Re: Access

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New Jersey law requires coverage of mental illness only if it is biologically based.

The fuck? As opposed to the kinds of mental illness that are really the affliction of Apollo?


Posted by: Cala | Link to this comment | 02- 2-08 7:26 AM
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As to the question in the post, I don't know enough about what kinds of things can count as evidence in insurance cases to judge where a semi-private network like Facebook or myspace would fall, but I'd rather the courts treat it more like personal correspondence than public declarations, because that's how the users seem to use it.


Posted by: Cala | Link to this comment | 02- 2-08 7:31 AM
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But the privacy issue is cut and dried: if you sue someone, and claim emotional injury, you're pretty much going to have to turn over your personal diary. If you destroy it after the suit starts, or even after suit is contemplated, you might get an adverse inference.

The discovery standard -- not direct relevance, but 'likely to lead to admissible evidence' is a very low threshold.

Litigation is not for the faint of heart. Or those who would maintain much in the way of privacy.

Except the US government . . .


Posted by: Nápi | Link to this comment | 02- 2-08 7:35 AM
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Personal correspondence is absolutely discoverable.


Posted by: Nápi | Link to this comment | 02- 2-08 7:36 AM
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. . . unless it's addressed to your husband or your lawyer.


Posted by: Nápi | Link to this comment | 02- 2-08 7:37 AM
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4: Oh, definitely. But I guess (?) there's a difference between personal correspondence and what would, e.g., be published by that person in a newspaper, and that I'd be happier if Facebook ended up in the former category.


Posted by: Cala | Link to this comment | 02- 2-08 7:47 AM
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The fuck, as seen in 1, is right; they won't cover mental illness unless it's physical? Um, huh? What kind of daffy-ass dualists are these people?


Posted by: Sifu Tweety | Link to this comment | 02- 2-08 7:51 AM
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5: Sexist.


Posted by: JP Stormcrow | Link to this comment | 02- 2-08 7:52 AM
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7: Equity between mental and physical illnesses is one of the major actual-health-care reforms being proposed by the Dems (as opposed to the health care payment reforms that are the prominent part of the discussion). I'm pretty sure that both HRC and BO are on board with this.

Usage question: My inclination is to match HRC with BHO, but of course I don't want to emphasize a middle name that he doesn't. Opinions?


Posted by: JRoth | Link to this comment | 02- 2-08 7:59 AM
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7: The kind that don't believe in akrasia.


Posted by: JP Stormcrow | Link to this comment | 02- 2-08 8:02 AM
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9:Hussein or Body Odor is the new Scylla and Charybdis.


Posted by: Cala | Link to this comment | 02- 2-08 8:07 AM
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7: Given how little acceptance the kind of psychological monism we're talking about has in the US populace at large, I'm not sure it's fair to vilify insurance companies so much for holding this position. I mean sure, insurance companies are the devil, but give US culture its fair share of the blame.


Posted by: pdf23ds | Link to this comment | 02- 2-08 8:14 AM
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12: So, people get the insurance companies they deserve?


Posted by: JP Stormcrow | Link to this comment | 02- 2-08 8:18 AM
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Well, if you want to be cynical about it. More like, discrimination by insurance companies against the mentally ill is just another instance of our wider culture's discrimination against them.


Posted by: pdf23ds | Link to this comment | 02- 2-08 8:23 AM
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12: I'm vilifying New Jersey, personally. It just seems ridiculous that a condition which, e.g., I would have to be diagnosed by a physician to obtain prescription drugs in order to treat it doesn't count as a physical disease.


Posted by: Cala | Link to this comment | 02- 2-08 8:30 AM
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15: I don't know how widespread the problem is in various states, but there does seem to be some energy to do something about it on a national level. The Paul Wellstone Mental Health and Addiction Equity Act. Patrick Kennedy is the Democratic sponsor. And there does seem to be something specific proposed in New Jersey as well.


Posted by: JP Stormcrow | Link to this comment | 02- 2-08 8:43 AM
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I presume, if the NJ statute is in any way reasonable, they are only requiring cover for conditions with a known physical etiology -- which excludes a lot.*

You don't have to be a dualist, or religious, or a bastard insurance company to seriously doubt whether many of the conditions currently diagnosed by mental health professionals form, for example, natural kinds whose conditions of membership are susceptible to physical description.**

You can argue that 'being a physical disease' is a dumb criterion for insurance coverage, and I'd probably be on board with that argument. However, you can also argue, pretty successfully in my view, that, if 'physical disease' is the criterion, then many psychiatric diagnoses don't meet that test.

* i.e. about 90% of the stuff listed in the DSM-IV.
** take that as hand-wavy stuff for a more detailed account of disease individuation.


Posted by: nattarGcM ttaM | Link to this comment | 02- 2-08 9:06 AM
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17: Finally, a dualist to argue with! (OK, are you a dualist? I can't really tell from 17.)

"seriously doubt whether many of the conditions currently diagnosed by mental health professionals form, for example, natural kinds whose conditions of membership are susceptible to physical description."

