Author Archives: cemurdoch

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New Insights into Psychopathy

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Psychopathy is a categorical psychological term describing chronic disregard for ethical principles and antisocial behavior. It is not a part of the DSM-IV and accordingly is not, strictly speaking, a mental disorder for the purposes of North American medical insurance or practice.

Although its medical status is somewhat muddled, psychopathy is of particular legal relevance because studies estimate that while only 1% of the general population could be described as psychopathic, up to 20% of the prison population may fall under this descriptor. It is popularly speculated that individuals who prove themselves capable of committing violent or horrendous crimes are in fact psychopathic.  Categorization as a psychopath usually occurs through the use of a forensic assessment instrument such as Hare’s Psychopathy Checklist-Revised (Hare’s PCL-R).

New research by Joseph P. Newman at the University of Wisconsin suggests that an attention deficit, rather than an inability to feel emotion, may be what makes people psychopaths. Newman measured fear-potentiated startle (FPS) in a group of 125 prisoners, who were also assessed for psychopathy using the PCL-R. Each prisoner was hooked up to a device that measures how strongly they blink – in other words, FPS – and placed a screen in front of them. The subjects were warned that during tasks in which letters flashed on the screen, an electric shock would sometimes follow a red letter, but never a green one. Psychopathic subjects displayed normal FPS under these threat-focused conditions relative to the control. However, when they were told to indicate whether letters were capitals or lower-case, the psychopathic prisoners displayed significant deficits in FPS – they barely blinked upon seeing red letters, while the others continued to anticipate the mild shock.

Newman’s team hypothesizes that this might be because psychopathy, contrary to traditional belief, actually involves an “attention-related deficit that undermines the processing of peripheral information, including fear stimuli.”

Of course, as Newman notes in a New Scientist news piece, one of the hallmark problems surrounding psychopathy, aside from clinical definition, is that it is ostensibly untreatable. The implication here appears to be that if the Newman hypothesis proved correct, psychopathy would be treatable in a manner similar to a “learning disability”. Given the use of language such as “distraction” and “attention-related deficit” throughout the news piece, it would appear these researchers are suggesting that some ADHD-like symptoms are present in psychopaths with respect to moral feelings. This definitional move would then presumably make the condition treatable by stimulants such as Adderal and Ritalin. It will be interesting to see whether this implied turn into the pharmaceutical magisterium will be continued by further studies, and whether these taken collectively will result in psychopathy’s inclusion as a psychiatrically legitimated, treatable mental disorder in the upcoming DSM-V.

The proposed shift from the archetype of cold-blooded, calculating criminals to that of disabled, distracted moral learners is a remarkable one.  As the researchers state, “The innate fearlessness of psychopathic individuals is arguably the most sacrosanct assumption in the field of psychopathy.” But do the results of Newman’s study provide grounds for this strong hypothetical shift?

First of all, even if we perceive a compelling link between higher cognitive processes such as attention and moral perception, whether persuaded by this study or not, should we move wholesale to a paradigm of psychopathy based on attention deficit, or simply qualify present theories accordingly?  Secondly, more abstractly, should we accept the hypothesis that moral sentiments are grounded in fear? While it is surely true that fear compels some social conformity, are moral feelings such as guilt or moral apprehension necessarily connected with fear, and is the lack of this fear the hallmark of the psychopath, as is popularly supposed by current psychological theorists? Thirdly, is FPS in any way a good measure of the complex emotional state of fear?  Is it possible that the behavior it measures carries many possible valences of purpose and habit in different individuals, and accordingly the correlation with fear is underdetermined on the basis of the available data?

Finally, a more speculative thought: the “fear” discussed in this context is presumably culturally bound to the social mores and punishments associated with them. Is attention not bound in such a way?   If we suppose that it is, and the results of this study can be replicated and built upon, is it possible to imagine a world in which all undesirable beliefs are explained on the basis of attention and treated with stimulants? This disease market would presumably be much larger than that for categorical psychopaths.  In what ways would this practice be different from the present use of atypical antipsychotics in the face of undesirable beliefs espoused by those diagnosed with schizophrenia?

CJ Murdoch

New Associations? Schizophrenia Comorbidity

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A new study in Psychiatric Services is the first systematic analysis of comorbidity in general with schizophrenia in the U.S. hospitalized population.  A series of recent studies have  examined single comorbidities with schizophrenia, but these studies were generally conducted with small or unrepresentative sample sizes and tested hypotheses rather than taking a broader approach.  By contrast, this study looked at nearly 6 million hospital discharge records to calculate proportional morbidity ratios.

Somewhat predictably, psychiatric and behavior related diagnoses accounted for 45% of comorbidity. Anyone who has been diagnosed with schizophrenia, or has a diagnosis in their family knows that other diagnoses frequently precede or follow suit.

However, the study showed more than just that.  Among non-psychiatric diagnoses, many patients with a primary diagnosis of schizophrenia were also diagnosed with acquired hypothyroidism, obesity and other hyperalimentation disorders, asthma, chronic airway obstruction not elsewhere classified, essential hypertension, and type 2 diabetes.

Head author Weber notes in a Psychiatric News article that the researchers expected cardiovascular and metabolic conditions to occur at a rate even greater than they found.  Author Newcomer explained that this likely represented endemic underdiagnosis. “The very nature of the problem with this diagnosis [of schizophrenia] is that the patients tend to receive a lower standard of medical care, so there is going to be massive underestimation”.

Interestingly, the news article does not mention one likely cause of increased metabolic dysfunction among schizophrenics: weight gain, often leading to diabetes is a well-known side-effect of atypical antipsychotic use.   Taking statistical comorbidity without this  contextualization can be misleading, and so followup research is required. The study authors seem well aware of this, as Weber notes: “”Our study is hypothesis-generating rather than hypothesis-testing.”

