The Circular Logic Argument

 

I thought I would do a quick post on this because I am interested in rhetoric and this is mind-numbingly simple rhetoric.  It goes like this:

Being depressed means that you have major depression and you are depressed because you have major depression…..

Having motor restlessness means that you have attention-deficit hyperactivity disorder (ADHD) and having ADHD means that you have motor restlessness

This has been presented as though it is an indictment of psychiatric descriptive diagnosis – but you don’t have to think about it too long to figure out why this is a fallacy.  By analogy

Having a cough means that you have COVID and having COVID means that you have a cough.

The circular logic fallacy obviously does not consider the biological complexity of medical and psychiatric diagnoses.  We can rewrite them more accurately using that knowledge.  For example:

Being depressed means that you may have one of hundreds of medical, neurological or psychiatric conditions causing depression or that you may have completely normal mood reactivity or you may have one of thousands of pluralistic causes and having any one of hundreds of medical, neurological and psychiatric conditions or normal mood reactivity or one of thousands of pluralistic causes means that you have depression.

In other words – there is no 1:1 mapping of clinical depression onto the symptom of depression.  The diagnostic process returns a hypothesis about a condition that may be responsible for depressive symptoms.  I hope that illustrates how fallacious this argument is. The problem with rhetorical arguments like this is that they are generally advanced by people who have not gone to psychiatry school or who may have done it but poorly. It is reinforced by business practices and what I would call the necessity of low-quality research.

Starting with the research issue first.  Practically all studies of depression in the literature do not consist of psychiatric diagnoses of depression. Large GWAS studies typically use a ratings scale like the PHQ-9 as the depressive phenotype of interest.  There is no assurance that the patient would be diagnosed with depression by a psychiatrist or have had any of the other thousands of causes of depression considered.  In some of those studies there is a more general diagnostic screen administered to research subjects by non-psychiatrists and if screening criteria are met – the inclusion criteria for the study are met. None of this is assurance that the subjects’ studied would be diagnosed with depression (and not something else) by a psychiatrist.  The low-quality diagnosis in this case is necessitated by massive databases.  For example, the UK Biobank has data on a half million individuals and that would require at least a million hours of interviews by research psychiatrists to make a clinical diagnosis of depression.  That would probably require several hundred full-time psychiatrists working their entire 35 year career to complete.

The business practice of treating depression has similar problems.  It is almost a universal experience today to take anxiety and depression rating scales in primary care clinics.  The primary care experience may be even more crude than the research experience because the PHQ-2 may be administered instead of the PHQ-9.   The PHQ-2 consists of the following 2 ratings over the past 2 weeks:

1:  Little interest or pleasure in doing things

2:  Feeling down, depressed, or hopeless

These screening methods were initiated to show that managed care plans were interested in treating depression.  Since there will never be enough psychiatrists to assess and treat depression, these proxy screenings were felt to be an adequate replacement for psychiatry and they generally result in a diagnosis and treatment of depression even though (once again) there is no guarantee that a psychiatrist would have made that diagnosis.  Just from a purely rhetorical standpoint – it is a syllogistic fallacy to conclude that 1 and 2 above are adequate premises to establish a diagnosis of depression.  The debate at that point may be: “Well the clinician seeing the score will engage in a more elaborate diagnostic interview to make the diagnosis.”  If that is the case – what prevented them from doing that in the first place?  There is an expected paucity of data related to this practice – but I suspect there are many cases of antidepressant overprescription and “treatment resistant depression” based on the wrong diagnosis.  I recently offered to analyze the data from a large health plan for free and they were not interested in looking at it.

The most recent commentary on circular reasoning apparently came from a paper (1) claiming that causal language about psychiatric disorders is the result of a logical error and leads to a confused public and intellectual dishonesty.  The authors make several errors along the way as they develop this argument including:    

Ideally, a medical diagnosis both provides a precise term for a given condition and identifies its etiological mechanism

This is a rhetorical construct that ignores what has been known for decades and that is according to Merskey (2): “Medical classification lacks the rigor of either the telephone directory or the periodic table.  It is exceptionally untidy but it is taken to reflect in some way “the absolute truth” or at least the wonderful truth as it is known to its best practitioners.”  Merskey elaborates on how the medical classification system has several conceptual parameters – most independent of etiological mechanism. In fact, if etiological mechanisms were known – all categories would be mutually exclusive and that is another property that does not exist in medical classifications.  The medical terms "diagnosis" and "disease" are anything but precise and that leaves them open to attack by anyone providing a restricted definition.

“By contrast, diagnostic categories in psychiatry are currently defined only by symptoms.”

The DSM classification has a significant number of disorders where the precipitating and etiological factors are known. The hundreds of causes of organic mental disorders are a case in point as well as an entire section of neurocognitive disorders where the pathology is at least as precise as examples that the authors give.  There is a universe of medical and neurological disorders that are polygenic quantitative disorders with no specific etiology like psychiatric disorders.  Psychiatric disorders are also comprised of clear reproducible signs including sleep and appetite disorders and motor disorders that produce measurable results.  

“While it would be entirely correct to say that the human experiences that the diagnostic criteria describe can feel like an illness, it is different from claiming that an identified external biomedical pathological entity is really causing the symptoms.”

The authors trivialize depression as a mere feeling. I have never seen a person who came in for an assessment based on a mere feeling. They are typically experiencing a disruption in many aspects of their life and have difficulty functioning on a day-to-day basis.  Most patients seeing psychiatrists also have considerable medical comorbidity.

“By contrast, psychiatric diagnoses are not conceptually independent of their respective symptom lists.”

 The authors contrast psychiatric disorders and their symptoms with a lung tumor and a cough and suggest that because psychiatric diagnoses “cannot exist” without symptoms and this is proof that a purely descriptive syndrome cannot be a “cause” of the symptoms.  They also make the error in suggesting that a person must “meet criteria” for depression to be diagnosed with depression.  The problem is that depression, mania, and psychosis existed for centuries before there was a DSM.  These conditions existed long before there were psychiatrists.  They are obvious to non-psychiatrists (the authors apparently excepted).  The only reason psychiatry exists today is to treat syndromes that have been systematically observed and recorded by both psychiatrists and non-psychiatrists.  The medical side of things is described well by DeGowin and DeGowin in their physical diagnosis text (3).

"For several thousand years physicians have recorded observations and studies about their patients.  In the accumulating facts they have recognized patterns of disordered bodily functions and structures as well as forms of mental aberration.  When such categories were sufficiently distinctive, they were termed diseases and given specific names.”

To this day – medical practice is largely based on recognizing sufficiently distinctive categories and not pathophysiology.  There is always a lot of speculative pathophysiology and I have witnessed that all changing over the course of my career.  The pathophysiology learned in medical school – even if based on Nobel Prize work – is not the pathophysiology that applies today.  These diagnoses were independent of symptom lists for centuries and to this day they still are - in that no experienced psychiatrist is treating depression based on symptom lists or “meeting criteria”.

