The Map Is Not The Territory

 

I ran into a quote this week that I must have read and forgotten from the past – because it was referenced in Bateson’s Steps to an Ecology of the Mind.  That was a book I read back in the hippie era after seeing it referenced in the Whole Earth Catalogue.  It happens at a time when I was writing about the usual philosophical rhetoric used to criticize psychiatry.  The circular logic argument I have encountered frequently by philosophers seeking to either destroy the profession or portray psychiatrists as unthinking buffoons.  That quote was “A map is not the territory” and it is attributed to Alfred Korzybski.

When I saw it – I associated immediately to the map I know the best and that is Hwy US2 running across northern Wisconsin between Minnesota and Upper Michigan.  I have travelled that road hundreds of times.  In fact, in 1988 I drove it over 200 times that year to keep a small inpatient psychiatric unit open. Maps these days are much better than they used to be.  For the old road maps to have the same scale and sufficient detail meant a large size that had to be folded and refolded to get it back into the glove compartment.  The above map is a clip from Google Maps and it can be scaled down to the individual house level and from there a street view that is regularly updated.

Thinking about old maps and new maps it is easy to see Korzybski’s argument. Driving US 2 late at night it is common to encounter characteristics of the territory that are not listed or even included in your GPS updates. The territory at night is much different than the territory during the day.  A major difference is deer on the highway.  There are the occasional deer crossing signs but I have suddenly found myself driving among a herd of 30 or 40 deer running next to my car and alongside the road.  The Google camera cars fail to update the video information fast enough to account for social and cultural changes that happen in the small towns along the way.  Am I going to encounter a large influx of out-of-staters for the Blueberry Festival in Iron River or the Strawberry Festival in Bayfield?  Is that small general store still there or is it finally gone? Is the posted or suggested speed limit accurate or do I have to correct for the weather?  

In the era of climate change even modern maps have uncertainty.  Highway 2 has been washed out and under water – both events that have never happened at any other point in my lifetime.  Using modern GPS guidance – I ended up on what appeared to be a dirt wagon trail that eventually got me back to Minnesota.  Every inch of that terrain looked like it had been seen by very few people in the last 50 years and no Google camera cars.  Most people unconsciously adapt to the terrain on the drive home – that sunken manhole cover or pothole to avoid.  We automatically adjust to the hazards even though they are not indicated on any map.  

Korzybski’s argument is basically twofold. First – no matter how far you drill down with a map – even a much-detailed map you will not find what you are experiencing – what your perceptions tell you is there. The map after all is an abstraction by someone and that is not a perfect representation of geography but also not your reality.  From consciousness science - your reality or experience of it is not my reality.   From information theory – the human brain is acquiring much more information going forward than you can get from one derived across a series of finite dimensions and time.  Second – this has clear implications for the ideas of subjectivity and objectivity.  In medicine we construct clinical trials – with exclusion and inclusion criteria that eliminate large real populations and at this point cannot account for the heterogeneity in the remaining research subjects. That does not preclude progress but it should introduce humility into the eventual results. No matter how broad or narrow those selection criteria are – they are only an approximation of the real population who will be treated.

Lest these connections be seen as speculative – here is what map makers and geographers have to say about the situation.  Basic geographic data is a space-time location. In addition, there is other relational data that contextualizes a location.  Data and relationships are discussed in terms of model and how the model is a simplified representation of reality but not reality itself.  A good example was John Snow’s map of cholera during the 1854 epidemic in London and how he used that to determine the source and isolate it. Cartographers are aware of these relational loops to space-time location as well as the limitations that are due to the large number of contextual features.  The map cannot account for them all.  

What does it say about philosophy and rhetoric applied to psychiatry?   

It says a lot about classification systems.  Much research today is preoccupied with ideal classifications.  The DSM for example is criticized for not being a perfect diagnostic system when in fact (like all medical classifications) it is a crude system with additional landmarks.  The graphic below illustrates the problem and how the assumptions made for the diagram on the left do not reflect the reality of the diagram on the right. That diagram is more complex – but not nearly as complex as the real clinical situation. After all – if the clinical situation was accurately reflected in the diagram on the left everyone with schizophrenia would be the same.  Psychiatrists would not have to concern themselves with a developmental history, a social history and life narrative, a medical history, and a family history.  They would not have to consider critical psychological events in a person’s life and putting all that together in a formulation about what is unique about that person.  The territory of that person would include supportive people and important contacts. Like the map of Highway 2 – the DSM gets us into the ballpark but it is not specific about what we will find. 

