tag:blogger.com,1999:blog-82471404433237627482024-03-19T06:01:13.876-07:00PsycriticA child psychiatrist's blog: critically examining psychiatry, wellness, parenting, modern culture, etc.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comBlogger74125tag:blogger.com,1999:blog-8247140443323762748.post-69047914407391616232019-03-02T09:08:00.000-08:002019-03-02T09:08:05.492-08:00But What About The Elephant In The Room?<p>One of the most triumphal talks I went to during last October’s American Academy of Child and Adolescent Psychiatry (AACAP) Annual Meeting was the <a href="https://aacap.confex.com/aacap/2018/meetingapp.cgi/Session/19481">Noshpitz Cline History Lecture</a>: "What Has Happened to Fifty Years of Child Abuse Reporting Laws? The One-Hundred-Forty Million Dollar Mistake.”</p>
<p>The talk was delivered by Dr. Lenore Terr, a San Francisco child psychiatrist famous for her work in the area of childhood trauma. As she reminded us during her lecture, she was one of the first to document the fact that victims of trauma can experience a <a href="https://www.friendshipcircle.org/blog/2013/09/12/8-symptoms-of-ptsd-in-children-and-teens/">foreshortened sense of the future</a>, which eventually became one of the DSM criteria for PTSD. She also discussed the history of how child abuse reporting laws came into existence and emphasized the importance of these laws in protecting children from adults in positions of power, such as teachers and coaches. Notably, she left out medical professionals, despite all that's <a href="https://en.wikipedia.org/wiki/USA_Gymnastics_sex_abuse_scandal">happened recently</a>.</p>
<p>Dr. Terr delivered her talk old-school, using handwritten notes with no PowerPoint slides to distract from her narrative. She spoke in well formed paragraphs of cogent prose, and <a href="https://www.nbclosangeles.com/news/local/Timeline-Miramonte-School-Scandal-138970604.html">the incident that she described</a> was truly stomach-churning. In 2010, a young woman who worked at a drugstore photo center developed a bunch of photos showing different children wearing blindfolds with tape over their mouths. There was no nudity or anything <em>explicit</em>, but the woman found the images unsettling, and her intuition told her that something was not right. Despite her manager saying that it was probably nothing, she contacted the authorities. This led to the investigation of Mark Berndt, a teacher at Miramonte Elementary School in the Los Angeles Unified School District (LAUSD), which was comprised of mostly low-income Hispanic students.</p>
<p>The investigation revealed <a href="https://www.nbclosangeles.com/news/local/Former-Teacher-Arrested-Classroom-Photos-138404744.html">horrifying details</a> of what dozens of girls suffered at the hands of Berndt, including being fed cookies topped with his semen. Perhaps more dismaying is the fact that years earlier, LAUSD had received allegations of abuse against Berndt. But the district not only failed to report him to the police, it also <a href="https://www.nbclosangeles.com/news/local/LAUSD-Admits-It-Destroyed-Documents-Regarding-Child-Sex-Abuse-New-Revelations-of-Abuse-by-Teacher-Berndt-257476981.html">destroyed records</a> detailing these prior accusations. The families of the victims then sued LAUSD for its negligence.</p>
<p>Dr. Terr was eventually brought in by the plaintiffs’ attorneys to interview the victims, who were then in their teens. She showed that without a doubt, the abuse did lasting damage, and these teens had serious PTSD that affected their lives in ways wide-ranging and profound, even though at the time of their victimization they were too young to fully grasp what was happening. Eventually, LAUSD <a href="https://www.scpr.org/news/2014/11/21/48132/140m-settlement-in-miramonte-civil-suit-against-la/">settled the lawsuit</a> for $140 million, a record sum. Dr. Terr ended her talk by praising the courage of the drugstore employee, whose actions ultimately led to the humbling of the nation’s second largest school district for failing to protect the children in its charge. </p>
<p>After Dr. Terr’s talk, I stood and applauded with everyone else. But something about her exultant tone seemed off to me. After all, here was a famous child psychiatrist who no doubt knew that one of AACAP’s former presidents, Dr. William Ayres, was <a href="https://www.mercurynews.com/2013/08/26/peninsula-child-psychiatrist-william-ayres-sentenced-to-eight-years-for-molesting-patients/">convicted in 2013</a> of sexually abusing multiple boys while they were his patients. In fact, she <a href="http://lynnponton.com/2009/09/the-romance-of-risk/">seems to be friendly</a> with Dr. Lynn Ponton, a child psychiatrist who <a href="https://www.sfgate.com/bayarea/article/Retired-child-psychiatrist-facing-molest-charges-2526577.php">reported Ayres to the authorities</a> after hearing from one of his former patients about what he did. Yet there was no mention that our profession can harbor predators as well and that we all need to do the right thing if we suspect one of our colleagues of abusing children.</p>
<p>Even more surreal was the fact that the very first audience comment after the talk came from Dr. John Dunne, one of the distinguished elders of child psychiatry. He clearly knew Ayres, since they had co-chaired AACAP’s Work Group on Quality Issues in the 1990’s and worked together on multiple practice parameters (basically our version of professional guidelines), including one on the <a href="https://www.jaacap.org/article/S0890-8567(09)66452-2/abstract">evaluation of children</a> who may have been physically or sexually abused. When I saw him stand up with a microphone in his hand, I naively hoped that he would ask Dr. Terr something like, “what if a member of our own profession was a serial child molester?” Instead, he praised her for her wonderful talk and then went on to discuss his own experiences working with traumatized youth. I should not have been surprised, for I have never heard another child psychiatrist mention William Ayres in public. Almost six years ago, I wrote the following tweet:</p>
<blockquote class="twitter-tweet" data-lang="en"><p lang="en" dir="ltr">Former AACAP president Ayres finally convicted of child molestation. Why hasn't <a href="https://twitter.com/AACAP?ref_src=twsrc%5Etfw">@AACAP</a> made a statement? <a href="https://twitter.com/hashtag/StopAbuse?src=hash&ref_src=twsrc%5Etfw">#StopAbuse</a> <a href="http://t.co/NOMhzF0VOK">http://t.co/NOMhzF0VOK</a></p>— Psycritic (@psycrit) <a href="https://twitter.com/psycrit/status/335436402328215553?ref_src=twsrc%5Etfw">May 17, 2013</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
<p>Now that Ayres has <a href="https://www.mercurynews.com/2016/05/12/san-mateo-infamous-child-molester-dr-william-ayres-dies-in-prison/">died in prison</a>, maybe this talk by Dr. Terr is finally some sort of attempt by AACAP at <a href="https://en.wikipedia.org/wiki/Undoing_%28psychology%29">undoing</a>? If so, it was not good enough. We’re the doctors who are supposed to be able to help others to <em>not be afraid to go there</em> and <em>give voice to the unspeakable</em>. Instead, I saw two preeminent child psychiatrists engage in a strangely self-satisfied dance around the dirty elephant in the room.</p>Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-55865041085631138162018-11-13T17:12:00.000-08:002018-11-13T17:12:39.347-08:00The "Rapid Onset Gender Dysphoria" Controversy at AACAP's Annual Meeting<p>Last month, when I saw the program for the Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP), my professional society, there was <a href="https://aacap.confex.com/aacap/2018/meetingapp.cgi/Session/19053">one session</a> that caught my eye. It featured a presentation by Lisa Littman, MD, MPH titled “Peer Group and Social Media Influences in Adolescent and Young-Adult Rapid-Onset Gender Dysphoria.” In case you’re not familiar with the term “rapid-onset gender dysphoria” (ROGD), it exploded into prominence and controversy in August following the publication of <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330">a paper by Dr. Littman</a> reporting data from parents who claim their children started to identify as transgender after being exposed to some form of online influence, social trend amongst their friend group, and/or acute stressor.</p>
<p>This story has been covered extensively in publications like <a href="https://www.sciencemag.org/news/2018/08/new-paper-ignites-storm-over-whether-teens-experience-rapid-onset-transgender-identity">Science</a> and <a href="https://slate.com/human-interest/2018/08/rapid-onset-gender-dysphoria-study-criticism-is-not-censorship-its-good-science.html">Slate</a>, but in short, the response to this paper was rapid and highly polarized, with the transgender community generally condemning it as flawed and transphobic, while others <a href="https://www.ipetitions.com/petition/brown-university-and-plos-one-defend-academic">rushed to defend</a> Dr. Littman from “ideologically-based attempts to squelch controversial research evidence.”</p>
<p>I’ve attended several previous AACAP meetings, where educational sessions tend to have a staid consistency: An academic child psychiatrist or psychologist presents a topic related to their research or clinical area of expertise, there is polite applause at the end, followed by a fairly mundane Q&A in which audience members either praise the speaker and/or talk about how the presentation relates to their own clinical experiences. You may not be surprised to learn that what happened following Dr. Littman’s presentation was very different.</p>
<p>For her presentation, Dr. Littman started by summarizing research from the past decade showing that the age of those presenting to gender clinics as transgender have become older (i.e. adolescents as opposed to pre-pubescent children), with a higher proportion being female-at-birth than male-at-birth, which is the opposite of the previous historical pattern. Dr. Littman noted that around 2015, parents of some transgender teens started reporting on online forums that their teens’ transgender identification seemed to arise in the context of belonging to a peer group in which multiple members came out as transgender around the same time, as well as adopting other behaviors like binge watching of transition videos online.</p>
<p>According to Dr. Littman, this raised the concern that there many be social contagion occurring, and she specifically cited the example of online websites with “<a href="https://en.wikipedia.org/wiki/Pro-ana">pro-ana</a>” or “<a href="https://en.wikipedia.org/wiki/Pro-ana#Thinspiration">thinspiration</a>” themes that encourage anorexic behavior. Her study started in 2016 with a Surveymonkey survey that was shared with parents who frequented forums where they shared their experiences of their teens’ “rapid-onset gender dysphoria.” Although Dr. Littman noted that ROGD is a term used by some parents and clinicians but is not an official diagnosis, she did not show much skepticism about the concept, basically accepting it as valid and deserving of research.</p>
<p>Her study, based on the responses of 256 parents who claimed their teens had ROGD, found that in 2/3 of these cases, those teens were part of a social group in which at least one other friend came out as transgender, and in an astounding 36.8% of the cases, the <em>majority</em> of the friend group came to identify as transgender. Also, 80% of the cases reportedly had zero symptoms of DSM-5 Gender Dysphoria before identifying as transgender, 62% had a prior psychiatric diagnosis, 45% had non-suicidal self-injurious behavior, and 58% were described as being easily overwhelmed by strong emotions. Dr. Littman put forth the hypothesis that the youths described in her study are adopting a transgender identity as a maladaptive way of coping, and she provided some example cases that parents shared, such as teens who began to identify as transgender after experiencing sexual assault, school failure, or bullying based on their appearance. In conclusion, Dr. Littman stated that more research is needed on ROGD, and that in future studies, she hopes to involve the transgender youth themselves rather than just their parents.</p>
<p>Following Dr. Littman’s presentation, there was no applause before several audience members launched into questions. Some were more civil than others, but pretty much all were critical. One audience member pointedly asked Dr. Littman what she had previously studied in her research (OB-Gyn public health issues), and whether she has worked with any transgender patients in the past (she has not), before concluding by telling Dr. Littman that she was not qualified to do this kind of research. Another questioner at the end repeatedly asked her “why did you do this study” and “what’s wrong with taking on a different gender identity,” to which she would only say that we should keep open the possibility that there may be social contagion occurring, as with her anorexia example earlier. The questioner then pointed out that unlike anorexia, a transgender identity is not by itself harmful.</p>
<p>Before every presentation at AACAP, the speaker is supposed to disclose any financial conflicts of interest, and I don’t recall Dr. Littman reporting any such conflicts. However, the most relevant conflicts often don’t come from financial interests, but from one’s own biases or personal allegiance to a particular theory, the pressure to publish, the desire for fame and validation, etc. To me, the most frustrating aspect of Dr. Littman’s presentation was that she remained opaque regarding her own views and why she undertook this study. Is she some sort of right-wing anti-trans ideologue? Is she an anti-PC academic who lacks a filter and doesn’t mind controversy, like a mild <a href="https://www.tabletmag.com/jewish-news-and-politics/262280/jordan-peterson">Jordan Peterson</a>? Could she just be a guileless public health researcher who unwittingly stumbled into a hornet’s nest? Or is Dr. Littman herself a parent (or a friend of a parent) who had frequented the ROGD forums looking for support and answers? I don’t know if Dr. Littman discussing her own experiences and opinions would have made her study any less controversial, but at least it would have felt more honest and transparent.</p>
<p>The discussant (a.k.a. summarizer and moderator) of the session was Dr. Scott Leibowitz, director of the gender program at Nationwide (Is On Your Side) Children’s Hospital in Columbus, OH. I did not envy the task before him, but Dr. Leibowitz admirably pointed out that child psychiatrists are often caught in the gray zone between opposing sides who view gender issues as black-and-white, whereas we've tended to recognize that a person’s gender identity is formed from biological, psychological, and social factors. He gently but persistently critiqued Dr. Littman’s study as far from neutral in how it presented the concept of ROGD to parents taking its survey. He pointed out that in a political climate where transgender people remain a marginalized minority under <a href="https://www.nytimes.com/2018/10/21/us/politics/transgender-trump-administration-sex-definition.html">constant attack</a>, any research that may affect their well-being has to be done with great sensitivity and consideration of the potential consequences, which this study was not. But he also pushed back against those audience members who thought Dr. Littman should not have gotten involved in an area in which she had no prior experience or expertise.</p>
<p>Dr. Leibowitz’s summation reminded me of the following quote, taken from the previously linked article on Jordan Peterson:</p>
<blockquote>
<p>We are living through a time of pervasive rhetorical overkill and genuine fear. In times of extremism, moderation itself can come to seem the greater enemy to those ideologically possessed, in part because it is the true danger: The public will tend to move toward it by default, and thus the instinctive recourse by those who sense the fragility of their extreme doctrines resort to coercive means to prevail in arguments they would not otherwise win.</p>
</blockquote>
<p>I hope that moderation can ultimately prevail, and I greatly appreciated Dr. Leibowitz’s approach. But I don’t think there was any applause either at the end of Dr. Leibowitz’s summation. Was the audience fearful of showing where they stood? Also, Dr. Leibowitz did not tweet about this session afterwards, even though he <a href="https://twitter.com/ScottLeibowitz">tweeted</a> about many other LGBTQ-related sessions at AACAP. I hope this wasn’t because he was wary of the immoderates of the Internet. In today’s political climate, I really wish the “silent majority” of those in the middle would not be so silent.</p>Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-8220497079222850472018-03-11T22:18:00.000-07:002018-03-11T22:18:05.991-07:00Reflections on a Bully From High School<p>Brett was the biggest jerk on my JV soccer team. He was short, stocky, and slow. Yet he also had a beautiful shot off either foot, and he was our star striker. He was the one Coach called upon to take all of our free kicks and PKs. He had more goals than anyone on the team.</p>
<p>I played defense, along with my friend Luke. Luke and I rarely got the chance to shoot the ball and almost never felt the glory of scoring a goal. While scrimmaging in practice, we got to spend plenty of time with Brett, since he would just loiter near the goal, never running back to help his side on defense. When the coach wasn’t looking, Brett would try to trip us or kick us in the shins, and sometimes he even jumped on my back and tried to wrestle me to the ground. During games, if the coach asked him to do something he didn’t like, he would curse and mutter insults not quite under his breath. This once led the captain of the opposing team to ask incredulously, “How can you talk to your own coach that way?”</p>
<p>During water breaks, Brett's favorite pastime seemed to be making fun of Luke and myself in front of the whole team. With me, Brett usually mocked my appearance, since I was very nerdy and not yet good at hiding it. There was a silly rumor going around the school that Luke had a testicle removed due to a medical condition, and Brett mercilessly and repeatedly mocked Luke by calling him “One-Ball” and telling him he would never have kids. Most of the team laughed along with Brett.</p>
<p>In the offseason, some of my teammates and I played on an indoor soccer team, which my dad helped coach. In the confined space of an indoor arena, Brett seemed to get even more personal with his insults. He owned the official Adidas soccer ball that my team used. He would tell me, “This ball cost $80. Since you get all your clothes at K-Mart, it’s worth more than your entire wardrobe!" Yet around my dad, he seemed more friendly to me, and I never heard him swear at my dad. On several occasions, he even said to me, “Your dad is so cool!” Back then, I interpreted those comments to be further mockery, which I did my best to ignore. Now, I’m not so sure.</p>
<p>My dad was a frequent spectator at my JV team’s games. He couldn’t make it to the afternoon games, but he invariably came to all of our evening and weekend games. Brett’s parents, on the other hand, were never there. From what I heard, his father was out of the picture, and his mother had to work 2 jobs to support him and his older brother, who was kicked out of high school for drug use. Brett’s brother did sometimes show up to our games, watching quietly from the sideline and usually leaving before the game was over.</p>
<p>There were some occasions when Brett seemed to show a softer side. During lulls in practice, I remember seeing him sometimes looking wistfully up at the sky. Out of the blue, he said to me once, “You see those birds over there? I wish I could be a bird and just be free and fly away.” At the time, I did not give a crap what he may have been trying to fly away from. But now I wonder.</p>
<p>I thought about Brett this week when Facebook suggested I add him as a friend under “People You May Know.” I did not. But he looked happy in his profile picture, and out of curiosity, I googled his name and found that he has moved far from our hometown, and he works as an operations manager for a fancy restaurant chain. I do not know if he has any kids, but if he does, I hope that he is able to go to all of their soccer games.</p>Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-1963911041257686662018-01-20T14:37:00.000-08:002018-01-20T14:37:17.780-08:00Is Apple Responsible for the Well-Being of Our Kids?<p>I was surprised to see that the most-viewed article on the blog this week was one that I wrote almost 5 years ago, <a href="http://www.psycritic.com/2013/06/if-your-kids-are-obsessed-with-technology.html">What to Do if Your Kids Are Obsessed with Technology</a>. (Thanks to whoever shared that on Facebook!) Reading it again, it seems to hold up fairly well, and I would still offer the same advice to parents wondering what to do if their young one seems too drawn to screens.</p>
<p>However, many things have changed since 2013. Smartphones have gotten so ubiquitous that every teenager I see has one, and most children older than 8 or 9 seem to have one as well (and if not a smartphone, then almost certainly a tablet or Chromebook). Snapchat and Instagram have gotten ever more entrenched as the platforms of choice for young people’s socializing and selfie-expression, and <a href="http://www.psycritic.com/2017/12/my-free-to-play-gaming-postmortem.html">games with addictive mechanisms</a> have proliferated like weeds. We’re even having a cultural conversation about whether a <a href="https://www.theatlantic.com/magazine/archive/2017/09/has-the-smartphone-destroyed-a-generation/534198/">generation has been destroyed</a> because of the effects of smart devices. I don’t think it’s gone quite that far, but I hear constantly from parents about the difficulty they have trying to separate their kids from their screens. </p>
<p>Now, I am an old-school Apple fan, using Apple computers and devices almost exclusively ever since my first experiences with an Apple II in elementary school. So it was with great interest that I saw the recent headlines about investors calling for Apple to look into <a href="https://www.nytimes.com/2018/01/08/business/apple-investors-children.html">how their technology may be harming kids</a> and to mitigate any potential harms. Then, earlier this week, Farhad Manjoo went even further with an article in the New York Times about how Apple can help <a href="https://www.nytimes.com/2018/01/17/technology/apple-addiction-iphone.html">save all of us</a>, adults included, from the attention-grabbing consequences of their technology by building a “less-addictive iPhone.” I agree with Manjoo that this represents a great opportunity for Apple, since their business model does not depend primarily on people using their devices nonstop. However, designing software to be less addictive for all is a much more complicated issue than putting in better parental controls for minors, so I’m going to focus on the latter for rest of this post.</p>
<p>Ultimately, I think the answer to the question posed in the title of this article is that parents are responsible for their kids, but parents need help, and Apple can do a lot more to make it easier for parents to set appropriate limits. Even for savvy parents who do not allow screens in bedrooms, sometimes the lure of the device is so tempting that a kid would sneak it into their rooms at night. Many parents I work with try to set screen time limits, but they can’t keep watch on their kids all the time, and it’s hard for a parent to know how much time a kid is spending watching videos vs. playing games vs. working on homework. And even when a parent can accurately track the time and tells a child to stop using the device, this often leads to arguments and fights if the child is super-engaged in what they’re doing (I probably see a biased sample of kids who tend to get very irritable when this happens). Plus, I’m sure that Apple can come up with a much more elegant solution than a <a href="https://www.youtube.com/watch?v=8NBgzttpDw0">lockbox with a timer</a>. </p>
