Saturday, March 27, 2010 - Jeremy Rifkin: More Empathy in the Global Economy?

It seems like today is a video day - here is another one.
Jeremy Rifkin, founder and President of the Foundation on Economic Trends, teases out the ways and means of creating a more empathetic, global society.

Jeremy Rifkin is president of the Foundation on Economic Trends and the author of seventeen bestselling books on the impact of scientific and technological changes on the economy, the workforce, society, and the environment. He holds a degree in economics from the Wharton School of the University of Pennsylvania, and a degree in international affairs from the Fletcher School of Law and Diplomacy at Tufts University.

Rifkin speaks frequently before government, business, and labor and civic forums, and has lectured at hundreds of the world's leading corporations and over 200 universities in some 30 countries over the past three decades. His most recent books include The Hydrogen Economy, The European Dream, The End of Work, The Age of Access, and The Biotech Century.

Mark Litt - Stress and Coping and Spiritual Dimensions of Coping

Interesting - more on resilience.
Mark Litt of the University of Connecticut examines momentary assessments in stress, coping and health followed by a look at the spiritual dimensions of Coping by Ken Pargament of Bowling Green State University. Series: The State of the Science in Stress and Coping [3/2010]

Dharma Quote - Rabbi Kushner and the Dalai Lama in Conversation

An Anthology of Writings
By and About the Dalai Lama
Foreword by Sen. Claiborne Pell
compiled and edited by Sidney Piburn

Dalai Lama Quote of the Week

This week's quote is from Rabbi Kushner and the Dalai Lama in conversation.

An unusual Buddhist-Jewish dialogue took place today, at a Buddhist monastery situated on an idyllic green hill rising above the shopping malls and discount outlets of New Jersey.

"I want to learn the Jewish 'secret technique' of survival," said the Dalai Lama, who initiated the meeting. The spiritual and temporal leader of six million Tibetans as well as many thousands of Westerners said he was intrigued by several possible parallels between Judaism and Tibetan Buddhism. These included a devotion to scholarship and, in particular, a belief in the sacredness and interdependence of all life.

A shofar (ram's horn) and a tallit (prayer shawl) were given to the beaming Buddhist leader, who tucked the horn into his belt and slung the shawl over his monk's robes.

The lively discussion lasted for three hours, and though it centered on serious issues of maintaining cultural identity in spite of a diaspora, and comparisons of religious, cosmological and theological issues, it was punctuated with laughter. On leaving the meeting, Rabbi Kushner spoke of the similarities between Tibetan Buddhism and the spiritual core of Judaism. "The core of Judaism is the irrepressible hunch that the unity of all beings is beyond all physical representation. This seems to be the essence of Buddhism," he said. "And the Buddhists' movement from that to love, compassion and non-violence is exactly what I always thought Judaism was--and still is."

--from The Dalai Lama, A Policy of Kindness: An Anthology of Writings By and About the Dalai Lama compiled and edited by Sidney Piburn, Foreword by Sen. Claiborne Pell, published by Snow Lion Publications

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Friday, March 26, 2010

Dr. Joseph Mercola - Alpha Lipoic Acid Can Smash Insulin Resistance and Autoimmune Disease

I am generally not a huge fan of Dr. Mercola - yet, while I sometimes disagree with him, I am also sometimes by his articles in a good way. As some of my long-time readers know, I am a huge fan of alpha lipoic acid (ALA) as a supplement. Most of the time, I recommend this nutrient for improving insulin function, and as a secondary benefit, it seems to be useful in treating diabetic (and other forms) neuropathy, and it may have benefits in delaying or preventing some neurological degeneration diseases (which are often caused by oxidative stress).

I generally recommend 600-1800 mg/day of ALA in the racemic form (what we generally get in supplements). If one is taking the more expensive, but more effective, R-Lipoic Acid, then I recommend 200-600 mg/day. The benefits of R-Lipoic Acid seem to be greater and more varied than the standard ALA:
The Benefits of R-Lipoic Acid (RLA)

• RLA significantly reduces inflammation, an underlying cause of the degenerative diseases of aging and is more potent by a factor of 10 over commercial ALA.

• RLA was found to reach higher plasma levels than S-lipoic acid (1.6:1) when given orally as the racemic mixture in a human study.

• RLA was more effective than the SLA in a battery of metal chelation tests. One hypothesis of the cause of diabetic complications involves overloading by transition metals which could explain the stereospecific effect of RLA.

• RLA is the only form of lipoic acid found in nature and, therefore, the only form recognized by the critical mitochondrial enzymes.

• RLA was more effective than SLA in enhancing insulin-stimulated glucose transport and metabolism in insulin-resistant rat skeletal muscle.

• RLA was more effective than racemic ALA and SLA in preventing cataracts in rats.

• RLA increases cellular and mitochondrial antioxidant activity and prevents mitochondrial decay. This effectively attenuates the reported increase in oxidative stress with aging.

• RLA improves memory, reverses cognitive dysfunction, and protects the brain from neurodegeneration associated with aging.

• RLA protects body fats against oxidative damage and reverses stress damage in the heart.

• RLA supplementation improves metabolic activity and lowers oxidative stress and damage evidentin aging.

• RLA significantly increase insulin sensitivity, enhances glucose transport, increases metabolic rate and reduces the gain in body fat from aging. RLA has insulin-mimetic effects in glucose uptake in insulin resistant cells and may have therapeutic implications in restoring glucose availability in tissues such as the skeletal muscle.