Is it intuitive that psychiatric conditions would be co-morbid with non-psychiatric medical conditions?  Why or why not?  Do lifestyle and behavioral factors associated with mental illness increase risk?  Is there is a biological connection? Finally, how much of this comorbidity is due to iatrogenic harm? If psychiatric conditions show significant non-iatrogenically induced comorbidity, what are the public health policy ramifications for the treatment of mental health?

CJ Murdoch

The Politics of Disease Definition: A Summer of DSM-V Controversy in Review

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On June 23rd, 2009, an article in press at Psychiatric Times was posted by Doug Bremner, MD on his health blog, igniting debate through the medical community.  That article was an editorial authored by Allan Frances, MD, chair of the committee that collaboratively authored the DSM-IV, in which he passionately criticizes the team presently working on the DSM-V. Frances expresses disappointment in the “confidentiality agreement” which has lent secrecy to the DSM-V authorship process, warns of the possibility of overdiagnosis and unintended consequences in revising disease definitions, and is especially worried about published interviews where David Kupfer, MD, chairman of the DSM-V Task Force has claimed: “There are no constraints on the degree of change”. This boldness is a cause for concern, according to Frances because:

“The simple truth is that descriptive psychiatric diagnosis does not need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday  psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM‐5.”

Shortly after the Frances editorial began lighting up medical blogs, the American Psychiatric Association released a scathing riposte, signed off by prominent APA members, including Dr. Kupfer and APA President Alan Schatzberg, MD. The response only partially addresses Frances’ arguments, suggesting that the confidentiality agreements Frances criticizes are really legal documents meant to protect intellectual property, that many clinicians feel the DSM-IV does not adequately meet the needs of the patients they encounter in practice, that many of the changes proposed for DSM-V are in fact supported by current research, and that, in fact, that the DSM-V process is the most open and inclusive “ever.” Perhaps most surprisingly, the article, penned by the heads of a prestigious medical association and task force, begins and ends dramatically by injuriously emphasizing Frances’ own conflict of interest:

“The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., submitted to Psychiatric Times contains factual errors and assumptions about the development of DSM-V that cannot go unchallenged. Frances now joins a group of individuals, many involved in development of previous editions of DSM, who repeat the same accusations about DSM-V with disregard for the facts.

Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.”

Another response, penned by William Carpenter, Professor of Psychiatry at the University of Maryland, and chairman of the DSM-V work group on psychosis, was published in the Psychiatric Times only a few days later, on July 7th, 2009. In this article, Dr. Carpenter is much more dispassionate than the APA piece, and systematically addresses some of the concrete arguments and concerns Dr. Frances put forward in his article, giving a bit more detail about the “confidentiality agreements” (they are in place to prevent task force members from publishing their own diagnostic manuals), and generally arguing that reality is less sensational than Dr. Frances had suggested. Daniel Carlat, MD, helpfully summarizes this article as follows:

“In actuality, there will be very few substantive changes in the DSM-V. Most of the diagnostic criteria will be the same. We might add a handful of rating scales. There will be no ‘paradigm shift.’ We are considering adding a sub-threshold psychosis diagnosis but then again we may not–it’s a complex scientific issue and we, like you, are concerned about overdiagnosis and stigma.”

Carpenter put forth an ostensibly reasonable voice in what was rapidly becoming a vicious battle, but the summer of drama was still unfolding.  Concomitantly with the Carpenter response, Dr. Jane Costello, Professor at the Duke Institute for Brain Sciences where she also co-directs the Center for Developmental Epidemiology and an international expert on the course of mental illness, publicly circulated her letter of resignation from the DSM-V Work Group on Disorders in Childhood and Adolescence. Sharing Dr. Carpenter’s more academic style, she nevertheless contradicts him in expressing a general discomfort with the underlying principle of rewriting psychiatric taxonomy all at once, claiming “I am not aware of any other branch of medicine that does anything like this.”  She further suggests that the taxonomic changes being made by the team are in fact overly dramatic given available data:

“When we began this process, we agreed that changes would only be made if there were empirical evidence to support them. Sometimes (as with Charlie’s work on preschool PTSD) this has been the case. But as time has gone by, the gap between what we need to know in order to make revisions and what we do know has grown wider and wider, while the time to fill these gaps is shrinking rapidly. More and more, changes seem to be made for reasons that have little basis in new scientific findings or organized clinical or epidemiological studies.”

This observation parallels the speculative worry Frances expressed in his editorial that time pressures on the DSM-V task force may soon lead to an unconsidered rush of last minute decisions without empirical support.

The work that the DSM-V task force is doing is of a significance barely comprehensible at present, as it will determine both disease categories for millions of individuals, and delineate drug markets for the world’s largest pharmaceutical companies.

Given this fact, how important is it for social scientists, lawyers, historians and philosophers to monitor the internal politics of this process? Genetics researchers have the assistance and resource of ELSI scholars, but is there an equivalent, well-organized network of researchers devoted to critically analyzing the social, ethical and legal ramifications of the work on the DSM?

Is the DSM-V process really the most open and inclusive process of its kind to date?  It may be the case that some of Frances’ arguments misapprehend the actual situation, but would he be making these kinds of worried, speculative arguments if it were truly an open process? Is it possible that controversy of this sort could lead to more transparency from the DSM-V task force?

Does the proliferation of medical blogs penned by high-profile academic researchers help or hinder the process of disease definition? What will be the public health impact of the universal accessibility of this information?

CJ Murdoch