<p>Most of us have probably heard by now that <a href="https://www.propublica.org/article/set-it-and-forget-it-how-default-settings-rule-the-world">defaults matter</a>, whether it’s for organ donation rates, food choices, or 401k participation. And right now the default when setting up a new iPhone or iPad is that the user is all-powerful; she can access all apps, all sites, and use the device at all hours of the day and night. Stricter controls have to be manually enabled, which many parents simply do not do. Also, Apple’s current parental controls (under Settings -> General -> Restrictions) are rudimentary: specific apps can be restricted, and if a child tries to download a new app from the App Store, parents can choose to get an alert on their device that would allow them to approve or deny the purchase. There is also a content filter for apps, movies, and music that restricts adult content, and a website filter that blocks access to adult sites.</p>
<p>This is not a bad start, but far from adequate in today’s environment. I think Apple should ask during the initial setup of a new device whether the device is intended for a minor, and if so, the age of the child. With that info, Apple should then set defaults (which the parent can always change later) that are age-appropiate, in line with <a href="https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/american-academy-of-pediatrics-announces-new-recommendations-for-childrens-media-use.aspx">expert recommendations</a> on screen time, gaming, and how much <a href="https://sleepfoundation.org/excessivesleepiness/content/how-much-sleep-do-babies-and-kids-need">sleep kids need</a>. If a device is in “kid mode” and it runs up against preset time limits, it should give the user a warning 5 minutes and 1 minute before the time limit is reached, so there will not be any surprises when the user gets locked out of what they’re doing. The device should also lock itself 1 hour before bedtime. If the child wants to use it past a time restriction, the parent would have to grant permission on a case-by-case basis. </p>
<p>Here’s an example of what I think might be roughly appropriate for 2 broad age groups:</p>
<p><span style="text-decoration: underline;">Kids (6-12)</span><br />Video watching: 30 mins<br />Games: 30 mins<br />Nighttime: No use after 8pm<br />Apps: All apps (except Phone, Mail, Messages, Music, Photos) initially restricted; parents can manually enable other apps<br />Contacts: Only allow calls/texts/email with approved contacts<br />Content: Block adult content and websites</p>
<p><span style="text-decoration: underline;">Teens (13-18)</span><br />Video watching: 1 hr<br />Games: 1 hr<br />Social media apps: 1 hr<br />Total use of above categories: 2 hrs<br />Nighttime: No use of most apps after 10pm, but can play music or podcasts<br />Apps, Contacts, Content: Less restrictive than for kids, but parents should have an easy way of seeing how much time is spent in different apps.</p>
<p>If you think I’m being too strict, then you probably haven’t been paying attention to how much tech industry executives tend to <a href="https://www.sfgate.com/technology/businessinsider/article/Bill-Gates-is-surprisingly-strict-about-his-kids-12497489.php">limit their children's access</a> to devices. As I said on the Twitter:</p>
<blockquote class="twitter-tweet" data-lang="en"><p lang="en" dir="ltr">Um…isn’t the red flag here how few limits most parents are setting about their kids’ electronics use, rather than what <a href="https://twitter.com/BillGates?ref_src=twsrc%5Etfw">@BillGates</a> is doing? He’s not surprising strict, most parents are surprisingly lax. <a href="https://t.co/rQyYA0nuhM">https://t.co/rQyYA0nuhM</a></p>— Psycritic (@psycrit) <a href="https://twitter.com/psycrit/status/954192796876812288?ref_src=twsrc%5Etfw">January 19, 2018</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
<p>I was encouraged recently when Apple took a step to look after for its users’ interests by requiring that game developers <a href="https://www.theverge.com/2017/12/21/16805674/apple-loot-box-app-store-games-odds-probability-disclosure">disclose the odds</a> in games that have gambling-style mechanics. Up to now, Apple may have viewed parental control software as a third party opportunity, creating an opening for successful businesses like <a href="http://ourpact.com">OurPact</a> or Disney's <a href="https://meetcircle.com/">Circle</a>. But Apple also has a long tradition of “<a href="http://time.com/4372515/apple-app-developers-wwdc-sherlock-sherlocked/">sherlocking</a>,” in which they steal the best features of a third party product and incorporate them into their operating system. When it comes to setting better defaults for kids, I would encourage Apple to sherlock away!</p>Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-35285244369252693132017-12-14T17:16:00.000-08:002017-12-14T17:17:35.886-08:00Euphoria At The Burger Joint<p>The line at the popular local burger joint was much shorter than usual when my fiancée and I arrived arrived with visions of freshly seared beef and milkshakes dancing in our heads. We couldn’t believe our luck: aside from the people currently ordering, there was only a middle-aged woman and a young couple standing in line in front of us. We didn’t notice anything amiss, at first.</p>
<p>Then I saw that the woman was not actually in line, but she was approaching the couple in front of us, apparently looking to strike up a conversation. Her hair was a bit unkempt, her make-up slightly excessive. And she was holding a thick wad of cash in one hand. She was <em>beaming</em> from ear to ear as she asked the couple in front of us, “Are you two on a date?”</p>
<p>“Yeah, it’s our first date,” said one member of the couple.</p>
<p>“How wonderful!” the woman exclaimed. “I can see love, and I can just tell that you two were meant to be together.”</p>
<p>The couple chuckled nervously, and the the woman started talking to them about the importance of Love in the Universe.</p>
<p>I watched what was happening in front of us with growing unease. I’ve seen this kind of irrational exuberance—and lack of boundaries—before during various psychiatric rotations, in patients who were manic or high. It usually didn’t end well. I noticed that my fiancée and I were standing closer together by now, and I glanced at her with a worried look that said, “What do we do?” She shot me a look back that said, “<em>You’re</em> the psychiatrist, you tell me!” We were both quite hungry, so leaving was out of the question. We stayed in line to await the inevitable.</p>
<p>Eventually, the woman held out a $20 bill to the male half of the couple and said, “Here, take this! I want to celebrate your beautiful young love!” As he reached for the money, the woman moved in closer, wrapping her arms around the guy and giving him a big kiss on the cheek. I think it would have been on his lips had he not turned his head at the last second. “Whoa!” he said, as he hastily backed away to free himself of her, with a new $20 bill in his hand.</p>
<p>Thoughts of worst-case scenarios crossed my mind. What if this lady got really agitated if we didn’t want to talk to her, or we didn’t want to take her money (or kiss her, for that matter)? I tried desperately to remember the brief training I got as a psychiatry resident on how to maintain a defensive stance when dealing with potentially aggressive patients. I stood a bit sideways to the woman, so my vulnerable belly was not as exposed. I kept my right foot, which was closer to her, pointed towards her and my weight on my left foot, in case I had to move in either direction. I crossed my arms and then pretended to stroke my chin with my right hand, so my arms would not be sitting uselessly by my side if I needed them.</p>
<p>Sure enough, the woman approached and asked us, “Are you on a date?”</p>
<p>I made sure not to look at her too directly as I mumbled, “Not really, just here for some burgers.”</p>
<p>Still, she held out a $20 and said, “Here, I have a present for you!” Not wanting to escalate the situation by saying no to her, I decided I might as well take it. I stuck my arm out as far as I could towards her, so that it would be more difficult for her to step closer for a smooch. I held my breath as she put the money in my hand and swiftly moved on to the next person in line behind me. “Whew,” I thought. “Guess that training really worked!”</p>
<p>As I looked at the $20 bill in my hand, I asked my fiancée, “What should we do with this?” Again, she would not let me off the hook. “You’re the one who took it, you decide!” I briefly debated paying for our meal with that money, but it just felt a little…<em>crass</em>. I paid with a credit card instead, and put the bill in my wallet. Once we got our food, I turned back towards the entrance to see what the woman was up to, but she had left, presumably to do good deeds elsewhere. I felt guilty, of course. It would certainly have been worse if she had been giving away Benjamins, but who knows what percentage of her personal savings she was wasting like this, one 20-dollar bill at a time?</p>
<p>But would it have made sense to call the police on her for causing a disturbance, or for sexual harassment, given her unwanted kissing? Even if they came, took it seriously, and hauled her to the nearest psychiatric ER, would there have been enough to involuntarily detain her? What if she had just won the lottery and was being <em>very</em> happy and generous?</p>
<p>Still, those burgers and shakes were tasty, and well worth the time spent standing in that particular line.</p>
<p>Readers, what do you think you would have done in this situation?</p>Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-73608819482295191082017-12-09T08:06:00.000-08:002017-12-09T14:21:26.906-08:00My Free-to-Play Gaming PostmortemSo there was this period of time from mid-September 2015 to mid-October 2017 in which I didn’t write a single blog post. What happened? This post is my attempt to reflect on my hiatus from blogging.<br />
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The most convenient answer—and the one most friendly to my ego—is that I had simply gone through some Major Life Changes that got in the way of devoting time to this blog. However, if I dig deeper, I must admit to myself that October 2015 is when I started playing a free Japanese mobile game called <a href="http://puzzleanddragons.us/">Puzzle and Dragons</a> (PAD), and October 2017 was when I started to get tired of playing it; I finally deleted the game from my phone last week.<br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><img border="0" data-original-height="1220" data-original-width="1600" height="488" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEje-YT-06tuwnFBgiZoLxCHaytz8zIwQZY-1iT3W6l13WqnG0F3pk71cXV2Z7D_FQwTbItEQEdZblU211u-phoZQg7caCC2g2NaVM4BkF3SRq0uPI_mnMGVQpvDdem4vcfK1X_voYnpKMDM/s1600/monsterbox.jpg" width="640" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Left: A random person's monster collection. Right: a monster card in all its glory.</td></tr>
</tbody></table>
The basic gist of PAD is that you assemble a team based on different “monster cards,” each of which has different properties. You obtain the best cards by spending “magic stones” on a <a href="https://www.youtube.com/watch?v=TfhsAXKtMUs">Rare Egg Machine</a>, which pops out a random monster card at a cost of 5 stones. The stones can be earned for free by beating levels in the game or purchased for $0.99 each (or only $59.99 for 85!). With your team, you fight your way through various dungeons, doing damage to the enemies based on how many orbs of the same color you can match in rows or columns of at least 3 on the game’s puzzle board. As with any decently fun game, it felt rewarding to finally beat a difficult level after multiple tries. And the artwork and graphics, hand-drawn by Japanese artists, were top-notch. But in addition to these basic features shared with most games, PAD has many mechanisms that increase its ability to grab ahold of players’ attention, time, and money, and these psychological manipulations are very clear for me to see in retrospect.<br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><img border="0" data-original-height="1280" data-original-width="1600" height="512" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiih2ckiAinxHsO_7cjmM1JsxBwKeA6soqD3CRMuOCWRBjNTO1AfjUIAyPJfAOtzv4bLY3Oai1UB1V80WfXADViW6CxI7LBnkK3I-fDxU2X5UVvli8zQ6H1ivI4KYSqXtiMRj3Rx-zF83F-/s1600/padboard.jpg" width="640" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Left: Narrowly escaped death from the enemy's attack. Right: My team doing some serious damage to Kali.</td></tr>
</tbody></table>
The game frequently gives away magic stones and other goodies for free, using <a href="https://en.wikipedia.org/wiki/Reciprocity_(social_psychology)">reciprocity</a> to make a player feel motivated (or obligated) to keep playing. Also, you get more rewards the more consecutive days you log in, which helps players make the game a daily habit à la <a href="http://mashable.com/2017/11/07/snapchat-down-snap-streaks/#4H17kVkzZgqU">Snapstreaks</a>. The most powerful cards, of course, are very rare, so there’s <a href="https://en.wikipedia.org/wiki/Reinforcement#Intermittent_reinforcement.3B_schedules">intermittent variable interval reinforcement</a> when you get lucky and land a good card. There are special events every few weeks called “<a href="https://www.facebook.com/notes/puzzle-dragons-north-america-gungho/hail-to-the-dragon-godfest/1891158900912693/">Godfests</a>,” which are the only times players can get certain rare cards, creating some serious <a href="https://en.wikipedia.org/wiki/Fear_of_missing_out">FoMO</a>. Once you’ve invested time and energy to assemble a nice collection, there’s a strong tendency towards <a href="https://en.wikipedia.org/wiki/Loss_aversion">loss aversion</a>, as no one wants to feel like they’ve wasted all this time for nothing. Since most of PAD’s players are young men, many of the most desirable cards feature scantily-clad female characters, a.k.a. “<a href="https://www.reddit.com/r/PuzzleAndDragons/comments/3kgg77/discuss_the_only_tier_list_that_matters_top_waifu/">waifus</a>.” And there’s a community aspect as well, with multiple forums devoted to the game where players share their accomplishments and good Godfest luck, leading to <a href="https://en.wikipedia.org/wiki/Social_comparison_theory#Upward_and_downward_social_comparisons">upward comparisons</a> and social reinforcement.<br />
<br />
Despite all that, I’m not sure I would say that I was <i>addicted</i> to the game in a clinical sense. I was spending ~30-60 minutes a day playing the game, and maybe another half hour a day reading about it. My personal relationships and work did not suffer, as far as I can tell. Over the course of 2 years, I spent a grand total of $10 on in-app purchases of magic stones. On PAD forums there are reports of “whales” who've spent upwards of <a href="https://www.reddit.com/r/PuzzleAndDragons/comments/3ltp96/question_am_am_i_a_whale/">thousands of dollars</a> on the game, so I got off relatively easy, at least in a financial sense.<br />
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Still, how PAD affected my mind is undeniable. Instead of reading blogs related to psychiatry and mental health, I was reading <a href="https://mantasticpad.com/">blogs</a> and watching <a href="https://www.youtube.com/channel/UClhm9EEQo48QiimEIbZYvwA">YouTube channels</a> related to PAD. I stopped even thinking about my blog, and every time I had a spare moment, I would open the PAD app instead of taking in my surroundings or reading a book. In fact, I read far fewer books in 2016 and 2017 compared to any other year in my life since I learned to read, though part of that may be due to reading more on the web. It wasn’t all bad, though. I wasted far less time on Twitter, and I was no longer waking up in the middle of the night with ideas for blog posts. I had a convenient and pleasant distraction from politics. And I’ve spent much less mental energy these last 2 years obsessing about my fantasy football teams than I have in previous years.<br />
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So what finally made me stop? A part of it was the fact that PAD’s creators are constantly adding more difficult dungeons, which in turn require ever more powerful (and rare) monster cards to deal with. Playing the game started to feel increasingly like a Sisyphean task. I’d also like to think that a part of me missed blogging and reading books. Recently, I came across the philosophically-oriented <a href="http://slatestarcodex.com/">Slate Star Codex</a> blog, written by a young psychiatrist, and I thought, “If he can write several 2000 to 5000-word blog posts in a week, then why can’t I be even 3% as productive (i.e. roughly a 1000-word post per month)?”<br />
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Lastly, some advice for parents out there: as fun as Super Mario Bros was for us in our youth, it does not remotely compare to the reinforcement mechanisms that today’s <a href="https://en.wikipedia.org/wiki/Microtransaction">microtransaction</a>-driven mobile games employ. I’ve heard multiple stories from parents about their kids stealing their credit cards to spend hundred of dollars on in-app purchases for games like Clash of Clans and Clash Royale. I now believe that parents should not be letting their kids play games like these, which all tend to use similar attention and money-grabbing tactics. As a general rule, this applies to any of the mobile games that you see advertised on TV; how else would those game companies have so much money to spend on prime time ad spots? Recently, regulators in The Netherlands have started investigating whether <a href="https://arstechnica.com/gaming/2017/11/belgium-denounces-loot-boxes-as-gambling-hawaiian-legislator-calls-them-predatory/">games that have “loot boxes”</a> (a similar idea to the Rare Egg Machine) are a form of gambling and should be regulated as such. In my mind there is no doubt that these games can work very similarly to gambling, except you can’t actually win any money, so it’s in a way worse than gambling.<br />
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Even if there are kids who can responsibly play these games without spending too much time or money, I would still strongly suspect that these games have an outsized influence on what their players think about—and stop thinking about—even when they’re not playing. And for me, that was ultimately the biggest negative impact.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-22598273930966816002017-12-05T17:17:00.000-08:002017-12-05T17:17:17.097-08:00Protests, Then and NowLately, I’ve been hearing and reading a lot about how America is the <a href="http://www.mercurynews.com/2016/11/04/commentary-america-has-been-this-divided-only-twice-before/">most divided it’s been</a> since the 1960’s. But given all of the social progress made over the course of that tumultuous decade, maybe that’s not such a bad thing. I was not around during the 60’s, but my mental image of that era is filled with vivid images of people protesting: at <a href="https://en.wikipedia.org/wiki/Selma_to_Montgomery_marches">Selma</a> and the <a href="http://www.history.com/topics/black-history/march-on-washington">March on Washington</a>, on campuses all over the country, even <a href="https://www.washingtonpost.com/news/retropolis/wp/2017/10/19/the-day-anti-vietnam-war-protesters-tried-to-levitate-the-pentagon/">at the Pentagon</a>. <br />
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Which got me thinking, how are today’s mass protestors doing? (My thoughts on the NFL’s anthem protestors—and celebrity protests in general—are somewhat separate and not covered here.)<br />
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Last month, I was somewhat taken aback when I read about some <a href="http://www.newsweek.com/antifa-rallies-november-4-promise-remove-trump-white-house-700406">anti-fascist rallies</a>: <br />
<blockquote class="tr_bq">
The explicit goal of the November 4 protests, which have been warped into a number of increasingly bizarre, "antifa"-related conspiracy theories by right-wing media, is to remove Trump and his administration from office. In order to achieve that end, millions of people will have to take to the streets of cities like New York, Austin and San Francisco, demanding that the administration step down, organizers tell Newsweek. It’s something that will not be achieved with the actions of only a few left-wing radicals, they say.</blockquote>
WTF?!? Am I the only one who thinks that holding an antifascist protest in SF is like Martin Luther King and other civil rights leaders marching down the streets of Harlem instead of down Hwy 80 from Selma to Montgomery? If you’re protesting fascism, why in the world are you holding your protests in the most diverse places with the fewest white nationalists and their sympathizers? Why not go to where the Trump voters actually live, like the Deep South or Kansas? If that’s too far for city people to travel, how about taking a bus from Pittsburgh to <a href="https://www.politico.com/magazine/story/2017/11/08/donald-trump-johnstown-pennsylvania-supporters-215800">Johnstown, PA</a> or from Detroit to one of those Michigan counties that went for Trump? Or is that still too inconvenient for people?<br />
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Given all this #Resist talk, what are people actually doing to resist our president? During the 50’s and 60’s, the protestors organized <a href="http://time.com/3691383/woolworths-sit-in-history/">very effective sit-ins</a> which not only highlighted the racism and oppression of “separate but equal,” but just as importantly, disrupted lots of segregated businesses. And who can forget the cries of “Hey hey LBJ, how many kids did you kill today?” causing Lyndon B. Johnson to <a href="http://www.presidentprofiles.com/Kennedy-Bush/Lyndon-B-Johnson-Protest-at-home.html">not have a moment’s peace</a>:<br />
<blockquote>
The president and his principal spokesmen were finding it harder each week to avoid the chanting protesters, who seemed to be everywhere. For the first time in history, a president was unwelcome in public in most parts of the country, making him a veritable prisoner in the White House, "hunkered down" there, to use one of his favorite expressions. </blockquote>
Fast forward to today, when we have a grossly narcissistic guy who cares most about his image, his money, and his opulent properties, so how is the fight being taken to that guy? Certainly lots of people are being blocked by him on Twitter, but what is most noticeable to me is how much he still gets to <a href="http://trumpgolfcount.com/">enjoy playing golf</a> almost every week. So why aren’t people protesting every single weekend at Mar-a-Lago or Trump National Golf Club? Why aren’t they blocking off traffic, as protestors have done in Oakland and St. Louis? Why aren’t protestors shaming everyone who goes to those Trump properties with shouts of “Hey hey DJT, all your lies won’t set you free!”? Is this asking too much, if indeed this man is as dangerous as we think he is?<br />
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Speaking of which, one of the most infuriating things I read this year is this account of what actually happened when anti-Trump protestors came face-to-face with Trump supporters at <a href="https://www.blogger.com/-%20https://medium.com/s/debacle-in-phoenix/no-madness-like-american-madness-73b2e899747a">a Trump rally in Arizona</a>:<br />
<blockquote>
Elsewhere in the city, the police had done a masterful job of ensuring that large groups of pro-Trump Americans were separated from groups of anti-Trump Americans. The two groups were usually placed on either side of wide barricaded streets, but on this corner, there were no barricades, no police nearby, and access between the two groups was unobstructed.<br />
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Which made it all the more surreal and tragic how genial and almost embarrassed the interactions were.