I guess, in your view, that if we did have a pretty thorough understanding of the brain, and were able to describe the physical patterns of connection that lead to these conditions, that it would still be improper to say that's a "physical" description, rather than a psychological one? Or do you doubt that such a description will ever be possible?

Now, I might accede, if pressed, that the severe bluntness of all of our current treatment methods (like fixing a watch with a hammer) and their unreliability might have some implications for how we need to insure them. I'm not too familiar with anorexia/bulemia--do they respond to standard treatments as well as, say, depression?


Posted by: pdf23ds | Link to this comment | 02- 2-08 9:13 AM
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"physical patterns of inter-neuronal connection", that is.


Posted by: pdf23ds | Link to this comment | 02- 2-08 9:16 AM
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You can argue that 'being a physical disease' is a dumb criterion for insurance coverage, and I'd probably be on board with that argument.

I think this is probably the way I'd argue it, just to sidestep natural kinds! I could press you on the etiology and diagnosis, but this is your area, not mine, and I have a feeling it would be a nice, polite high-level discussion that would just annoy you.

So I should amend my 1 to say "the fuck? given that many mental illness are at least as debilitating as physical illnesses, and that the procedure for obtaining care is remarkably similar (must go to licensed professional to obtain anti-depressants or a treatment plan), "biologically based" is a dumb criterion."


Posted by: Cala | Link to this comment | 02- 2-08 9:25 AM
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re: 18

I'm not a dualist, no, and I'm perfectly happy with psychiatric conditions with known physical etiologies and well-understood pathologies being described as 'physical'.

So you're misreading me, I'm afraid. I'm coming from the much more straightforward viewpoint that the majority of our psychiatric diagnostic categories are, not to put too fine a point on it, utter bullshit. That is, they have about as much likelihood of featuring in some full-developed, neuro-scientifically informed future psychiatric disease classification as 'melancholy' or 'an excess of yellow bile', i.e. none at all.

[on preview]
re: 20

Yeah, I think that's the way I'd be inclined to go, too. That is, I think that given that right now we don't have a fully-developed psychiatric nosology*, the only right way to go is to adopt some criterion based on quality of life, or 'harm'.

* there are psychologists and psychiatrists who dispute even the basic division between affective and psychotic disorders, for example.


Posted by: nattarGcM ttaM | Link to this comment | 02- 2-08 9:33 AM
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Ahh, I see now that's what you meant by "natural kinds". I have a hard time believing, though, that categorizations like anorexia, OCD, and autism are bullshit. The symptoms are too consistent and too distinct. OTOH, things like depression, ADHD, and personality disorders I could more easily believe are nowhere near being properly understood, since there's so much overlap between symptoms individual cases. Is that what you mean by 90% of the DSM?


Posted by: pdf23ds | Link to this comment | 02- 2-08 9:41 AM
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The politics and PR of psychology and psychiatry are quite a mess. In counseling psychology you have a lot of entrepreneurs claiming to be able to make unhappy people unhappy in various ways, and not all of them are fakes but some are, and even some of the non-fakes misuse scientific and medical language. At the clinical end you also have entrepreneurs marketing syndromes and traits and disorders and treatments to schools, employers, corrections entities, and the military. The intellectual and scientific controls on this seem quite weak.

The confusion of the normative and the descriptive, and the applied and the theoretical, in the context of financial and institutional interests and power relationships, is the dirty secret of social science. You can see it everywhere.


Posted by: John Emerson | Link to this comment | 02- 2-08 9:44 AM
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re: 22

Is that what you mean by 90% of the DSM?

Yes, more or less.

Btw, 'Natural kind' is a philosophers' term of art, rather than any usage specific to me.

categorizations like anorexia, OCD, and autism are bullshit. The symptoms are too consistent and too distinct.

Yes, and in some cases the patterns of symptom clusters are well-attested going back centuries. However, those sorts of stable conditions with reliable diagnoses are far from being the majority.


Posted by: nattarGcM ttaM | Link to this comment | 02- 2-08 9:44 AM
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21: I still have a quibble, though. Even disorders we have no fucking clue about still have a physical etiology, just not a known one. Now, it's true that usually someone calling it "physical" is trying to imply all sorts of other things involving moral responsibility, propriety of treatment, implying that the etiology is much more well understood than it actually is (i.e. the "a chemical imbalance in the brain" bullshit), etc., that don't actually follow, but technically "physical" is a proper term.


Posted by: pdf23ds | Link to this comment | 02- 2-08 9:46 AM
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21: I was thinking that a good analogy might be pain management. Utterly subjective, often no identifiable physical cause, but not usually excluded by insurance.


Posted by: Cala | Link to this comment | 02- 2-08 9:47 AM
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24: You and your carving nature at the joints.


Posted by: Cala | Link to this comment | 02- 2-08 9:48 AM
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My sister deals with alcoholics and drug addicts, many with criminal pasts and with "borderline personalities", and many have histories of family abuse as well as poverty. I have no doubt that they need help and I'm increasingly convinced that counseling is good for them, but I'm not at all sure that their problems are medical or physiological in cause, though presumably any behavioral predisposition has some kind of physiological coding somewhere in the brain.