• RLA significantly increases or maintain levels of other antioxidants including Coenzyme Q10, vitamin C, vitamin E and glutathione.

• RLA prevents depletion of the glutathione pool within the cytoplasm and mitochondria. Pre-treatment of PC12 cells with RLA leads to the preservation of mitochondrial complex I activity lost due to glutathione depletion.

• RLA is much more effective than SLA at enhancing insulin-stimulated glucose transport and non-oxidative and oxidative glucose metabolism.

• RLA, through its positive effects on cellular energy metabolism, attenuates metabolic dysfunction associated with advanced glycation endproducts (AGEs). AGEs accumulate on long-lived proteins, including beta-amyloid plaques in Alzheimer's disease and contributes to neuronal dysfunction and cell death.

• RLA , a membrane permeable antioxidant, prevents the up-regulation of the AGE-induced gene expression responsible for regulating nitric oxide (NO) production. NO oxidizes and nitrates proteins which are markers of a chronic neuroinflammatory condition. This mechanism is relevant for Alzheimer's disease and for many chronic inflammatory conditions.
For relief of neuropathy pain, I generally suggest a combination of ALA and N-Acetyl-Cysteine. I am becoming more convinced that the R-LA form may actually be better for this as well. Because this is a potent anti-oxidant combination, I suspect that it may be more effective than either alone in helping support liver function in those with Hepatitis C.

In this new column at Huffington Post, Dr. Mercola outlines the many benefits of alpha lipoic acid. But as I have noted above, the R-Lipoic Acid form may be even better for most conditions.

This Antioxidant Can Smash Insulin Resistance and Autoimmune Disease

Dr. Joseph Mercola, Physician and author

Posted: March 26, 2010 08:38 AM

I first became aware of the alpha lipoic regimen by Dr. Burt Berkson in the late 90's. Early on in his career, while an internist, he was given several patients who were expected to die from hepatitis C. His job was more or less to simply baby sit them in the ICU and watch them die.

But Dr. Berkson was a rebel at heart and he simply couldn't do that. Instead he called an associate at the National Institutes of Health and found out how he could treat them. He learned that alpha lipoic acid had some impressive experimental support. Remarkably, although these patients were expected to die within a few weeks, they all completely recovered!

However not all went well for Dr. Berkson. As he made his superiors look foolish, they simply could not tolerate that so rather than embrace his findings, they actively suppressed the results and made his life miserable for showing them up.

This was a pivotal moment in Dr. Berskson's career and caused him to make choices that eventually led to where he is at now. Since then, Dr. Berkson has lectured all over the world on this topic, and published a study on the use of antioxidants for the treatment of hepatitis C.

His first book, The Alpha-Lipoic Acid Breakthrough was published in 1998.

As many of you already know, I am not fond of recommending many supplements, but I do believe that antioxidants make sense for many of us.

Why You Need Antioxidants

Your entire body, including your DNA, is under endless, daily assault from a variety of sources, from poor diets to pollution. Think of your cells, including your brain cells, each getting hit by free-radicals thousands of times a day. This violent process is called "oxidation," which damages your cells.

Enter antioxidants. They include vitamins and other nutrients that target free radicals.

Food, particularly fruits and vegetables, is a powerful source of these valiant protectors, and your body produces some itself. Their role is to limit the damage to your cells, which can slow down disease and signs of aging.

In the case of alpha lipoic acid, your body does produce it in minute quantities, but most of it comes from your diet. Some of the best natural sources include grass-fed red meat and organ meats.

The Benefits of Alpha Lipoic Acid

Alpha lipoic acid (ALA) has many functions, but it's one of the most effective free radical scavengers, and the only one known to easily get into your brain.

It also has the ability to regenerate other antioxidants such as vitamins C, E, and glutathione. So, when your body has used up these antioxidants, if there's ALA around, it helps regenerate them.

You may not know this, but glutathione is another very important antioxidant. You can get it from supplements, but the only form that works effectively is the reduced form, which is difficult to absorb when taken orally. It is much more cost effective to supplement with precursors, or items like alpha lipoic acid that regenerates glutathione.

Alpha lipoic acid also recycles coenzyme Q10 and NAD (nicotinamide adenine dinucleotide).

But, if that wasn't enough, this powerful antioxidant is also:

  • A great modifier of gene expression to reduce inflammation
  • A very potent heavy metal chelator
  • An enhancer of insulin sensitivity

The benefits of ALA can appear near miraculous. For example, according to Dr. Berkson, Russia has successfully used ALA intravenously to reverse ischemia reperfusion injuries by injecting it right after a heart attack or a stroke.

And people with diabetes or metabolic syndrome tend to do much better when taking lipoic acid, as it enhances insulin sensitivity.

There's even been quite a bit of research showing it can restore T cell function. T cells are a type of white blood cells that are of key importance to your immune system, and are at the core of adaptive immunity, the system that tailors your body's immune response to specific pathogens.

What Health Conditions Can be Treated With Alpha Lipoic Acid?

Clinically, alpha lipoic acid seems to be a useful supplement in treating hepatitis C. It can also be used for painful nerve conditions in diabetes, and may help slow down the aging process itself through its reduction in free radicals.