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<br />
[…]
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<br />
The Trump supporters looked up and down at their sudden audience, and, if they could get over their astonishment, smiled and held up their phones to take pictures.<br /><br />
And when the protesters saw just how unarmed and unassuming most of the Trump supporters were, and how free they were of signs, weapons, anything — they were left speechless.<br />
<br />
That was a strange thing. There were a hundred or so protesters standing on the high steps, and at any given time a few dozen Trump attendees passing them on the sidewalk, but for much of the time they were in close proximity, and no one said anything.<br /><br />
Something was happening there, in that close confrontation between the two groups. There was recognition. There was the uncomfortable knowledge that they were in many ways very similar people. The rally attendees were not frothing at the mouth and were not spouting racial epithets. They were moms, dads, teenagers, and families who for whatever reason have an exceedingly high tolerance for wretched behavior and the absence of moral leadership from their chief executive.<br />
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Thus the protesters were flummoxed. It seemed cruel and strange to yell “Nazi” to a pair of grandparents in yellow polo shirts, or at a trio of Eagle Scouts, and so given the chance to say something directly to Trump supporters passing by them, mere inches away, much of the time they said nothing.</blockquote>
How about “Shame, shame, shame!” or “Your emperor has no clothes!” or “We want a president, not a wannabe dictator!” Am I just being unrealistic? Are my expectations too high? I think that on some level, this lack of basic effectiveness at protesting is one reason why the man is still in office.<br />
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Has our consumerist culture (see my <a href="http://www.psycritic.com/2017/11/how-making-consumers-happy-got-us-here.html">last blog post</a> on this), smartphones, and the internet made everyone so complacent that they don’t know how to break out of their own little bubbles to stage an effective protest anymore? Do we really think that some hashtags, clever signs, and funny hats are enough?Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-50511457176428097972017-11-08T14:48:00.001-08:002017-11-08T14:48:36.762-08:00How Making Consumers Happy Got Us HereIf you’ve never seen Malcolm Gladwell’s 2004 TED Talk: “Choice, happiness and spaghetti sauce,” please take a moment to check it out:<br />
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<iframe allowfullscreen="" frameborder="0" height="480" scrolling="no" src="https://embed.ted.com/talks/malcolm_gladwell_on_spaghetti_sauce" style="height: 100%; left: 0; position: absolute; top: 0; width: 100%;" width="854"></iframe></div>
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In the talk, Gladwell focuses on the work of “someone who, I think, has done as much to make Americans happy, as perhaps anyone over the last 20 years, a man who is a great personal hero of mine, someone by the name of Howard Moskowitz, who is most famous for reinventing spaghetti sauce.”<br />
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Gladwell goes on to describe Moskowitz’s key insight in coming up with chunky pasta sauce for Prego, which is that there is no single sauce that is perfect for everyone, but there is a perfect sauce for each individual consumer. As the saying goes: “The customer is always right.” Thus, the explosion from just Prego vs Ragu to different varies of Prego and Ragu to the cornucopia of choices we have for pasta sauce today.<br />
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But as the sauce went, so went everything else. We no longer have to suffer through the primitive days of ABC’s Wide World of Sports or just one cable sports channel. There’s ESPN 2 (and 3 and Classic), FS1, NBCSN, CBSSN, even channels devoted to motorsports or golf. Long gone are the days of everyone tuning in to Walter Cronkite for the day's news. Instead, everyone can find the talking head who agrees most with their personal views and never have to be inconvenienced by a dissenting view.<br />
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Online, we no longer have to be exposed to the same reality or set of facts. Facebook, YouTube, Google News, et al. make it so we don’t even have to go out of our way to search out those with similar views; these behemoths <i>feed</i> us stuff based on all the data they have gathered from tracking our online behavior. Of course, they’re doing this to make us happy, but what price are we paying for this sort of happiness?<br />
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Which brings us, inevitably, to the present political situation. I think it’s obvious that our current president would not be in office if not for this drive to feed consumers only what they want to see, hear, and experience. Much has been made about how the Russians took advantage of people’s news feeds to try to drive Americans further apart. However, even without foreign interference, I believe that modern America’s brand of consumerism is damaging to all Americans, young and old, left and right. It tells the consumer, “only you and what you want matters.” This kind of implicit message inevitably leads to inflated egos all around, self-selection into smaller and smaller interest groups, and less of a willingness to see things from another perspective. Not surprisingly, frustration, anger, and inability to compromise are the result when people who are used to shaping their own reality are confronted by realities determined by others with different beliefs, such as when a black president gets elected or a <a href="https://www.bostonglobe.com/metro/2017/03/03/protesters-aggressively-confront-controversial-scholar-middlebury-college/vJcDcIouqyZ9cbu5LLLahL/story.html">controversial speaker</a> gets invited to speak at a college campus.<br />
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Is fixing our system (which I believe involves fixing our culture) even possible at this point? Once the Pandora’s Box of unlimited choice for the consumer has been opened, is there any going back to the spirit of “ask not what your country can do for you—ask what you can do for your country”? In my less hopeful moments, I think that it would take some sort of unimaginable catastrophe—like the Great Depression bringing an end to the Roaring 20’s—to drive people to put sufficient effort into overcoming the centrifugal forces that are splitting us apart. Yet, as <a href="http://www.cnn.com/2017/10/21/politics/tom-hanks-national-archives/index.html">Tom Hanks said</a>, “If you’re concerned about what’s going on today, read history and figure out what to do because it’s all right there.” I'm not sure if he was thinking about a specific historical era, but what came to my mind was what happened during the <a href="https://en.wikipedia.org/wiki/Renaissance_Papacy">Renaissance Papacy</a>, when the Popes became so focused on worldly riches, pleasure, and power that they lost their religious legitimacy, leading directly to the Protestant Reformation.<br />
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From the Wikipedia entry:<br />
<blockquote class="tr_bq">
The popes of this period used the papal military not only to enrich
themselves and their families, but also to enforce and expand upon the
longstanding territorial and property claims of the papacy as an
institution. […] With ambitious expenditures on war and construction projects, popes turned to new sources of revenue from the sale of indulgences and of bureaucratic and ecclesiastical offices. […] The popes of this period became absolute monarchs, but unlike their European peers, they were not hereditary, so they could only promote their family interests through nepotism.</blockquote>
That period of the papacy lasted roughly a century before the Reformation forced Catholicism to reform itself. Yes, there were bloody religious wars as a result of the split in Western Christianity, and peace between Catholics and Protestants took centuries to achieve in some places. And some pundits argue that the Reformation <a href="https://www.nytimes.com/2017/11/01/opinion/protestant-reformation.html">created as many horrors as it addressed</a>. But the overall (admittedly simple) lesson I get from this history is that there are many potential Martin Luthers out there, waiting to change the world, even if inadvertently. I just hope we don’t have to wait a hundred years for that to happen.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-28986401702428292482017-10-15T12:14:00.000-07:002017-10-15T12:14:18.652-07:00About That Jean Twenge Smartphone Article<i>Note: As you may notice, this is my first blog post in over 2 years. This blog isn’t dead, it was just resting! I’m thinking about writing a post about why I haven’t blogged in so long; maybe it'll even be done less than 2 years from now.</i><br />
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For the past 3 months, my most <a href="http://www.psycritic.com/2013/08/what-jean-twenge-gets-wrong-about-narcissism.html">frequently-visited blog post</a> has been my critique of Jean Twenge’s claims of a “narcissism epidemic” from 2013. Google tells me that it’s one of the top results in searches for “<a href="https://www.google.com/search?q=jean+twenge+criticism&oq=jean+twenge+criticism">jean twenge criticism</a>.” So in this post, I would like to share my views on her latest work.<br />
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I read her article for The Atlantic, “<a href="https://www.theatlantic.com/magazine/archive/2017/09/has-the-smartphone-destroyed-a-generation/534198/">Have Smartphones Destroyed a Generation?</a>” (an excerpt from her new book iGen), the day that it came out, because as a psychiatrist who works with adolescents, it’s clear to me that smartphones have been changing their lives in ways profound and subtle. I actually like many aspects of the article, including her sympathetic portrayal of the complexity that smartphones have brought into teenagers’ already complex lives. Also, I think she presents the data well, and the data sources that she uses are nationally representative surveys that have been around a long time and are well-respected. I think she makes a rather convincing case that many teens today are living their social lives online rather than hanging out with their friends in person.<br />
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However, I do have some criticisms of Twenge’s far-reaching claims about the effects of smartphones, but first, that ridiculous title:<br />
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The bubonic plague & WWI certainly destroyed some generations. Smartphones? 😂 Not so much. "Hampered", maybe. <a href="https://t.co/clZpBKFjJN">https://t.co/clZpBKFjJN</a></div>
— Psycritic (@psycrit) <a href="https://twitter.com/psycrit/status/893151639296557058?ref_src=twsrc%5Etfw">August 3, 2017</a></blockquote>
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Thankfully, it seems the author agrees:<br />
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As is customary with these types of pieces, I did not write the headline. Not sure that is the word I would have chosen.</div>
— Jean Twenge (@jean_twenge) <a href="https://twitter.com/jean_twenge/status/893173247298207746?ref_src=twsrc%5Etfw">August 3, 2017</a></blockquote>
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One criticism that <a href="https://www.psychologytoday.com/blog/once-more-feeling/201708/no-smartphones-are-not-destroying-generation">others have voiced</a> is that Twenge seems to draw conclusions based primarily on the correlation between the rise in smartphone use and increases in mental health issues in teens over the same span. While she acknowledges that many of the trends she highlights, such as adolescents taking longer to take on adult responsibilities, predate the introduction of smartphones, she sees the rising use of smartphones as some sort of inflection point. But there are so many other trends going on in our culture, including parents becoming more over-protective, rising political/racial/economic divides, etc., to pin the blame on smartphones seems overly facile. Heck, if I were being cheeky, I would point out that the sale of yoga pants has drastically increased since 2011, corresponding to increases in teen depression:<br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://www.businessinsider.com/jeans-are-being-replaced-by-yoga-pants-2015-10"><img border="0" data-original-height="642" data-original-width="909" height="452" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheH1m6klVs-4plZ0mxIwzf3Dg0v_Z1DU2Jo1uHSxiwcNFJzQoALsBhzaltblR8fVEdzxxK1V3pWWH8SVfBMxdSzmZ3gLyUsB0tUstbnzySP8HnwtKe6Wdd2NxoTjS9cLtKf5W2TiEposH-/s640/athleisure.jpeg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Source: Business Insider</td></tr>
</tbody></table>
<br />
But just because they correlate does not mean that one has anything to do with the other.<br />
<br />
Thus, my biggest criticism stems from Twenge’s seeming certainty about the decisive role of smartphones coupled with a seeming lack of curiosity about examining deeper causes for why these trends are happening. In a recent <a href="https://www.nytimes.com/2017/10/11/magazine/why-are-more-american-teenagers-than-ever-suffering-from-severe-anxiety.html">NY Times Magazine article</a> about increasing rates of anxiety in teens, Twenge had this to say: <br />
<blockquote class="tr_bq">
“The use of social media and smartphones look culpable for the increase in teen mental-health issues,” [Twenge] told me. “It’s enough for an arrest — and as we get more data, it might be enough for a conviction.”</blockquote>
I’m sorry, but I think the situation is closer to her finding evidence of a crime, and possibly even a weapon, but she is nowhere near identifying—much less convicting—a suspect. <br />
<br />
I find it vexing that Twenge seems to view each generation as a distinct and determinative entity, rather than some arbitrary line drawn by demographers, as she shows in this tweet:
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<blockquote class="twitter-tweet" data-lang="en">
<div dir="ltr" lang="en">
They don't look mad! Sure, send some questions via e-mail. Also: If they are 22 or less, they're iGen -- so GenMe might not apply as much.</div>
— Jean Twenge (@jean_twenge) <a href="https://twitter.com/jean_twenge/status/917858673023770624?ref_src=twsrc%5Etfw">October 10, 2017</a></blockquote>
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That is just preposterous. She writes as though each generation somehow pops into existence with its own innate characteristics, rather than being influenced by—and reacting to—the generations that have come before. However, one of the few things I know for sure is the huge extent to which young people are influenced by their elders. For example, <a href="https://www.theatlantic.com/science/archive/2017/09/infants-can-learn-the-value-of-perseverance-by-watching-adults/540471/">this recent article</a> (also in The Atlantic, lol) highlighted just how much even 1-year-old infants learn from observing the actions of the adults around them. And what are kids observing these days?<br />
<br />
In my own practice, I often hear from kids and teens who say that their parents are on their laptops checking work email or on their phones checking Facebook all the time. These kids are bored and lonely, so as soon as they have access to a smart device, what do they do? Twenge’s work makes it easy for parents to blame the devices and not think about how their own actions may be influencing their children. While that may protect parents’ egos and sell more books, it’s a very incomplete and misleading picture, to say the least.<br />
<br />
I have not yet read Twenge’s new book, but I was hoping that it would take a deeper look at the culture as a whole, especially the critical role that parents can play in changing the situation. However, one look at the book’s table of contents reveals that only the last 26 pages are devoted to a chapter on “Understanding—and Saving—iGen”. This <a href="http://nymag.com/selectall/2017/08/jean-m-twenges-igen-review.html">scathing review</a> from NY Mag further breaks down the book and the motivations of the author. The reviewer takes the view that Twenge is less a scholar who investigates all aspects of a complex issue than she is someone positioning herself as a guru for marketers looking to understand the latest generation of teens.<br />
<br />
In conclusion, while there certainly is a mental health crisis going on in today’s teens (and adults!) and pinning the blame on smartphones is understandable, I believe it will take far more than getting rid of everyone’s favorite devices to make our culture healthier for future generations.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-43035402178339999602015-09-16T15:46:00.002-07:002015-09-17T06:47:21.341-07:00The Paroxetine Study 329 Re-WriteI've not really written about GlaxoSmithKline's infamous paroxetine (Paxil) <a href="http://www.ncbi.nlm.nih.gov/pubmed/11437014">Study 329</a>, except to briefly allude to it in a <a href="http://www.psycritic.com/2014/03/insels-techno-utopia.html">previous post</a>. This is probably because I felt others had covered it so extensively already, especially over at the <a href="https://duckduckgo.com/?q=study+329+site%3A1boringoldman.com">1boringoldman</a> blog. Another anonymous child psychiatrist has an <a href="http://allcapsunlocked.com/">entire website</a> summarizing the study, and there's even a detailed <a href="https://en.wikipedia.org/wiki/Study_329">wikipedia page</a>. So go to those sites if you haven't heard of this study before. However, I wanted to write this post to share my thoughts about the <a href="http://study329.org/">re-analysis</a> of the study's data by an <a href="http://study329.org/rewrite-team/">independent, mostly-international team</a>, which was accepted for <a href="http://www.bmj.com/cgi/doi/10.1136/bmj.h4320">publication in the <i>BMJ</i></a>.<br />
<br />
First off, I want to be clear that I don't think the new publication's results will be news for anyone in the profession who has been paying attention. In my years of practice (which admittedly are not many), I've never seen a young patient prescribed paroxetine by a child psychiatrist. While studying for a board exam the other day, I saw this (<a href="http://www.amazon.com/Psychopharmacology-Child-Psychiatry-Review-Board-Style/dp/0199744688/">source</a>):<br />
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If it's been covered in a <a href="http://www.amazon.com/Pediatric-Psychopharmacology-Andres-Martin/dp/0195398211/">textbook published in 2010</a>, you can be sure it's pretty common knowledge by now. In this regard, the profession has been self-correcting. However, it seems that despite acknowledging the risks of paroxetine, the profession has turned a blind eye toward the actions of the psychiatrists who had helped popularize its use in kids in the first place. None of the well-known academics whose names are attached to the study have offered to retract the paper, and as far as I know, none have suffered professionally. In fact, one of them, Karen Dineen Wagner, was just elected president of the American Academy of Child and Adolescent Psychiatry (AACAP).<br />
<br />
There have been efforts to <a href="http://ncrocap.org/ethical-issues-with-s329-and-aacap/">address this issue within AACAP</a>, most notably by 2 regional child psychiatry organizations, including the Northern California Regional Organization of Child and Adolescent Psychiatry (NCROCAP). Dr. Mickey Nardo, the brains behind 1boringoldman.com and one of the authors of the Study 329 re-write, <a href="http://1boringoldman.com/index.php/2014/04/06/45376/">informed the AACAP Ethics Committee</a> about the study's faults, and they initially seemed receptive.* However, those efforts went nowhere. At a recent AACAP annual meeting, I was chatting with an older child psychiatrist, who is a "Distinguished Fellow" of the organization and has been involved in AACAP affairs for decades. Somehow, the topic of NCROCAP came up. When I commented that they seemed to be an activist bunch, he replied, "Yes, probably too much so, which is not good for the group process."<br />
<br />
Well, now we see the outcomes of this "group process." By prioritizing group harmony over doing the right thing, AACAP has invited outside intervention. This <a href="http://www.bmj.com/content/351/bmj.h4629"><i>BMJ</i> editorial</a> accompanying the new publication, by Peter Doshi, is one of the most damning things I've ever read about institutional intransigence.* It'll be interesting to see how the organization reacts.<br />
<br />
UPDATE: As I was finishing this blog post, I got the following email (<i>New York Times</i> <a href="http://www.nytimes.com/2015/09/17/health/antidepressant-paxil-is-unsafe-for-teenagers-new-analysis-says.html">article published</a> around 6:30pm EST, email was sent around 6:34pm*):<br />
<blockquote>
Dear Members,<br />
<br />
This week, <i>The BMJ</i> published a study, “Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence,” which reanalyzes data from a clinical trial performed in the late 1990s and published in <i>JAACAP</i> in 2001. The conclusions of this article contradict those of the original study. Please know that the Academy has been fully aware of the pending publication of this article by <i>The BMJ</i>.<br />
<br />
Research provides the foundation for child and adolescent psychiatry’s knowledge base. The Academy encourages rigorous scientific design and methodology and supports the highest ethical and professional standards. We also believe it is essential that research be conducted within a strong framework of transparency and disclosure. As an organization, AACAP has been a leader in advocating for the positive changes that have taken place in the last decade in the relationship between the pharmaceutical industry and academic and professional associations.<br />
<br />