Posted by: John Emerson | Link to this comment | 02- 2-08 9:48 AM
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"the dirty secret of social science"

I thought that was the lack of proper statistical techniques, and most of the big theories being nebulous bullshit? Or am I thinking of economics?


Posted by: pdf23ds | Link to this comment | 02- 2-08 9:50 AM
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How about this, everyone? Instead of saying something is "physical" vs. "psychological", we instead say "proximately physiological" and "proximately psychological"? In 10 years when those are the default understanding we can stop being so explicit.


Posted by: pdf23ds | Link to this comment | 02- 2-08 9:53 AM
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re: 27

Actually, I'd not want to argue that a natural kind model is the right one to adopt. I'm just talking of natural kinds as short-hand for something a lot more complicated that I'm not going to outline here.

Even disorders we have no fucking clue about still have a physical etiology

Actually, that's far from certain. There's a whole load of other work that would need to be done to establish that. You'd need to establish that the putative disorder i) was a disorder, that ii) the individuals diagnosed with that disorder shared a common pathophysiology with a similar etiology, etc. among a load of other stuff.

The problem with a lot of the diagnoses we 'have no fucking clue about' is that it's far from certain whether the various individuals grouped together have much in common except their symptoms.

The most you can say is just to affirm physicalism. Sure, in every individual case [if physicalism is true] there's a physical explanation for that individual's behaviour. But, er, that's about it. Establishing that all the people behaving in that way are suffering from the same disease is a much stronger claim. All of this is just a plea for more methodological robustness in psychiatric disease classification.


Posted by: nattarGcM ttaM | Link to this comment | 02- 2-08 9:58 AM
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31: Yeah, I agree with all that. I'm probably misusing "etiology"; I didn't mean to imply that it would necessarily be common between people currently classified the same way.


Posted by: pdf23ds | Link to this comment | 02- 2-08 10:02 AM
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31: What makes me suspicious is that this law is being used to exclude anorexia, which is not, as I understand it, usually considered one of the out-there diagnoses. Specific measurable physical criteria (weight loss, physical changes), &c. And that's what's up for exclusion?


Posted by: Cala | Link to this comment | 02- 2-08 10:02 AM
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Basically, if someone grows up poor and abused in a seriously disfunctional alcoholic family, and goes on to become a poor, disfuctional alcoholic individual, there will certainly be physical effects. But the causes might just be the result of events and experience. A lot of people default every explanation to heredity, brain damage, etc. (physical causes), but I think that's overdone.


Posted by: John Emerson | Link to this comment | 02- 2-08 10:03 AM
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34: From my point of view, "events and experience" are every bit as physical as anything else, but much more proximately psychological than physiological. Make sense? I don't mean to limit "physical" to heredity and large-scale physiological problems (e.g. brain damage, thyroid dysfunction, etc.), although I realize the word's commonly abused thusly.


Posted by: pdf23ds | Link to this comment | 02- 2-08 10:08 AM
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33: Yeah, even under the intellectual model the insurance companies are using of mental disease, their position is still a huge stretch. Bastards.


Posted by: pdf23ds | Link to this comment | 02- 2-08 10:10 AM
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re: 33

Yeah, that seems like bullshit.

Fwiw, I'm playing devil's advocate a bit above. There's a paper by David Papineau -- which I'm probably crudely misrepresenting -- from a few years back that argues that we shouldn't expect nice clean cut physical explanations for psychiatric disease and he bases that claim on some arguments from the philosophy of mind -- which I broadly buy into -- and some arguments from the philosophical analysis of biological function -- which I don't.

I'd not even necessarily oppose some sort of 'psychodynamic' account of some symptoms. I'd just want to defend the view that we ought to expect greater methodological robustness in disease classification that we currently have, though.


Posted by: nattarGcM ttaM | Link to this comment | 02- 2-08 10:14 AM
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Greater methodological robustness would be a nice thing to have in a lot of fields.


Posted by: pdf23ds | Link to this comment | 02- 2-08 10:15 AM
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||

I'm a sucker for stuff like this video Obama's campaign just put out. Goes to my bumper sticker slogan, 'Progressives: No Power, More Fun'.

|>


Posted by: asl | Link to this comment | 02- 2-08 10:19 AM
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A definition from the 1999 NJ statute:

"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism.


Posted by: Nápi | Link to this comment | 02- 2-08 10:22 AM
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Pdf, I think that you're pushing th argument into metaphysics. To me it's reasonable to ask what the distinction "physically caused" / "not physically caused" might mean, and then decide whether it's a meaningful distincyion which should be applied the way it's being applied.


Posted by: John Emerson | Link to this comment | 02- 2-08 10:22 AM
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Also, I wouldn't expect the physical explanations to necessarily be clean-cut at all. What I'm visualizing is simply, at some point, being able to directly see inside someone's brain at a high level (using analysis tools and abstractions that will be developed if we're ever going to be able to understand the brain), and being able to point out what's going wrong in a way that'll probably end up sounding a lot like psychoanalysis, except that it'll demonstrably map onto structures in the actual brain. And that understanding would lead to a much better psychiatric nosology, resulting in cognitive therapy/NLP/neurofeedback/hypnosis/etc techniques of much greater specificity and potency.