Dr. Berkson uses ALA along with low dose naltrexone (LDN) for the reversal of a number of more serious health conditions such as:

  • Lupus
  • Rheumatoid arthritis
  • Dermatomyositis (an inflammatory muscle disease)
  • Autoimmune diseases

Most of his patients normalize in about one month on this combination of ALA and LDN.

What is Low Dose Naltrexone?

Naltrexone (generic name) is a pharmacologically active opioid antagonist, conventionally used to treat drug and alcohol addiction -- normally at doses of 50mg to 300mg. As such, it's been an FDA approved drug for over two decades.

However, researchers have found that at very low dosages (3 to 4.5 mg), naltrexone has immunomodulating properties that may be able to successfully treat cancer malignancies and a wide range of autoimmune diseases like rheumatoid arthritis, multiple sclerosis (MS), Parkinson's, fibromyalgia, and Crohn's disease, just to name a few.

As explained on the informative website, when you take LDN at bedtime -- which blocks your opioid receptors for a few hours in the middle of the night -- it is believed to up-regulate vital elements of your immune system by increasing your body's production of metenkephalin and endorphins (your natural opioids), hence improving immune function.

Can Alpha Lipoic Acid Help Your Workout?
Alpha lipoic acid can be a potent aid when you exercise vigorously.

In my interview, Dr. Berkson gives an anecdotal story about a friend - an international weight lifting champion -- who regularly uses ALA prior to meets.

Unfortunately, there are no set guidelines on dosage and timing. It can be highly individual, and is something that requires a little bit of trial and error in order to get it just right.

But if you suffer from any of the conditions listed above or diabetes it would certainly seem like a useful supplement to consider.

Dr. Joseph Mercola is the founder and director of Become a fan of Dr. Mercola on Facebook, on Twitter and check out Dr. Mercola's report on sun exposure!

Are You Still Suffering from Memories of an Unpleasant Experience? (PTSD from Mild Trauma)

Interesting article from Robert London, MD at Psychology Today (his blog is Two-Minute Shrink). Dr. London points to the prevalence of PTSD in people who have not suffered severe trauma. This is important.

PTSD-like symptoms can stem from a milder traumatic event.

By now, most people are familiar with post traumatic stress syndrome, or PTSD. PTSD is defined clearly in the DSM-IV, the psychiatric manual that aims to define psychiatric disorders, as the development of "characteristic symptoms following exposure to an extreme traumatic stressor" (italics mine). Examples can be found in patients who have experienced military combat, violent personal assault, kidnapping, torture, incarceration, and/or man-made or natural disasters. The list of extreme traumatic stressors can be quite long. But what many people---even psychiatrists and psychotherapists---don't know is that you can suffer PTSD-like symptoms from a less-intense unpleasant experience. The trigger for PTSD does not have to be extreme.

I have seen a fair number of cases where people had symptoms that masqueraded as anxiety and depressive disorders, but when we explored the historical events in a person's life, these symptoms could be traced to milder traumatic or unpleasant experiences than are not normally associated with PTSD. And yet, their symptoms were exactly those of PTSD. In my experience, a milder traumatic event does not necessarily lead to a milder set of symptoms.

If you think you might be suffering from a past distressing experience, see if any of the following symptoms rings true for you: having recurrent nightmares, flashbacks, upsetting thoughts, or memories; feeling distressed when you're reminded of it; having physical symptoms, such as a racing heart or sweating when it comes to mind; irritability, jumpiness, angry outbursts, or difficulty sleeping; or feeling distant, negative, or uninterested in activities you used to enjoy. I've found that these are some of the classic PTSD symptoms you can get from an unpleasant experience, even if that experience would not be defined as "intensely traumatic."

Let me offer two examples illustrating problems of PTSD---two people who experienced life events that were emotionally disturbing but not the kind of extreme trauma suggested by the DSM-IV. Each had suffered a major loss and disruption of lifestyle. The first was a woman affected profoundly by a job loss that resulted in a major reduction in income. The second was a man who suffered after-effects from a divorce. Neither of these two events is usually considered a potential source of PTSD. Besides anxiety and depression, though, both people experienced flashbacks and nightmares, which forced them to relive the spectrum of traumatic experiences long after the events, as well as other symptoms usually present in PTSD.

In the clinical setting, one of the most modern successful treatments for PTSD is using virtual reality in which, using a head-mounted device, the person watches an interactive program created to replay traumatic events in an ascending hierarchy-from least to most disturbing-to expose and desensitize the person from the problem.

However, if you're still suffering the aftereffects from a distressing or unpleasant experience, you don't need fancy equipment to improve your symptoms. There are very clear treatment strategies involving relaxation, hypnosis, guided imagery, behavior modification. and cognitive behavior therapy that are useful in resolving the symptoms arising from unpleasant recurrent experiences, and there are therapists who specialize in such treatments.

For you, the first step is to recognize your own PTSD-like symptoms, and identify the unpleasant experience from whence they originated. I've found that once people understand the connection between their symptoms, the original event, and present-day situations that re-trigger those symptoms, we can very quickly and efficiently minimize or eliminate the condition. Best of all, many people with these symptoms can also begin to use self-care techniques I've developed-simple, practical strategies to counter PTSD-like symptoms stemming from unpleasant experiences in their past.

