applied.  


The patient had to only loosely meet the criteria.  If you were homeless because you were too paranoid to find adequate shelter or get a job, you would be considered gravely disabled.


If you walked into your neighbor's house in the nude because the voices told you to (this is NOT a hypothetical example, by the way), that was enough to make you a danger to yourself.  After all, the neighbor had the right to shoot you, and just might do so.  Likewise if your delusions led you to jump out of a moving car, that would make you a danger to yourself, even if the car was barely advancing.  


Now, those sorts of situations might lead to you be quickly released from a hospital or, in some cases, imprisoned in a jail for lawbreakers.


Slowly but surely, grave disability as a criteria also became rarer and rarer.  If you had a cardboard box on Main Street to live in and you were eating out of garbage dumps because of mental illness (as opposed to say, chronic unemployment or poverty), you were deemed to have the ability to provide for your own food and shelter.  Not committable! This would be true even if, after proper treatment, you would run away from that scene in absolute horror as fast as you possibly could.


As I have pointed out previously on this blog, more severely mentally ill people are now incarcerated in prisons than in hospitals.  BTW, they get forcibly medicated there as well.


This seems to be what these bat-guano crazy, so-called "civil rights" activists want.  And they have the unmitigated gall to claim to have the moral high ground. Shame on them.