“Some authors therefore emphasize that depression can be described as an adaptive response or a functional signal to adverse circumstances.  Contrary to the erroneous causal beliefs that circular claims promote, this approach underlines that low mood and/or loss of pleasure are often meaningful reactions to life events, and that they can be meaningfully understood.”

This is a potentially erroneous causal belief and the authors apparently have no problem with circularity in this case or the potential lack of investigation of associated causes.  They also seem to misunderstand the idea that to have a disorder – there has to be some form of altered functioning beyond what would be expected.  Most people have that knowledge.  This is also a naive statement from the perspective of assessment and treatment of suicide risk. Can suicidal thinking associated with loss be explained away as a “meaningful reaction to life events” or does something more definitive need to be done?  Before anyone dismisses the idea as rhetorical - some of these same authors have suggested that psychosis is an adaptive response.  Finally – they include a quote from authors on the adaptive response theory as if psychiatrists have not been involved in theories, clinical observations, and developing therapies of these phenomena for decades (4-11).  

Rather than continuing a point-by-point analysis – a look at the rhetoric is probably a better summary.  From the diagram, the authors argue using a typical biomedical psychiatry conflation combined with controlling the premise. The top of the diagram illustrates that when all of psychiatry (in this case depression) is condensed or conflated into a monolithic nondescript biomedical model  - it is easy to demonstrate not only circularity but also how clueless psychiatrists are.  This should come as a surprise to no psychiatrist since this is really a longstanding rhetorical approach to the deconstructive criticism of the field.

A more realistic assessment can be seen in the lower graphic. I labelled it clinical depression since in this case the authors’ use of biomedical psychiatry is largely pejorative.  Every psychiatrist I worked with in acute care would not consider it to be a problem – since we were confronted with hundreds of conditions that had depressive symptoms that we had to figure out.  We were good at it and looked forward to it.  The emphasis is on multiple etiologies.  Numerous psychiatric disorders have depressive symptoms as well as medical and neurological disorders that psychiatrists need to be able to diagnose.  There are known biological causes as noted in the DSM, but many psychiatric disorders are complex polygenic disorders with no specific etiology.  With rule out diagnoses – that means that depression can cause depressive symptoms that can be addressed at the pluralistic level.  The authors suggest that “guild issues” may be a reason that biomedical psychiatry is defended as causal of depressive symptoms. Psychiatry in fact has produced a solid literature (4-11) of various etiologies of depression and how to treat them that easily encompass the authors’ suggestion that meaningful events may have a role to play. That theme has been present in psychiatry for decades prior to this paper.

Anyone reading a paper like this one needs to have an awareness of biology and human biology as a subset.  As I tried to point out in previous posts – for many reasons biological classifications will be imperfect.  That is true for biology without human constraints like speciation in all living organisms.  It is also true for disease classifications and I hope to have more on this soon. Any argument that there exists a standard for categories, diagnoses, or disorders in medicine or psychiatry that is perfect or even unidimensional should be considered rhetorical.

 

George Dawson, MD, DFAPA

 

1:  Kajanoja J, Valtonen J. A Descriptive Diagnosis or a Causal Explanation? Accuracy of Depictions of Depression on Authoritative Health Organization Websites. Psychopathology. 2024 Jun 12:1-10. doi: 10.1159/000538458. Epub ahead of print. PMID: 38865990.

2:  Merskey H. The taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. doi: 10.1016/j.mcna.2006.10.009. PMID: 17164101.

3:  DeGowin, EL, DeGowin, RL. Bedside Diagnostic Examination. United Kingdom: Macmillan, 1976.

4:  Sifenos PE.  Short-term Dynamic Psychotherapy.  New York.  Plenum Medical Book Company, 1979.

5:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  Interpersonal Psychotherapy of Depression, New York: Basic Books, 1984.

6:  Yalom ID.  Existential Psychotherapy.  New York: Basic Books, 1980.

7:  Beck AT, Rush JA, Shaw BF, Emery G.  Cognitive Therapy of Depression.  New York: Guilford Press, 1979.

8:  Bennett D.  Social and community approaches.  In:  Paykel ES (ed).  Handbook of Affective Disorders.  New York:  Guilford Press, 1982:  pp.  346-357.

9:  Arieti S.  Individual psychotherapy.  In: Paykel ES (ed).  Handbook of Affective Disorders.  New York:  Guilford Press, 1982:  pp.  298-305.

10:  Stein A.  Group therapy.  Paykel ES (ed).  Handbook of Affective Disorders.  New York:  Guilford Press, 1982:  pp.  307-317.

11:  Viederman M. The psychodynamic life narrative: a psychotherapeutic intervention useful in crisis situations. Psychiatry. 1983 Aug;46(3):236-46.

Explanatory Note:  When I use the terms psychiatric, neurological, and medical diagnoses - I am referring to medical as including all internal medicine specialties (Infectious Disease, Endocrinology, Nephrology, Cardiology, Rheumatology, Allergy and Immunology) as well as general Internal Medicine and Family Medicine.  Neurology and Psychiatry generally have non-overlapping conditions but there is a considerable amount of comorbidity from the medical fields.

Ignoring Joe Biden’s Unassailable Fact: A Serious Deficiency of the Debate Analysis

 

The Debate uproar continues largely at a very superficial level.  That level is basically that Joe Biden is too old and feeble to be President and therefore he needs to step down and the Democrats need to run another candidate for the sake of “not losing the office.”  This is being spun at multiple levels.  We are hearing stories about White House Staff being conflicted, the President offering cookies to members of Congress, the plausibility of sleep deprivation as an explanation, and even provided with a list of 10 possible Democratic candidates. Whenever supporters of the President come forward the wisdom of loyalists is being questioned rather than what they describe.  The actual content of the debate continues to be ignored as if Joe Biden did not provide any. 

I came up with the following diagram to put things into perspective.  It consists of Trump’s hyperbole about Joe Biden and the single Biden response that effectively cancels that hyperbole across multiple dimensions.  Instead of hearing anything about that response the news media continues the endless speculation about Biden’s Presidency and who should replace him.  The excerpts in the table below are taken directly from the CNN transcript that is easily accessible.  For the sake of simplicity – I eliminated Biden’s point-by-point responses to the Trump hyperbole that were more than adequate and included only the responses that included his reference to the Presidential Greatness survey.