Thomas R. Insel, MD - Psychiatrists' Relationships With Pharmaceutical Companies

In this recent JAMA article, Dr. Insel takes a look at the issue of psychiatrists and the pharmaceutical companies essentially being in bed together (and the FDA has really failed to supervise this reality, thus the cartoon) - and the resulting loss of respect from the public. Seroquel is one of many examples where Big Pharma pushes a drug they know is harmful, even getting it approved for kids. The MDs are complicit in this.

[Furious Seasons is the best blog on the Web for keeping up with Big Pharma's collusion with psychiatry to promote harmful drugs.]

I agree with Dr. Insel that there is a problem. But it's much bigger than whether or not psychiatrists are being paid by the pharmaceutical companies to study and promote their products. The REAL problem in my mind is that psychiatry is moving toward a complete medical/disease model of mental illness, which totally negates the large and real influence of culture, experience, and other factors that cannot be treated with a drug.

I also realize that this brings into question how we conceive of the mind. Is mind a by-product of electro-neural function in the brain, or is it an emergent property of body-brain, experience, culture, environment, and temporal factors?

How we answer this question will finally shape, at least in part, how we treat mental illness. For those who work in the trenches as counselors, the biopsychosocial model has already move into the mainstream. I wish this were true in psychiatry as well.
Psychiatrists' Relationships With Pharmaceutical Companies

Part of the Problem or Part of the Solution?

Thomas R. Insel, MD

JAMA. 2010;303(12):1192-1193.

Psychiatrists have rarely enjoyed a surplus of public trust. During the past 3 years, public trust in psychiatry has been further undermined with accusations that several leading academic psychiatrists failed to disclose financial conflicts of interest. Sen Charles Grassley (R, Iowa), ranking member of the Finance Committee, has thus far accused 7 psychiatrists of failing to disclose income from pharmaceutical companies. As public trust in the pharmaceutical industry has plummeted, the close connection between leading psychiatrists and the pharmaceutical industry, once a sign of progress for the profession, is now cited as evidence of corrupt influence.1

The investigations spawned by these allegations already have had major effects, including restrictions on outside income, removal of investigators from National Institutes of Health (NIH) grants, and the resignation of the chair of a prestigious psychiatry department. Conflict of interest policies at many US universities have been enhanced to provide more rigorous requirements for disclosure. The National Institute of Mental Health (NIMH), which funded some of the accused individuals, has initiated an internal review system to detect potential problems with the management of financial conflicts of interest and has implemented changes to minimize possible bias in its funded studies. More broadly, the NIH is substantively revising its regulations on financial conflict of interest, which were originally adopted in 1995. The proposed new regulations are slated to be available for public comment in early spring 2010. But one of the largest effects of this scandal has been to raise a difficult and still unanswered question about the integrity of psychiatrists. Is the financial conflict of interest problem worse for psychiatrists or are psychiatrists just an easy target? A review of evidence is in order.

First, are psychiatrists in clinical practice receiving more industry money than other specialists? Although several states now require public disclosure of all pharmaceutical industry payments to physicians, only in Vermont are the results currently available in a form that permits comparisons across specialties. In Vermont, psychiatrists received more money from pharmaceutical companies than all other medical specialists.2 Complementing state disclosures, several pharmaceutical companies are volunteering to post payments to physicians. For instance, Eli Lilly lists 25 faculty (speakers, consultants, etc) receiving more than $50 000 in the first 3 quarters of 2009.3 Of these top 25 faculty, 17 were psychiatrists. Lilly's major investment in psychotropic medications may skew this sample relative to other pharmaceutical companies. For example, comparable data from Merck, which markets drugs for diabetes and cancer, show overrepresentation of payments to endocrinologists and oncologists, with no payments to psychiatrists.4 Not surprisingly, companies are paying the specialists most likely to promote or prescribe their products.

These data from state and company registries largely reflect payments to practicing physicians. As a second question, what about academic thought leaders and researchers who may influence practice through publications and lectures? In a recent study of all medical school department chairs, 60% reported receiving personal income from industry, most often as a consultant or member of a scientific advisory board. In the clinical departments, 80% of faculty reported a departmental relationship with industry, most often for support of continuing medical education.5 There is no published evidence that departments of psychiatry or chairs of these departments receive more or less industry funding than their colleagues in other specialties.

Third, are academic psychiatrists disclosing more financial interests in publications? Relative to other professional journals, the major psychiatric journals appear to have comparable standards for disclosing financial interests.6 Based on a review of 397 published reports of clinical trials in 4 psychiatric journals, Perlis et al7 found that 60% had industry funding and 47% had at least 1 author reporting a financial relationship. The prevalence of industry funding in general medical journals has been reported to range from 40% to 66%, with author industry support reported between 34% and 43%, slightly lower than reported in psychiatry journals. Importantly, Perlis et al7 noted that articles with reported industry support were nearly 5 times more likely to report positive results.

Fourth, do financial payments to academic leaders influence clinical practice guidelines? Cosgrove et al,8 reviewing the 20 work group members who authored the American Psychiatric Association guidelines for the treatment of schizophrenia, bipolar disorder, and major depressive disorder, reported that 90% had financial ties to industry (72% as consultants). None were disclosed. A review of 192 authors of 44 clinical practice guidelines for multiple common adult diseases found 87% with some form of industry involvement, and in only 2 cases were disclosures included.9

Because industry support to academic departments, individual scientists, and academic leaders in these various surveys appears to be widespread, it is difficult to conclude that academic psychiatrists receive more or disclose less than their colleagues in other areas of medicine. But what is clear is that current pharmaceutical industry investment in academic psychiatry is prevalent.

