I was getting ready for work yesterday morning and watching The Today Show in the background as usual. Suddenly there was the story of a young woman trying to ram the security barriers at the White House and then being pursued in a high speed chase down Pennsylvania Avenue. It eventually showed a direct confrontation with law enforcement and them opening fire on her through the window of her vehicle. There was an initial report saying that she had fired shots but she was unarmed. The police discovered her one year old daughter in the car and removed her. The acute reaction captured on film was surreal. There were descriptions of some of her recent behavior and thoughts. A police official commented that the security barriers "worked" as though this was an assault by a terrorist. A different official commented how her daughter was "rescued" by the police. People were talking as though this was an actual assault by a terrorist. The last person I heard was a politician who made the quote at the top of this post and finally suggested the real problem.
Confrontation between people with severe mental illnesses and law enforcement are very common. During my years of acute inpatient work I have talked with many people who have been injured in every imaginable way during these confrontations. In some cases they were themselves engaged in very dangerous and aggressive behavior as the direct result of a mood disorder or a psychosis. In other cases law enforcement just misinterpreted their behavior. That happened most commonly when the person refused to comply with what the officer wanted them to do. These confrontations are always high risk situations because most people in society know that it is in their best interest to be law abiding and comply with the police. The people who don't are criminals or people with impaired judgment due to mental illness or intoxication states. Even if the police can make that distinction rapidly that does not mean they can easily use a different approach to the person with mental illness. Police officers have been injured or killed in these situations.
There seems to be a great deal of misunderstanding and continued bias about how these situations can occur. It can happen as rapidly as waking up one morning finding out that your entire state of consciousness has changed. That gas company truck across the street is there to monitor you and direct microwaves at you. The phones and your computer are bugged. Going to work that morning you decide you need to take evasive action because it seems like you are being followed. Your anxiety levels build all day and that night at home you can't sleep. You decide you need to move the refrigerator in front of the door because you had the thought that it would be too easy for government agents to kick the door down and grab you. You do a Google search on microwaves and decide these people are trying to do a lot more than harass you - they are trying to kill you. You start to make plans on that basis.
That is how paranoid delusions evolve and how they change your behavior. You are no longer making rational assessments of the environment. Your brain has come up with a theory and you are now interpreting all of the environmental information according to that theory. When I approach the problem psychotherapeutically, I generally explain that delusional thoughts are very low probability explanations or interpretations of an event in the environment. I illustrate this by asking the question: "If we had 100 people in the room right now - how many of them would agree with what you just told me?" Many people know that hardly anyone would agree with them, but that doesn't stop them from continuing to misinterpret the data or trying to cast me with everyone else who either doesn't believe them or is just saying that they are "crazy".
Before I outline an approach to the problem of people experiencing episodes of psychosis or mania and running into problems with law enforcement consider what gets in the way of any of early intervention? Keeping with my cardiology comparison from a previous post - most people know that chest pain is a warning sign for a possible heart attack. With continued public health interventions most people know cardiac risk factors. Public health intervention has been so effective that the current campaign is focused on decreasing the denial in women and decreasing cardiac sudden death in women. Two generations of public health intervention are associated with a decreasing rate of cardiac mortality.
How does that compare with psychosis and mania? I have never seen a public service ad advising about the warning signs of psychosis or mania. There are countless euphemisms for acute changes in a persons mental status. The public treats it like a mystery. When a tragedy occurs there is often no explanation or an inadequate one like "some sort of mental illness." The cultural approach is an obstacle to a rational approach to helping affected individuals. Stigma is considered to be a factor, but it could as easily be an artifact of the process. What would be a better approach?
I have been advocating a public health approach to the problem for a long time now. At a political level there is a lot of confusion about whether this is a firearms issue. Firearms are just a subset of the problem. The overriding public health goal is to get people the help that they need as soon as possible. Our current system of care is set up to provide minimal care to people with severe mental illnesses. The level of care and condition of the facilities where the care occurs is widely known in communities and most people do not want to access these facilities for help. I hear a lot about the concern that someone is going to be stigmatized by treatment at a psychiatric facility. I think it is as likely that many facilities are substandard physical plants that are poorly managed. Based on the length of stay policies alone, nobody wants to bring their relative to a facility that has a reputation for discharging partially stabilized people back into the community. The long term goal needs to be improving the quality of psychiatric facilities in addition to changing the culture about severe mental illness.