As the leading national professional medical association dedicated to promoting the healthy development of children, adolescents, and families, through advocacy, education, and research, our response to <i>The BMJ</i> publication is as follows:<br />
<ul>
<li>AACAP has the utmost respect for the <i>The BMJ</i> and we thank them for their continued efforts to further scientific knowledge and understanding.</li>
<li>AACAP supports transparency in clinical trial reporting and welcomes the RIAT initiative, which enables publicly available primary data to be reanalyzed and published as new, potentially revised reports.</li>
<li><i>JAACAP</i> is a forum for scientific reporting and scholarly discussion. The scientific process builds on itself over time through a cycle of new research, analysis, and ongoing dialog. This process stimulates debate and moves the field forward toward a better understanding of critical issues.</li>
<li>As with most medical journals, <i>JAACAP</i> operates with full editorial independence. AACAP does not influence or direct decisions regarding specific publications. Furthermore, the statements and opinions expressed in <i>JAACAP</i> articles are those of the authors, and not necessarily those of AACAP, the editors, or the publisher. Inquiries about the articles and study in question should be addressed to their respective authors.</li>
</ul>
Moving forward, we will continue to monitor any developments and keep the membership informed of relevant information as it becomes available. Please direct any questions to the Communications Department via email at communications@aacap.org.<br />
<br />
Thank you for your continued support!<br />
<br />
Paramjit T. Joshi, MD<br />
President, AACAP</blockquote>
Like I said, this is gonna be interesting.<br />
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* <i>These sentences were added/edited after original publication for completeness.</i>Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-54965852108066342152015-09-05T14:03:00.003-07:002015-09-05T14:03:34.636-07:00Who Controls the Future of Medical Knowledge? Part IThe recent <a href="http://www.kevinmd.com/blog/2015/03/the-abim-response-to-newsweek-determines-how-far-anti-moc-sentiment-will-spread.html">discontent amongst physicians</a> regarding the process of <a href="http://www.kevinmd.com/blog/2014/07/mission-creep-maintenance-certification.html">maintaining board certification</a> in various specialties got me thinking about a broader question: how do doctors acquire new medical knowledge, especially after medical school? Which brings me to an even more critical question: who controls said knowledge?<br />
<br />
I would argue that next to our ability to listen to and empathize with patients, the other most valuable aspect of the medical profession is our knowledge. Ever since the days of Hippocrates, medical knowledge has been transmitted from one doctor to another in essentially the same way. In medical school and residency, we attend lectures, read textbooks, study cases, answer <a href="http://www.ncbi.nlm.nih.gov/pubmed/15833730">Socratic questions</a> posed by more experienced clinicians, and most importantly, learn by seeing numerous patients and accumulating experience. After graduating medical school, it seems that most doctors learn by conferring with one another, reading journals, and attending conferences.<br />
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But the more information there is, the more time it takes to access and acquire new knowledge, and the harder it becomes for individual physicians to keep up.<br />
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You can be sure that corporations are well aware of this. On the patient side, of course, <a href="http://www.kevinmd.com/blog/2013/02/dr-google-tips-patients-diagnose-online.html">Dr. Google</a> already provides incredible ease of access to knowledge and profits handsomely from selling ads to consumers. Pharmaceutical companies <a href="http://www.washingtonpost.com/wp-dyn/content/article/2007/05/21/AR2007052101701.html">know more about my prescribing</a> practices than I do, which fuels their targeted marketing efforts. More ambitiously, <a href="http://www.ibm.com/smarterplanet/us/en/ibmwatson/health/">IBM's Watson Health Cloud</a> promises to "bring together clinical, research and social data from a diverse range of health sources, creating a secure, cloud-based data sharing hub, powered by the most advanced cognitive and analytic technologies." And as much as I panned <a href="http://www.athenahealth.com/">athenahealth</a>'s advertising in an <a href="http://www.psycritic.com/2014/07/the-limits-of-big-data-in-psychiatry.html">earlier post</a>, the electronic medical record companies will certainly find clever ways of profiting from the vast troves of health care data that they accumulate. And doctors are paying for the privilege of providing that information to them!<br />
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At least <a href="http://www.sermo.com/what-is-sermo/overview">SERMO</a> ("the most trusted and preferred social network for doctors") pays doctors for completing surveys, but you can be sure that they're in the same game. They keep their service free by monetizing the attention and knowledge of doctors: "Organizations seeking physician expertise, such as pharmaceutical companies, medical device firms, and biotechs, underwrite the market research and sponsorship opportunities within our site."<br />
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So what options are available for doctors who want to share their knowledge with each other free from the confines of a data mining operation? Of course, we can still consult with colleagues the old fashioned way, either in person or by phone. But after having these conversations, the knowledge still resides in the brains of people, not easily accessible to future doctors who may run into similar situations. Our professional associations post <a href="http://psychiatryonline.org/guidelines.aspx">practice guidelines</a> that hardly anyone reads, and at annual meetings, there are opportunities to meet with <a href="https://aacap.confex.com/aacap/2015/webprogram/CCB.html">expert clinicians</a> to discuss cases, which seems terribly inefficient. What about higher-tech options? There are <a href="http://www.jwatch.org/">numerous</a> <a href="http://www.thecarlatreport.com/">subscription</a> <a href="http://www.uptodate.com/home/product">services</a> that provide summaries of research studies, but I believe that the patients doctors see do not necessarily resemble those who sign up for clinical trials. There are electronic mailing lists in which doctors can discuss cases, and which allow members to search through previous conversations. And there's <a href="http://www.wikidoc.org/index.php/Main_Page">wikidoc</a>, a free wikipedia for doctors. However, these options are used by very few doctors and are paltry efforts next to the commercial ambitions of Big Data.<br />
<br />
With all these business interests aiming to aggregate and profit from the knowledge of doctors, is there anything that the medical profession can do to avoid having our knowledge become some company's proprietary intellectual property?<br />
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I don't claim to have the answers, but I will explore some ideas in Part II. Stay tuned…Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-27953257084925379102015-08-28T13:09:00.002-07:002015-08-28T13:09:28.619-07:00The Old Man: A Story<h3 class="h3post">
Part I</h3>
The first time I met the old man was during my residency interviews. He was spry and looked younger than his age, and why not? He was at the top of his game: head of a department, boatloads of research funding, one of the most well-known psychiatrists around. Another psychiatry department chair who had interviewed me previously hinted that the old man was quite a businessman and enjoyed cozy relations with industry.<br />
<br />
As he asked me his first question, the old man practically winked: "So, are you single, in a relationship, or married, or what?" That was my first hint that he might not be the most ethically-inclined individual. I had been told by my medical school before interview season that such personal questions were <i>definitely</i> off limits. Yet he made his greeting seem like the most natural and friendly thing in the world.<br />
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<h3 class="h3post">
Part II</h3>
The old man was fuming. He was supposed to be giving a talk on depression treatment, but what seemed to preoccupy his mind was a just-published <a href="http://www.webmd.com/mental-health/news/20080227/antidepressants-no-better-than-placebo">study from Irving Kirsch</a> suggesting that antidepressants were not better than placebo for mild to moderate depression. Our speaker seemed deeply and personally offended. After many words assailing Kirsch's motives, he concluded: "Even if it's no better than placebo, it doesn't mean we shouldn't treat the patient!" Almost sounded like <a href="https://twitter.com/allenfrancesmd/status/507565359978000384">advice</a> <a href="https://twitter.com/allenfrancesmd/status/546293728667631617">from</a> <a href="https://twitter.com/allenfrancesmd/status/585444430045257728">Allen</a> <a href="https://twitter.com/allenfrancesmd/status/625689202848624640">Frances</a>, but twisted.<br />
<br />
<h3 class="h3post">
Part III</h3>
By random chance, I saw the old man again recently, when I was going out to dinner in the city where he lives. There he was, walking down the sidewalk with his wife, right past where I had just parked my car. He was wearing a sweatshirt with the name of his university employer on it. I'd never seen him out of a suit before. I thought he seemed older, frumpier, humbled. Or perhaps that was just my wishful thinking?<br />
<br />
A lot has happened since the last time I saw him. He was no longer the department chair, replaced by someone known for work related to ethics. I briefly considered going up to him and saying something, but what? "Thank you for being an example of what not to aspire to?" Or, "That's a very plain-looking sweatshirt; did all your industry funding dry up?" Poor sportsmanship and too passive-aggressive. I briefly imagined following him down the sidewalk, yelling: "<a href="http://www.newsday.com/entertainment/tv/game-of-thrones-season-five-finale-mother-s-mercy-shame-shame-shame-1.10544275">Shame, shame, shame</a>!" But he probably would've mistaken me for a Scientologist or something.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-36796783316473904312015-07-11T10:00:00.001-07:002018-07-24T17:02:55.599-07:00A Child Psychiatrist's Review of Pixar's Inside OutI finally watched Disney/Pixar's <i>Inside Out</i>, and I agree with the <a href="http://www.rottentomatoes.com/m/inside_out_2015/">consensus opinion</a> that Pixar has done it again, making a movie that's both fun and poignant, with a narrative that young children can understand while containing deeper messages for adults. Read on for more of my thoughts, but be aware that MAJOR SPOILERS FOLLOW, since it is hard to discuss my thoughts as a child psychiatrist on the movie's depiction of emotions without going into the details.<br />
<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiySqzFsQOo_fe-4EKeszL2r49_se_WQNkBtvh5iHu4KGf0R3WDeCSfGtSwE6dRQScSfgjSPD7SRs_xMZqSgTFveOc0aEtRdTutn03pd0MiTjWSz0odzDDvG8-DZSDQdqejlrpf_M-GQ4YH/s1600/inside-out-characters.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img alt="Fear, Disgust, Joy, Anger, and Sadness." border="0" height="376" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiySqzFsQOo_fe-4EKeszL2r49_se_WQNkBtvh5iHu4KGf0R3WDeCSfGtSwE6dRQScSfgjSPD7SRs_xMZqSgTFveOc0aEtRdTutn03pd0MiTjWSz0odzDDvG8-DZSDQdqejlrpf_M-GQ4YH/s640/inside-out-characters.jpg" title="Fear, Disgust, Joy, Anger, and Sadness." width="640"></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The main characters: Fear, Disgust, Joy, Anger, and (sigh) Sadness.</td></tr>
</tbody></table>
<br />
<br />
The plot of <i>Inside Out</i> is fairly straightforward: a preteen girl named Riley moves with her parents from Minnesota to San Francisco, and she experiences a crisis in her emotional state, in her relationship with her parents, and in her concept of herself. Most of the action takes place inside Riley's head, where 5 different emotions (Joy, Sadness, Anger, Disgust, and Fear) take turns at the control center of the brain's headquarters, directing Riley's actions depending on which emotion is at the controls. Joy is the energetic (cheer)leader who attempts to remain in control as much as possible, especially over Sadness. The crux of the movie is about Joy going on a journey in which she (and everyone else) learns to value Sadness.<br />
<br />
How the Pixar filmmakers takes us on the journey, though, is where they show off their delightful imagination and remarkably <a href="http://www.nytimes.com/2015/07/05/opinion/sunday/the-science-of-inside-out.html">decent grasp of psychology</a>. Here are my thoughts on the aspects of <i>Inside Out</i> that delighted me the most:<br />
<ul>
<li>The movie demonstrates the inner workings of memory in a visually coherent and fairly accurate way. I especially like how Riley's incoming memories, which look like softball-sized glowing orbs, are temporarily kept at headquarters until Riley sleeps, at which point they are sent into long term memory. They also find a way to neatly show core aspects of Riley's identity/personality as floating islands that serve as repositories of concepts such as Family, Honesty, and Goofiness.</li>
<li>The depiction of the weight of parental expectations is very well-done. When Riley becomes upset after the move, her parents say to her: "Where's my happy girl?", clearly indicating their preference for how she should feel. This is one way that parents insidiously and inadvertently tell their children it's not OK to be sad, and the fact that (if I recall correctly) each parent says this to Riley on separate occasions shows that Pixar is emphasizing the harm that this sort of communication can do.</li>
<li>A critical scene that works incredibly well both as a turning point in the plot and a learning opportunity is when Sadness convinces a character to do something that Joy could not, simply by listening and showing empathy for that character's feelings. This teaches Joy (and us) the importance of validating another person's emotions.</li>
<li>Some of my favorite moments in the movie are when it delves into the minds of characters other than Riley. I really enjoyed how each character has a different predominant emotion, and the emotions work together in different ways depending on the individual. For example, inside the head of Riley's mother, the different emotions sit around like a committee with Sadness presiding, while a teen boy's mind is dominated by fear, with all his emotions running amok.</li>
<li>When Riley and her father get into an argument during dinner, the camera dives into each person's mind and clearly shows how Anger in one person leads to escalating Anger in the other, in a mutually assured destruction kind of way. This is a good example of an <a href="https://en.wikipedia.org/wiki/Amygdala_hijack">amygdala hijack</a>, which comes up frequently when I discuss family conflict with patients.</li>
<li>Despite being a primary emotion, each of the emotion characters are capable of expressing other emotions. This helps make them more interesting and less one-dimensional; it also helps subtly reinforce the point that having one emotion dominate all the time may not be desirable.</li>
<li>Initially, each of Riley's memories passing through the control center is a distinct color, corresponding to the emotion associated with the memory. By the end of the movie, memories have become multi-hued, nicely illustrating Riley reaching a developmental stage where she is capable of more emotional nuance.</li>
</ul>
However, I do have one major criticism, and that is the portrayal of Sadness as short, rotund, and bespectacled. How…sad that Pixar uses such obvious stereotypes to depict her appearance! Sure, this may get more laughs from the audience and fit the look of the <a href="http://www.imdb.com/name/nm0809613/">actress supplying the voice</a>, and the movie does try to redeem itself by turning Sadness into a heroine. But how would kids fitting that description feel inside early on, even if they're laughing along with everyone else on the outside? I wish Pixar had simply portrayed Sadness on the basis of her facial expressions and body language without adhering to our cultural norms regarding the physical characteristics of a sad person; they're good enough animators to be capable of that. A few of other nitpicks:<br />
<ul>
<li>A scary clown is locked away in Riley's subconscious, visually depicted as a vault in a deep cavern. I'm not sure if even the psychoanalysts still use the term "subconscious," yet it persists in the popular culture, perhaps because it's so easy to conjure up that visual image of something deeply buried.</li>
<li>Memories, of course, are not accurate recordings preserved in amber, but are malleable and <a href="http://www.thedailybeast.com/articles/2014/02/09/it-s-shockingly-easy-to-create-false-memories.html">often unreliable</a>. While it would have been nice for the movie to show this, I understand that it would probably overcomplicate things. Similarly, expanding beyond just the 5 emotions featured would have been nice but too complicated.</li>
<li>Though dramatic, I do not feel that the scene of Riley taking a credit card from her mother's wallet and getting on a bus back to Minnesota is very believable. Given her generally good relationship with her parents in the past, it would take much more than a couple of arguments to make a kid who did not have previous conduct problems steal and run away from home.</li>
</ul>
Despite my criticisms, <i>Inside Out</i> is easily one of my three favorite Pixar movies of all time, along with <i>Wall-E</i> and <i>Ratatouille</i>. I can even envision it being useful in therapy. Asking a child to think about a situation and consider what Joy would say versus what Sadness or Fear would say about it might help make cognitive-behavior therapy more engaging and fun. If you're a child therapist/psychologist/psychiatrist and haven't seen it yet, what are you waiting for? It's the only Pixar movie where I'm eagerly anticipating a sequel, given the portents at the end about Riley turning 12. I'd love to see what Pixar does with the even more tangled emotions and relationships of adolescence.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-70311333093038732462015-05-19T10:56:00.000-07:002015-05-19T10:56:00.765-07:00Free Branding Advice For The American Psychiatric AssociationOn Sunday, while going about my weekend business (which means possibly wasting some time on Twitter), I was greeted with this unsolicited gift from the American Psychiatric Association:<br />
<blockquote class="twitter-tweet" lang="en">
<div dir="ltr" lang="en">
Say hello to the APA's new brand! <a href="https://twitter.com/hashtag/APAAM15?src=hash">#APAAM15</a> <a href="http://t.co/wV062FoLbK">pic.twitter.com/wV062FoLbK</a></div>
— American Psychiatric (@APAPsychiatric) <a href="https://twitter.com/APAPsychiatric/status/600035594996097024">May 17, 2015</a></blockquote>
There's also <a href="http://www.psychiatry.org/advocacy--newsroom/newsroom/american-psychiatric-association-unveils-new-brand-at-168th-annual-meeting">an announcement</a> on the APA website and an accompanying <a href="https://www.youtube.com/watch?v=soDtLf8eYAY">Youtube video</a>. Here's an alternative version of the new logo:<br />
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<img alt="American Psychiatric Association Logo w/ Brain" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBw_-Btv4BEnUvriV71F8Rg1c6WVJ8ARRRASWHFUaf-tNj32Mbj_U9nmlyVnfmuv4QxhF1IK2hQMukgu4AWw0X-MkO07-Ne3bpBAy2gS79BdmQCw8P7wVQaQMXXuLb9OyGh7IrnhhfBZUv/s1600/apa-new-white.jpg" title="American Psychiatric Association Logo w/ Brain" /></div>
<br />
Now, I'm not an APA member, but as a psychiatrist, this is just embarrassing. Poor <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhl2HaTmRLGYe3ymui7C24o3XLBZ00zAL1TbybLBtWItjTnCePRL7bk88cxaNvL0SpxYh6Sy16TwqHQajGSDE-cNt49UvscENcUprMhfnOVGzC8rw8Z7MlusdfLvBldz2ZLt6TMPdNkOdFU/s1600/apa_logo.jpg">Benjamin Rush</a> must be rolling over in his grave! I'm also not a "branding expert," but it seems that the APA could use all the help it can get these days. Thus, I'm offering some pro bono advice as a public service.<br />
<br />
<h3 class="h3post">
Typeface</h3>
First off, the text becomes very fashion-forward with the use of a skinny font (resembles Avenir, but I'm not sure exactly what it is) for "American" and "Association." The semi-bold and colored emphasis on the word "Psychiatric" just seems a bit…desperate. Look at us, we're <b>psychiatrists</b>! I'm not saying that the typeface doesn't look nice, but it smacks of trying too hard to match the latest trends in visual marketing:<br />
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<div class="separator" style="clear: both; text-align: left;">
<img alt="Apple Watch Edition" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj15miqZWbYpmJv0tZq65IzESGFXLkaVO69v1L54pbL8-2qbg5n7pNuH4un8UUxJWe9LDkLp1Vf8LKkxCg0Gzfufshkea6-eM5ZEXyKjJ_OgdQYZpH_bRc1WwaqT0VgbgdUdsRiOvFgpuzH/s1600/watch-edition.png" title="Apple Watch Edition" /></div>
<br />
Now, Apple can do with this because they actually are producing new high-tech products. But the APA? Sorry, I don't think <i><a href="https://twitter.com/VahabzadehMD/status/600682302151221248">Understanding Mental Disorders: Your Guide to DSM-5</a></i> qualifies. Why not make something that looks timeless and classy, rather than trendy and fashionable? Here's my suggestion:<br />
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<div class="separator" style="clear: both; text-align: left;">
</div>
<div class="separator" style="clear: both; text-align: left;">
<img alt="American Psychiatric Association Classier Type" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjK5thxCa2adu20WXMdO3SgiAIfL5kUjd3KdzbZca1dAa324ajTWyNpoP2WPeYWGamw_UCYfzkYH6v_CbM-vKRIRSZbA_m6967rfnZr5bNFuguz5zHCSzM5oS5BpIG2DC3SyS96lm8Ypp2v/s1600/APA-Garamond.png" title="American Psychiatric Association Classier Type" /></div>
<br />