As a final question, setting aside the relative magnitude of disclosed or undisclosed financial relationships, is psychiatric practice biased by industry? Certainly psychiatric treatments have become largely pharmacological. Antidepressants and antipsychotics represent 2 of the top 5 classes of medications sold in the United States, with combined sales in excess of $25 billion in 2008.10 Although several large-scale studies have demonstrated equivalent effectiveness of older, off-patent (generic) antipsychotics and antidepressants, more expensive, patented compounds continue to hold the majority of the market share. But aside from the evident success of marketing of specific medications, what is perhaps most worrisome is the relative neglect of effective nonpharmacological interventions such as cognitive-behavioral therapy for mood and anxiety disorders or powerful psychosocial interventions for schizophrenia. Numerous studies have demonstrated the effectiveness of such interventions, and their use has been recommended in the practice guidelines mentioned above, yet they are woefully underused and frequently not reimbursed.

The bias in prescribing practices and the conspicuous tilt toward pharmacological interventions are not unique to psychiatry. But this in no way diminishes the severity of the problem in psychiatry. The focus on financial conflicts of interest in psychiatry is an opportunity to take the lead in setting new standards for interactions between all medical disciplines and industry. Academic leaders, professional societies, and patient advocacy groups could turn the tables of public trust by developing a culture of transparency for psychiatry's collaborations with industry, including the clear separation of academic-clinical missions from industry marketing.

There is no denying the need for academic and industry scientists to collaborate. Indeed, the public health imperative for scientific collaboration is formidable. Families struggling with schizophrenia, bipolar disorder, and other psychiatric illnesses are seeking a new generation of treatments. Current medications are not good enough. Public trust will ultimately depend on finding better treatments, but this goal can only be reached if psychiatry finds a way for academic investigators to interact with industry without real or perceived financial conflicts of interest. New NIH regulations will increase clarity and rigorous NIMH oversight can ensure better management, but academic leaders and their professional societies will need to transform what has become a culture of influence. The greatest threat to an era of improved public health stemming from the productive and ethically sound relationship among academia, industry, and practice is a defiant embrace of the status quo, in which psychiatrists are seen as a leading source of the problem rather than as leaders in finding the solution for financial conflicts of interest.


Corresponding Author: Thomas R. Insel, MD, National Institute of Mental Health, 6001 Executive Blvd, Room 8235, Bethesda, MD 20892 (

Financial Disclosures: None reported.

Author Affiliation: National Institute of Mental Health, Bethesda, Maryland.


1. Freedman R, Lewis DA, Michels R; et al. Conflict of interest—an issue for every psychiatrist. Am J Psychiatry. 2009;166(3):274. FREE FULL TEXT
2. Vermont Office of the Attorney General. Pharmaceutical Marketing Disclosures July 1, 2007-June 30, 2008: Report of Vermont Attorney General William H. Sorrell. April 2009. Accessed February 19, 2010.
3. Sandburg B. Lilly outside "faculty" is headed by 22 physicians receiving $50 000 or more. BioPharma Today. October 29, 2009. Accessed February 4, 2010.
4. Merck. Disclosure of Payments to US Speakers for Promotional (Non-CME) Medical Education Activities Conducted in 3Q 2009. Accessed February 4, 2010.
5. Campbell EG, Weissman JS, Ehringhaus S; et al. Institutional academic industry relationships. JAMA. 2007;298(15):1779-1786. FREE FULL TEXT
6. Blum JA, Freeman K, Dart RC, Cooper RJ. Requirements and definitions in conflict of interest policies of medical journals. JAMA. 2009;302(20):2230-2234. FREE FULL TEXT
7. Perlis RH, Perlis CS, Wu Y, Hwang C, Joseph M, Nierenberg AA. Industry sponsorship and financial conflict of interest in the reporting of clinical trials in psychiatry. Am J Psychiatry. 2005;162(10):1957-1960. FREE FULL TEXT
8. Cosgrove L, Bursztajn HJ, Krimsky S, Anaya M, Walker J. Conflicts of interest and disclosure in the American Psychiatric Association's Clinical Practice Guidelines. Psychother Psychosom. 2009;78(4):228-232. FULL TEXT | WEB OF SCIENCE | PUBMED
9. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA. 2002;287(5):612-617. FREE FULL TEXT
10. IMS Health. Top line industry data: 2008 US sales and prescription information. Accessed February 4, 2010.

Phil Elias - Crazy Controversy (a look at the DSM-5)

MercatorNet takes a look at the controversies surrounding the forthcoming DSM-5, the first major revision of the psychiatric "handbook" in more than a decade. This is another in a long series of looks at the controversies about the changes to the DSM.

Crazy controversy

We need psychiatrists to tell us whether we are bad, sad, or mad. But how do they know? They look it up in the DSM. And who writes the DSM?

A psychiatrist told me once that some people are born mad (eg, his wife’s relatives), others achieve madness, and others have madness thrust upon them by the Diagnostic and Statistical Manual (DSM).

Earlier this year American Psychiatric Association released its draft version of the fifth edition of DSM, DSM-5. The controversy raging around this publication, previously fuelled by its alleged secrecy, radicalness, and lack of organisation, was now fanned by the proposal of significant changes to various diagnoses. Critics, led by editors of previous DSMs, have expressed their concern that new disorders and the loosening of criteria in old ones will greatly increase the number of false positive diagnoses and generate a host of negative consequences.