Trump	Biden
“He also said he inherited 9 percent inflation. No, he inherited almost no inflation, and it stayed that way for 14 months. And then it blew up under his leadership because they spent money like a bunch of people that didn’t know what they were doing. And they don’t know what they were doing. It was the worst – probably the worst administration in history. There’s never been.”
“But look, we had the safest border in history. Now we have the worst border in history. There’s never been anything like it. And people are dying all over the place, including the people that are coming up in caravans.”
“Nobody had been worse. I had the highest approval rating for veterans, taking care of the V.A. He has the worst. He’s gotten rid of all the things that I approved – Choice, that I got through Congress. All of the different things I approved, they abandoned.”
“First of all, our veterans and our soldiers can’t stand this guy. They can’t stand him. They think he’s the worst commander in chief, if that’s what you call him, that we’ve ever had. They can’t stand him. So let’s get that straight. And they like me more than just about any of them. And that’s based on every single bit of information.”
“His presidency, his – without question, the worst president, the worst presidency in the history of our country. We shouldn’t be having a debate about it. There’s nothing to debate.”	“The idea that veterans are not being taken care of, I told you before – and, by the way, when I said “suckers and losers,” he said – he acknowledged after it that he fired that general. That general got fired because he’s the one that acknowledged that that’s what he said. He was the one standing with Trump when he said it, number one.   Number two, the idea that we’re going to be in a situation where all these millions and millions, the way he talks about it, illegal aliens are coming into the country and taking away our jobs, there’s a reason why we have the fastest-growing economy in the world, a reason why we have the most successful economy in the world. We’re doing better than any other nation in the world.   And, by the way, those 15 Nobel laureates, economists, they all said that if Trump is re-elected, we’re likely to have a recession, and inflation is going to increasingly go up.   And by the way, worst president in history. 159 presidential scholars voted him the worst president in the history of the United States of America.”
“He caused inflation. As sure as you’re sitting there, the fact is that his big kill on the black people is the millions of people that he’s allowed to come in through the border. They’re taking black jobs now and it could be 18. It could be 19 and even 20 million people. They’re taking black jobs and they’re taking Hispanic jobs and you haven’t seen it yet, but you’re going to see something that’s going to be the worst in our history.”
“Did you fire anybody? Did you fire anybody that’s on the border, that’s allowed us to have the worst border in the history of the world? Did anybody get fired for allowing 18 million people, many from prisons, many from mental institutions? Did you fire anybody that allowed our country to be destroyed? Joe, our country is being destroyed as you and I sit up here and waste a lot of time on this debate. This shouldn’t be a debate.”   “He is the worst president. He just said it about me because I said it. But look, he’s the worst president in the history of our country. He’s destroyed our country. Now, all of a sudden, he’s trying to get a little tough on the border. He come out – came out with a nothing deal, and it reduced it a little bit. A little bit, like this much. It’s insignificant.”   “He wants open borders. He wants our country to either be destroyed or he wants to pick up those people as voters. And I don’t think – we just can’t let it happen. If he wins this election, our country doesn’t have a chance. Not even a chance of coming out of this rut. We probably won’t have a country left anymore. That’s how bad it is. He is the worst in history by far.”	“Number two, the idea that we’re talking about worst presidents. I wasn’t joking. Look it up. Go online. 159 or 58, don’t hold me the exact number, presidential historians. They’ve had meetings and they voted who’s the worst president in American history. One through best to worst. They said he was the worst in all of American history. That’s a fact. That’s not conjecture. He can argue the wrong, but that’s what they voted.”
“Just you understand, we have polling. We have other things that do – they rate him the worst because what he’s done is so bad. And they rate me – yes, I’ll show you. I will show you. And they rate me one of the best. OK.”
“All my life I’d grow up and I’d see politicians talking about cutting taxes. When we cut taxes, as I said, we did more business. Apple and all these companies, they were bringing money back into our country. The worst president in history by far, and everybody knows it.”
“But he hasn’t cut the tariffs because he can’t, because it’s too much money. But he’s got the largest deficit in the history of our country and he’s got the worst situation with China. China is going to own us if you keep allowing them to do what they’re doing to us as a country. They are killing us as a country, Joe, and you can’t let that happen. You’re destroying our country.”
“Then he came along. The numbers – have you seen the numbers now? It’s not only the 18 million people that I believe is even low, because the gotaways, they don’t even talk about gotaways. But the numbers of – the amount of drugs and human trafficking in women coming across our border, the worst thing I’ve ever seen at numbers – nobody’s ever seen under him because the border is so bad. But the number of drugs coming across our border now is the largest we’ve ever had by far.”

 

What do I conclude from this analysis?  Far from being feeble – Joe Biden presented solid information that (as far as I can tell) was ignored by all the talking heads.  Trump’s characterizations of Biden as the worst President are strictly hyperbole. Biden’s response points out that according to a survey of 154 Presidential scholars Biden is ranked #14 and Trump is dead last at #45.  Beyond that obvious fact – Biden is ranked higher than Reagan (#16), George HW Bush (#19), and George W Bush (#32).  In a follow up article it was noted that Trump ranks lower than William Henry Harrison (#41) who died 31 days after taking office.  There seems to be no doubt about where Presidential scholars rank Trump.

The implications of this transcript are clear.  There is always the possibility that Biden has suddenly developed severe problems by per my previous post – but I doubt it. Anyone should be very skeptical about the stories coming out of the press at this time.  Ageist bias is so prevalent that it affects all these stories.  The associated lack of criticism of Trump by comparison is telling. There have been stories suggesting that Trump “lied” anywhere from 30 to 50 times.  I checked these lies against the transcript and they are there. The problem with that analysis is that Trump gets a pass by the MAGA crowd and most of the media whenever he does lie.  The best example is the stolen election lie. Any interview about this typically results in Trump repeating the statement until the journalists stops asking the question.  That strategy is obvious even in the debate transcript.

Another consideration is misinformation and how that affects the ongoing debate spin. The standard MAGA misinformation channels should be ignored.  There is undoubtedly a more insidious effort by enemies of the United States to create additional misinformation on social media.  It is obvious that Russia and Putin see the election of Trump as more consistent with their interests because of Trump’s lack of support for Ukraine and NATO.  Russia clearly supports groups hacking and extorting American businesses.  Threat analysis suggests that Russia, China, and Iran are actively interfering with US elections by misinformation that includes generative AI based approaches.  It should be clear that these countries would prefer a President who is isolationist, does not back Ukraine or NATO, and one who they believe they can manipulate.  Trump’s former National Security Advisor John Bolton believes that Putin knows he can easily manipulate Trump.

All of this information is being ignored in the face of the Presidential debate and the fact that Biden basically looked bad even though he easily produced content that countered Trump’s hyperbole and advanced his own case.  This is not the first-time appearances at a debate were considered a deciding factor.  As I have written in the past, I don’t generally consider the economy to be determined by Presidents – they either take credit or get blamed even though most of the economy is outside of their sphere of influence.  There is plenty of misinformation out there about the economy and the fact it is a motivating factor for people to vote for Trump. There is no doubt that the Biden economy is better and his policies will strengthen the economy in the future.