Posted by: pdf23ds | Link to this comment | 02- 2-08 10:24 AM
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41: Well, I'm assuming deterministic physical reductionism, which I guess is a metaphysical position, but I'm not aware that you're taking a different position.


Posted by: pdf23ds | Link to this comment | 02- 2-08 10:27 AM
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40: Seems like a definition arrived at by compromise.

42: The question seems to me whether they'd be necessary. I brought up pain before because pain management is something where the treatment (ameliorate the pain via drugs) is such that even when there is a demonstrable physical cause (e.g., osteoarthritis), the physical cause is less important than the patient's day-to-day comfort. (E.g., when I fell ice skating and banged the heck out of my tailbone, the doctor didn't need to scan my brain in order to figure out whether I was in pain.)


Posted by: Cala | Link to this comment | 02- 2-08 10:31 AM
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Yeah, but you seemed to push it to the degree of saying "all conditions are physical", which is truistic in your system. The words they used seem to indicate a somewhat different metaphysical system, perhaps dualist, but rather than refute their metaphysics it makes more sense to figure out what they were trying to say.

I think that the kind of total knowledge of the brain that you sketch is a bit Borgesian and, at best, very far in the future.


Posted by: John Emerson | Link to this comment | 02- 2-08 10:32 AM
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44a -- No question about that. Sadly, the NJ legislature rejected a bill in 2006 to explicitly include eating disorders in this definition. Maybe they'll have better luck this time 'round.


Posted by: Nápi | Link to this comment | 02- 2-08 10:35 AM
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44: Well, no, actually looking inside wouldn't be necessary if our (improved, fairly complete) understanding allowed us to accurately infer what's going on from patient interviews, but I can imagine there might be some pairs or groups of conditions with significantly different etiology and treatment with similar symptoms where an fMRI (or future equivalent) would end up being called for to differentiate.

45: Well, yes, I think "all conditions are physical" is a truism. That's why I've been trying to push language that's more using in making distinctions in my system--"proximately physiological" and "proximately psychological". I think those terms roughly correspond to a dualist's "psychological" vs. "biological".


Posted by: pdf23ds | Link to this comment | 02- 2-08 10:39 AM
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using s/b useful


Posted by: pdf23ds | Link to this comment | 02- 2-08 10:40 AM
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39: asl, in case you missed the link from last night, here's more Obama fun for you.


Posted by: Jesus McQueen | Link to this comment | 02- 2-08 10:47 AM
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I'm glad this got cleared up quickly. When I read the first paragraph, I couldnt understand what the big deal was.

When you sue, I get everything.

HOWEVER, in Virginia, now mental health treatment records are privileged and you can block the child or the parent's therapist from testifying in any custody case.

The mental health professionals successfully outlobbied the lawyers.

It is really stupid because a factor in a custody case is the mental well being of the parent and child. So the parent is screwed up or the child is screwed up, but the court doesnt find out.


Posted by: will | Link to this comment | 02- 2-08 11:03 AM
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"I think that the kind of total knowledge of the brain that you sketch is a bit Borgesian and, at best, very far in the future."

Well, science tends to be really good at figuring out the physical structure of things that are really hard to look at directly. Chemistry has always amazed me about how much it knows using such meanderingly indirect methods about atomic and molecular structure. Same for cellular biology. We're developing techniques to do the same sort of thing for the brain.

IOW, I'm not imagining they'll be able to *literally* look at the brain like that until long after they've already figured out what they'd see.

And, of course, being a singularitarian, I expect much sooner and faster progress in the cognitive sciences than most people. But we've already been over that.


Posted by: pdf23ds | Link to this comment | 02- 2-08 11:06 AM
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To me the problem with that is that reading off mental states from neurons would be like reading off a math answer calculated on a computer from the bits and bytes on the readout. Metaphysically there's no doubt that computer programs are reducible to bits and bytes, but in information terms, getting information that way is prohibitively time-consuming.


Posted by: John Emerson | Link to this comment | 02- 2-08 11:13 AM
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49: Plagiarized from the internet "Atlas Shrugs", but funnier. Normally a cheesecake model for Maxim.


Posted by: John Emerson | Link to this comment | 02- 2-08 11:17 AM
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Well, if you're doing in manually, sure. I don't imagine that would be the case, though. You got your fancy brain-readin' equipment, and your fancy bioinformatic data-mining super-duper programs to help you out with the raw output.

I mean, there's already an example of that sort of thing. There's tons and tons of processing and fancy image formatting required to make the output of MRI machines readable.


Posted by: pdf23ds | Link to this comment | 02- 2-08 11:19 AM
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You got your fancy brain-readin' equipment, and your fancy bioinformatic data-mining super-duper programs to help you out with the raw output.

There are good reasons for thinking that that might never be possible [or at least for believing it to be really hard, for very large values of hard].

[However, at this point I'm not going to rehash decades of philosophy, cognitive science, neuroscience, etc.]


Posted by: nattarGcM ttaM | Link to this comment | 02- 2-08 11:26 AM
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55: Plus, there's very good reason to think that even if science makes those advances, medicine might not take that route, since it's really a different sort of process than science.