Korzybski has been described as an independent scholar.  He is credited with inventing the field general semantics.  There is a research institute founded on his ideas. There are not a lot of scholars taking his work forward.  There is an excellent online biography of Korzybski that describes the controversies associated with his writings and varying degrees of acceptance.  Interestingly he wrote about psychiatry and in his biography, there was apparently a group of psychiatrists interested in his work.  He referenced “neuropsychiatry” as a field that had generally been ignored by the rest of medicine.

 

Irrespective of the complexity and controversy of general semantics – I am still focused on the map is not the territory concept for several reasons.  First it reflects what is going on in the DSM classification system.  Second, it describes limitations of any classification system and how that abstraction differs from reality. That is probably the reason that medical diagnostic systems die hard, especially after decades or centuries of the same observations.  Is there any reason to suspect a dimensional or sub phenotyping system would be any better?  Probably not at least until very detailed observations can be made.  A classic paper (4) suggested that hundreds of true/false questions identified psychological traits and that this was an actuarial method superior to clinical judgment.  Despite that alleged superiority many of the methods suggested in that review like the Minnesota Multiphasic Inventory or MMPI have fallen out of use and are no longer used for screening purposes or making diagnoses.  Machine learning and artificial intelligence can produce these results faster and on a larger database but continue to have limited applications.   Third, it reflects expert opinion by at least one of the top theorists in the field (5).  Fourth it reflects good clinical practice that includes a formulation with additional commentary on psychopathology, associated observations and theories. 

At the minimum I hope that you find Korybski’s observation as interesting as I do.  I probably will not read his voluminous works – but I am always aware of the fact that no matter what classification system you are using it is always an abstraction with various degrees of precision.  Further it is an abstraction by one person or a group of people.  The way the DSM (and all of medicine) is structured the precision of both the diagnosis and treatment of a particular patient depends on what occurs during the encounter and the experiences and abstractions of that physician.   

George Dawson, MD, DFAPA

 

Supplementary: Doing research for this post, I encountered another quote that expresses a similar idea:  "The menu is not the meal".  Alan Watts is credited with that quote. 

References:

1:  Korzybski: A Biography (Free Online Edition) Copyright © 2014 (2011) by Bruce I. Kodish.  See chapter 30 for Korzybski’s contact with psychiatry including Harry Stack Sullivan and William Alanson White:  https://korzybskifiles.blogspot.com/2014/06/korzybski-biography-free-online-edition.html?spref=tw

2: Doerr E. General Semantics. Science. 1958 Jul 18;128(3316):156.

3: Gardener M. General Semantics. Science. 1958 Jul 18;128(3316):156.

4:  Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science. 1989 Mar 31;243(4899):1668-74

5: Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.

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What Do Readers of This Blog Want To See?

 

I thought I would ask basically to see if I can be more helpful.  My interest in writing this blog came about because I had many people ask me what I was reading.  They seemed to find my information sources to be interesting. A secondary interest of mine is making sure that the best possible information is available to clinicians who are on the front lines making decisions each day.  Thirdly, the analysis of research whether it is basic science or clinical research is also an interest - both the scientific measures but also the rhetorical aspects.  Many people don't think that rhetoric enters into medicine and science. If you are a psychiatrist we have been contending with rhetoric for decades whether we want to or not and it has extended into literature that most would consider to be scientific.  There are a lot of posts about that rhetoric on this blog.  Fourth - I post about society, culture, and politics and how that impacts us.  I have frequent posts on the cultural effects on behavior - with many posts on my hypotheses about how gun extremism affects us all and is associated with the American mass shooter phenomenon.  Fifth - I have posts on diagnostic reasoning and taught a course to medical students about this for a decade in the past.  I try to tie in diagnostic thinking in psychiatry as a comparison.  Sixth - I have done book reviews on poetry with psychiatric themes and consciousness  and am currently reviewing another poetry book, Keith Rasmussen's book on ketamine, and a book on spirituality where I hope to illustrate a path to connecting that to psychiatry.

My most viewed page recently has been the updated review of systems for psychiatrists.  This is actually a tool I use in clinical practice and there are several other pages like it.  It has recently been viewed over 31,000 times - but I think at some point Blogger (the Google interface that this is published in) - stopped counting page views from virtual private networks (VPNs) by the page and only counts them in aggregate - where there are about 2.1 million views.   Additional highly viewed pages about clinical psychiatry include 2000 Words About the Last Ten Minutes of a Psychiatric Evaluation and Additional Work on the Review of Systems for Psychiatrists.  