There is a big interview between Biden and George Stephanopoulos coming up this evening.  We will see if Biden can present in a way to reassure the voters – but all things equal they are still going to hold his age against him.  It is unfortunate that there is little rational discussion of the issue at this point – including the points that Biden made in the debate.   

 

George Dawson, MD, DFAPA

 

Addendum:

The Joe Biden - George Stephanopoulos Interview:

I watched the entire brief interview this evening.  I thought it was an exercise in gotcha journalism.  Biden responded with reasonable answers to why he wants to continue to run and why he is the best person for the job.  His response about whether or not he would take a "cognitive exam" was also reasonable - basically that his job is a cognitive exam every day.  Stephanopoulos' interview technique was controlling and trying to get Biden to respond to hypotheticals that he eventually stated he would not respond to.  He also asked Biden to respond to uncorroborated speculation.  I thought that overall it was a very poor interview and Biden handled it as well as anyone could.  In many ways it was an interrogation rather than an interview. Another disappointing aspect of the interview was the additional four journalists that Stephanopoulos discussed the current situation with. They all clearly had a fixed agenda that Biden should withdraw for various reasons and seemed to be trying to create news rather than report it.  That seems to be the basic problem for Biden at this point.  The news media is more critical of him than Trump - despite Trump's massive deficiencies. As an expert on cognitive testing of the elderly I can add that the "cognitive test" that Trump brags about - is really a screening test that is not sensitive enough to pick up anything short of a moderate to severe problem.  They are easy for anyone who is not cognitively impaired.  Trump has also been noted to brag about his results on this screening test as well as inaccurately describing the test - specifically the naming tasks and word recall task.  All of those details as well as this quote are from reference 1:

"It's a very, very low bar for somebody who carries the nuclear launch codes in their pocket to pass and certainly nothing to brag about," said Jonathan Reiner, a cardiologist and professor of medicine and surgery at the George Washington School of Medicine &Health Sciences.

If there is a cognitive contest between Biden and Trump - and I am sure that will never happen - testing should occur in the same manner, given by the same examiner and it should be recorded for outside validation purposes.  It should also be a more rigorous screen - like the test battery given to physicians in some centers if they want to practice past the age of 75.

But at this point Biden's fate appears to be predetermined by a media bias against him that does not exist for his opponent.

References:

1:    Parker A, Diamond D.  A ‘whale’ of a tale: Trump continues to distort cognitive test he took.  Washington Post Jan 19, 2024.

Graphic Reference:

Presidential Greatness Project - see rankings at this site.  Biden #14  Trump #45 

Disclaimer: 

As previously noted I am not now and have never been a member of any political party in the United States.  At the same time, it is clear to me that the Republican party, their Presidential candidate Donald Trump, and their partisan Supreme Court are an unprecedented danger to the United States that I have known all of my life and that they should be defeated. It is also clear that they have a level of organization that resulted in political advantages over the opposition and that their rhetorical strategy is to blame the opposition for what they in fact are doing

Supplementary 1: 

The following Tweet today from Norman Ornstein:

He does a good job capturing the media bias against Biden.  There is also more than a little conflict of interest at the NYT - since their editorial board has already said that Biden should step down.  Practically every journalist I see - even after the Stephanopoulos interview is either explicitly or implicitly suggesting that Biden should step down, that Democrats will tell him to step down, or that he will lose the election if he doesn't.  That kind of stacks the deck against you in polls - especially when almost all of the polls quoted are poorly characterized to the point that they may lack validity.   There have been comparisons with Supreme Court Justice Ruth Bader Ginsburg who is often faulted by the left for not stepping down in time for President Obama to appoint a successor.  She is an easy scapegoat for a party who failed to win the Senate or maintain any countermeasures for right wing activism that seeks to appoint as many federal judges as possible.  Comparing a life long appointment in the case of Ginsburg to being elected President and according to experts doing a better than average job lacks equivalency.  There is also a clear asymmetry in the criticism with Trump getting a complete pass despite his abysmal rating as a President.  Instead of even mild criticism in Trump's direction - I expect the press to continue to portray Biden's presidential bid as a scandal and look for any evidence to back that opinion up.  

Supplementary 2: 

Conclusory language is discouraged in many formats in psychiatry like evaluations for civil commitment, guardianship, and conservatorship.  The idea is that conclusory language short circuits uncertainty and statutory requirements and can prematurely lead to a wrong conclusion.  Even routine psychiatric evaluations should avoid conclusory language in favor of probability statements or statements about the inherent uncertainty in medical evaluations.   

All of the press that I have seen comment on the debate or the Stephanopoulos interview have been using conclusory language or suggesting that they have a source who will provide that language.  Needless to say that is all highly prejudicial against Biden.

The Irrational American Voter – Arrogance, Ignorance, or Both?

 

 “Critics are men who watch a battle from a high place then come down and shoot the survivors."  -  Ernest Hemingway

Let me preface this essay by saying that I am an expert in assessing cognition and cognitive disorders  based on my 35 years as a psychiatrist doing that specific job in acute care settings, outpatient clinics, nursing homes and other healthcare centers, guardianship and conservatorship proceedings, and contested hearings about decisional capacity.  For 15 years I ran a Geriatric Psychiatry and Memory Disorders Clinic.  I have made positive diagnoses of the various forms of dementia, detected and treated reversible forms of cognitive impairment, and corrected misdiagnoses of dementia. So, I was more than slightly taken back by all the armchair diagnosing of President Biden during the debate last Thursday. The press got (at least) – 3 days of sensational and speculative headlines. I just saw a poll today that showed an increase in the number of Americans who think “President Biden has a cognitive problem” from 35% prior to the debate to 70% after the debate.  As an expert – with no special knowledge of the President’s health status I can tell you why there is no sufficient information to make that determination.  I also have doubts about what “cognitive problem” means to the average American based on the hundreds of family conferences I have had to explain that concept.  

Just based on the debate, the President’s responses and overall presentation were suboptimal - but there are many untouched explanations.  I would describe the resulting press as excessive and discriminatory against Biden. Here are a few possible explanations:

My first thought was he was over preprepared and probably angry about having to confront a liar and a propagandist.  Let’s face it – this is the first time any Presidential debater has been forced to do this.  Trump is the first convicted felon and repetitive liar in any presidential debate.  He is good at it.  Recall how Trump made his fellow Republican primary candidates look in those debates.  Many of them were speechless and ineffective.  Trump’s propaganda style clearly makes it difficult for the media to criticize him.  He effectively neutralized the moderators who were unable to get him to answer questions.  Some in the press described him as a “ball of energy” rather than a “ball of lies”. They know that no matter what they say – Trump is repetitive and successful in wearing them down.  The best example is “The Big Lie” about how the election was stolen but there are more. He maintains lies in the face of solid evidence and even the press does not know how to handle it. They eventually acquiesce and start to treat the propaganda as fact.  During the debate he was able to not provide responses to questions while repeating his own brand of propaganda.  