This has the added benefit of allowing the letters "APA" to line up, emphasizing to the world that the fight over what "APA" stands for is not over, even though the American Psychological Association owns <a href="http://www.apa.org/">apa.org</a> and the Google <a href="https://www.google.com/?gws_rd=ssl#q=APA">search results</a>. We <b>psychiatrists</b> don't give up!<br />
<br />
<h3 class="h3post">
Logo</h3>
Though I discussed the choice of typeface first, the new logo emphasizing the brain is the most jarring aspect of the APA brand refresh. Here were my initial thoughts:<br />
<blockquote class="twitter-tweet" lang="en">
<div dir="ltr" lang="en">
New <a href="https://twitter.com/APAPsychiatric">@APAPsychiatric</a> logo looks like a fuzzy egg from the distance. Hope they didn't pay too much for it! <a href="https://twitter.com/hashtag/APAAM15?src=hash">#APAAM15</a> <a href="https://t.co/hJVNDWpGJ4">https://t.co/hJVNDWpGJ4</a></div>
— Psycritic (@psycrit) <a href="https://twitter.com/psycrit/status/600039334406791168">May 17, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script>
A couple of days later, I still feel the same way. If you're trying so hard to signal that the organization is modern and future-looking, then why in the world use such a literal outline of a brain? The whole point of logos is to make a <i>simplified</i> visual representation of something so it becomes an instantly recognizable icon. That's why Apple's logo doesn't look like an actual silhouette of an apple, and the Microsoft <a href="http://logos.wikia.com/wiki/Windows">Windows logo</a> doesn't look like a photorealistic window. It's also why the serpent on the <a href="https://en.wikipedia.org/wiki/Rod_of_Asclepius">Rod of Asclepius</a> winding its way through the brain (wisely) does not show snake scales. Also, note what happens to the APA's brain when it's shrunk:<br />
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<img alt="Fuzzy APA Brain Logo" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiayNiOZju1WwfvUMQUOFL6g8dpBMrTzIJnKC-SBg99W-w9ioD4nQLfa6po9nj1_RiO-MPAniWQQipU3zOEwt3SY4PfCZ1BuPzCdHfG0Cb600DNcYHWNI3xD0kz5Eh51a5dCja1HfDHb4T3/s1600/apa-brain-fuzzy.jpg" title="Fuzzy APA Brain Logo" /></div>
<br />
Look how fuzzy the brain becomes, while the Rod of Asclepius retains its shape nicely. So, APA, if you're going to use a brain with folds, then at least make them look somewhat rounded:<br />
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<img alt="Rounded APA Brain Logo" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEithiREVMC2DdaIP0bX9B-_WTkRG8mfLst_qm-BL2TaO6VEjkVIQasPUakgaCJA5wp8ywWAb_kSvNm7RuuRUfXBGcIvZjj1Mxtxz0ERl1ixvUgYHxehH5KjcqHCNtMS6hZ8wGm3_t4tnPVl/s1600/apa-brain-rounded.jpg" title="Rounded APA Brain Logo" /></div>
<br />
Even though it's a bit cartoony and not anatomically accurate, it's at least visually cogent, especially at smaller sizes. Alternatively, you can get even more minimalistic:<br />
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<div class="separator" style="clear: both;">
<img alt="Smooth APA Brain Logo" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinDTGJU_ajIFsPzSuTObQOAyaASnUXemuJuiKIEHP4OjpYpFxkKb2aBGr97gxL9MgBI9wSNCYAHMRqDg0Q29cqV4i3kyvDU425KFhNiplz8VfBn9pEc99nHIdWdgKAu6zRh8_O6idPktt2/s1600/apa-brain-smooth.jpg" title="Smooth APA Brain Logo" /></div>
<br />
These changes took me all of 20 minutes in Photoshop, and I'm no graphic artist. I wonder how much the APA paid <a href="http://www.porternovelli.com/">their consultants</a> for all this?<br />
<br />
<h3 class="h3post">
Tagline</h3>
Finally, that tagline: "Medical leadership for mind, brain and body." While I won't argue too much over the missing <a href="http://www.buzzfeed.com/adamdavis/the-oxford-comma-is-extremely-important-and-everyone-should">Oxford comma</a>, I do think: wouldn't it be nice if the tagline matched the typeface and the logo? The typeface signals future-think, while the logo features a traditional symbol of medicine within the brain. I don't see anything conveying "mind" or "body." Since I believe honesty is the best policy when it comes to branding, why not this:<br />
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<div class="separator" style="clear: both; text-align: left;">
<img alt="APA: Leaders in medicalizing the brain." border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC3MPHU0dyu5cpATLKjcQbuG0ZC-dosXhF8TGKkS_pcPm4DoohC555LfdXJ1Bod7SQVExN70VDC3kAN33V2h0Z-5h_trEq5NzV7DQgWBVuBk0-TmfH7ugm08TZ822-RKjHpVtLxn22N1fd/s1600/apa-newtag.png" title="APA: Leaders in medicalizing the brain." /></div>
<br />
Or even better, if the focus in going to be on medical brain disorders, why not a complete rebrand of the APA into something even awesomer?<br />
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<img alt="American Clinical Neuroscience Association: Leaders in medicalizing the brain." border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjT7Ga6djJW7y4dHzc-ROluuT40ovenw7Ex5Y0htQQL6lNYNkQSUbBKWIIeW2bQ6QcxSWUaxPozl04wZmiP09P0FXjqv9MYsI6kh_1jHkKTNidEflbyhWi4kjBkvQzYxlUFIU7vs5N41wtd/s1600/acna-newtag.png" title="American Clinical Neuroscience Association: Leaders in medicalizing the brain." /></div>
<br />
There, that's more like it!Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-22239362293249868812015-05-03T08:48:00.000-07:002015-05-03T08:48:59.847-07:00One PringleLike many psychiatrists, I see a fair number of patients whose relationship with food has been fraught with difficulty. Some of the patients that we worry about the most are those with anorexia, who are at a high risk of dying from their illness. However, it seems that those who have problems with binge or over-eating are <a href="http://www.nimh.nih.gov/news/science-news/2007/study-tracks-prevalence-of-eating-disorders.shtml">much more common</a>.
<br />
<br />
One memorable patient that I saw during residency was a man in his 50s, who reported feeling severely depressed ever since he had gastric bypass surgery 2 years prior. The man had been obese his whole adult life; he ate whenever he felt lonely, bored, or stressed, and eventually he weighed close to 400 pounds. I was surprised when he told me this, because he was trim and fit when I first met him, and he was fortunate enough to not have noticeably loose skin from losing over half his body weight. Of course, his doctors initially wondered whether a nutritional deficiency caused his depression, but all their tests came back normal. The patient himself attributed his mood change to no longer being able to eat the foods that he used to enjoy, and no amount or combination of medication made a difference. It seemed that his main coping skill was taken away without him gaining anything to replace it. Seeing this patient led me to think a lot about how one develops or fails to develop self-control with food.<br />
<br />
Growing up, I sometimes travelled with my family to visit my grandparents, who lived in another country. During one week-long visit to their home, one of the things that drew my interest was a can of Pringles® sitting high on a book shelf in the living room. Day after day, it remained there, out of my reach. I'm sure I would have eaten most of the can during that time if it were more easily accessible. Then one day, I saw my grandfather open the can, take one chip out, and then he put the can back on the shelf. He bit off half the chip, closed his eyes, and chewed slowly and deliberately, savoring every last bit of that salty, crunchy goodness. Then, he did the same thing with the other half. One Pringle, and he was done. I can't even type the word "Pringle" without the spellchecker highlighting it and suggesting that I change it to "Pringles", but there was my grandfather, eating just one at a time, less than once per day.<br />
<br />
While writing this, I checked out what <a href="https://www.pringles.com/us/home.html">Pringles</a>® is using as their latest marketing slogan. Here it is:<br />
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdr06EDfEjxODwYvwKXzs8wCPj58vKuJ3vaYgticY8GTAganGpsmbRJ-XXhIcmGweIyzmNZIyKJ1ZoVuUbdr6QZ3HL4_bGImNtEd56qLjwm1m5gF_G0IFxSEjgZvq0usSxPXLoOiapso7u/s1600/Pringles.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Pringles: You don't just eat 'em" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdr06EDfEjxODwYvwKXzs8wCPj58vKuJ3vaYgticY8GTAganGpsmbRJ-XXhIcmGweIyzmNZIyKJ1ZoVuUbdr6QZ3HL4_bGImNtEd56qLjwm1m5gF_G0IFxSEjgZvq0usSxPXLoOiapso7u/s1600/Pringles.png" title="Pringles: You don't just eat 'em" /></a></div>
Well, my grandfather did in fact "just eat 'em," and he would have easily won a bet with anyone repeating the Lay's® phrase "betcha can't eat just one." How was he able to do that? I never thought to ask him directly, but I've often wondered how his journey through life shaped him. His father died when he was still an infant, and he was raised by his mother and grandfather. His was a scholarly family, and despite growing up in a place under foreign occupation during World War II, he was able to do well academically, eventually attending medical school. After the war, instead of enjoying the <a href="http://www.nytimes.com/2015/04/17/opinion/david-brooks-when-cultures-shift.html">consumer exuberance</a> that swept the U.S., my grandfather had to contend with decades of ongoing deprivation and strive while working long hours and raising a family.<br />
<br />
Since I grew up in America, I had abundant access to food and never had to worry about getting enough to eat. I was also exposed to all the mass media messages that we Americans are inundated with. I craved Happy Meals® and Kellogg's® Froot Loops® and Nabisco Chips Ahoy!® and anything from those cute Keebler® elves. Not surprisingly, I often did not stop eating when I was full; there have been times when I ate so much at buffets that I felt sick. Yet as I got older and was faced with the temptations of overeating, I would often think back to that image of my grandfather and his one Pringle, and then I would ask myself, "Do you really want that extra serving?” And over time, my self-control gradually improved. How much of that was influenced by the fact that I randomly witnessed my grandfather's way of snacking? I'll probably never know, but I'm still grateful for the memory.<br />
<br />
Of course, my grandfather was not perfect; he had his bad habits just like anyone else. He was a pulmonologist, but he also smoked cigarettes for many years. However, when he smoked, guess how many cigarettes he had on each occasion?Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-813707511997746852015-04-27T12:50:00.000-07:002015-04-27T12:50:10.272-07:00The Most Popular Psychiatrists in America (According to Twitter)All the <a href="http://www.newyorker.com/news/daily-comment/columbia-and-the-problem-of-dr-oz">recent hubbub</a> over Dr. Memhet Oz got me thinking more about fame when it comes to medical doctors: how they gained their popularity, to what end they employ their platforms, and how they keep (or don't keep) their professional integrity. One of the easiest ways to estimate popularity is to look at how many people follow an individual on Twitter. There, <a href="https://twitter.com/DrOz">Dr. Oz</a> is clearly way ahead of the practicing physician pack with 3.75 million followers. <a href="https://twitter.com/drdrew">Dr. Drew Pinsky</a> is second at 3.16M, while CNN's <a href="https://twitter.com/drsanjaygupta">Dr. Sanjay Gupta</a> is a distant third with 1.98M. In comparison, well-known blogger <a href="https://twitter.com/kevinmd">Dr. Kevin Pho</a> "only" has 122K followers.<br />
<br />
Curious about who the most popular psychiatrists are, I searched Twitter for individuals (not organizations) with profiles matching "psychiatrist" on 4/26/15. I examined the first 100 or so profiles written in English, looking at the follower count and selecting the 4 psychiatrists with the most followers for further scrutiny (and speculation), focusing on the nature of their popularity and just how much B.S. they espouse. Here's what I found:<br />
<br />
<h3 class="h3post">
#4: <a href="https://twitter.com/JudithOrloffMD">Judith Orloff</a> (40.0K followers | following 10.3K)</h3>
<b>Claim to fame:</b> According to her Twitter profile, Dr. Orloff is a "psychiatrist, intuitive healer, and author of THE ECSTASY OF SURRENDER about how to let go of stress, trust intuition, and embrace joy." She has also written other books with titles such as [her CAPS]: EMOTIONAL FREEDOM, POSITIVE ENERGY, INTUITIVE HEALING, and SECOND SIGHT. I have never heard of her or any of her books; judging by their descriptions, they are very much targeted toward a non-scientifically-minded audience (which is to say, just about <i>everyone</i>).<br />
<b>B.S. meter:</b> 7 <img alt="poo" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_cTvfzvCNnfb2EwRctIXuQLgZej9wZh5hzPAvlzLAU-L5Qnau5dWSWzRMzqalJptUihyphenhyphena-0LkhHQYctq8iYSuw9O6ZAcHOXm4EpdHdz2OZHJT6dlZkmp9JrVUsSrxpMtLnFBbXaoOGzHh/s1600/poopile.png" height="24" title="poo" width="24" />. Dr. Orloff's <a href="http://www.drjudithorloff.com/about-judith-orloff.htm">about page</a> emphasizes the power of intuition to help us "heal—and prevent—illness" and is full of quotations describing her as "a prominent energy-based healer" and a "positive energy guru." I have no doubt that she is a great psychiatrist who helps her patients and readers feel better, and I happen to agree with the message in her latest book about the importance of letting go as opposed to "pushing, forcing, and over controlling people and situations." Yet my intuition tells me that anyone who promotes herself with a sentence like "Dr. Orloff is accomplishing for psychiatry what physicians like Dean Ornish and Mehmet Oz have done for mainstream medicine" needs to be approached with a healthy dose of skepticism.<br />
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<h3 class="h3post">
#3: <a href="https://twitter.com/DocAmen">Daniel Amen</a> (78.7K followers | following 29.3K)</h3>
<b>Claim to fame:</b> Frankly, I was surprised that he was not #1. He's the only psychiatrist that I immediately recognized out of the 4 I found doing this search and the only one with a <a href="https://support.twitter.com/articles/119135-faqs-about-verified-accounts">verified Twitter account</a>, which Twitter only bestows upon "key individual and brands." Dr. Amen is the founder of Amen Clinics, which uses SPECT brain scans to purportedly diagnose mental disorders. He has been <a href="http://www.kqed.org/tv/programs/archive/index.jsp?pgmid=22009">featured in programs</a> running on PBS, and he even has influence amongst <a href="http://www.christianpost.com/news/saddlebacks-daniel-plan-co-author-churches-hurting-members-with-food-they-offer-71784/">Christian audiences</a>. In 2012, a <i>Washington Post</i> article called him "<a href="http://www.washingtonpost.com/lifestyle/magazine/daniel-amen-is-the-most-popular-psychiatrist-in-america-to-most-researchers-and-scientists-thats-a-very-bad-thing/2012/08/07/467ed52c-c540-11e1-8c16-5080b717c13e_story.html">the most popular psychiatrist in America</a>."<br />
<b>B.S. meter:</b> 8 <img alt="poo" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_cTvfzvCNnfb2EwRctIXuQLgZej9wZh5hzPAvlzLAU-L5Qnau5dWSWzRMzqalJptUihyphenhyphena-0LkhHQYctq8iYSuw9O6ZAcHOXm4EpdHdz2OZHJT6dlZkmp9JrVUsSrxpMtLnFBbXaoOGzHh/s1600/poopile.png" height="24" title="poo" width="24" />. There have been <a href="http://www.quackwatch.org/06ResearchProjects/amen.html">numerous</a> <a href="http://skepdic.com/skeptimedia/skeptimedia30.html">well-articulated</a> <a href="http://neurocritic.blogspot.com/2012/08/the-dark-side-of-diagnosis-by-brain-scan.html">criticisms</a> of Dr. Amen and his ridiculous claims regarding SPECT scans that I won't rehash here, save for one especially galling fact: his clinic charges $3500 for an initial evaluation and SPECT scan, which is generally not covered by insurance. While the clinic's website does not reveal this cost up front, it does say they've done over 100,000 scans, so you do the math. PBS's own ombudsman has <a href="http://www.pbs.org/ombudsman/2008/05/caution_that_program_may_not_b.html">disavowed any association</a> with Dr. Amen's infomercials that were aired by local PBS affiliates without adequate disclaimers. Dr. Jeffrey Lieberman, former president of the American Psychiatric Association, was quoted in the <i>Washington Post</i> article as saying this about Amen: "In my opinion, what he’s doing is the modern equivalent of phrenology." On that point, Dr. Lieberman and I can agree.<br />
<br />
<h3 class="h3post">
#2: <a href="https://twitter.com/DrBrianWeiss">Brian Weiss</a> (80.7K followers | following 25)</h3>
<b>Claim to fame:</b> Dr. Weiss's <a href="http://www.brianweiss.com/">website</a> tells us he "was astonished and skeptical when one of his patients began recalling past-life traumas that seemed to hold the key to her recurring nightmares and anxiety attacks. His skepticism was eroded, however, when she began to channel messages from 'the space between lives,' which contained remarkable revelations about Dr. Weiss's family and his dead son. Using past-life therapy, he was able to cure the patient and embark on a new, more meaningful phase of his own career." He is the author of books such as <i>Miracles Happen: The Transformational Healing Power of Past Life Memories</i>, and <i>Many Lives, Many Masters: The True Story of a Prominent Psychiatrist, His Young Patient, and the Past-Life Therapy That Changed Both Their Lives</i>. Not surprisingly, his homepage prominently features a photo of him and Oprah. He runs <a href="http://www.brianweiss.com/5-day-training-workshops/">5-day workshops</a> costing $1000/person for "anyone interested in exploring these profound psychospiritual techniques."<br />
<b>B.S. meter:</b> 10+ <img alt="poo" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_cTvfzvCNnfb2EwRctIXuQLgZej9wZh5hzPAvlzLAU-L5Qnau5dWSWzRMzqalJptUihyphenhyphena-0LkhHQYctq8iYSuw9O6ZAcHOXm4EpdHdz2OZHJT6dlZkmp9JrVUsSrxpMtLnFBbXaoOGzHh/s1600/poopile.png" height="24" title="poo" width="24" />. Someone in a past life once told me, "If you ain't got nothin' nice to say, then it's better to say nothin' at all." I will stick with that for my current life and any of my future lives…<br />
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Thus far, the trend seems to be greater popularity correlating with ever escalating levels of B.S. I was losing what little faith I had entering this exercise. So I was shocked by who ranked first:<br />
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<img alt="Dr. Tobias Fünke" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXClULiLB3JHvdzDoHyrgq0Hd7Um7TTdisBGlQmon3Wfjv6mKQw9yPjchDJ4Eitx4Ae74974jRENkzlIZJO0v6P9VPTzmRgaUGz0cE_figD7SOAGhCwttqkHmSKapWqLYAmRWzSDHY9RQf/s1600/tobias.jpg" height="400" title="Dr. Tobias Fünke" width="580" /></div>
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For a moment, I thought I was looking at <a href="http://arresteddevelopment.wikia.com/wiki/Tobias_F%C3%BCnke">Dr. Tobias Fünke</a> from <i>Arrested Development</i>. But no, it's actually this guy:<br />
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<img alt="Dr. Normal Rosenthal" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEju3oyi6Joh99ZalMf2gDeRRWxyV7rRyyEC2JStw4YDwAbz-dyaWnIal2F1FGwmSIfFVfNyaYwzEJk41sRhZWODJZ9C9DSqOVSOZgA1t5AI0RcbUXQ9jVC9WRTJW5fK5wuDS0mdpYJCrlr7/s1600/drnorman.jpg" title="Dr. Norman Rosenthal" /></div>
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<h3 class="h3post">
#1: <a href="https://twitter.com/DoctorNorman">Norman Rosenthal</a> (101K followers | following 28.3K)</h3>
<b>Claim to fame:</b> I have never heard of Dr. Rosenthal before, but he is the only psychiatrist I can find with over 100K followers. According to <a href="http://www.normanrosenthal.com/about/">his website</a>, he "has written over 200 scholarly articles, and authored or co-authored eight popular books. These include <i>Winter Blues</i>, the <i>New York Times</i> bestseller <i>Transcendence</i>, and the <i>Los Angeles Times</i> bestseller <i>The Gift of Adversity</i>. Rosenthal has conducted numerous clinical trials of medications and alternative treatments, such as Transcendental Meditation for psychiatric disorders, and the treatment of depression with Botox." Watching him <a href="https://www.youtube.com/watch?v=gVnO5bOXYkk&spfreload=10">on Youtube</a>, it seemed that his South African accent instantly gave him added authority and gravitas (I call this the <a href="https://www.youtube.com/watch?v=2evU02UocpQ&spfreload=10">Salvador Minuchin</a> effect).<br />
<b>B.S. meter:</b> 1 <img alt="poo" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_cTvfzvCNnfb2EwRctIXuQLgZej9wZh5hzPAvlzLAU-L5Qnau5dWSWzRMzqalJptUihyphenhyphena-0LkhHQYctq8iYSuw9O6ZAcHOXm4EpdHdz2OZHJT6dlZkmp9JrVUsSrxpMtLnFBbXaoOGzHh/s1600/poopile.png" height="24" title="poo" width="24" />. I was ready to be skeptical of Dr. Rosenthal, and <a href="http://www.normanrosenthal.com/bonus-offer/">this promotional page</a> for his newest book is chock full of celebrity endorsements, including one from Dr. Oz himself. But the book actually seems to offer very sensible advice (based on Dr. Rosenthal's own life) on how to cope with adversity, and reading a passage from it <a href="https://books.google.com/books?id=uBuMMfxKMewC&pg=PT129&lpg=PT129#v=onepage&q&f=false">on Google books</a>, I even learned some interesting things about how the NIMH worked during the transition to the Steve Hyman/Tom Insel era. Dr. Rosenthal's <a href="http://rosenthalnew.wpengine.com/articles/">research publications</a> also left me impressed. He worked at the NIMH for 2 decades, and he did impactful studies on <a href="http://www.ncbi.nlm.nih.gov/pubmed/6581756">seasonal affective disorder</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/3812788">sleep disturbance in mania</a>, and the <a href="http://www.ncbi.nlm.nih.gov/pubmed/2267478">use of light therapy</a> for delayed sleep phase syndrome. He still sees patients in his <a href="http://www.normanrosenthal.com/healing/">clinical practice</a>, where he seems to emphasize integrating different treatment modalities instead of pretending there's some magic bullet. And this is my own personal bias, but I find it touching that his son Joshua has <a href="http://www.normanrosenthal.com/blog/2012/08/your-adhd-child-what-can-you-expect-from-medications/">followed in his footsteps</a>, becoming a child and adolescent psychiatrist.<br />