I thought of a public service announcement that would potentially have the same advertising power as some of the more popular health spots like the "7 warning signs of cancer". I call it the 4 warning signs of severe mental illness. A concerted effort to focus on severe mental illnesses that can potentially lead to errors in judgment is a logical way to approach this problem. Based on my previous paragraph it takes a much more enlightened approach to treating the problem. Health care systems in general are not friendly to people with severe mental illnesses. There are no specialty centers designed to cater to their needs like the high margin businesses get. Many of these health care organizations sponsor walks for mental illness and other programs like National Depression Screening day. But none of them say - if you have these symptoms we want to see you and treat you in a hospitable environment.
That attitude has to change to prevent the loss of innocent lives as the direct result of severe mental illness.
George Dawson, MD, DFAPA
Showing posts with label anosognosia. Show all posts
Showing posts with label anosognosia. Show all posts
Sunday, October 6, 2013
Saturday, August 17, 2013
Straight Talk About the Government Dismantling Care for Serious Mental Illness
The ShrinkRap blog posted a link to an E. Fuller Torrey and D.J. Jaffe editorial in the National Review about how the government has dismantled mental health care for serious mental illnesses and some of the repercussions. Since I have been saying the exact same thing for the past 20 years, they will get no argument from me. Only in the theatre of the absurd that passes for press coverage of mental illness and psychiatry in this country can this subject be ignored and silenced for so long. It was obviously much more important to see an endless stream of articles trying to make the DSM-5 seem relevant for every man. The stunning part about the Newtown article is the commentary about what government officials responsible for policy have actually been saying about it.
The authors waste very little time examining the sequence of events in the Obama administration following the Newtown, Connecticut mass shooting. President Obama initially stated he would "make access to mental health care as easy as access to guns." and set up a Task Force under Vice President Biden to make recommendations. The authors argue that the agency that was consulted, the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes a model of treating mental illness that has no proven efficacy, does not discuss serious mental illnesses in its planning document, ignores effective treatments for serious mental illnesses and actually goes so far as to fund programs that block the implementation of effective treatment programs. In an example of the obstruction of effective programming by SAMHSA funded programs following the Newtown mass shooting:
"But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass." (page 3, par 2.)
In other words, a SAMHSA funded program was opposed to a law in Connecticut that could potentially reduce violence from persons with severe mental illness.
SAMHSA administrators are quoted at times in the article. Any quote can be taken out of context but the characterizations of severe mental illness as "severe emotional distress", "a spiritual experience" and "a coping mechanism and not a disease" reflect a serious lack of knowledge about these disorders. The idea that "the covert mission of the mental health system ...is social control" is standard antipsychiatry philosophy from the 1960s. How is it that after the Decade of the Brain and the new Obama Brain Initiative we can have a lead federal agency that apparently knows nothing about the treatment of serious mental illnesses? How is it that apart from some fairly obscure testimony, no professional organizations have pointed this out? How is it in an era where governments at all levels seem to demand evidence based care, that a lead agency on mental health promotes treatment that has no evidence basis and ignores the treatment that is evidence based?
Having been a long time advocate for the prevention of violence by the treatment of severe mental illnesses my comments parallel those of the authors. Inpatient bed capacity in psychiatry has been decimated. They point out that there are only 5% of the public psychiatry beds available that there were 50 years ago. It is well known that people with mental illnesses are being incarcerated in record numbers and some of the nation's county jails have become the largest psychiatric institutions. Where are all of the civil liberties advocates trying to get the mentally ill out of jail?
Only a small portion of the beds available can be used for potentially violent or aggressive patients and that number gets much smaller if a violent act has actually been committed. Most of the bed capacity in this country is under the purview of some type of managed care organization and that reduces the likelihood of adequate assessment or treatment. The discharge plan in some cases is to just put the patient on a bus to another state.