Second, the cognitive task was much more demanding for Biden.  In the news leading up to the debate there was clear messaging from both camps on how they were being prepared. Trumps preparation was clearly casual and not information intensive. That was reflected exactly in his ease with repeating his overlearned propaganda, dodging solid answers to questions, and ad hominem attacks on Biden.  The Biden camp reported an intensive schedule of fact-based mock debates and attempting to answer moderators’ questions based on much more factual content.  Clearly the Trump strategy presented a markedly lower cognitive load and practically no information content to memorize.

Third, a single debate is not a marker of much – recall Barack Obama’s problematic debate from 2012 when CNN stated that Mitt Romney “trounced” Barack Obama in a debate. That is one reason Obama came out two days ago with the statement that “bad debates happen”.

Fourth, choking in a presentation even substantially should be a common experience. Public speaking is an almost universal fear. It happened to me in a memorable incident where I found myself suddenly blank and thinking about driving across Montana – as I was presenting in a pharmacology seminar in medical school.  I was about 26 years old at the time. My professor snapped me out of it by reminding me where I was and what we were doing. I was intensely prepared and sleep deprived at the time. Since then, I have found that the ability to focus and pay attention to what is happening in a presentation is inversely related to preparation intensity.  In other words – if I overprepare, I am likely to get bored with the content and will find my mind wandering in the presentation even to the point that I do not want to be there. Now, once I have the content mastered – I stop studying it and my plan is to just free associate to the bullet points.  President Biden had no bullet points.

Fifth, the reaction of the pundits has bordered on mass hysteria. Their conclusions that Biden is acutely impaired and too “feeble” has very little basis in fact. Several people including some pundits have described talking to Biden and noticing that in his face-to-face conversations there is no doubt that he is capable and mentally competent.  The fact that he seemed like his old self immediately after the debate in a Waffle House and the next day in a rally also defies the common explanation of what happened in the debate – that he is somehow irreparably impaired. I also had some interesting reactions to this when I was contacted and asked about “what they gave Biden after the debate that brought him back to normal.”  To my knowledge there is nothing.  Memantine was suggested to me, but as a physician who has prescribed this medication for cognitive problems the results are far from impressive. The real question is whether he took anything for cold symptoms before the debate.  Typical medications used have clear cognitive side effects. 

Sixth, time of day – the debate started at 9 PM and went to 10:30 PM Eastern time.  Circadian rhythms are important.  Drawing on my own experience I would never schedule a presentation or a lecture in the morning.  I am not a morning person and that is probably the main reason I did not elect to go into a surgical specialty.  I could not imagine trying to concentrate intensely in the early morning hours. The later in the day the better. I don’t know Biden’s typical schedule but speculate it is loaded in the mornings rather than evenings.

Seventh, Biden’s longstanding articulation disorder.  He has never tried to cover it up. It is a life long problem with no cure, but he has discovered some management strategies. It is probably worsened by stress and changes in voice quality from a recent cold.

Eighth, the pervasive ageism bias has never been more real.  The next day Biden observed that he doesn’t walk, talk, or debate like he did when he was a young man but he is still competent to do the job. His record of accomplishments in the face of an obstructionist party and their Supreme Court - backs him up.

If anything, the debate has taken the focus off Trump’s severe deficiencies.  There were several attempts to fact check the candidates and it was clear Trump had 3 to 4 times as many inaccurate statements.  Some were obvious like the stolen election and infanticide propaganda.  Like all propagandists – repetition seems to work on an unknowing or willfully ignorant public. Apparently, Mussolini was such a skillful propagandist that some of what he said is still believed as accurate today.  In this case the focus on Biden has basically given Trump and the MAGA GOP a free pass and they have been emboldened to the point of suggesting the 25^th Amendment be invoked against Biden based on a 90-minute television broadcast.

Rather than provide another point-by-point contrast between the candidates like I have done in the past there is a simple thought experiment that involves common sense thinking that can be applied. It is not based on wishful thinking or speculation.  It involves looking at the Presidency like a job application. Anyone who has ever applied for a job knows that you need to get recommendations from previous employers, supervisors, and in some cases co-workers.  The Presidency is interesting from this perspective because – all the coworkers are hand selected by the President himself.   Of the 15 cabinet level positions in the Trump administration only 6 people endorse him for re-election.  Eleven do not.  That number does not add up to 15 because of the turnover in the Trump administration and there are probably more people that I missed.  In addition, the most recent same party President George W. Bush and 2 of his 3 Chiefs of Staff, and a National Security Advisor do not endorse Trump in some cases criticizing him with the harshest possible language.  I am not aware of a single Biden staffer who has not endorsed him and President Obama came out with a statement of his support after the debate.

Although a direct comparison of Trump versus Biden is not possible on Cabinet level endorsements because of the lack of a survey of the Biden cabinet – the Trump results are striking based on the level of vehement criticism and what they say about the former President’s intelligence, inquisitiveness, and character.  A direct comparison across multiple dimensions is possible in the survey that President Biden described during the debate.  Presidential scholars rank Presidents across a number of dimensions and in that process, Biden ranks number 14 and Trump is dead last at number 45. Refer to the link for the specifics and outside validation.  The survey has received no coverage post debate relative to President Biden’s performance – even though it is an acknowledgement of his administrations’ accomplishments and a stark contrast to Trump’s rhetoric about how Biden has “destroyed” the country (he used the word destroy 22 times) and he is the “worst” President – (he used the word worst 22 times).  That contrast alone reveals Trump’s strategy.

That is my analysis of the debate from the perspective of a physician who has done thousands of cognitive and decisional capacity examinations.  To be clear, I have no way of knowing whether my suggestions are accurate.  I have not examined either candidate or their medical records. But I know that it takes a lot more to determine a person’s cognitive capacity than what we saw in that debate. The most straightforward solution would be to have each candidate take a standard assessment of their cognitive status and release the results to the public – but politics rarely takes a rational approach.  In the meantime, it is best to avoid the assessments of partisan politicians and party members, comedians, and gossip show pundits.  

This is not a laughing or pitiable matter.

 

George Dawson, MD, DFAPA

 

References:

1:  Nicholas P, Liebowitz M.  Dozens served in Trump’s Cabinet. Four say he should be re-elected.  NBC News July 30, 2023 https://www.nbcnews.com/politics/donald-trump/trump-cabinet-endorsements-rcna96648

2:  Joint Statement from Elections Infrastructure Government Coordinating Council & the Election Infrastructure Sector Coordinating Executive Committees.  November 12, 2020.  Accessed July 1, 2024  https://www.cisa.gov/news-events/news/joint-statement-elections-infrastructure-government-coordinating-council-election

This was known within days of the 2020 election. It is still not accepted by former President Trump and MAGA Republicans:

“The November 3rd election was the most secure in American history. Right now, across the country, election officials are reviewing and double checking the entire election process prior to finalizing the result.