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So what did I learn about psychiatrists and fame, at least when it comes to Twitter? Obviously, it helps to write multiple best-selling books and to regularly appear on television. Presenting oneself as an "alternative" practitioner with special knowledge or healing techniques helps as well. I won't delve into the content of their tweets in this post, but it seems relentlessly positive messages and pithy tips on how to improve one's life are a must in order to reach as broad an audience as possible.<br />
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Also, 3 of the 4 psychiatrists employ the method of following tens of thousands of people in hopes of trying to get as many people to follow them back as possible. In contrast, the truly famous doctors tend have much more sane follow counts: Dr. Oz follows 85, Dr. Pinsky follows 422, and Dr. Gupta follows 198. Thus, Dr. Weiss may well have the most impressive follower count amongst psychiatrists, given that he only follows 25 people for a follower:following ratio of 3228!<br />
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Before doing this search, I did not follow any of these top 4 psychiatrists on Twitter. Of the accounts that I follow, 8 of them follow Dr. Amen, 4 follow Dr. Orloff, 4 follow Dr. Rosenthal, and only 1 follows Dr. Weiss (really, <a href="https://twitter.com/aacap">@AACAP</a>?). While writing this post, I've decided to follow Norman Rosenthal. He's the one out of the 4 who seems to have most preserved his professional integrity without wading deeply into the realm of pseudoscience, pop spirituality, or utter nonsense. I think every psychiatrist (or doctor, for that matter) aspiring to semi-celebrity status can learn something from him ;-)Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-74027943466431565522015-04-23T08:23:00.000-07:002015-04-23T08:23:26.383-07:00Success, but at What Cost?<div>
<i>Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.</i></div>
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The patient, who was in his late 20's, was clearly very driven. He was a straight-A student from K-12, graduated from an Ivy League school with a 3.9 GPA, and proudly tells me that he works at a startup. He wakes up early every morning for his hour-long commute and works 12-hour days. Admirably, he makes sure to exercise for an hour each night after he gets home. Then, after he eats dinner, he even tries to spend a couple of hours with his girlfriend. When he finally gets to bed, he sleeps from about midnight to 5:30am. Ever since starting college, he has not gotten more than 6 hours of sleep a night.<br />
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He tells me he's been feeling more tired and less focused over the past year, a period coinciding with him gaining greater responsibilities at work. This lack of focus is not constant, and he tends to have the hardest time concentrating around 2-3pm, when he would often feel tired and sleepy. Not surprisingly, he wonders if he has ADHD and if a stimulant medication can help.<br />
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I tell him: "I can't really diagnose you with ADHD because there is no evidence of impairment when you were younger. Plus, most people really do need close to 8 hours of sleep, and almost everyone who gets less than 6 will eventually have trouble staying alert and focused during the day. I recommend that you try to sleep between 7 and 8 hours a night for a few months and see if things improve." He was both dismayed and somewhat defiant: "Look, I'm really busy, and I'm not about to compromise any aspects of my life. There's no way I'm going to work less or give up my workouts or not spend time with my girlfriend."<br />
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This was the patient that came to my mind when I was reading the <a href="http://www.nytimes.com/2015/04/19/us/workers-seeking-productivity-in-a-pill-are-abusing-adhd-drugs.html"><i>New York Times</i> article</a> over the weekend about adult prescription stimulant abuse:<br />
<blockquote class="tr_bq">
Elizabeth, a Long Island native in her late 20s, said that to not take Adderall while competitors did would be like playing tennis with a wood racket.<br />
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"It is necessary — necessary for survival of the best and the smartest and highest-achieving people," Elizabeth said. She spoke on the condition that she be identified only by her middle name. […]<br />
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Elizabeth’s sleep tracker was confused. Her nightly rests were so brief, the iPhone software thought they were just naps. It recorded her average sleep over nine months: from 4:17 a.m. until 7:42.<br />
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After founding her own health technology company, Elizabeth soon decided that working hard was not enough; she had to work harder, longer. Sleep went from an indulgence to an obstacle.<br />
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So she went to a psychiatrist and complained that she could not concentrate on work. She received a diagnosis of A.D.H.D. and a prescription for Adderall in about 10 minutes, she said.<br />
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"Friends of mine in finance, on Wall Street, were traders and had to start at 5 in the morning on top of their games — most of them were taking Adderall," Elizabeth said. "You can’t be the one who is the sluggish one."</blockquote>
I'm saddened that we live in a world where the founder of a <i>health</i> technology company doesn't seem to care about how sleeping 3.5 hours a night affects her own health. It seems very Kafkaesque and short-sighted to me. How did things get this way, to the point where "success" is defined by individual achievement and productivity above all else?<br />
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I found David Brooks's <a href="http://www.nytimes.com/2015/04/17/opinion/david-brooks-when-cultures-shift.html">column from last week</a> to be quite pertinent. He traced the changes in American society stemming from the late 1940s, when the generation who had suffered through the Great Depression and World War II let loose and embraced consumerism, transforming the culture from one of self-effacement and sacrifice to one of self-expression and indulgence:<br />
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But I would say that we have overshot the mark. We now live in a world in which commencement speakers tell students to trust themselves, listen to themselves, follow their passions, to glorify the Golden Figure inside. We now live in a culture of the Big Me, a culture of meritocracy where we promote ourselves and a social media culture where we broadcast highlight reels of our lives. What’s lost is the more balanced view, that we are splendidly endowed but also broken. And without that view, the whole logic of character-building falls apart. You build your career by building on your strengths, but you improve your character by trying to address your weaknesses.</blockquote>
Instead of "broken," I would've chosen "incomplete," but otherwise I agree with Brooks's main points. And speaking of a glorified Golden Figure, I thought I was reading a late April's Fool joke when CNN/Money ran an article last week titled: "<a href="http://money.cnn.com/2015/04/15/technology/mark-zuckerberg-hours/index.html">Mark Zuckerberg only works 50 to 60 hours a week</a>." Unfortunately, it was not a joke, and of course the author qualified Zuck's work hours with: "But he conceded that if the definition of 'work' were expanded, he'd be working his 'whole life.'" Is this the sort of role model that we want for our kids? Do we want a society where people are admired for driving themselves to extremes, and a lucky few will become fabulously wealthy, while many more get stressed out and sleep-deprived, and a certain regrettable percentage end up with depression, anxiety, or <a href="http://www.psycritic.com/2015/03/the-tragedy-of-palo-alto.html">suicide</a>?Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-7192930888788262452015-04-15T21:26:00.000-07:002015-04-15T21:26:17.680-07:00Disruptive Mood Dysregulation Disorder RevisitedIn the brief history of this blog, <a href="http://www.psycritic.com/2013/05/child-psychiatrist-dsm5-disruptive-mood-dysregulation-disorder.html">the post where I shared my thoughts</a> on DSM-5's disruptive mood dysregulation disorder (DMDD) has gotten by far the most pageviews. It's been almost two years since I wrote that post, and I would like to revisit DMDD with some updated thoughts on this diagnosis.<br />
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As you may recall, DMDD sprang out of a desire to have a diagnosis other than "bipolar disorder" to describe children who are chronically irritable and have explosive tantrums. Almost all of the children with DMDD also meet the criteria for oppositional defiant disorder (ODD) and are at higher risk of developing depression but not mania. The NIMH researcher <a href="http://www.nimh.nih.gov/labs-at-nimh/principal-investigators/ellen-leibenluft.shtml">Ellen Leibenluft</a>, whose work on severe mood dysregulation (SMD) strongly influenced DMDD's creation, had commented in the past that she was not 100% sure that DMDD was a good idea.<br />
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In the last few years, I have only seen a handful of children who met the criteria for DMDD. Here is what I noticed in my own practice:
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<ul>
<li>One boy was being raised by a single mother who worked full time, so his grandparents were very involved in childrearing. The mother tried to set rules, but the grandparents were much more permissive, and whenever the mother tired to enforce her rules, explosive tantrums resulted.</li>
<li>Another boy was very violent toward his mother on an almost daily basis. His father was home but did not intervene, while the mother had anxiety and literally appeared fearful of her son during their visits with me. When he hit her, she would tell him verbally that it was wrong, but did not do anything else (like using a time-out) to try to change his behaviors.</li>
<li>There was a girl (who I'd <a href="http://www.psycritic.com/2013/12/in-whom-does-mental-illness-reside.html">written about previously</a>) whose mother was very emotionally distant and pulled away further every time the girl acted out because the mother was reminded of her own emotionally intense mother. This distancing seemed to lead to the daughter becoming even more irritable.</li>
<li>And then there was a boy who was extremely aggressive at home, constantly fighting with his 3 siblings. The household was very chaotic, with parents still married but frequently arguing with each other. Both parents often resorted to spankings, which did not seem to decrease the boy's aggression or irritability.</li>
</ul>
Certainly, correlation between the parental characteristics and the children's behaviors does not tell us about causation. It is very stressful raising irritable, explosive children, and the children described above definitely had intense, strong-willed temperaments. My intuition is that it's an interactive process where both parental and child characteristics trigger maladaptive behaviors in each other that escalate over time. But are these families typical of cases of DMDD? I <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=%22disruptive+mood+dysregulation+disorder%22">searched Pubmed</a> for "disruptive mood dysregulation disorder" and found 20 papers published in the last 2 years (out of 29 total).<br />
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Of the 20, most were reviews/commentary, and only 6 papers were original research. One was a <a href="http://www.ncbi.nlm.nih.gov/pubmed/23732841">brain imaging study</a> looking at "neural mechanisms of frustration in chronically irritable children." Another <a href="http://www.ncbi.nlm.nih.gov/pubmed/25504765">examined the prevalence</a> of SMD 2 and 4 years out from initial diagnosis, and found that 40% still met full criteria at 4 years, but a significant number not meeting the criteria were still moderately impaired. Another study from Duke's developmental epidemiology program used a large database to <a href="http://www.ncbi.nlm.nih.gov/pubmed/24781389">examine the adult outcomes</a> of those who would have met DMDD criteria as children and found higher adult rates of depression, anxiety, adverse health outcomes, impoverishment, police contact, and lower educational attainment.<br />
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To my pleasant surprise, there were actually several papers that included data on family characteristics of children with DMDD. The first was a <a href="http://www.ncbi.nlm.nih.gov/pubmed/24443797">cross-sectional study</a> of a community sample of 6 year-old children, which found that 8.2% of them met DMDD criteria based on a structured interview of parents. Impressively, the study examined 6 domains ("demographics; child psychopathology, functioning, and temperament; parental psychopathology; and the psychosocial environment") for correlates of DMDD. The parents were also interviewed about what things had been like when their children were 3 years old, and here's what the researchers found:<br />
<blockquote class="tr_bq">
The age 3 years predictors of DMDD at age 6 years included child attention deficit hyperactivity disorder, oppositional defiant disorder, the Child Behavior Checklist - Dysregulation Profile, poorer peer functioning, child temperament (higher child surgency and negative emotional intensity and lower effortful control), parental lifetime substance use disorder and higher parental hostility.</blockquote>
The <a href="http://www.ncbi.nlm.nih.gov/pubmed/25183553">second study</a> was a prospective one that "followed 317 high-risk children with early externalizing problems from school entry (ages 5-7) to late adolescence (ages 17-19)." The children sorted into 3 groups by the time they were adolescents: one group with conduct/criminal problems and anger, one group with mood dysregulation, and one group with a low level of symptoms. The authors found that generally, those who were more overtly aggressive as children tended to have conduct problems as adolescents, while more emotionally dysregulated children had more mood dysregulation in adolescence. The key finding:<br />
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For children with early emotion dysregulation, however, increased risk for mood dysregulation characterized by anger, dysphoric mood, and suicidality - possibly indicative of disruptive mood dysregulation disorder - emerges only in the presence of low parental warmth and/or peer rejection during middle childhood.</blockquote>
Another study (with 13! authors) was <a href="http://www.ncbi.nlm.nih.gov/pubmed/24655650">published in a much more prestigious journal</a> than the previous 2 papers, and to me it was the least enlightening. The study examined the risk of DMDD in offspring of parents with bipolar disorder and found a much higher risk of DMDD (odds ratio = 5.4 "when controlling for demographic variables and comorbid parental diagnoses") compared to offspring of control parents. Given what those two other studies found, I'm not surprised that parents with bipolar disorder, one of the most severe psychiatric illnesses, would have children at risk of DMDD.<br />
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One last <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329886/">noteworthy paper</a> that turned up in my Pubmed search is a recent article on whether DMDD should be included in ICD-11. The International Classification of Diseases is the World Health Organization's standard system for classifying every health problem imaginable, and the 11th revision is due in 2017. Even in the U.S., the ICD diagnostic codes are the standard for coding and billing purposes, and each DSM diagnosis is mapped to a corresponding ICD code. In this paper, the authors, who were members of a task group convened by the WHO to provide recommendations on the classification of disruptive behavior disorders, wrote:<br />
<blockquote class="tr_bq">
The task group has recommended that WHO not accept DMDD as a diagnostic category in ICD-11, but rather approach the issue in an alternative, more conservative and more scientifically justifiable way. Specifically, the group has proposed that ICD-11 include a specifier to indicate whether or not the presentation of ODD includes chronic irritability and anger. We believe this option provides the most parsimonious basis for identifying and appropriately treating children with this maladaptive form of emotional dysregulation.</blockquote>
In my previous post on DMDD, I thought that it was overall a positive step away from the rampant over-diagnosis of pediatric bipolar disorder. But I did not end up using it; I was not about to diagnose those children with bipolar disorder in the first place. Thus, I find myself agreeing with the WHO task group. With ODD, the <a href="http://www.jaacap.com/article/S0890-8567(09)61969-9/pdf">standard first line treatments</a> are interventions that help parents better manage their children's behaviors and/or improve the parent-child relationship. I still worry about drug companies trying to market a medication for DMDD that supposedly targets a problem in the brain of the child. Thankfully, at least Abilify hasn't been approved yet for treating DMDD and hopefully never will, having gone off-patent this year.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-68615440353181683552015-04-05T16:12:00.000-07:002015-04-29T08:47:10.256-07:00Psychiatry as a Clinical Neuroscience, Why Not?I first heard the term "clinical neuroscience" used in relation to psychiatry as a resident in 2009, when my associate program director handed out a paper to us trainees titled: "<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769014/">The Future of Psychiatry as Clinical Neuroscience</a>." She presented this as a ground-breaking document that would greatly influence the rest of our careers. Shockingly, the authors of that paper did not cite NIMH Director Thomas Insel, who had an earlier article in 2005 titled: "<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1586100/">Psychiatry as a Clinical Neuroscience Discipline</a>." Since then, Dr. Insel has posted an updated version of the article <a href="http://www.nimh.nih.gov/about/director/bio/publications/psychiatry-as-a-clinical-neuroscience-discipline.shtml">on his blog</a> (publication date: unknown) and wrote <a href="http://www.nimh.nih.gov/about/director/2012/the-future-of-psychiatry-clinical-neuroscience.shtml">other blog posts</a> championing the notion that in order for psychiatry to advance, we must focus on basic neuroscience research. And now, a recent article asks, "<a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=2174543">The Future of Psychiatry as Clinical Neuroscience: Why Not Now?</a>"<br />
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The authors, who are program (or associate program) directors of residency training at Yale, Pitt, and Columbia, bemoan the fact that advances in understanding mental illness based on neuroscience research have not made their way into clinical practice. As barriers, they cite "the pervasive belief that neuroscience is not relevant to patient care," as well as the complexity of the research. They argue that the best place to start enacting this paradigm shift is in psychiatry residency programs right now. They also write:<br />
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The diseases that we treat are diseases of the brain. The question that we need to address is not <i>whether</i> we integrate neuroscience alongside our other rich traditions but <i>how</i> we work as a field to overcome the barriers that currently limit us. Ultimately, the most powerful force will be the improved translation of research into more refined explanatory models of psychiatric pathology and into novel therapeutics. To ensure that our field is ready to embrace new findings as they emerge, we need to begin the process of culture change today by enhancing communication and collaboration between researchers and practitioners.</blockquote>
I think 1BOM <a href="http://1boringoldman.com/index.php/2015/03/13/yellow-brick-roads/">hit the nail on the head</a> when he wrote: "Rather than being '<i>ready to embrace new findings as they emerge</i>', tomorrow’s psychiatrist needs to know how to <i>critically evaluate new findings as they emerge</i> [italics in original]." I remember being taught as a resident about Broadmann Area 25 being critical in the pathogenesis of depression, based on <a href="http://www.cell.com/neuron/abstract/S0896-6273(05)00156-X">exciting initial deep brain stimulation results</a> from Dr. Helen Mayberg. This was almost treated as an established fact, despite the very preliminary nature of the research. Well, what happened when they tried to do a larger clinical trial? Neurocritic reported that the trial was <a href="http://neurocritic.blogspot.com/2014/01/broaden-trial-of-dbs-for-treatment.html">halted before its planned endpoint</a> in December 2013, and last month <a href="http://neurocritic.blogspot.com/2015/03/update-on-broaden-trial-of-dbs-for.html">it was revealed</a> that the medical device company conducting the trial (St. Jude) stopped it due to perceived study futility.<br />
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Do the clinical neuroscience curriculums for psychiatry residents teach the importance of humility and emphasize just how much we don't know? One of my favorite articles in the past year has been <a href="http://www.bbc.com/future/story/20141216-can-you-live-with-half-a-brain">Tom Stafford's BBC Neurohacks column</a> from December 2014 in which he discussed the importance of redundancy in the brain. He described the case of a woman who, despite missing her entire cerebellum, was able to live a fairly normal life:<br />
<blockquote class="tr_bq">