The DSM was first published in 1952 and evolved from US military classifications of mental disturbances. It listed 106 diagnoses. The first two editions were slim (less than 150 pages) and heavily influenced by psychoanalytical concepts of mental illness. DSM-III, published in 1980, represented a paradigm shift. Assumptions about the underlying causes of disorders were abandoned in favour of a classification system based on clusters of symptoms. Mental illness became categorical (that is, present or not present based on finding a certain number of symptoms) rather than dimensional (that is, more or less present in an individual based on psychological experiences and one’s adaptation to them). Some argue that while early editions of DSM were merely a guide to psychiatric diagnoses, DSM-III and subsequent revisions took on a much more authoritative guise. It became the psychiatrist’s Bible. It certainly weighed as much as a Bible, being 494 pages long with 265 diagnoses. DSM-IV continued in the same vein and added a great deal of empirical data.

The changes in DSM-5

The task force in charge of DSM-5, apart from dropping the Roman numeral in the acronym, has proposed a number of significant changes for the manual. At the diagnostic level, these include the addition of subclinical or pre-morbid conditions (such as “psychosis risk syndrome”) as disorders, a reclassification of the personality disorders, and the addition of an assortment of new diagnoses such as gambling addiction. At a more global level, the editors have proposed adding severity assessments to many diagnoses, purportedly making the manual more dimensional in its approach.

A simmering conflict over the publication has erupted over the past months. It would be impossible to detail here the interests of the parties involved or the specifics of the points of disagreement. As mentioned, editors of earlier editions are particularly concerned that new diagnoses and the loosening of existing criteria will create many more “false positive” diagnoses, that is, patients being labelled with a mental disorder where none is present. The risks for individuals include stigma, a reduced sense of responsibility, unnecessary exposure to potentially dangerous medications, and difficulties getting life insurance. Society may become increasingly medicalised and resources may be misallocated. At a philosophical level, there are implications for human freedom.

Defenders of DSM-5 deny this, saying that the changes are not that radical. This may be the case. But the problem of false positives in psychiatry remains. It predates the current controversy and could reflect not a problem with DSM-5 but with DSM and psychiatry itself.

Psychiatry’s identity crisis

Most non-psychiatric medical practitioners (including myself) recognise the unique position of psychiatry in the medical profession. Psychiatrists have an incredibly large and complex patient population. Little is known about the cause of most of the disorders they treat. They have not a single diagnostic test at their disposal. Their most comprehensive and definitive manual continues to expand its base and extend its reach and is constantly undergoing substantial revisions. A member of one of the DSM-V Work Groups recently resigned over this point, stating “I am not aware of any other branch of medicine that does anything like this.”

The DSM debacle resurrects the question as to whether psychiatry should be considered solely as a “branch of medicine”. Psychiatrists seem to want this. Much of the definitiveness of DSM III and IV and their purported reliance on clinical trials, along with their claim to be “atheoretical”, reflect a profession which is desperate to identify with and emulate the success of other fields of medicine. But psychiatry loses a lot from this approach. Being definitive, or categorical, may be useful for the purposes of statistics and clinical trials, but it belies the observable fact that psychiatric symptoms are complex beasts of continuous, rather than discreet, nature. Clinical trials are essential but they cannot be the only source of knowledge about mental illness. I was told once that an actually practicing psychiatrist also needs a good deal of “Verstehen” (I had to look up the meaning of the German word). Such knowledge is acquired from experience and from exposure to literature, history and philosophy.

That psychiatry is atheoretical is hardly a boast. It is akin to being proud of the fact that one’s car has no engine. It may be green but it doesn’t take you very far. Psychiatry needs some sort of account of fundamental causes beyond what biology reveals and I don’t think this will change. Without a theoretical framework or a delineation of normal human psychology there is no limit what could potentially be considered pathological. Clinical studies will find new symptoms, new categories, and new permutations of the two. More diagnoses will be made, and more pharmaceuticals will be sold.

Psychiatry is not like the rest of medicine. Its aspiration to become so has, rather than shedding light on mental disorders and simplifying their diagnosis, greatly complicated the matter. It has contributed an epidemic of false positive psychiatric diagnoses. Whether DSM-5 will have anything significant to say in this regard remains to be seen.

Phil Elias is a Sydney doctor.

This article is published by Phil Elias, and under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation. Commercial media must contact us for permission and fees. Some articles on this site are published under different terms.

Thursday, March 25, 2010

Review - Stuff: Compulsive Hoarding and the Meaning of Things by Randy Frost & Gail Steketee

Stuff: Compulsive Hoarding and the Meaning of Things
Randy Frost & Gail Steketee
  • Hardcover: 304 pages
  • Publisher: Houghton Mifflin Harcourt (April 20, 2010)
  • ISBN-10: 015101423X
This book wasn't due out until late next month, yet here it is, on sale at Amazon at more than $9 off the cover price.

When this book became available for review (FTC disclosure: I received a free review copy from the publisher), I jumped at the chance to read it. My girlfriend, Jami, was fortunate to study with Dr. Frost at Smith as an undergraduate, and she was in one of the first classes to be exposed to his ground-breaking research into hoarding behavior. At the time, no one else had done any serious studies of this most intriguing variation on obsessive-compulsive disorder (OCD).