“When states have close elections, many will recount ballots. All of the states with close results in the 2020 presidential race have paper records of each vote, allowing the ability to go back and count each ballot if necessary. This is an added benefit for security and resilience. This process allows for the identification and correction of any mistakes or errors. There is no evidence that any voting system deleted or lost votes, changed votes, or was in any way compromised."

3:  Presidential Greatness Project - see rankings at this site.  Biden #14  Trump #45   

No mention of this comment by Biden or the survey by any of the press.

Graphics Credit:  

Wikimedia Commons - click on photo for full credits and Creative Commons License

Disclaimer: 

As previously noted I am not now and have never been a member of any political party in the United States.  At the same time, it is clear to me that the Republican party, their Presidential candidate Donald Trump, and their partisan Supreme Court are an unprecedented danger to the United States that I have known all of my life and that they should be defeated. It is also clear that they have a level of organization that resulted in political advantages over the opposition and that their rhetorical strategy is to blame the opposition for what they in fact are doing.   

Classification in Biology, Medicine, and Psychiatry

 

Classification in Biology, Medicine, and Psychiatry

I was a double major in college – biology and chemistry. Anyone with similar experience who has done fieldwork in zoology, botany, or associated systems disciplines like ecology is aware of various forms of biological classification. I spent months doing population surveys of plants, aquatic invertebrates, and plankton in undergrad courses and working on water quality surveys for the southern tributaries of Lake Superior.  In the winter, a friend and I would go out on the ice in various locations, chop a hole in the ice, and pump about 80 gallons water through a plankton net – and then carefully take that concentrated sample back to the lab and count plankton species under a microscope. It was painstaking work – but the payoff was a much greater knowledge of the life forms around you.  The lakes, streams, and rivers, and even the ground you were standing on is teeming with life.  Hundreds of species that were unknown until you took those courses and learned how to collect and classify them.

All of that classification was done using a Linnean binary classification system – genus followed by species. As an example, Loblolly pine is Pinus taeda.  Douglas fir is Pseudotsuga menziesii. The Douglas fir example is given because it is not a true fir tree (genus Abies) despite the common name.  The difference is based on morphological characteristics although the entire genome was characterized in 2017. Both the common and scientific names illustrate how species are named.  The common name was after David Douglas a Scottish botanist who described it and the species name after Archibald Menzies – a Scottish physician and naturalist.

Other physicians have been involved in the taxonomy of both human diseases and biological species most notably Carl Linnaeus (1707-1778) – a Swedish physician who is credited with founding the binomial nomenclature used in all modern taxonomy.  He also recognized the necessity of organizing illnesses so that physicians could know they were discussing similar problems. By 1746 he had organized them into nine classes – critici, phlogistici, doloritici, mentales, privatii, spastici, deformans, evacuatorii, and chrirurgia.  Linnaeus was trained as a physician and got his doctorate degree in 1735, but worked as a physician intermittently and for a short period of time until 1741 when he became a professor of botany and theoretical medicine.  

Linnaeus also focused on a species diagnosis rather than a description, meaning features that could clearly distinguish one taxon from another. He went as far as saying the diagnosis should not exceed 12 words and should include previous references and diagrams (6). According to the same reference, the concept of species diagnosis is included in modern nomenclature for species as: “a statement of that which in the opinion of its author distinguishes the taxon from others.” (p. 1090).

Linnaeus taught medical students a course in the diagnosis of disease and in 1759 published a book - Genera Morborum (Varieties of Disease).  He described 11 classes of disorders, 37 orders and 327 genera.  Mental disorders (Mentales) were divided into 3 orders and 25 genera (7). Inspecting the list from that reference suggests that delirium, mania, melancholia, hypochondriasis, anxiety, sleep, and appetitive disorders were all included.  Vertigo was also included and today is considered a neurological or otolaryngological diagnosis.  The overall tenor of reference 7 is that the various systems devised by 17^th and 18^th century physicians would never attain the level of certainty as the biological taxonomy used in natural history that we now know is also controversial.

That brings me back to the problem of biological classification – specifically speciation. That has been a predominate area of study in biology since Darwin and it is not without controversy despite the broad use of these methods in all of biology and science. What is equally interesting is that as far as I know there have been no direct comparisons to medicine and psychiatry.

Let me start by touching on the controversies of speciation from a biological standpoint.  I qualify these remarks by saying my training was at the undergraduate level and all of what I say here is based on recent readings.  I am very interested in hearing from professional biologists on this topic and so far have not been able to get any email responses. My overriding hypotheses are that the same mechanisms leading to speciation controversy in biology may be responsible for classification controversy in medicine and psychiatry.

Coyne and Orr (1) break down speciation into three phases.  The first phase began with Darwin and they point out that he had more to say about changes within species than the origin of new species.  Natural selection was seen as the most important force. The second phase began in about 1935 and was also known as the Modern Synthesis.   It was also marked by a critique of the species concept by Dobzhansky a noted evolutionary biologist.  Reproductive isolating mechanisms were stressed as a necessary cause of speciation. Ernst Mayr another noted evolutionary biologist came up with the biological species concept (BSC).  He defined species as interbreeding populations that are reproductively and geographically isolated from one another.  The third phase started in the 1980s. Coyne and Orr suggest that “more work on speciation has been performed in the past two decades than the entire period from 1859 to1980.”   They speculate that this explosion of work was due to several factors including the new tools of molecular genetics, more extensive use of mathematical models, a new emphasis on ecology, and a use of comparative studies.  The old hypotheses about speciation were re-examined and many new concepts were introduced (in addition to the BSC).  They list nine possibilities grouped as based on interbreeding, genetic or phenotype cohesion, evolutionary cohesion, and evolutionary history (p. 27).

Coyne and Orr described how the species concept was validated over the years.  First, arguments from common sense.  That is that anyone can see clusters of species and recognize they are real. This same phenomenon occurs with physical and psychiatric illnesses.  A second stronger argument is that there is concordance between folk and scientific species.  In this case researchers will look at the species in a given area and see if it is separated out and recognized by local people as being a unique cluster of traits.  That has also been referred to as folk taxonomy.  The concordance is typically high, and I suggest that the same type of concordance experiment is not only possible in medicine – it may have been done using the disease concept (2,3). And finally statistical identification of clusters. This has been done with both medical and psychiatric diagnoses to examine diagnostic features and also to determine if they separate different clusters adequately enough from one another.