Posted by: Cala | Link to this comment | 02- 2-08 11:39 AM
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My first reaction to this was essentially what Cala said more eloquently than I could in the first comment. ttaM, you make interesting points about the primitive state of psychiatric diagnosis, but does that apply to eating disorders? Google turns up a lot of papers, and it's hard for me to get a quick sense from the results of whether there's any consensus about anything, but it looks like there may be known physical aspects of these disorders. The role of leptin and a particular part of the hypothalamus in regulating appetite is well-known, textbook intro-psych stuff (who hasn't seen pictures of the "fat mouse"?). I'm sure anorexia and bulimia are much more complicated, and shaped to a fairly large extent by our society, but I expect there are still underlying biological aspects that can be identified.


Posted by: essear | Link to this comment | 02- 2-08 11:45 AM
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On some level, I have a hard time with these distinctions. I think that they only really amount to a societal decision which says that schizophrenics, as a matter of right, deserve more insurance coverage than people who just want couples counseling, but on some level everything is biological. We are biological creatures, and none of this occurs outside of our brains.

As a personal aside, I recently got back a neuropsychological evaluation, and it is really depressing me. My verbal scores are great, but my motor skills are appalling and my visual-spatial reasoning is very weak. I said, "Fine, so I should avoid work which places excessive demands on visual-spatial reasoning, but is there anything I can do to try to improve my performance IQ." Short answer: no. We know how to help people improve their verbal disabilities, but we don't know much at all about workign on visual-spatial stuff.


Posted by: Bostoniangirl | Link to this comment | 02- 2-08 11:54 AM
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What's visual-spatial reasoning?


Posted by: Cala | Link to this comment | 02- 2-08 11:58 AM
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You might try video games even though you won't play them well.


Posted by: John Emerson | Link to this comment | 02- 2-08 12:03 PM
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May I suggest? I know I have deadlines when I start sniffing around the net for little games I haven't seen before.


Posted by: LizardBreath | Link to this comment | 02- 2-08 12:04 PM
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Wikipedia has what looks like a good summary of literature on the physiology of anorexia, with links to the relevant literature. The interesting bit is that serotonin pathways remain disrupted after recovery. Shouldn't this sort of finding make laws that treat these disorders differently from "biological" ones untenable?


Posted by: essear | Link to this comment | 02- 2-08 12:08 PM
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Curse you, LB. Right back at you.


Posted by: Jesus McQueen | Link to this comment | 02- 2-08 12:09 PM
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A few examples visual-spatial reasoning tasks:

Block designs. They give you 4, 9 or 16 blocks and you have to re-create the pattern. The blocks are white and red on different sides and some of them have are split diagonally down the middle, half red and half white. They time you to see how fast or if you can recreate the design at all.

Picture creation. They show you a picture, take it away and ask you to recreate it. Nobody is expected to get it exactly, but they look at the process you employ. I went straight for the details and faield to notice that it was a square bisected diagnonally.

Noticing what's missing in a picture. I'm very slow at it, and I missed several entirely.

There are other executive function tests that involve telling a story using a variety of pictures. The verbal version involves answering questions about a story you've been told.


Posted by: Bostoniangirl | Link to this comment | 02- 2-08 12:10 PM
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This is a great discussion. If Ttam posted links to a good introductory version of some of the philosophy he was alluding to in 55, I for one would find that very interesting.

My own view: almost everyone's personality is a psychiatric disorder, awaiting only the proper set of social circumstances to manifest itself.

There are stronger and weaker personalities, more and less socially adaptable and functional people. Some get broken more easily than others. But putting a disease model onto that is a big mistake.

"Mental health parity" is silly because personality disorders and physical health are quite different and are mainly related by analogy.

And the consistency of hysterical reactions to stress through time -- such as the refusal to eat -- is not cause for calling them all a single disease. There are only so many ways humans are physically capable of throwing a fit.

What defines most mental health disorders
is failure to live up to some external social demand, hence psychology/psychiatry is irreducibly social. (Beyond of course brain dysfunctions that cripple universal capacities ranging from metabolism up through first language acquisition).


Posted by: PerfectlyGoddamnDelightful | Link to this comment | 02- 2-08 12:12 PM
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Shouldn't this sort of finding make laws that treat these disorders differently from "biological" ones untenable?

As BG said in 58, it's all biological, all physical. But the thing is that higher order brain functions don't have a purpose in the same way other organs do. When digestive organs stop functioning, you're definitely sick. When your brain makes you hate your job or your marriage and perform badly at it, is the sickness in you or in our oppressive society or your fucked up spouse?

The interesting thing is that we will develop -- are already developing -- physical "cures" for psychological dysfunctions. Those could be extremely socially valuable. But it's still dangerous to call those cures "medicine" and the dysfunction "disease". If there was a pill that would reconcile you to your morally questionable job and make you twice as productive at it, what sickness does that cure?

It's all social.


Posted by: PerfectlyGoddamnDelightful | Link to this comment | 02- 2-08 12:22 PM
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But putting a disease model onto that is a big mistake.