Posts that are currently pending include:

1:  Updated post on Neanderthals and why they disappeared.  Paleogenetics is a fascinating read and it has implications for human illnesses, evolutionary aspects of psychiatry, and the evolution of man. 

2:  Review of the poetry book Coming to Love My Darkest Places by Jennifer Kelly. 

3:  Review of The Varieties of Spiritual Experience by David B. Yaden and Andrew B. Newberg.

4:  Review of Ketamine: The Story of Modern Psychiatry's Most Fascinating Molecule by Keith Rasmussen.

5:  Continued posts on the rhetoric of medicine and psychiatry including the theory of that rhetoric.

6:  Continued posts on the importance of biological theory to psychiatry.  I am referring to theory that originates in biology rather than the usual biological hypotheses in psychiatry although they are not mutually exclusive. I hope that I give the impression that I am not very impressed with the proliferation of purely philosophical ideas about the field, especially from people who have never been trained in psychiatry or medicine.  

7:  A musculoskeletal case including images (CT, MRI, bone) with a discussion of complex misdiagnosis and how all of that applies to psychiatry.  

I will avoid a top ten list of what is coming, but that is what is percolating right now. I tend to work better when I am thinking (and writing) about many things at once.  My motivation for this brief post is too see if there are any topics that readers would either like to see or like to see elaborated on.  They can be clinical or theoretical - medical or psychiatric. Feel free to send me your ideas either posted here or to my direct email address. 

I would also like to address two related topics.  The first is the use of these blog posts.  I think most people read them for their own interest, but some have been incorporated into books.  Everything on this blog is Creative Commons licensed.  That means it can be shared for no charge in just about any medium that you want it to be.  The only stipulation is that you cite me and this blog as a source.  I have found myself in the awkward situation of being at a conference and seeing my blog pages projected by a prominent researcher without referencing my work. I do not make any money writing this blog.  I have no paid subscribers or advertisers and pay all of the expenses out of my own pocket.  I think one line of 12 point font referencing my work in the bottom corner of a PowerPoint slide is not too much to ask. 

Even better, I am happy to collaborate.  I am willing to research, cowrite, or make graphics for your project for co-authorship credit and nothing else.  In fact, I recently offered to analyze the utilization of psychiatric medications for a large healthcare plan for free.  They declined the offered but I remain very interested in the analysis of real world data in health care setting.  Send me an email if you are interested.

George Dawson, MD, DFAPA

Supplementary 1:  Requests for topics:

 The request for topics has gone well so far.  The following is a list by topic and/or specific question.  If this leads to any other ideas – feel free to send them to me.  I am also interested in learning about any graphics that people would find useful. 

 

1:  ADHD – rates of diagnosis, how people present for assessment, missed diagnoses and other associated problems, diagnosing adults, and neurodevelopmental diagnoses in general.  (see comment below).

2:  ADHD – stimulant treatment and cannabis use.

3:  Antidepressant withdrawal with a focus on gastrointestinal symptoms.

4:  The models of mental functioning that are helpful in psychiatry.

5:  Indications/guidelines for antipsychotic use in children and teenagers.  Data on long term use.

6:  Memory and cognitive problems associated with POTS (Postural orthostatic tachycardia syndrome) – and recommended medical treatment.

7:  How psychiatry was practiced and the current transition – implications for the future of the field.

8:  Dementias associated with Lyme Disease and other infectious diseases

9:  More biological psychiatry!

10: Pharmacology and psychiatric applications of alpha-1 and alpha-2 adrenergic receptor agonists and antagonists.

11:  Pharmacology and psychiatric applications of beta adrenergic antagonists in psychiatry.

12:  What are inverse agonists in 10 and 11 above?

13:  Post Finasteride Syndrome (PFS) – I continue to get treatment requests for this syndrome.  Some of the people sending me emails explain that I am listed on web sites as a treatment resource, even though I have never personally assessed or treated the disorder.  I will probably post a review on PFS in the next year.