The authors carefully explain the exceptions to the various species concept and settle on their own version of the BSC as the more viable one. But even the modern-day species concept is a problem because it does not clearly define all cases.  Several authors refer to it as the “species problem” and there is ongoing controversy in the literature. At the extreme there have been suggestions that the idea of species stems from a limitation of human cognition (we must lump things into categories) or there is a biological continuum that we are marking up arbitrarily.  Any reader of this blog realizes that these are frequent arguments made against psychiatric diagnoses and by extension other complex polygenic medical conditions.  Keep in mind that as far as I know all biology majors working on taxonomy in the past 50 years use the same binary system of classification that I used in college.

To their credit the authors propose how the species concept is useful and they come up with the following observation most biologists want an operational classifier that allows for systematic classification, describes what is seen in nature, helps develop an understanding about how things occur in nature, is consistent with evolutionary history, and applies to most organisms. In other words, it is not very different from what physicians expect diagnostic classifiers to do.  They realize that these are imperfect complex, multidimensional classifiers that are nonetheless useful for daily work and can be fine-tuned for improvements in the individual case.

That is what I am working on so far. I think I have demonstrated how biological classification even using all available methods and directly observable data is difficult if not impossible in many cases. The same can be said about medical diagnoses. That is because both the medical diagnoses and binary species designations are complex, multidimensional variables rather than basic physical structures. It does not mean that groupings in biology do not exist.  The key questions for my additional focus will be on the underlying mechanisms.  I have already described stochastics as a basic biological mechanism introducing some degree of uncertainty into biological systems – but I am sure there are many more.  In this era of proposed alternate diagnostic systems for mental disorders (Research Domain Criteria (RDoC), The Hierarchical Taxonomy Of Psychopathology (HiTOP), etc) – my reading so far suggests that there has been very little input from biological sciences. In most cases it seems like just a reshuffling of existing theory and measurement. My hypothesis going forward is that biological theory has a lot more to offer.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Coyne JA, Orr HA.  Speciation.  Sunderland, MA Sinauer and Associates, 2004: 1-82.

2:   Tikkinen KA, Leinonen JS, Guyatt GH, Ebrahim S, Järvinen TL. What is a disease? Perspectives of the public, health professionals and legislators. BMJ open. 2012 Jan 1;2(6):e001632.

3:  Tikkinen KAO, Rutanen J, Frances A, Perry BL, Dennis BB, Agarwal A, Maqbool A, Ebrahim S, Leinonen JS, Järvinen TLN, Guyatt GH. Public, health professional and legislator perspectives on the concept of psychiatric disease: a population-based survey. BMJ Open. 2019 Jun 4;9(6):e024265. doi: 10.1136/bmjopen-2018-024265. PMID: 31167856; PMCID: PMC6561450.

4:  Hey J.  Genes, categories, and species. NY, NY. Oxford University Press, 2001.

5:  Broberg G.  The man who organized nature.  Princeton, NJ. Princeton University Press, 2023; p. 221.

6:  Renner SS. A Return to Linnaeus's Focus on Diagnosis, Not Description: The Use of DNA Characters in the Formal Naming of Species. Syst Biol. 2016 Nov;65(6):1085-1095. doi: 10.1093/sysbio/syw032. Epub 2016 May 4. PMID: 27146045.

7: Munsche H, Whitaker HA. Eighteenth century classification of mental illness: Linnaeus, de Sauvages, Vogel, and Cullen. Cogn Behav Neurol. 2012 Dec;25(4):224-39. doi: 10.1097/WNN.0b013e31827de594. PMID: 23277141.

 

Graphics Credit:

Stonefly drawing by Carpenter, George H. (George Herbert), 1865-1939.  Public domain per Wikimedia Commons.  Genus is Plecoptera and it was one of the many species I studied in freshwater streams of Wisconsin and Michigan as an undergrad.  Click on the graphic for details. 

Irrational American Gun Landscape Gets Worse….

The Supreme Court voted 6-3 to lift the ban on bump stocks yesterday (on June 14, 2024). The bump stock is a device that allows a shooter to depress the trigger of a semiautomatic rifle once.  After the initial firing the recoil energy of the firearm is used to bring the trigger back against the trigger finger for repeated firing without a subsequent trigger pull.  The result is a very high rate of fire with various quotes of 800 rounds per minute.  The limiting factor is rounds in the magazine and a standard magazine is 30 rounds with some states having lower limits or no limits.  

The majority decision was done by the Republican appointed justices (Roberts, Alito, Gorsuch, Kavanaugh, and Barrett), who used a series of rationalizations to show that in their opinion the bump stock does not convert a semiautomatic weapon to a machine gun as defined by the National Firearms Act of 1934.  Note that the majority opinion uses graphics (Figures 1-6) from the Firearms Policy Foundation - an organization that fights gun control laws (see reference 2 and their web site).  The dissenting opinion by Justice Sotomayor in the final few pages points out the inconsistencies in the majority opinion.  

Both court opinions include the precipitant for the bump stock ban – a 2017 Las Vegas shooting where the perpetrator was able to fire over 1,058 rounds from a hotel room into a crowd at a music festival killing 60 people and wounding 413.  An additional 454 people were injured in the ensuing panic. The gunfire occurred from 10:05 to 10:15 PM.  It is the deadliest mass shooting in the country that holds the record for mass shootings.  From the perspective of bump stocks, the Las Vegas shooter used 14 AR-15 (.223 cal) semiautomatic rifles and 8 AR-10 (.308 cal) semiautomatic rifles.  All of the AR-15s were fitted with bump stocks and 100 round magazines.  None of the AR-10s were fitted with bump stocks and 5 of 8 had 25 round magazines.  The remaining three AR-10s had no magazines. The AR-15s had a potential capacity of  1400 rounds that could have been discharged with a bump stock. The relevant factors from this list is that magazine capacity rather than firing rate is the major limiting factor in the total number of rounds that can be discharged and the shooter overcame that limitation by using more firearms with bump stocks. Only 15 states ban or restrict large capacity magazines.

There are various opinions in the media about how a bump stock ban originated in the Trump administration. The politics is interesting because the precipitating event was so egregious that the National Rifle Association supported restrictions on bump stocks.  I can find no action by the Trump administration other than encouraging the Bureau of Alcohol, Tobacco, and Firearms (ATF) to consider rule changes and in fact this report suggests there was a memo circulated with the usual “guns don’t kill people” message.  The Supreme Court refers to the ATF rule changes but also makes one reference to Trump.  Unless I missed something it seems clear that he did very little on the issue.