A few years later, Frost teamed with Dr. Gail Steketee at Boston University, an expert in OCD, to continue his research into hoarding. She and Frost, along with David F.Tolin, PhD of The Institute of Living on the most recent one, have published the following books prior to Stuff:

Tolin, D.F., Frost, R.O., and Steketee, G. (2007). Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding. Oxford University Press.

Stektee, G. and Frost, R.O., and Steketee, G.S. (2006). Compulsive Hoarding and Acquiring: Therapist Guide. Oxford University Press.

Steketee, G., and Frost, R.O. (2006). Compulsive Hoarding and Acquiring: Workbook. Oxford University Press.
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In the last couple of years, A&E has been running a series called Hoarders (you can watch full episodes at the site), bringing this rather obscure disorder more fully into our cultural consciousness. While I have enjoyed the show, it pales in comparison to the work of Frost & Steketee in its inquiry into hoarding. So if you enjoy and are fascinated by the show, then Stuff is exactly what you should be reading - it's written for the lay reader, not the psychological expert (although I am sure clinicians would benefit from this book as well).

When I was growing up, my mother was friends with a woman who hoarded. She had stacks and stacks of old newspapers, magazines, mail, and boxes filled with all forms or junk you can imagine. She also hoarded cats - having as many as 15 or 20 at a time - and her house wreaked of cat shit, and there were flies everywhere. I hated when we went over there (my mom used to check up on her to make sure she was ok).

As a kid, she was just the scary woman with the messy house. Now I know she was a hoarder. We thought she was a rather uncommon person - yet some people estimate that there are 3 million hoarders in the United States (1% of the population). Frost previously estimated as many as 2% to 3% of the population has OCD, and up to a third of those exhibit hoarding behavior (Cohen, 2004), but in this new book, he suggests that between 2-5% of the population exhibits hoarding behavior, 6-15 million people (p. 9). Despite these numbers, as of now (going into the DSM-5), there is not yet a distinct DSM diagnosis for hoarding, but there most likely will be in the coming years, or even in the fifth edition (the committee hasn't decided yet):
Hoarding disorder is currently being considered for inclusion in DSM-5, but task force members haven't yet determined whether it will be in the main manual or in the appendix. According to the proposed inclusion, symptoms of hoarding disorder would include: struggling to part with personal possessions; accumulating objects to the point that they clutter living space, preventing normal use; and suffering social, work or other distress as a result of hoarding behaviors.
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Frost & Steketee have been doing some interviews about his book, and in this excerpt from iCareVillage they define compulsive hoarding (NOTE: I'd prefer to quote the book, but my review copy is an Adobe Digital Editions eBook, so I can't cut and paste passages to share with you - but in these quotes from interviews, you can get a sense of the book's ideas):
Compulsive hoarding is the acquisition of and the failure to discard a large number of possessions. Many of us engage in this type of behavior to some extent. We all collect things, we all have a lot more possessions than we probably need. But there are two important distinctions that point to a disorder rather than the more common behavior of collecting.

First, the accumulation is so vast that it clutters living spaces and makes them unusable. For instance, you can’t sit on the couch because it’s full of stuff, as is the kitchen sink, the kitchen table, the bathtub, and so on.

The other component is the level of distress and impairment the hoarding causes. While the person usually enjoys the act of collecting, the distress occurs when they worry about someone seeing the home, or become anxious about having to get rid of any possessions.

The hoarding causes significant impairment. It affects their ability to handle financial affairs, because when your home is filled with disorganized stuff, it’s easy to lose bills and important papers. The home is often unsafe because exits are blocked. There are fire hazards.

Appliances often stay broken. The person with a hoarding problem is afraid to have anyone into the house for repairs because the home’s condition may be reported to authorities. We’ve seen elderly people who have no working refrigerator, no working stove, sometimes no working hot water – sometimes no water at all, which means no working bathroom.
And in a follow-up question, they discuss the possible etiology of hoarding:
We think that people who hoard process information in several unusual ways. A person with a hoarding problem pays attention to the unique detail in objects, such as the shape, the color, the texture, and so forth. For example, take a bottle cap. They might focus on these details and give it value rather than focusing on the fact that it’s a bottle cap without a bottle and therefore has no useful function.

Another feature of information processing that differs in the person that hoards has to do with the amount of information they pay attention to with respect to an object. So they will look at an object and focus on all its unusual details and those details will have meaning. When that person tries to make a decision about that object, they’re faced with many more details to consider than most of us are. Therefore, making any kind of decision requires taking a large amount of information and filtering it down and using it to come to a conclusion – and this is very difficult for them. It affects everything they do, from ordering off a menu to choosing what to wear in the morning. These are decisions they sometimes struggle with for long periods of time.

The other characteristic of people who hoard has to do with the way in which they organize their lives. Most of us organize our lives categorically. We get an electricity bill, we put it the category called bills, and when we need to find it we can go to that location. But people who hoard seem for the most part to organize visually and spatially instead. So if you ask them where their last electricity bill is, they’re likely to tell you that it is halfway down in the middle of the pile in this room, because that’s where they saw it last. Their organization occurs by remembering where objects are in space.

Now, a lot of us organize some things this way. My desk is organized like this – I have piles of things and I remember what’s there because I last saw it there. But if I were to do that for all my possessions, that system would break down quickly.
Here is another explication of the behavior, from an interview posted at Amazon - these questions and responses are very illuminating:

Q: What factors contribute to the development of hoarding?