14:  Post SSRI Sexual Dysfunction (PSSD)/Persistent Genital Arousal Disorder (PGAD) – I have posted a review of this disorder and I am listed on web sites as a treatment resource. I have also had at least one person try to convince me to remove my post or modify it to their liking.

https://real-psychiatry.blogspot.com/2023/07/post-ssri-sexual-dysfunction-pssd.html

15:  Antidepressant withdrawal/discontinuation:  I have posted on this and my opinions are all consistent with a recent major review.  I am always interested in medication side effects – no matter the medication and how they can be mitigated. I have also had treatment requests to assist with this problem. I will probably add a post on the major review and also continue to comment on the politicization and the associated rhetoric. As well as placebo/nocebo responses.   

https://real-psychiatry.blogspot.com/2018/06/the-problem-of-antidepressant.html

16:  Supportive psychotherapy:  Throughout my career I practiced supportive psychotherapy in practically every clinical encounter and across every diagnostic category.  I consider it to be a necessary skill for psychiatrists – but it is difficult to write about in terms of both observations and techniques.  At some point I will be posting about this.

17:  How to walk down stairs and minimize the risk of falling:  That's right - I am a psychiatrist and old speedskater with an interest in biomechanics. I will post this as soon as I can figure out how to draw stick figures walking up and down stairs.  Let me know if there is software out there that might help with this type of drawing. 

That should keep me going for a while.  Do not hesitate to send more ideas or questions.

A final note on treatment requests.  I have received these requests as noted on #13, #14, and #15 above from many different states.  My response is always that I am retired from clinical practice and no longer provide active treatment since 1/19/2021.  That also means that I do not have access to what is required to provide medical care and meet licensing requirements (records, malpractice insurance, support staff, etc.).  And even if I did – treating people across state lines remains somewhat of a logistic nightmare.  As a result, I cannot provide telepsychiatry services or casual advice.  What I write on the blog has always been educational and for a large part directed at physicians and more specifically psychiatrists.  It is not medical advice and I hope I have always emphasized that the best treatment with continuity is available from your local physicians and specialists.  Proper medical care requires a formal doctor-patient relationship and that cannot be casual advice.  And for the physicians out there I hope I come across as an interested colleague.  Another intent in writing this blog is not to suggest that my knowledge or practice is superior to anyone else.  Life, biology, and medicine are too complicated for that.

Supplementary 2:

Elements of a dynamic textbook:  In my spare time I will be arranging my blog posts from the past 12 years in the general form of a book.   The intention is not to create a book but an outline for a book.  Not all of the posts will translate well but most will.  I would like it to be dynamic - not psychodynamic but useful to all psychiatrists.  Typical texts waste too much space on just technical details and I would prefer to focus on key concepts and approaches including how that evolves. I will post the outline here when I have it - in the meantime feel free to suggest chapters. 

The American Gun Protection Fantasy and the Secret Service....

 

Ten days ago, a lone shooter attempted to kill former President Trump at a rally in Pennsylvania. About 6 minutes after he began speaking, Trump is noticed to turn his head to the right and then grab his right ear and drop to the ground. He is swarmed by Secret Service agents and after a period that seems too long is escorted off the stage and taken to a local hospital for assessment and treatment.  Three people in the audience are shot – one dead and two seriously wounded.  They were all in the line of fire seated behind Trump.  About one minute later the Secret Services Counter Assault team returns fire fatally wounding the shooter.  Weeks later it is learned that the shooter may have fired as many as 8 rounds based on shell casings found near his body on the roof.

There is immediate speculation and controversy about the incident. Quite incredibly several members of the Republican party blame the incident on Democrats even though they are the party that has been espousing political violence and gun extremism. Preliminary reports suggest that although the shooter is a registered Republican – he donated $15 to a liberal cause a few years earlier.  The shooter was using an AR-15 rifle that he borrowed from his father and he had purchased 50 rounds of ammunition.  At the time of this post there is no information on whether he was using a high-capacity magazine or not.  The state of Pennsylvania has no prohibition on assault rifles or high-capacity magazines.

We subsequently learn that the shooter did not make the cut for his high school shooting team, but did belong to a local shooting club.  He was described as a loner who was bullied in school. Some people described him as bright and eccentric.  All agreed that there was no suggestion that he was a potentially violent individual and nobody ever heard him make any threats. It was later learned that he did some drone surveillance of the site and had saved materials on several people from both parties.  To at least one analyst this data suggested that his goal was a mass shooting rather than an assassination.  Others speculated that it may have been a “suicide by cop” scenario.  Some information leaked from the preliminary investigation suggested he was searching “major depression” on the Internet. 