Community psychiatry is a valuable unmentioned resource in this area. In most of the individual cases mentioned in this article, the lack of insight into mental illness or anosognosia is prominent. It is not reasonable to expect that a person with anosognosia will follow up with outpatient appointments or even continue to take a medication that treats their symptoms into remission. Active treatment in the community by a psychiatrists and a team who knows the patient and their family is the best way to proceed. All of this active treatment has been cost shifted out of insurance coverage and is subject to budget cuts at the county and state level.
Civil commitment laws and proceedings are probably the weakest link in treatment. Further cost shifting occurs and violent patients often end up aggregating in the counties with the most resources. Even while they are there, many courts hear (from a budgetary perspective) that they are committing too many people and the interpretation of the commitment law becomes more liberal until there is an incident that leads to the interpretation tightening up again. Bureaucrats involved often become libertarians and suggest that commitment can occur only if an actual violent incident has happened rather than the threat of violence.
Although Torrey and Jaffe are using the extreme situation of violence in the seriously mentally ill to make their point, the majority of the seriously mentally ill are not violent. They need the same resources. It has been thirty years of systematic discrimination against these people, their families and the doctors trying to treat them that has led to these problems. I pointed out earlier on this blog the problem I have with SAMHSA and the use of the term "behavioral health". The problems with SAMHSA and current federal policy are covered in this article and I encourage anyone with an interest to read it. If history is any indication, I don't expect anything serious to come of the criticism. I anticipate a lot of rhetorical blow back at Dr. Torrey. But as a psychiatrist who has worked in these environments for most of my career, his analysis of the problem is right on the mark.
George Dawson, MD, DFAPA
E. Fuller Torrey & D.J. Jaffe. After Newtown. National Review Online.
White House. Now Is The Time. The President's plan to protect our children and our communities by reducing gun violence. January 16, 2013.
The authors waste very little time examining the sequence of events in the Obama administration following the Newtown, Connecticut mass shooting. President Obama initially stated he would "make access to mental health care as easy as access to guns." and set up a Task Force under Vice President Biden to make recommendations. The authors argue that the agency that was consulted, the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes a model of treating mental illness that has no proven efficacy, does not discuss serious mental illnesses in its planning document, ignores effective treatments for serious mental illnesses and actually goes so far as to fund programs that block the implementation of effective treatment programs. In an example of the obstruction of effective programming by SAMHSA funded programs following the Newtown mass shooting:
"But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass." (page 3, par 2.)
In other words, a SAMHSA funded program was opposed to a law in Connecticut that could potentially reduce violence from persons with severe mental illness.
SAMHSA administrators are quoted at times in the article. Any quote can be taken out of context but the characterizations of severe mental illness as "severe emotional distress", "a spiritual experience" and "a coping mechanism and not a disease" reflect a serious lack of knowledge about these disorders. The idea that "the covert mission of the mental health system ...is social control" is standard antipsychiatry philosophy from the 1960s. How is it that after the Decade of the Brain and the new Obama Brain Initiative we can have a lead federal agency that apparently knows nothing about the treatment of serious mental illnesses? How is it that apart from some fairly obscure testimony, no professional organizations have pointed this out? How is it in an era where governments at all levels seem to demand evidence based care, that a lead agency on mental health promotes treatment that has no evidence basis and ignores the treatment that is evidence based?
Having been a long time advocate for the prevention of violence by the treatment of severe mental illnesses my comments parallel those of the authors. Inpatient bed capacity in psychiatry has been decimated. They point out that there are only 5% of the public psychiatry beds available that there were 50 years ago. It is well known that people with mental illnesses are being incarcerated in record numbers and some of the nation's county jails have become the largest psychiatric institutions. Where are all of the civil liberties advocates trying to get the mentally ill out of jail?
Only a small portion of the beds available can be used for potentially violent or aggressive patients and that number gets much smaller if a violent act has actually been committed. Most of the bed capacity in this country is under the purview of some type of managed care organization and that reduces the likelihood of adequate assessment or treatment. The discharge plan in some cases is to just put the patient on a bus to another state.
Community psychiatry is a valuable unmentioned resource in this area. In most of the individual cases mentioned in this article, the lack of insight into mental illness or anosognosia is prominent. It is not reasonable to expect that a person with anosognosia will follow up with outpatient appointments or even continue to take a medication that treats their symptoms into remission. Active treatment in the community by a psychiatrists and a team who knows the patient and their family is the best way to proceed. All of this active treatment has been cost shifted out of insurance coverage and is subject to budget cuts at the county and state level.