At the end of the day – we have a typical party line vote supporting gun extremism.  I don’t care who you are – the only reason you need a bump stock is to kill large numbers of people.  A bump stock is not useful for hunting or target shooting.  It converts a weapon that is already a military weapon (semi-automatic rifle) to what is essentially a fully automatic rifle. Justice Sotomayor’s opinion also includes the original reason for the machine gun ban and that was to keep these weapons out of the hands of gangsters.  Two of the typical gun extremist arguments against even minimal forms of gun control are:  “We already have enough gun laws on the books and they are not enforced” and “If we have more gun control laws only the criminals will have guns.”  They make these arguments while continuing to deregulate guns, make gun regulations harder to enforce, and make guns even more widely accessible either by Republican legislators or judges.

A second development on firearms was a recently released report by the CDC on the accessibility of firearms by children.  This is a timely study because of the April 2024 Michigan court case against a couple whose son shot and killed 4 students at his high school.  In that case the couple was found guilty of involuntary manslaughter and sentenced to 10 years in prison because their son used an unsecure handgun and they did not attend to behavior suggesting he could become violent. At the time of the shooting Michigan did not have a statute about securing firearms at home and that law was passed during the first prosecution of the parents. It was widely hailed as a warning to parents about securing firearms at home.

The CDC report was based on a Behavioral Risk Factor Surveillance System module administered in 8 states (AK, CA, MN NV, NM, NC, OH, and OK)  in 2021–2022.  The survey was administered by land line telephone calls. The nonresponse rate ranged from 3.5% to 12.8% by state.  The prevalence of firearms kept “in or around the home” was 18.4% (CA) to 50.6% (AK).  The general figure from Gallup is in the high 40%.  In 19.5% (MN) to 43.8% (NC) the firearm was stored loaded. Half of those reporting storing a loaded firearm said it was unlocked.  25.2% (OH) to 41.4% (AK) of those reporting storing an unlocked loaded firearm also reported children less than the age of 17 in the home.  For adults 65 years of age or older 58.5% (NM) to 72.5% (OK) of those with firearms had them stored unlocked.  The authors list the usual limitations of telephone self-report surveys but do not comment on cultural or political factors like the belief of some gun owners that the government is coming for their guns.  

The authors conclude that unlocked firearms may place children and other vulnerable populations at risk.  There is a higher suicide risk in the elderly.  It also illustrates how common the scenario is that led to the conviction of the parents for their son being a mass shooter. A secondary consideration of those convictions was a warning to parents that firearms at home need to be secured to prevent them from similar risks. As I commented at the time, that is a very inefficient approach to a problem that could be addressed at the population wide level. It is in effect, one political party putting parents at risk to continue saturating the population with firearms. And now we know it may be  about four in ten parents who store unlocked, loaded firearms, with children in the home.

To me, mass shootings are a function of:

- mass availability of high-capacity and rapid-fire firearms - both rifles and handguns

- gun extremism translated into effects at every level

- cultural effects - the disgruntled employee/student/etc as mass shooter has been an American meme for 50 years...

The Republican Party and their judicial appointees essentially control two of those three variables.  They are a party with no good ideas but they know how to get votes by stimulating excessive emotion around issues like firearms and abortion.  Their current approach to firearms is to place large part of the population at chronic risk with an arbitrary interpretation of the Second Amendment that they think that they can use to get votes. The basis for their gun extremist view, including the current Supreme Court decision is based on false premises rather than rational thought or legal precedent.  Americans generally don’t expect much from political parties and now they can expect the same from a highly partisan Supreme Court.    

George Dawson, MD, DFAPA

 

Supplementary:

I frequently talk about gun extremism on this blog and decided to attach a checklist of what I consider gun extremism to be.  Basically it is a marked divergence with common sense gun laws from the 1970s and earlier (see Tombstone ordinance from 1881). From a political standpoint it is clearly a political maneuver to excite and agitate people and get them to vote for a particular political party.  Like all of the so-called hot button issues it is an exercise in rhetoric and conspiracy theories that has unfortunately led to historic levels of gun violence in the US when compared with high income and low and medium income countries around the world.    

 

Gun extremism checklist:

☐  Advance “stand your ground” and “castle doctrine” laws.

☐  Eliminate bans on handguns

☐  Eliminate bans on assault weapons

☐  Minimize the characterization of “assault weapons” or military style weapons because they are not fully automatic weapons

☐  Eliminate bans on large capacity magazines

☐  Eliminate waiting periods

☐  Eliminate bans on public carry of guns

☐  Eliminate the need for permits to purchase handguns and/or carry them openly or as concealed weapons

☐  Eliminate gun-free locations (ie. places of worship, public transportation, healthcare facilities, public buildings)

☐  Eliminate bans on self-manufacturing of firearms

☐  Eliminate laws on age limits to firearm purchase and possession

☐  Eliminate laws on age limits for handgun and ammunition purchase

☐  Eliminate bans on gun accessories like bump stocks and pistol grip extensions

☐  Eliminate laws on “cannot issue” firearms to certain purchasers

☐  Eliminate gun purchase bans for perpetrators of domestic violence

☐  Eliminate gun purchase bans for convicted felons

References:

1:  Friar NW, Merrill-Francis M, Parker EM, Siordia C, Simon TR. Firearm Storage Behaviors — Behavioral Risk Factor Surveillance System, Eight States, 2021–2022. MMWR Morb Mortal Wkly Rep 2024;73:523–528. DOI: http://dx.doi.org/10.15585/mmwr.mm7323a1

2:  Lithwick D, Stern MJ. The Group Helping the Supreme Court Rewrite America’s Gun Laws Is Worse Than the NRA.  Slate June 15, 2024.  https://slate.com/news-and-politics/2024/06/supreme-court-nra-gun-laws-bump-stocks.html

3:  McClellan C, Tekin E. Stand your ground laws, homicides, and injuries. Journal of human resources. 2017 Jul 1;52(3):621-53.

4:  Rosenthal L. The limits of Second Amendment originalism and the constitutional case for gun control. Wash. UL Rev.. 2014;92:1187.

5:  Rowh A, Zwald M, Fowler K, Jack S, Siordia C, Walters J. Emergency Medical Services Encounters for Firearm Injuries — 858 Counties, United States, January 2019–September 2023. MMWR Morb Mortal Wkly Rep 2024;73:551–557. DOI: http://dx.doi.org/10.15585/mmwr.mm7324a3

6:  Andrade EG, Hoofnagle MH, Kaufman E, Seamon MJ, Pah AR, Morrison CN. Firearm laws and illegal firearm flow between US states. J Trauma Acute Care Surg. 2020 Jun;88(6):752-759. doi: 10.1097/TA.0000000000002642. PMID: 32102044; PMCID: PMC7799862.

"States with stricter firearm legislation are negatively impacted by states with weaker regulations, as crime guns flow from out-of-state."

 

Graphics Credit:

From Wikimedia Commons per the posted Creative Commons licensing agreement. Click on the graphic for all details including author, color coding, and specific CC license.