We also learn that the shooter had a picture of a recent mass school shooter whose parents were also convicted for allowing him access to firearms.  The shooter in this case places his father in the same predicament, although there have not been any statements from the parents.

At this point there are signs that there were significant security lapses.  That led to Congressional testimony by the Director of the Secret Service on July 22.  Several members of Congress demanded an immediate resignation and she subsequently resigned on July 23. She did accept full responsibility for the security lapse, an administrative maneuver that is apparently expected only in the government.  She resigned at a time when the results of the investigation of the incident are still pending.

The public has been presented with interviews of people who saw the shooter on the roof and tried to get the attention of law enforcement including the counter assault team without success.  The shooter was approached on the roof by a police officer who apparently had to back down because the rifle was pointed at him and he was not able to draw his weapon in defense.  There was a story today that Secret Service agents were located at the roof level on the interior of the same building that the shooter was on but did not see him.  The shooter was identified as a “suspicious person” but not a threat because his rifle was not seen initially. If he had been identified as a threat – Trump would have been sequestered in a safe area until the threat was neutralized.

I have not heard any information about the perimeters established for security.  I heard initially that there was a Secret Service perimeter closest to Trump and extending out for 200 yards.  The meant that Secret Service was responsible for anything inside that perimeter and local law enforcement was responsible for the next tier beyond 200 yards.  That may explain the aborted attempt by the police officer to intervene moments before the shots were fired at Trump. 

Most significant to me as a psychiatrist is the continued “search for a motive” or that “no motive has been found.”  That is a routine finding in these events.  There really are no rational motives for picking up a gun and trying to kill the former President or anyone else.  There is no motive for essentially firing into the crowd beyond Trump and killing a spectator and seriously injuring two more.  Most firearm related homicides are irrational acts – related to angry disagreements and firearm accessibility.  The fact that motives are lacking is probably the reason mental illness is often considered to be a factor in firearm homicides. 

That takes me back to my hypothesis of mass shooters that can probably also be related to lone shooters in this case.  The United States has a long history of cultural memes related to firearms.  Film and television is a rich source of revenge stories where the hero/antihero is wronged and proceeds over the next 90 minutes to kill everyone who wronged him.  That has extended in the media to include mass shooters and school shooters. Many are described as “bullied”, loners, or mentally ill.  The overriding story is the revenge meme – whether it is accurate or not.  For several decades the meme involved postal workers "going postal" due to workplace stress and mismanagement although a subsequent investigation showed the incidence of post office violence was not greater than other workplaces.   All it takes is a marginal person without self-control ability to decide to project their problems onto an available individual or group and extract their revenge.  The method of choice in the US is a firearm.

There is another group and cultural factor that may be important in these cases and that is the American sniper.  There are thousands of snipers in the US military.  They typically operate at a range of 600-1200 meters, although several shots have occurred at much greater distances. The IMDB database lists 18 sniper movies dating back to 1963. Just inspecting that list suggests to me that there are many more. And of course there are constant real-life stories about mass shooters.

My point about snipers is fourfold.  First, it reinforces the shooter meme in that a sniper is generally seen as a very competent person who is shooting people for the right reason.  Even the cinematic revenge version often has the audience primed to see the shooter's viewpoint.  Second, snipers are generally portrayed as cool and professional.  Third, there are any number of weapons that can be used to become a self-styled sniper.  The first mass shooting I became aware of was the Texas Tower mass shooting of 1966.  The incident occurred at the University of Texas and the shooter fired from the same clock tower position.    Snipers are generally portrayed as possessing some special talent to shoot well – but the reality is that anyone can shoot well – even at a distance if they have enough practice. Fourth, gun access in the US is easy.  The problem of how long mass shooters experience thoughts about shooting people is unknown and probably an impossible study.  That leads to a certain politics of explaining the motives.  To gun extremists the shooter is just “a bad guy with a gun.” who needs to be stopped by a “good guy with a gun.”  Many of these same gun extremists tend to blame the behavior either on mental illness or the treatment of mental illness even though most incidents are not related to either.  This group rigidly avoids acknowledging their possible role due to cultural changes and the widespread availability of guns.  They are joined by some mental illness advocates for not treating mental illness who suggest the behavior is due to medical treatment.  In the past, I have suggested going after the problem directly and approaching it as a public health problem.  That is – if you have homicidal thinking call an emergency number for intervention.  Acute care psychiatrists intervene in the problem when it is precipitated by severe psychopathology, but in most cases that is not the issue.  It is safe to say, the problem and successful interventions cannot be well studied in the current landscape.

