Real Psychiatry: mass psychogenic illness

Tuesday, June 18, 2013

DSM-5 and Primary Care

In the pre-DSM-5 hysteria, I posted the observation that primary care physicians were not "avid readers" of the DSM and therefore the idea that they would be likely to be influenced by it was erroneous. Of course I was responding to the propaganda that the DSM-5 was basically a tool for psychiatric hegemony and that upstanding physicians everywhere would be mere pawns of organized psychiatry. Tens of millions of people would be overmedicated. There would be total chaos while Big Pharma, the APA, and psychiatrists everywhere lined their pockets with the proceeds of inappropriate prescribing. In that atmosphere some considered my statement controversial.

From this week's American Medical News:

"....Perry A. Pugno, MD, MPH, vice president for education for the American Academy of Family Physicians, is not surprised that he hasn't heard about DSM-5 from the organization's members.

'From a pragmatic perspective, we don't use (the manual) very much,' he said. 'Most of the things we see we already know the diagnostic criteria for them.' " (page 12, AMEDNEWS, June 17, 2013).

Remember I also said that psychiatrists are not memorizing the DSM-5 either, for a similar reason.

As I think about what happened in the press before the release of DSM-5, mass hysteria is not a bad phrase. Mass psychogenic illness is probably more politically correct these days but some experts consider an anxious form and a somatic form. There are numerous examples of each and some references suggest that it is compounded by the presence of social media. At any rate, the dynamic is very similar to the critical DSM-5 frenzy prior to the release. In both cases, it can start as a rumor or speculative theory. If that speculation sounds plausible to a larger group it is accepted and built upon. At some point the response to the speculation is critical. Will some experts step in and confirm the original speculation or introduce their own shocking hypotheses? The reaction of the authorities takes it to the next level. Will they seem to take the problem seriously. Media coverage makes things worse. Will additional systems be activated to broaden the response? Momentum builds and before you know it the anxiety or somatic symptoms are linked with a totally implausible hypothesis. Some reviews suggest that treatment involves separating the affected individuals and keeping them out of the limelight for a while until the symptoms fade away. As a psychiatrist who has treated many cases of conversion disorders with neurological symptoms using psychotherapy, I can't imagine competing with several "experts" in the media all having their own theories about the problem. My guess is that my therapy would be either neutralized or severely protracted.

A lot of these things happened in the run up to the DSM-5. So I am using mass hysteria here as a metaphor and not a "diagnosis". I thought I should clarify that because I fully expect that somebody would accuse me of that and go on to suggest that I am a control agent for somebody (?)

It is also not a diagnosis because it is not in DSM-5 or DSM-IV for that matter.

Hopefully cooler heads will prevail in the next big public controversy about psychiatry. But I doubt it.

George Dawson, MD, DFAPA

Monday, February 18, 2013

The run on guns and ammunition - is this mass psychogenic illness?

I was watching my usual Sunday morning news programs two weeks ago when I heard that Wal-Mart had such a run on their ammunition supply customers that they were limiting sales to three boxes per customer per day. That brings up the image of tens of thousands of people going to Wal-Mart every day to buy their three boxes of ammo. What is it about the American psyche that drives this behavior and the recent stockpiling of guns?

It reminded me of the Y2K situation from over a decade ago. Do you remember that scenario? In the antithesis of the Terminator series, computers would be crippled by inadequate programming to account for the change to the 21st century. The power grids would collapse. The logistics of food and medical supplies would be paralyzed. There would be chaos in the streets. In Minnesota in the middle of winter that translated to a run on electrical power generators. It got to the point that one of the big home stores cancelled their return policy for generators. I never noticed it but I wonder if the generator aisle at the Home Depot ever looked like this gun shop display.