Why? Assume we mean nothing pejorative by treating it as a medical condition; what's wrong with treating anorexia nervosa as being ill, rather than a failure to live up to some social demand? What's supposed to follow from saying "Yes, but in a society where we were all anorexic, you'd be morbidly obese" ? I'm honestly curious, because I'd rather see something as an illness, i.e., potentially fixable and not a sign of moral decay, than something that shows how one has failed to live up to society.

Autism isn't just a failure to be sociable, whatever Wired would have us believe. Schizophrenia doesn't seem like an amusing personality trait. Mental disorders may well be on a continuum, but sometimes differences of degree are really important.

64: Oh, I took those as a kid and sucked ass at them. Fucking red and white blocks with their fucking diagonals. I had to put together a picture of a face, too, and I couldn't do that either. And to this day I find games where one has to imagine a model reversed or turned very, very difficult, requiring much more concentration than it should.


Posted by: Cala | Link to this comment | 02- 2-08 12:25 PM
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My own understanding was that the "physically based" or "biologically based" terminology existed largely to exclude, or at least separate, treatment for drug addiction or abuse. In MA, my various health insurance coverage documents over the years have usually said "For biologically-based mental illness, you have coverage X; for drug addiction, you have coverage Y" (with Y being generally less generous than X).


Posted by: Nathan Williams | Link to this comment | 02- 2-08 12:34 PM
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65, 66: Maybe I'm misunderstanding you, but have you ever actually known someone with a mental illness? Do you really think they were just "throwing a fit"?

"It's all social" is a pretty ridiculous reduction. So is "it's all biological", I admit, but at least the biological view identifies treatable, localized problems. Blaming society for someone's OCD or bipolar disorder or schizophrenia is not only absurd, it's useless.


Posted by: essear | Link to this comment | 02- 2-08 12:35 PM
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And to this day I find games where one has to imagine a model reversed or turned very, very difficult, requiring much more concentration than it should.

I dunno. I test high on that sort of problem -- I get mostly right answers at a reasonably high speed -- and I still find those very effortful. I think they're just an unusual enough class of problem in real life that they're painful to bend your head around.

Even people who think of themselves as good at those often don't easily use those skills in real life situations. I find an interesting question when you're talking about this sort of thing is to ask people what the phase of the moon has to do with the time of moonrise and moonset. In our artificially lit world, most people don't know offhand. For someone who has an easy time visualizing objects in space and mentally observing them from different perspectives, the answer should be obvious as soon as you think about it. But I've never run into anyone who didn't already understand the relationship who could figure it out without a substantial period of puzzling, regardless of how strongly they assessed their spatial reasoning skills.


Posted by: LizardBreath | Link to this comment | 02- 2-08 12:36 PM
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70: Video games aren't exactly "real life situations", but they do exercise those skills a lot. (I was reminded of this recently by playing Portal, which has many mind-bending, Escher-esque spatial relationships)


Posted by: Nathan Williams | Link to this comment | 02- 2-08 12:40 PM
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70: It also suffers from a bit of a comparative effect. I can get verbal/analytic reasoning questions very quickly, so when it comes to spatial ones, after a short period of puzzling over it I get very annoyed with it (can't I outsource these problems to someone else?) or try to reduce the imagining to an algorithm (how I beat the Bloxors game, eventually.)


Posted by: Cala | Link to this comment | 02- 2-08 12:42 PM
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Schizophrenics really do hear voices, see things that aren't there and can be paranoid. It's true that there are psychotherapeutic techniques, primarily cognitive behavioral, which can help people recognize their delusions, but they remain real physical problems, and schizophrenia is definitely a medical illness. It's malpractice to treat schizophrenia without antipsychotics; it's not simply a failure to live up to social expectations. That's absolutely absurd.


Posted by: Bostoniangirl | Link to this comment | 02- 2-08 12:42 PM
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72: I had an interesting conversation with Dr. Oops once, about older surgeons complaining that the whippersnappers are all stupid with their hands. The sort of top-of-their-class kid who becomes a surgeon often doesn't have a lot of time spent doing anything physical, and so they're very fumbly and slow when it comes to solving the sorts of physical problems you need to solve when you're moving body parts around. Dr. Oops does well with that sort of thing, but she had a childhood/adolescence/young adulthood of knitting/sewing/making pastry/making furniture/sports/fixing cars, which gets you habituated to solving that class of problems.


Posted by: LizardBreath | Link to this comment | 02- 2-08 12:48 PM
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what's wrong with treating anorexia nervosa as being ill, rather than a failure to live up to some social demand? What's supposed to follow from saying "Yes, but in a society where we were all anorexic, you'd be morbidly obese" ?

Give me credit for being a little more complex than that. Obviously anorexia is in itself objectively damaging. But like a lot of mental disorders, one can understand it as a form of self-destructive acting out. Then there is the question of why that has occurred, why they have reached a self-destructive place. That question is about their own understanding of themself as a person in a society. My sense is that it will not go away when you address the anorexia, which in my understanding is a symptom. If you can have a drug that will let you mute or suppress the extreme self-destructive symptom before it kills the person, that's great. But don't mistake the drug as the cure for a disease.