Civil commitment laws and proceedings are probably the weakest link in treatment. Further cost shifting occurs and violent patients often end up aggregating in the counties with the most resources. Even while they are there, many courts hear (from a budgetary perspective) that they are committing too many people and the interpretation of the commitment law becomes more liberal until there is an incident that leads to the interpretation tightening up again. Bureaucrats involved often become libertarians and suggest that commitment can occur only if an actual violent incident has happened rather than the threat of violence.
Although Torrey and Jaffe are using the extreme situation of violence in the seriously mentally ill to make their point, the majority of the seriously mentally ill are not violent. They need the same resources. It has been thirty years of systematic discrimination against these people, their families and the doctors trying to treat them that has led to these problems. I pointed out earlier on this blog the problem I have with SAMHSA and the use of the term "behavioral health". The problems with SAMHSA and current federal policy are covered in this article and I encourage anyone with an interest to read it. If history is any indication, I don't expect anything serious to come of the criticism. I anticipate a lot of rhetorical blow back at Dr. Torrey. But as a psychiatrist who has worked in these environments for most of my career, his analysis of the problem is right on the mark.
George Dawson, MD, DFAPA
E. Fuller Torrey & D.J. Jaffe. After Newtown. National Review Online.
White House. Now Is The Time. The President's plan to protect our children and our communities by reducing gun violence. January 16, 2013.
Sunday, October 28, 2012
The diagnosis of anosognosia
Follow up on another blog today where the author proclaims "It is not possible to diagnose anosognosia in schizophrenic patients on brain scan."
No kidding. Here is another shocker and you can quote me on this - it is not possible to diagnose anosognosia in stroke patients based on a brain scan. Quoting an expert: "Anosognosia refers to the lack of awareness, misbelief, or explicit denial of their illness that patients may show following brain damage or dysfunction. Anosognosia may involve a variety of neurological impairment of sensorimotor, visual, cognitive, or behavioral functions, as well as non-neurological diseases." I encourage anyone who is interested in this topic to find a copy of this book chapter listed in the references below. The author thoroughly discusses the fascinating history of this disorder, specific protocols used to make the diagnosis, various neurological subtypes with heterogeneous lesions and the fact that no specific mechanism has been determined.
No kidding. Here is another shocker and you can quote me on this - it is not possible to diagnose anosognosia in stroke patients based on a brain scan. Quoting an expert: "Anosognosia refers to the lack of awareness, misbelief, or explicit denial of their illness that patients may show following brain damage or dysfunction. Anosognosia may involve a variety of neurological impairment of sensorimotor, visual, cognitive, or behavioral functions, as well as non-neurological diseases." I encourage anyone who is interested in this topic to find a copy of this book chapter listed in the references below. The author thoroughly discusses the fascinating history of this disorder, specific protocols used to make the diagnosis, various neurological subtypes with heterogeneous lesions and the fact that no specific mechanism has been determined.
In a more recent article available online, Starkstein, et al provide an updated discussion in the case of stroke. They discuss it as a potential model of human awareness, but also point out the transient nature and difficulty in developing research diagnostic criteria. They provide a more extensive review of instruments used to diagnose anosognosia and conclude: "Taken together, these findings suggest that lesion location is neither necessary nor sufficient to produce anosognosia, although lesions in some specific brain areas may lower the threshold for anosognosia. Strokes in other regions may need additional factors to produce anosognosia, such as specific cognitive deficits, older age, and previous strokes."
The experts here clearly do not base the diagnosis of this syndrome on imaging. It is based on clinical findings. For anyone interested in looking at the actual complexity in the area of anosognosia in schizophrenia I recommend reading these free online papers in the Schizophrenia Bulletin in an issue that dedicated a section to the topic in 2011. You will learn a lot more about it than reading an anti-biological antipsychiatry blog. But of course you need to be able to appreciate that this is science and not an all or none political argument.
George Dawson, MD, DFAPA.
Patrik Vuilleumier. Anosognosia in Behavior and mood disorders in focal brain lesions. Julien Bogousslavsky and Jeffrey L. Cummings (eds), Cambridge University Press 2000, pp. 465-519.
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