A: People who hoard often have deficits in the way they process information. For example, they are often highly distractible and show symptoms of attention deficit hyperactivity disorder. These symptoms make is difficult for them to concentrate on a task without being diverted by other things.

Most of us live our lives categorically. We put our possessions into categories and use those organizing systems to store and retrieve them easily. But categorization is difficult for people who hoard. Their lives seem to be organized visually and spatially. The electricity bill might go on the five-foot-high pile of papers in the living room, to keep it in sight as a reminder to pay the bill. Hoarders try to keep life organized by remembering where that bill is located. When they need to find it, they search their memory for the place it was last seen. Instead of relying on a system of categories, where one only has to remember where the entire group of objects is located, each object seems to have its own category. This makes finding things very difficult once a critical mass of possessions has been accumulated.

Q: Do all people who hoard save things for the same reason?

A: No, but there are some general themes. The most frequent motive for hoarding is to avoid wasting things that might have value. Often people who hoard believe that an object may still be usable or of interest or value to someone. Considering whether to discard it leads them to feel guilty about wasting it. "If I save it," reasons the hoarder, "I might not ever need it, but at least I am prepared in case I do."

The second most frequent motive for saving is a fear of losing important information. Many hoarders describe themselves as information junkies who save newspapers, magazines, brochures, and other information-laden papers. They keep stacks of newspapers and magazines so that when they have time, they will be able to read and digest all the useful information they imagine to be there. Each newspaper contains a wealth of opportunities, and discarding it means losing those opportunities. For such people, having the information near at hand seems crucial, whereas knowing that the information also exists on the Internet or in a library does little to help them get rid of their out-of-date papers. Hoarders are often intelligent and curious people for whom the physical presence of information is almost an addiction.

A third motive for saving is that the object has emotional meaning. This takes many forms, including the sentimental association of things with important persons, places, or events, something most people experience as well, just not to the same degree as hoarders. Another frequent form of emotional attachment concerns the incorporation of the item as part of the hoarder's identity--getting rid of it feels like losing part of one's self.

Finally, some people hoard because they appreciate the aesthetic appeal of objects, especially their shape, color, and texture. Many people who hoard describe themselves as artists or craftspeople who save things to further their art. In fact, many are very creative with their hands. Unfortunately, however, having too many supplies gets in the way of living, and the art projects never get done.

Q: Why can't people who hoard control their urges to acquire and save things?

A: Understanding this requires knowing what happens at the moment the person decides to acquire or save something. At the time of acquisition, people who hoard often experience a sort of high or euphoric sensation during which their thoughts center on how wonderful it would be to own the object in front of them. These thoughts are so pleasant that they dominate thinking, crowding out information that might curb the urge to acquire. For instance, hoarders may forget that they don't have the money or the room for the item, or that they already have three or four of the same item.

When faced with the prospect of discarding, hoarders have different thoughts from other people. All their thoughts center on what they will lose (for example, opportunity, information, identity) or how bad they will feel (distress, guilt), while none of the thoughts focus on the benefits of discarding. Saving the item, or putting off the decision, allows them to escape this unpleasant experience. In this way people become conditioned to hoard.
Much of the book is filled with individual stories of people who hoard. The most painful one, for me, was a woman, Bernadette, who had been raped at knife-point and proceeded to turn her apartment into a safe bunker of protection (Chapter 4). This points to one of the seeming causes of hoarding behavior - trauma. However, they found that trauma is more associated with excessive clutter rather than with the inability to discard or excessive acquisition (p. 88).

The most extreme example of hoarding is found in the introduction, where they introduce us to the Collyer brothers, Langley & Homer, who lived in New York City in the first half of the last century. Following their deaths in 1947, it took several hours to find a way into the house, a three-story brownstone. There were only very narrow passages through the house, some of them dead ends, others booby-trapped to keep people out. After Homer was found dead in the house, apparently having died of a heart attack brought on by starvation (he was blind and paralyzed by rheumatoid arthritis, depending on Langley for his survival), a full scale search began for Langely.

As they entered the house through a sky-light in the roof (inspectors concluded the house would collapse if they did not begin at the top and work down), the array of stuff in the house was mind-boggling: rusted bicycle, a complete car, and early x-ray machine, a two-headed fetus, a sawhorse, rusted bed springs, and then there was the vermin - more than 30 feral cats, in addition to rats and roaches. After three weeks, they discovered Langley only ten feet from where Homer had died, having inadvertently triggered one of his own traps and was killed.

By the time they were finished, 14 grand pianos, a Model T Ford, and a full 170 tons of junk was removed from their home.

While the story of the Collyer brothers is so incredible as to be entertaining, the other people discussed in the book inspire compassion and, yes, curiosity.

This attachment to things is the most extreme variation of something we all experience - in fact, the Buddha, more than 2,500 years ago, identified attachment as the source of suffering. We all become attached to ideas, beliefs, people, objects, outcomes, and so many other things. But in hoarders, that attachment goes haywire and becomes extreme. Stuff: Compulsive Hoarding and the Meaning of Things helps us understand a little better how this happens, and in seeing it so amplified in others, we also see our own attachments a little more clearly.

Cohen, J. (2004) The dangers of hoarding. USA Today, 19th February, 2004