Of course there is a lot of biology in how quick we are to reach a self-destructive place, how much pleasure certain forms of damaging behavior will give us (like a predisposition to alcoholism). But this is the same kind of biology that there is in personality in general. Slicing it off as a separate dysfunction or disease that can be treated in isolation strikes me as dangerous. A kidney stone is something external and damaging that needs to be removed from the kidney itself to let it function. I'm not so sure a personality disorder cannot be separated from one's broader personality in that way.

I'd rather see something as an illness, i.e., potentially fixable and not a sign of moral decay,

Well, being moralistic and judgemental is a flaw in and of itself that should be avoided. Using a non-disease model should not be a license to be moralistic. The great, frequently touted benefit of the disease model is that it counteracts moralistic judgementalism. But I'm not sure it's so effective at that in the end. And it has many other flaws (such as removing the "patient's" sense of agency, removing the "disease" from its context in the person's life, and just plain being misleading).

than something that shows how one has failed to live up to society.

A mental disorder *does* mean that the person has failed to live up to some social or external demand. That's just a fact. It's also a very good place to start in figuring out what to do.

Autism isn't just a failure to be sociable, whatever Wired would have us believe.

Severe autism definitely is not, and fits what I said above about damage that prevents the brain from performing basic human functions (severe autistics never learn language). The autism spectrum stuff does strike me in a lot of cases as just a variant of regular personality.


Posted by: PGD | Link to this comment | 02- 2-08 12:49 PM
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Many severe autistics do learn language, but not spoken language. FWIW.


Posted by: A White Bear | Link to this comment | 02- 2-08 12:52 PM
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Mental illnesses and syndromes and disorders are diagnosed my failure to behave correctly, which is socially defined. Not caused socially, necessarily. A functional, successful person is unlikely to have his problems diagnosed, and a lot of functional people are pretty sick. E.G., my sociopath brother-in-law, a very succesful small businessman who treats everyone badly including his kids.


Posted by: John Emerson | Link to this comment | 02- 2-08 12:53 PM
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75: I'm sensing that your worry here is that you wouldn't want, e.g., your garden-variety avuncular misanthrope, to be diagnosed with borderline personality disorder. But that just leads to a call for better diagnostic criteria, and for one, better treatments, which can and do include trying to assess, e.g., why the person has self-destructive habits.

Using a non-disease model should not be a license to be moralistic.

It often is, though. If you're suffering from depression, being told "it's all in your head", "there's nothing wrong with you", "you just need to pray more", or "you have nothing to be sad about" isn't nearly as effective as being told "this pill will help you get to a place where we can work through what is making you sad" or "exercising more can lift your mood, so have someone drag you to the gym when you start to feel depressed again."


Posted by: Cala | Link to this comment | 02- 2-08 12:58 PM
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75: You're assuming that because a mental disorder leads people to think differently, act differently, respond to society differently, and in general exhibit an extremely complex pattern of responses, that the disorder is itself a result of a complex pattern of causes. And in some cases that's true. In others, the disorder really can be caused by a particular biological mechanism, and treating that is all that is necessary. In some cases, drugs are the cures for the disease.


Posted by: essear | Link to this comment | 02- 2-08 1:01 PM
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It's malpractice to treat schizophrenia without antipsychotics; it's not simply a failure to live up to social expectations. That's absolutely absurd.

Given the amount of damage that antipsychotic drugs have done, I take accusations of absurdity with a grain of salt.

Schizophrenia is always the limiting case used to justify the medical model and thus the social authority of psychiatry. But as I understand it there is far less understanding of either the definition of or the treatment for schizophrenia than the medical community likes to represent to outsiders.

Look, obviously there is a wide range of natural personalities. There are extreme cases that any society will find it near-impossible to accomodate. There are blurry cases where low functioning becomes close to lacking a basic human capacity (probably most people have occasional minor hallucinations; someone who has major hallucinations all of the time basically has non-functioning sensory organs and cannot perceive the external world). But if you let yourself medicalize a lot then it's amazing how fast the medical model becomes a dominant metaphor for understanding the human personality in general. We've seen that here. Try reading the DSM sometime.


Posted by: PerfectlyGoddamnDelightful | Link to this comment | 02- 2-08 1:03 PM
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Autism isn't just a failure to be sociable, whatever Wired would have us believe.

Ok, I am an expert on this one!!!

My daughter loves people. Loves to walk up and hug you and kiss you. She would probably rub your boobs or pat your butt.

However, she is a hit and run hugger or fondler. She doesnt like to be held.

Of course, she is probably only touchy-feely because I have trained her from a baby to hug and kiss.


Posted by: Will | Link to this comment | 02- 2-08 1:04 PM
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Also, when she was first coming into the school system the school pyschologist told us at a meeting that my daughter wasnt autistic because she came up and hugged him and smiled.

Instead of saying, "what kind of dumbass are you?" I calmly asked him what definition of autism he was working from. He stuttered and stammered until I told him that he should keep his mouth shut.


Posted by: Will | Link to this comment | 02- 2-08 1:06 PM
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79 is sensible, although I don't think my 75 was working from that presupposition (my reason for believing anorexia has complex and socially embedded causes is not just that it has complex manifestations). But anyway, a simple pair of glasses could solve a complex pattern of acting out at school.

