Sunday, October 28, 2012

It is not possible to diagnose anosognosia in schizophrenic patients on brain scan

As I mentioned in my previous post there has been a clash between Sandra Steingard and E Fuller Torrey about anosognosia in schizophrenia. Where they are both agreed is that it is not possible to use a brain scan to diagnose this condition or even schizophrenia itself. However, it may be difficult to realise this from the brain scan image above taken from the Treatment Advocacy Center's  backgrounder webpage on pictures of anosognosia, which implies that anosognosia is due to decreased blood flow in the precuneus region of the brain. Sandra Steingard is right to object to this misleading brain overclaim, which is very common in the literature (see eg. previous post).

Despite Fuller Torrey's accusation, I am aware of the evidence that he cites for brain volume reduction in schizophrenia. However, I do object to his interpretation of this data as evidence of schizophrenia being a brain disease as such and his apparent unwillingness to debate his speculation. Any differences in brain volume are modest and there is an overlap with the normal population. The result is also non-specific as similar findings are found in other psychiatric conditions. Confounding variables such as nutrition and hydration also affect brain volumes. An association does not necessarily imply a causal link, as Fuller Torrey knows, and he should be more cautious in interpreting the data. 

Saturday, October 27, 2012

E Fuller Torrey attacks "The new antipsychiatry"

E Fuller Torrey has upset Robert Whitaker (see Dear Dr Torrey: Please stop the lies) because of his response to a post by Sandra Steingard on the Mad in America blog (to which she has also replied). Fuller Torrey says that the Mad in America blog has become "one of the new antipsychiatry centers". I've said in a previous post that I get irked sometimes if I'm seen as an anti-psychiatrist.

I mentioned Fuller Torrey in my Critical psychiatry book (see relevant passage). In 1974 he wrote a book  called The death of psychiatry, which agreed with Thomas Szsaz, who unfortunately recently died (see previous post and Guardian obituary), by opposing involuntary psychiatric interventions and the insanity defense. Fuller Torrey subsequently changed his mind and now advocates for forced treatment through being founder of the Treatment Advocacy Center and executive director of the Stanley Medical Research Institute. He doesn't mention The death of psychiatry in his list of books on his "about" webpage on the Treatment Advocacy Center website. I did a critical review of The invisible plague, a book which is on the list.

I don't think I'm as ignorant as Fuller Torrey says I am by questioning what it means to say that schizophrenia is a brain disease. As I keep saying, please do not misunderstand me. Of course, schizophrenia is a brain disease in the sense that mental health problems, just like our normal and everyday behaviour, thoughts and emotions, are due to the brain. That's mere tautology. But Fuller Torrey is claiming more than this. He's suggesting there's brain pathology, and the evidence for this is lacking.

As for anosognosia, which started this spat off, I think it's stretching a point to regard lack of insight in schizophrenia as the same as anosognosia caused by brain injury or stroke. But I doubt whether there's anything to be gained by arguing with Fuller Torrey about it. He's too stuck in his reaction formed from giving up his Szaszian views from the past. His worldview means too much to him (see previous post about this point in relation to Robert Whitaker) to give it up. 

Saturday, October 20, 2012

Stronger conflict of interest policies needed

Article analyses five cases exposed by Senator Chuck Grassley of eight psychiatrists under-reporting pharmaceutical company earnings to their academic medical centers and the National Institute of Health. The concern is that these conflicts of interest affect promotion of a drug and are not taken into account when research funding is allocated.

It is difficult to know how generalisable these cases are or whether psychiatry is more problematic than other specialities. The article questions whether transparency in physician-industry exchanges is sufficient. Apart from the emotional consequences, the psychiatrists in these cases escaped largely unscathed. Only one academic medical center had its research funding affected. The NIH seems reluctant to intervene and the head of NIMH helped one of the worst violators avoid serious consequences, for which he later apologised (see The Chronicle of Higher Education article). The problem is endemic in the system.

Friday, October 12, 2012

The majority of psychiatrists think adult ADHD is an example of the over-medicalisation of everyday life

I have just attended the second day of the annual conference of the General and Community Faculty of the Royal College of Psychiatrists. There was a debate today on the motion that adult ADHD is an example of the over-medicalisation of everyday life. Perhaps surprisingly, the majority present voted in favour of the motion.

When I trained, adult ADHD was never mentioned - it's a relatively new concept, gaining popularity in the 1990s. Many psychiatrists don't feel happy diagnosing a condition in adults that they were taught children generally grow out of. There may be problems with diagnosing children, mainly boys, as hyperactive (eg. see my eletter), but it is even more problematic to recognise ADHD later in life, the majority identified being females. Interestingly enough, the majority of British psychiatrists seem to share these concerns. The diagnosis of adult ADHD has been led by the Americans, and it has been said that it is the most common undiagnosed chronic psychiatric disorder in adults (see my BMJ article). British psychiatrists are following their lead in diagnosing it more commonly.

The point I'm making is that psychiatry doesn't seem to be in control of this development. The majority of psychiatrists, at least British ones, have reservations, but they don't seem to express them. There is a problem with voicing concerns about such trends for fear of being labelled as anti-psychiatry (see eg. previous post). We need to encourage a more open debate on issues within psychiatry.

Sunday, October 07, 2012

Driving the development of mental health services by rhetoric

West Australian Labor MP Martin Whitely has given a speech in the Legislative Assembly, Parliament of Western Australia, a transcript of which he has posted on his Speed Up & Sit Still website. He is critical of Patrick McGorry, who I have mentioned in a previous post. McGorry's ideas are affecting the development of youth mental health services in the UK.