All of the signs point to this being a record year for gun and ammunition sales. The National Instant Criminal Background Check System (NICS) has a record number of checks. Nine of ten of the top highest days and 10/10 of the top ten highest weeks for gun checks since the system was started in November 1998 have occurred within the past two months (see below). The charts below give the NICS checks month by month since then and the actual listing of top days and weeks for checks. Although there is usually a disclaimer about how checks do not necessarily equate to gun purchases, the issue has been studied and for each check there is about a 70% chance that a firearm will be acquired taking into account all of the possible outcomes. (click to enlarge)

Another perspective comes from the Bureau of Alcohol, Tobacco, Firearms, and Explosives. They keep a record of firearm manufacturing in the US by the type of firearm and also whether or not a firearm is exported. The data going back to 1998 is available on their web site. I plotted that data for rifles, pistols, revolvers, and shotguns on the following graph. Some interesting trends noted include the fairly recent increase in rifle production. There were relatively flat revolver and shotgun sales, and a sharp increase in pistol production over the past decade. The year 2004 is also an interesting inflection point for rifle sales since that was the year that the ten year ban on assault rifles expired. Without knowing the exact breakdown of rifle sales, the rise at that point combined with flat rate of shotgun sales suggests that the rising rate represents sales of assault rifles or military style weapons that are not necessary for hunting.

All of the signs point to a greater prevalence of guns in homes and communities especially hand guns. Not only that but it appears that Americans are arming themselves at a much higher rate than at any time since we started to keep these statistics. They also appear to be arming themselves using handguns and possible military style weapons that are not typically used for hunting. Hunters are frequently mentioned in NRA and pro-gun rhetoric but they certainly are not responsible for the huge increase in hand gun sales. If we are ruling out hunters who is buying the guns?

My guess is that it comes down to people arming themselves because they believe that they need protection. Although a previous post here clearly shows that the violent crime rate is at an all-time low there are numerous self protection ideologies. At one time or another I have heard the following arguments:

1. Protect yourself against violent criminals (even though there are fewer of them and they seem to be committing fewer violent crimes than at any point in the past 30 years).

2. Protect yourself against terrorists. My guess is that terrorists would not be foolhardy enough to walk into any well armed American neighborhood and start a gun fight

3. Protect yourself against the government. This is an interesting argument because it basically is the same thing as treason. When I argued that point with a famous gun advocate he pointed out that it would depend on "who won". Some conservative and liberal politicians of both parties have made this argument, including Minnesota's well known liberal Senator Hubert H. Humphrey. The basic argument is that if the government becomes completely unresponsive to the people for one reason or the other - we should have enough firepower to overcome it. I guess if we can't vote the bums out - there is always another way.

4. Protect yourself against your neighbors. This is the survivalist argument. The survivalists believe that we are always "9 meals away from chaos". It is therefore logical to stockpile food. When the apocalyptic event happens, you need enough guns and ammo to shoot anyone who threatens you or your food stockpile.

5. Protect yourself against the zombies. That's right - you thought the zombie apocalypse was just fiction. I happened to catch an episode of Doomsday Preppers that was full of information ranging from how zombies might scientifically happen to staircase design that would slow them down long enough so that you could administer the old "double tap".

An inspection of the above list suggests that there are many more imagined than real threats. Possibly several orders of magnitude greater if you are considering that all of your neighbors who ignored your warnings about the apocalypse are either coming for your food or have contracted the virus that turns them into zombies and want to eat you for food. In that scenario - how much ammo is enough? All of this would be more fodder for the film industry if it was not true at some level. Very few real threats and many imagined would seem to be driving the current gun buying frenzy. After all - what would happen if any of the mass scenarios unfolded and we did not have enough guns and ammo?

I don't want to go too far out onto a limb here. For all of you DSM5 detractors - don't worry there is no diagnostic category to critique. I think that there is room for studying the problem, but it would involve collecting data from the gun purchasers and we all know that would not fly. Anyone knows that if you can be identified - the government can kick your door down and take your guns.

George Dawson, MD, DFAPA