But it's best to keep such explanations for cases where we actually clearly understand the mechanisms from start to finish. The neurotransmitter stuff doesn't seem to meet that standard.

None of this means that drugs aren't useful, as I tried to make clear above. They can save lives. But they shouldn't be sold as the cure to a clearly defined disease when they're not.


Posted by: PerfectlyGoddamnDelightful | Link to this comment | 02- 2-08 1:14 PM
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76: If the evidence for that is "facilitated communication" with severe autistics, then it is weak to nonexistent:

http://skepdic.com/facilcom.html

I'm sensing that your worry here is that you wouldn't want, e.g., your garden-variety avuncular misanthrope, to be diagnosed with borderline personality disorder.

Partly, especially since I'm a garden-variety misanthrope at times. But I think there's a broader point about the problem with medicalization that applies well beyond "garden variety" personality disorders, to things like schizophrenia as well. This is a worthwhile book:

www.madinamerica.com


Posted by: PGD | Link to this comment | 02- 2-08 1:46 PM
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This autistic is charming and terrifying. It's something of a wonder that he's so severely affected but still able and willing to keep such a public record of his struggles with the condition he doesn't seem to be entirely aware he has. Especially worth reading: the parts about his school experience, his imaginary friends, and his blog.


Posted by: mano negra | Link to this comment | 02- 2-08 1:51 PM
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your garden-variety avuncular misanthrope

There's a category for that.


Posted by: Michael Vanderwheel, B.A. | Link to this comment | 02- 2-08 1:53 PM
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But it's best to keep such explanations for cases where we actually clearly understand the mechanisms from start to finish. The neurotransmitter stuff doesn't seem to meet that standard.

That is a pretty high standard. I think they're still trying to figure out all of the mechanisms underneath type 2 diabetes. Does the treatment there address the ultimate cause or just ease the symptoms?


Posted by: md 20/400 | Link to this comment | 02- 2-08 3:10 PM
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The problem with anti-medicalization in practice is that it turns into license to dismiss the sufferer. In this it's very much like, say, free trade zealotry that comes with the language of "oh, and we'll do something to help those who lose out" beforehand, then says "oh, but it's very complicated to work out who's actually any worse off because of this deal", and then dumps them. Individuals may very well believe that people suffering for purely mental reasons are nonetheless genuinely suffering and need help too, just a different sort of advice. But as a force in discussions about medical coverage, the viewpoint is inextricably linked to the idea that such people have no problem worth anyone else's consideration or respect, and also no problem worthy of coverage by insurance.

Why yes, since someone's going to ask, I've been on the receiving end of that. And the problems so dismissed did turn out to be side effects of underlying autoimmune problems that could have been diagnosed earlier but weren't because people in charge of my case at that time felt sure they recognized purely behavioral problems when they saw them. M*therf*ckers. I don't carry a lot of hostility toward many people, but I do toward that office, and a few others (public and private) I've dealt with in 25 years (and counting) of life with highly variable illness.

There's a pragmatic case to be made for treating the problems that actually are purely behavorial as worthy of coverage and the rest, in any event. People who are messed up become at risk for infection, thanks to immune suppression from mood. That's a real thing. It's measurable and well-established. Good moods strengthen the body's defenses; bad ones weaken them. Call it placebo effects if you want, but then placebos provide genuine relief of known physical ailments in statistically significant percentages of cases, too. I respect them, and so should others. The point here is that someone who's messed up and sad or angry and having a hard time holding a stable life together is at thoroughly real risk of other complications. Helping them get it together is, precisely, a form of preventative care. It's cost-efficient. It's only judgmentalism-inefficient.


Posted by: Bruce Baugh | Link to this comment | 02- 2-08 4:09 PM
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It was the same with deinstitutionalization. There was a good case to be made, but it depended on follow-up, outpatient care, and other support, and that didn't happen.

Likewise reform of higher education. I can imagine all kinds of reforms, but the reforms we're actually likely to see mostly amount to cost-cutting and downgrading the profession, reducing autonomy, etc.


Posted by: John Emerson | Link to this comment | 02- 2-08 4:24 PM
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Very much so, John. Same shit, different days, different lives to be discarded (or sometimes the same ones again and again).


Posted by: Bruce Baugh | Link to this comment | 02- 2-08 4:26 PM
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I don't see how this is any different from any other legalese parsing of a contract with one side trying to fuck over the other side.


Posted by: yoyo | Link to this comment | 02- 2-08 8:07 PM
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and yeah agree with the antimedicalisation but only when coupled with nonjudgmental helping/caring


Posted by: yoyo | Link to this comment | 02- 2-08 8:09 PM
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and carving out drug abuse is rediculous even on that criteria because most people are abusing drugs (when we talk about actual abuse of the drugs, not the AMA line how any drug consumption not prescribed by a doctor is 'abuse') are self-medicating. Probably less true of heroin and some other things but those aren't a large percentage of substance abuse anyway.


Posted by: yoyo | Link to this comment | 02- 2-08 8:11 PM
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