This case points to a sad fact about brain science. We don't often shout about it, but there are large gaps in even our basic understanding of the brain. We can't agree on the function of even some of the most important brain regions, such as the cerebellum. Rare cases such as this show up that ignorance. Every so often someone walks into a hospital and their brain scan reveals the startling differences we can have inside our heads. Startling differences which may have only small observable effects on our behaviour.<br />
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Part of the problem may be our way of thinking. It is natural to see the brain as a piece of naturally selected technology, and in human technology there is often a one-to-one mapping between structure and function. If I have a toaster, the heat is provided by the heating element, the time is controlled by the timer and the popping up is driven by a spring. The case of the missing cerebellum reveals there is no such simple scheme for the brain. Although we love to talk about the brain region for vision, for hunger or for love, there are no such brain regions, because the brain isn't technology where any function is governed by just one part.</blockquote>
As Neuroskeptic recently tweeted:<br />
<blockquote class="twitter-tweet" lang="en">
Neuroscientist: someone who knows how little we know about the brain.<br />
— Neuroskeptic (@Neuro_Skeptic) <a href="https://twitter.com/Neuro_Skeptic/status/581887653139881984">March 28, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script>
This is a point that needs to be made and repeatedly emphasized to those who write things like "the diseases we treat are diseases of the brain." The irony for me is that I do appreciate the importance of neuroscience in psychiatry and agree with the authors when they wrote: "The more sophisticated and nuanced our science becomes, the more critical it is to have individuals who can translate this work to make it accessible to students at all levels." It reminded me of one of my favorite college classes, Principles of Neuroscience. The professor, who studied ion channels in different animals, was an amazingly good teacher, and the first lecture started something like this:<br />
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"Ernest Hemmingway once boasted that he had a six-word story—complete with beginning, middle, and end—that would bring tears to anyone who heard it. Here it is [he lowered the lights in the room and said the following words softly and slowly]: 'For sale…baby shoes…never used.' [dramatic pause] While not all of you are tearing up, very few people could have heard those words without thinking of or feeling <i>something</i>. Any images in your mind (did you see the shoes, what color were they?), any thoughts or emotions you may have experienced after hearing those six words, formed as signals in your nervous system. Without the nervous system, we cannot see, hear, feel, taste, or smell—in short, our five senses would produce no corresponding thoughts, and life as we experience it does not exist."</blockquote>
The tour de force lecture progressed to descriptions of single neurons and how our nervous system is comprised of approximately 100 billion of them, each of which can have tens of thousands of synaptic connections to other neurons. The quote I remember most clearly: "All of the neurons together in one brain form more connections with each other than there are stars and planets in the galaxy." The professor ended his lecture by giving us some practical tips based on his knowledge of neuroscience. Time and repetition, he told us, is what will help us succeed in the class, because that is how neuronal circuits are programmed and how processes in the brain ranging from retrieving facts from memory to riding a bicycle become automatic. I use the same advice almost daily with my patients when I emphasize to them the importance of practicing new behaviors or ways of dealing with difficult thoughts and emotions. Similarly, based on my reading of research on the effects of sleep, exercise, and social interactions on the brain, I share with my patients the importance of getting enough of each.<br />
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I learned more neuroscience of clinical relevance in one semester from this PhD Biology professor than I have from years of attending lectures and reading papers from psychiatry researchers who are considered world experts in areas like the neurobiology of OCD, pediatric bipolar disorder neuroimaging, or how transcranial magnetic stimulation affects neural circuits in depression. For me, the most important distinction when we talk about clinical neuroscience is whether we take a <i>broad</i> view of neuroscience or a <i>narrow</i> view. The broad view would emphasize the huge effect of all of the different inputs on the brain (e.g. that six words can bring a person to tears), whereas the narrow view tends to emphasize things like genetics, neurotransmitters, biomarkers, and circuits.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-69999454199503613252015-03-21T11:22:00.000-07:002015-04-29T08:51:23.496-07:00The Tragedy of Palo Alto<i>Sorry for the long absence. I'm going to try to shake off the winter doldrums and resume blogging semi-regularly.</i><br />
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Palo Alto, CA (est. 2013 population: 66,642) is one of the <a href="http://en.wikipedia.org/wiki/List_of_highest-income_places_in_the_United_States#100_highest-income_places_with_a_population_of_at_least_50.2C000">wealthiest cities in America</a>, with <a href="http://www.usnews.com/education/best-high-schools/california/districts/palo-alto-unified-school-district/henry-m-gunn-high-school-2992">nationally-ranked</a> public high schools, quiet tree-lined streets, and <a href="http://www.city-data.com/crime/crime-Palo-Alto-California.html">exceedingly low</a> crime rates. Since 2000, the city has averaged about 1 murder per year. Sadly, that number has been dwarfed by the number of Palo Alto teens committing suicide every year.<br />
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In 2009, Palo Alto gained <a href="http://abcnews.go.com/US/palo-alto-struggles-rash-teen-train-suicides/story?id=8881813&singlePage=true">national notoriety when a cluster of suicides</a> occurred amongst students at Henry Gunn High School. The attention-grabbing nature of the suicides (most occurred by jumping in front of an oncoming train) and the relative ease of access to the suicide method likely contributed to subsequent suicides. The national youth suicide rate is about <a href="http://www.cdc.gov/violenceprevention/suicide/statistics/rates03.html">10 per 100,000</a> per year, so any suicide in a district that has several thousand high school students is a cause for concern. Multiple suicides in such a short span of time understandably led to alarm.<br />
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At the 2011 AACAP meeting in Toronto, I attended the session <a href="https://aacap.confex.com/aacap/2011/webprogram/Session7414.html">Teaching the Community in Times of Crisis: Responding to Teen Suicide</a>. The main speaker (Madeline Gould, MPH, PhD) was very informative and presented a wealth of research-based data emphasizing how suicides can cluster and spread, while media reports on the suicides can either help or hurt the situation. Dr. Shashank Joshi, a psychiatrist at Stanford, discussed the school-based suicide prevention program that Stanford helped the Palo Alto school district put in place after the suicides. The program has similarities to public health approaches designed to combat disease outbreaks: There are efforts to decrease stigma, provide education about depression how it can lead to suicide with emphasis on the effectiveness of available treatments, train teachers and parents to recognize signs of depression, teach coping skills, and identify vulnerable teens through screening and then making appropriate referrals. From what I gather, this program is still in place, and Dr. Joshi just published an article titled <a href="http://www.ncbi.nlm.nih.gov/pubmed/25773329">School-Based Suicide Prevention: Content, Process, and the Role of Trusted Adults and Peers</a>, with one of the <a href="http://www.sciencedirect.com/science?_ob=PdfExcerptURL&_imagekey=1-s2.0-S1056499314001254-main.pdf&_piikey=S1056499314001254&_cdi=273334&_orig=article&_zone=centerpane&_fmt=abst&_eid=1-s2.0-S1056499314001254&_user=12975512&md5=fd6f025b07d38b26d8b59f787ced2b22&ie=/excerpt.pdf">key points</a> being: "Prevention efforts must focus on school-based mental health education and promotion."<br />
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What was not addressed at the AACAP session was what may have been happening at the community level that was triggering the suicides in the first place. Given the relative rarity of suicides, it is hard to prove what causes each suicide or how effective current school-based prevention methods are. Unfortunately, what we do know is that suicides amongst Palo Alto students are still occurring, with another one <a href="http://www.mercurynews.com/bay-area-news/ci_27675076/person-hit-killed-by-caltrain-palo-alto">earlier this month</a>, bringing the total to 3 for the year.<br />
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In this past week, <i>Palo Alto Weekly</i> has published two opinion pieces, <a href="http://paloaltoonline.com/news/2015/03/16/guest-opinion-keep-calm-and-parent-on">one by Palo Alto psychiatrist</a> and parent Dr. Adam Strassberg, the <a href="http://paloaltoonline.com/print/story/2015/03/20/guest-opinion-what-we-can-do-to-reduce-risk-for-our-teens">other by pediatricians</a> from the Palo Alto Medical Foundation. Both are worth reading in full, because in my opinion they make a valiant attempt to get to the root of the problem. Neither one mentioned anything about screening for depression or increasing access to mental health care. Dr. Strassberg emphasized the pressure that parents place upon their children to succeed:<br />
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We are so many of us wealthy and secure beyond imagining, and yet we have such enormous anxiety. We fear the future harm that we will lose our wealth and privilege and be unable to pass it on to our future generations. Maintaining and advancing insidiously high educational standards in our children is a way to soothe this anxiety.<br />
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But it harms our children.</blockquote>
The pediatricians make a similar point:
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While we are not education specialists, as pediatricians we do recognize dangerously unhealthy lifestyle patterns and habits that are known to exacerbate stress, anxiety, depression and physical illness. These include chronic sleep deprivation, lack of unscheduled time for thought and relaxation, unhealthy eating habits, lack of exercise and unrealistic pressures (real or perceived) to achieve. Those unrealistic pressures include excessive homework, overly ambitious course loads and a seeming demand for perfection in grades, sports and extracurricular activities.<br />
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We see these problems day after day in our teen patients. We believe there are specific factors that could be targeted for change.<br />
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Sleep: Surveys have shown that Palo Alto teens sleep an average of 6.5 hours per night. Studies have shown that teens need 9 hours of sleep to function at their best. […]</blockquote>
Six-and-a-half hours of sleep, <i>average</i>. So for every teen sleeping 8 hours a night, there's one who's only getting 5. I know that I feel grumpy and foggy even with 7 hours, so it's hard for me to imagine what these teens are going through. I'm not saying that the school-based mental health programs are useless, but it's clear as day to me that they do not go far enough up the chain of causality to address the most important factors leading to all of these adolescent suicides. And it's not just Palo Alto, but achievement-driven communities everywhere, that have this problem. Hopefully, more professionals will start engaging families in a discussion of these root causes, rather than only trying to treat surface symptoms.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-63808575390755225432014-11-22T13:41:00.001-08:002015-04-29T08:54:16.781-07:00Like WaterThe flustered mother told me this about how difficult it was to get her school-aged son to do what she wanted: "He's like water. Whatever I try to do, whatever rules I set up, he finds a way around them."<br />
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I said, "Well, that must be very frustrating."</div>
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Here's what I wish I had been clever enough to say to her instead: </div>
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"You're right. Kids are a lot like water. The harder you try to grab them, the more they slip through your fingers.<br />
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Like water, kids can mirror their surroundings. They are given shape by their environment, while over time they are also shaping the environment.<br />
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Similar to water, kids can exist in different states. Too much heat or too much cold, and they may become explosive or get more rigid and brittle.</div>
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Water is very resilient. Most of the time, like water, kids can return to their previous state after a perturbation if the environment allows it.</div>
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It always takes energy to change the flow, the direction, the trajectory of water. Otherwise it just follows the path of least resistance.</div>
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Just as you can make water move against gravity through capillary action, giving the right scaffolding for a child can make all the difference. </div>
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While water running rampant can be destructive, water put to purpose can do immeasurable good.<br />
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So you're absolutely right: your child is very much like water. Now what shall we do about it?"</div>
Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-69973071621477133782014-11-15T10:59:00.000-08:002018-07-24T17:04:07.470-07:00Why I Love Wall-E (and Question the ACA)<i>Spoiler warning: If you haven't seen Wall-E yet, why not? See it first before reading this post if you don't want certain aspects of the plot revealed.</i><br />
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Let me tell you why <a href="http://www.imdb.com/title/tt0910970">Wall-E</a> is my favorite Pixar move. The title protagonist begins the movie as a humble robot, programmed with a very specific purpose: to pick up garbage, compress it, and stack it in neat, towering piles. In Wall-E's world, man-made trash overwhelmed the earth generations ago, smothering all plant life. The humans escaped in giant spaceships, leaving robots behind to clean up the mess. Over time, all of the other robots broke down, with Wall-E the sole survivor living a repetitive, lonely existence. Yet Wall-E somehow transcends his programming and develops a sense of curiosity about the world. What were those humans like? What are these relics that they left behind? What's that green thing growing amongst the trash?<br />
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After a series of improbable but exciting events, Wall-E finds himself on board one of those giant spaceships. There, he encounters real, live humans and the robots that serve their needs. The people were uniformly plump with adiposity, reclining comfortably on mobility chairs while sipping futuristic Big Gulps™ and fixated on screens. Wall-E was aghast, eventually discovering that the villainous AI of the ship was trying to keep the humans confined to their blissful but vacuous existence. Wall-E finds a way to rally the other robots and spread the news that plant life was growing on earth once again. The movie ends on a hopeful note, with the ship returning home and the humans taking small, earthbound steps that feel like giant leaps. I love that Wall-E acted in humanity's long term interests instead of either rejecting these disappointing humans or attending only to their short term comfort.<br />
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Recently, I was reminded of Wall-E when I attended a session at <a href="http://www.aacap.org/AnnualMeeting/2014">AACAP's Annual Meeting</a> in San Diego titled: "The Affordable Care Act [ACA] and How We Think About Systems, Care, Quality, and Ethics." The discussants covered various aspects of the ACA (for an overview of the ACA, see this <a href="http://psychpracticemd.blogspot.com/2014/10/lets-talk-about-aca.html">recent post</a> from Psych Practice). What interested me most was the talk by Dr. Michael Houston on how the ACA relates to child and adolescent psychiatrists. Dr. Houston discussed the ethical underpinnings of the ACA, namely how it seeks to institute a more egalitarian and less libertarian health care system. The law lays the groundwork for transitioning us from a fee-for-service system in which doctors have a financial incentive to do lots of procedures to a system in which both patients and doctors have a responsibility to society to contain costs.<br />
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Clearly, one of the goals of the ACA is to make doctors provide more efficient care. One of the justifications for why we need this is the chart above (from <a href="http://www.huffingtonpost.com/2013/11/22/american-health-care-terrible_n_4324967.html">this HuffPo article</a>) showing how, despite spending way more than any other country on health care per capita, the U.S. trails most other developed nations in life expectancy. The logic seems to be that since we're not getting good bang for our buck, the health care delivery system must be streamlined.<br />
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This focus on efficiency would have an especially high impact on child psychiatrists, given how relatively few of us there are compared to the high numbers of patients. Here's an <a href="http://www.nbcnews.com/id/12190434/ns/health-childrens_health/t/shortage-child-psychiatrists-taking-big-toll">old article from 2006</a> about the shortage, and not much has changed since, except that even more children are being diagnosed with conditions like ADHD and <a href="http://www.nytimes.com/2014/11/15/us/one-drug-or-2-parents-see-risk-but-also-hope.html">taking multiple medications</a>, putting further strains on the health care system. Last year, AACAP <a href="http://www.aacap.org/App_Themes/AACAP/docs/Advocacy/policy_resources/preparing_for_healthcare_reform_201303.pdf">published a document</a> describing how the ACA will impact the practice of child and adolescent psychiatry. More mental health care will be delivered by pediatricians and care managers, with psychiatrists overseeing cases but not seeing patients directly unless they were especially complicated.<br />
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To me, this seems like a herculean effort to create ever more efficient Wall-Es, without trying to address why there was so much for Wall-E to clean up in the first place. Instead of just focusing on the shortage of child psychiatrists, why are we not doing more about the over-abundance of patients? After the session, I asked one of the speakers this very question. Her answer was sobering: she had thought about this issue herself, but when she tried to a submit a paper on the prevention of mental disorders in children, no child psychiatry journal would accept it. She thinks that is just not our mindset, just not what we are trained or paid to do. It reminded me of the old adage by Upton Sinclair, "It is difficult to get a man to understand something, when his salary depends on his not understanding it."<br />
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Don't get me wrong, I believe in universal health care. I just don't think that the ACA is going to successfully address the mental health issues of children in this country, just as it won't address the obesity epidemic by making obesity treatment more streamlined. For example, <a href="http://www.nytimes.com/2014/11/15/us/one-drug-or-2-parents-see-risk-but-also-hope.html">today's NYTimes article</a> that I linked to earlier profiled a California mother who has a child with ADHD and severe behavioral issues. Here's the crucial paragraph:<br />
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Some would consider Matthias a textbook candidate for combined treatment. His rages have overwhelmed schools and child care programs for years, and he is already struggling in first grade. He and his mother — a medical technician whose typical workday drawing blood lasts from 7 in the morning until 4 p.m. — share a cramped and clamorous three-bedroom ranch house with her sister and brother-in-law and their spirited children, ages 3 and 6 months. Matthias is having nightmares and bladder-control issues.</blockquote>
I'm not sure that any amount of meds or access to a child psychiatrist would help this child as much as having a less stressful home environment. I don't claim to know what the best solution for our society as a whole would be, but I do think we need to put more effort into investigating what can be done to better support children and families, and not just from a medical/health care system point of view.<br />
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I hope that more of us in the child psychiatry field can be a bit more like Wall-E: a bit more curious about the world we find ourselves in and how it became that way, a bit more willing to ponder what can change things for the better. Let's not continue to just put our heads down in order to squeeze ever more efficiency and productivity out of our days.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-47094259848126864932014-08-31T13:53:00.000-07:002015-04-29T08:58:58.997-07:00Boyhood Movie ReviewPutin. Gaza. Ebola. ISIS. Ferguson. Robin Williams. This has been one of the more unsettling summers in recently memory. However, as we head towards Labor Day and I look back on the last couple of months, what I recall most clearly and fondly (besides some personal and family matters that are irrelevant here) is watching <a href="http://www.ifcfilms.com/films/boyhood"><i>Boyhood</i></a>, by director Richard Linklater.<br />