Getting back to the shots fired at the Trump rally, Trump was speaking 430 ft away from the shooter or about 131 meters.  That is well within typical sniper range.  Further – given the military sniper range suggests that the Secret Service would need to secure the entire area out to 10 times the distance to that rooftop and even then, that may not be far enough.  If there are two important lessons from this event it should be that guns are inadequate protection from a shooter with an element of surprise and a long-range weapon.  You can make the argument that the Secret Service snipers may have stopped a mass shooting event, but at this point that seems to be highly speculative.  Secondly, the perimeter is very significant.  If the initial descriptions of a 200-yard perimeter are accurate – new strategies are required and even then, I would question the likelihood of stopping catastrophic results from single shot fired by a sniper who was trained in evasive action.  These are important considerations when the political solution at this point appears to be an investigation focused on who to blame for security lapses.  Members of Congress are saying all that is needed is a thorough and transparent investigation.  So far – very few details of the investigation are available.

It is doubtful that the obvious cultural factors like gun extremism, widespread availability of weapons and military style weapons, and the cultural phenomena of the lone wolf shooter will be addressed. It is doubtful that public health approaches to the problem will be discussed. I expect a final report several hundred pages long focused on what law enforcement and the Secret Service should have done.  I look forward to reading that report to see what perimeters and measures are considered and anticipate that they will be woefully inadequate compared with any determined shooter from a long range. 

And then there are the legal considerations. After the Reagan assassination attempt, the Brady Bill – a modest modification of existing gun control laws was eventually passed 12 years later.  Since that time there have been decades of gun extremism put into the law, basically because one of the major parties needs the issue for political purposes.  This has made the United States less safe for everyone including Presidential candidates.  The most striking example is that the city of Milwaukee was not able to ban firearms outside of the hard security perimeter at the Republican National Convention that occurred 2 days after Trump was shot at.  Wisconsin law prohibits local municipalities from banning firearms.

Over the past 30 years we have gone from a nation of common-sense gun laws – to a nation of gun extremism.  That is almost entirely due to the actions of the Republican party and its politicians.  There has been a clear association with increased firearm deaths and there has been no resulting retracing of the path to gun extremism.  Gun extremism puts everyone at risk including Presidential candidates. I will refrain from the usual political platitudes about how I hope everyone will be safe out there. Hopes and prayers for the victims of firearm violence have not changed anything so far and I expect more of the same until the party of gun extremism decides to change their mind or they are voted out. 

These are my observations about this Trump rally. It was a shocking event, but probably not shocking enough to change any gun laws or the steady march towards gun extremism that is oddly enough in the hands of the party whose candidate was targeted. 

George Dawson, MD, DFAPA

References:

1:  Update on the FBI Investigation of the Attempted Assassination of Former President Donald Trump Update: July 15, 2024, 3:05 p.m. EDT:

https://www.fbi.gov/news/press-releases/update-on-the-fbi-investigation-of-the-attempted-assassination-of-former-president-donald-trump

2:  Neuman S, Westervelt E.  Trump's close call: A detailed time line.  NPR:  https://www.npr.org/2024/07/19/nx-s1-5041734/trump-shooting-assassination-crooks-bulter-secret-service 

 

Supplementary 1:

I decided to write this essay ahead of any investigation results because it appears that will be a very slow process. I will read those reports as they become available.

Supplementary 2:  This article became available after I completed the above post.  It is based on testimony by the FBI Director Christopher Wray.  He states the AR-15 used by the shooter had a collapsible stock and therefore was easier to conceal.  He also said the shooter flew a drone for 11 minutes over the site about 2 hours before the event.  And in terms of the motivation:   

"Wray said investigators haven’t found a manifesto or obvious motive for the shooting. He said pictures were saved in the cache of Crooks' electronics from news searches, rather than necessarily because of a specific search for a public official."

https://www.yahoo.com/news/fbi-director-wray-set-house-143641332.html

Supplementary 3:  Additional fragments of information today in the news. There were 8 expended cartridges next to the shooter's body.  No word on the location of the other 42 rounds or whether there was a high capacity magazine.  Some data from the shooters laptop showed that he did a Google search on the JFK assassination searching on both Kennedy and Lee Harvey Oswald. 

Graphics Credit:

Click on graphic to get full information and CC license on Wikimedia Commons.

 

 

 

 

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.