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The film stars Ellar Coltrane as Mason, who is 6 at the beginning of the story. We watch as he grows year by year into an 18 year-old young man. Forget all those gimmicky 3D movies; this is a 4D film, where the genuine passage of 12 years of time adds an extra dimension that cannot be faked by CG.<br />
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<i>Boyhood</i> succeeds in capturing something about the essence of our times when it comes to parenting and childhood. The parents have split, and the dad, played by Ethan Hawke, is barely around initially, only occasionally swooping into his kids lives like a tornado of fun. Meanwhile, the mom (Patricia Arquette) struggles to raise her children while trying to go back to school so her family could break free from the struggles of low-wage America.<br />
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Amazingly, the director found a young actor in Coltrane who was able to deliver a consistently convincing performance from childhood to adolescence. The film opens with him lying on the grass staring into the sky, leaving us to wonder what he makes of life. Coltrane was able to project this introspective nature throughout, and as a young man engages in the kind of philosophical discussions that Linklater's characters are <a href="http://en.wikipedia.org/wiki/Waking_Life">known to do</a>.<br />
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However, <i>Boyhood</i> is as much a coming of age movie about Mason's parents as it is about Mason's own journey. I found it interesting that the adults seemed to be engaged in a search for identity as much or more so than the children. The character who evolves the most over the 12 years is Mason's father, who becomes a minivan-driving, church-going actuary in middle age. Mason's mother ends up as a somewhat tragic figure who has to balance her career with parenting while dealing with a string of bad relationships. Our culture really is harder on women, and this film reflects that reality.<br />
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Boyhood has been the <a href="http://www.rottentomatoes.com/guides/summer-movie-scorecard-2014/">best reviewed movie</a> of the summer and deservedly so. One may look at the box office receipts for the latest <a href="http://www.rottentomatoes.com/m/transformers_age_of_extinction/"><i>Transformers</i></a> assault on the senses ($243.8M) vs. <a href="http://www.rottentomatoes.com/m/boyhood/"><i>Boyhood</i></a> ($16.3M) and despair; I choose to see the fact that this movie was made at all as a sign that there is still hope.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-22967114790456751812014-07-06T20:16:00.000-07:002015-04-29T08:59:42.006-07:00The Limits of Big Data in PsychiatryWhile browsing <a href="http://www.theatlantic.com/">The Atlantic</a> earlier this week, I came across this:<br />
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Yes, I was tempted to click on the article involving electric shocks, but it was the ad "<a href="http://www.theatlantic.com/sponsored/athena-where-does-it-hurt/">Rising Mental Health Issues Facing Our Children, in Five Charts</a>" that caught my attention. The colorful charts show some alarming-looking numbers that most readers of this blog are probably used to seeing by now: that there is a large increase in children receiving mental health diagnoses, that ADHD is diagnosed at very high rates (especially in the South), that children on Medicaid are more likely to receive a mental health diagnosis than children with commercial insurance, etc. The data for the charts were gathered from pediatrician visits across the country by <a href="http://www.athenahealth.com/">athenahealth</a> (apparently they're too cool for capital letters), the electronic health record (EHR) company who paid for the ad.<br />
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They helpfully included a video at the bottom of the ad so we can get "perspectives on these trends from top health care leaders." Take a look:<br />
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Watching this video, I was struck by the words of Kurt Newman, M.D., President and CEO of Children's National Medical Center:<br />
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"These graphs are just probably the tip of the iceberg. The directional trend is very disturbing, but also the magnitude is disturbing, and these pediatricians are swamped.<br />
[…]<br />
That's why we need to do more research, we need to have a better system in terms of more providers, we need to be able to pay the providers a reasonable amount for the care they're giving. But I think if we do all that, we're going to have a huge impact for these kids and families."</blockquote>
Classic. There's an epidemic on, doctors are swamped—we need more funding so we can provide more treatment! No wonder he's the CEO. And like many other CEOs, he oversells when talking about the future:<br />
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"We're on the cusp of something really huge there. It's kind of like big data and big analytics that are gonna really revolutionize how we can identify these trends or get specific about certain diseases […] Autism might be a hundred different rare diseases that are all rolled up into one. We won't figure that out unless we have the analytics, all of the the really sophisticated capability of probing into: is that patient like that patient, is that child like that child, what made them more similar?"</blockquote>
Perhaps I'm too dumb to comprehend big data/analytics, but I fail to see how information mined from an EHR is going to shed light on the etiology of autism. Also featured in the video is Angela Diaz, M.D., Director of the Mt. Sinai Adolescent Health Center, who seems to have a more common sense take on the data:<br />
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"We need to figure out what is leading to these kids…30% of U.S. students to feel sad and hopeless for the last 12 months, and of those, 40% of the girls? What is going on? So we need to get to the root causes of these things, and try to identify and then figure out, how to prevent?"</blockquote>
I certainly agree with Dr. Diaz on the importance of trying to determine the root causes of the rising rates of these conditions. However, having the raw data and figuring out causality are two very different things. I would argue that in psychiatry we already have access to tons of data, but unfortunately much of it is interpreted through a very narrow, biologically-oriented lens. Having faster access to bigger pools of data is not going to help. Example in point: the January 2014 <a href="http://www.jaacap.com/article/S0890-8567(13)00594-7/abstract"><i>JAACAP</i> article</a> that described rising rates of ADHD in the US, which I had previously <a href="http://www.psycritic.com/2014/02/adhd-big-picture.html">blogged about</a>. That article was accompanied by an editorial by Drs. Walkup, Stossel, and Rendleman that essentially heralded the findings as good news and a sign that ADHD is being increasingly recognized and treated, which is desirable from a "public health" point of view.<br />
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In the June 2014 issue of <i>JAACAP</i>, Dr. Jonathan Posner wrote a very reasonable <a href="http://www.jaacap.com/article/S0890-8567(14)00156-7/fulltext">letter to the editor</a> (subscription required), pointing out that other, more rigorous studies (relying on both parent and teacher report instead of parent report only) have found rates of ADHD closer to 5-7% instead of the 11% reported in the <i>JAACAP</i> article. He concludes that the reason for the rapidly increasing rates of ADHD diagnosis in the community may be "that a substandard approach to diagnosing ADHD has become the norm." Drs. Walkup and Rendleman <a href="http://www.jaacap.com/article/S0890-8567(14)00155-5/fulltext">wrote a reply</a> (subscription required); here's the first paragraph of their response:<br />
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Thank you very much for your comments. Your position is one that we believe is shared by many, which is why we wrote the piece. Although we respect your and others’ opinions, we find it difficult to support the statement that rising rates are due largely to substandard assessment of ADHD—it is just too simplistic an explanation. The solution that you allude to is likely not tenable for a high-prevalence condition such as ADHD, because there just aren’t enough child psychiatrist providers to do it all. We are not advocating poor-quality diagnosis or inappropriate treatment; rather, the goal of the editorial was to understand the role of advocacy and education in rising rates, the importance of a public health approach to high-prevalence conditions, and to help child and adolescent psychiatrists come to terms with the fact that our traditional model of care, which is time intensive and highly personalized, is not likely to be able to address the public health burden of ADHD. We certainly do not want to inhibit the pediatric prescriber from taking on the challenge. They need our support to do it well.</blockquote>
So the assumption they make is that cases of ADHD reflect a biological disorder and that increasing awareness of the condition amongst the population, diagnosing it, and treating it with medications is good and proper.<br />
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Imagine, for moment, something like this happening with the obesity epidemic. The maps of <a href="https://www.google.com/search?site=&tbm=isch&q=child+obesity+map+U.S.&gs_l=img">child obesity in the U.S.</a> look suspiciously like those of the ADHD epidemic, with the highest rates in the deep South. Sure, there are <a href="http://www.win.niddk.nih.gov/publications/prescription.htm">drugs to treat obesity</a>, but would anyone talk with a straight face about a "public health" approach to obesity consisting of identifying the cases and then treating them with medications? Wouldn't a better (and true) public health approach be to ensure that children can get adequate exercise, good nutrition, and that people aren't incentivized to buy the cheap calories and processed "foods" that are making them obese?<br />
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Thus, as long as the prevailing view of psychiatric conditions is a narrow one, the data will be used for narrow purposes, such as academic leaders/CEOs arguing for more resources, or to justify the high rates of psychiatric medication prescribing. Here, I'm not even going to get into some other <a href="https://twitter.com/psycrit/status/484845134119313409">questions I had</a> about the athenahealth ad, including who its intended audience is and what it is trying to achieve. Most doctors recognize that EHRs do not help them care for patients. These systems mostly appeal to large clinics and hospital organizations, for reasons that I will let Dr. George Dawson's <a href="http://real-psychiatry.blogspot.com/2014/07/a-toxic-work-environment-for-physicians.html">recent blog post</a> explain.Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.comtag:blogger.com,1999:blog-8247140443323762748.post-21046206899868595942014-06-21T15:55:00.000-07:002015-04-29T09:01:20.646-07:00The Impact of False Diagnostic LabelsBack in April, an <a href="http://www.mdpi.com/2077-0383/3/2/334">extraordinary article</a> was published by Dr. Peter Parry, an Australian child psychiatrist, about his correspondence with an American adolescent who had been diagnosed with pediatric bipolar disorder (PBD) during the PBD craze in the early 2000's. I had linked to the article <a href="https://twitter.com/psycrit/status/453230579580821504">on Twitter</a>, but I haven't had a chance to write about it until now.<br />
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The power of this article comes from the fact that it includes a detailed first-person account from the patient "Adam." He comes across as an extraordinarily thoughtful young man, who had a tragic but far from uncommon encounter with psychiatry. Here's what Adam had to say about being diagnosed with PBD and treated:<br />
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I was 12 when first diagnosed. I had suffered depression and anxiety including severe OCD, which has since disappeared. It should also be mentioned I come from a screwed-up family and was physically abused by a sibling. Parents divorced young. My mother had a lot of issues, etc. So it goes without saying there was a lot the psychiatrist should have asked if he was ever so inclined. But unfortunately, he holds a faculty appointment at [edited—A PBD oriented child and adolescent psychiatry clinic].<br />
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Within about three months, I was on 8 different medications at one time. Very scientific treatment—all the best—several anticonvulsants, several antipsychotics, a couple of antidepressants and lithium too.<br />
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Things got so bad, that I ended up being referred to the neurology department, for different opinions about strange symptoms I began having on this cocktail. Which resulted in their giving me a working diagnosis of some kind of mitochondrial myopathy. "Bipolar plus mitochondrial disease" as it went. Which I have been told only recently could have been precipitated by the huge amounts of divalproex I was taking. The symptoms quickly disappeared when I coincidentally stopped the drug for unrelated reasons. Oh well, but it is a clear illustration of what one of the "best" academic medical centers in the world has to offer a struggling young boy.</blockquote>
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And here is Adam's perspective on how the diagnosis and treatment affected him:<br />
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But the worst part of this, which I have only been recently able to shake within the last year (2008/9), is the defectiveness I felt. Just kind of in some core way. Like I'm totally different. When I was younger, that feeling was a lot stronger and more prominent. Now I feel like a fool for even having given thought after eight years to the question of whether I might go to sleep one night and wake up manic. I decided with my (new) psychiatrist's support a year ago to stop my medicines. I’m not doing especially well now, but I have at least been able to shake the feelings the diagnosis itself carved into me. The same can’t be said for its physical and social effects though.</blockquote>
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It's not just children and teenagers who are vulnerable to being misdiagnosed with bipolar disorder; it can even happen to an NBA millionaire. A couple of weeks ago, I read one of the best articles that I've ever encountered on mental health in professional sports, titled "<a href="http://www.slate.com/articles/sports/sports_nut/2014/06/delonte_west_he_was_branded_as_crazy_and_became_the_subject_of_a_vicious.html">Why Isn't Delonte West in the NBA?</a>" As a casual basketball fan, I knew that West had been a part of the Cleveland Cavaliers during the LeBron James years. I've heard that he struggled with mental illness and had been diagnosed with bipolar disorder. I recalled that he had been arrested after being found driving around with multiple weapons, and there were even rumors that he had slept with LeBron's mother. But this article provides the inside story of what actually happened, and the facts were deeply unsettling.<br />
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Delonte West grew up without a stable home, with a single mother who worked multiple jobs just to keep afloat after his parents divorced.<br />
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West has an older brother, a younger sister, and a vast extended family that he refers to as "a village." He stayed with many of those relatives growing up. "I lived off of every exit," he says, rattling off 11 specific ones from memory. "I lived in so many apartments … with cousins, uncles, and aunts, just making it."</blockquote>
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In the NBA, he had several outbursts of anger, which led to him seeing a psychiatrist.<br />
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West was diagnosed as bipolar by a D.C.-area specialist. He says that when he saw the doctor, he’d been feeling down, having days when he was sad and tired and didn’t want to get out of bed. But he told the specialist that there were also times when he "might just go out and buy a car. Or go to the mall and spend 25 grand." West doesn't think the doctor took into consideration that such behavior might not be unusual for a professional athlete with a big paycheck. He now thinks that he was suffering a temporary bout of depression, not exhibiting symptoms of a chronic disorder.</blockquote>
Another part of the article provided additional context for West's inner struggles:<br />
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As a kid, moving from school to school, he often found himself the target of playground taunting. "I was real funny-looking," he says, with big ears, a mole on the back of his head that he had removed once he got to the NBA, and a birthmark below his lip that he's also had partially removed. His light skin and red hair stuck out, too. "I was made fun of a lot growing up, but I just knew the basketball court was the place where you couldn’t make fun of me, you had to respect me." He says he always had "more jokes for me than you had," but that he internalized the cruel things kids said to him. Last year, West told an interviewer that he believed his real problem was not bipolar disorder, but "self-loathing."</blockquote>
This was what actually happened in the weapons incident that contributed to derailing West's NBA career:<br />
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It was the offseason, and a few of West's cousins had come over to his house with their children. West's mother was looking after the kids while he slept and the other adults went out. At some point in the evening, West's mother woke him up. She said the kids had gotten into a closet in his small, in-home music studio, where he stored guns that he had bought, legally, in Cleveland. He needed to do something about those weapons, she told him.<br />
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With the driveway crowded by his cousins' cars, West got on his motorcycle so he could bring the guns to another residence. Earlier in the evening, he'd taken Seroquel, which is often prescribed for bipolar disorder. Seroquel makes you drowsy, and as he headed out on the highway, he found that he was dozing in and out. After he felt himself drifting off, West was pulled over for making an unsafe lane change, and he told the officer that he was carrying weapons. The day after the arrest, a police spokesman said that West was "very cooperative the entire time."</blockquote>
After his arrest, West played for the Cavaliers for another season, but the article makes the plausible argument that because West had been labelled with a mental illness, people were willing to believe whatever crazy things they heard about him, including the false rumor that he had slept with his teammate's mother. Undoubtedly, taking Seroquel contributed to his arrest. Without the "bipolar disorder" label, if instead the narrative had been that West had emotional issues due to childhood stresses, he may well still be in the NBA.<br />
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Earlier this week, Dr. David M. Allen had a blog post on misdiagnosis: "<a href="http://davidmallenmd.blogspot.com/2014/06/is-your-psychiatrist-committing.html">Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing?</a>" (The short answer is "yes.") However, according to Dr. Parry's article, when Adam looked into his legal options, he was told "his treatment would be deemed 'standard practice' where he lived," which is a big deterrent for the lawyers when it comes to medical malpractice lawsuits. What a sad irony: the crappier the standard diagnosis and treatment becomes, the more the practitioner is protected by the herd.<br />
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When I was in medical school at a very <a href="http://www.psycritic.com/2013/10/losing-white-coat-part-i-medical-school.html">biological psychiatry-oriented institution</a>, the psychiatry professors made sure to educate us on the past evils of blaming refrigerator mothers for schizophrenia. And yet, as Dr. Parry pointed out, we have gone from the "brainless psychiatry" of the psychoanalysts to today's symptom-focused "mindless psychiatry" that tends to ignore the patient's inner life and the developmental biopsychosocial context. Here is my favorite section of Dr. Parry's article:<br />
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In addition to being a method of inquiry, science is a social process and there is a vast research literature concerning the sociology of science. Scientific disciplines do not build on knowledge in a purely linear fashion, but at times undergo dramatic upheavals according to paradigm shifts. The dominant paradigm governs what is acceptable to study, research, publish and practice. Softer sciences like psychiatry can be more susceptible to extreme paradigm shifts. The history of psychiatry reflects this. </blockquote>
One of my biggest frustrations while reading Dr. Parry's words is that his wisdom is relegated to an opinion article published in a little known <a href="http://www.mdpi.com/journal/jcm">open-access journal</a>, while the leading <a href="http://jaacap.com/">child psychiatry journal</a>, which claims to be "advancing the science of pediatric mental health and <i>promoting the care of youth and their families</i>" [emphasis mine] would never permit such a sharp critique within its pages.</div>
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Psycritichttp://www.blogger.com/profile/05279225254350525266noreply@blogger.com