Year: 2009

Scientific American has a knock-out article that questions whether the diagnosis of post-traumatic stress disorder is a coherent psychological concept or whether it is actually making the situation worse for soldiers with post-combat mental health problems.

As we’ve noted before, PTSD is a controversial diagnosis for two major reasons. The first is that it is not clear that the diagnosis describes anything different from other forms of anxiety and depression, except for that fact that it is related to a specific traumatic incident.

The second is that the diagnosis was largely introduced after pressure from veterans’ lobbying groups after the Vietnam war. In fact, PTSD was originally called ‘post-Vietnam syndrome’ and there are concerns that while it was politically expedient at the time, the concept doesn’t lead to good mental health care.

In fact, combat stress reactions have taken various forms through the years of which PTSD is the latest reincarnation.

The SciAm article tackles research in the US military suggesting that the syndrome is over-diagnosed and that the treatment plan is counter-productive and actually encourages people to remain disabled.

But one of the most interesting things about the article is that it tackles the one of the core features of the diagnosis – that the anxiety symptoms are directly tied to a specific traumatic event.

Many people who are diagnosed with PTSD turn out not to have been traumatised by the event they later attribute the trauma to, or may not have even been traumatised at all.

J. Alexander Bodkin, a psychiatrist at Harvard’s McLean Hospital, screened 90 clinically depressed patients separately for PTSD symptoms and for trauma, then compared the results. First he and a colleague used a standardized screening interview to assess symptoms. Then two other PTSD diagnosticians, ignorant of the symptom reports, used another standard interview to see which patients had ever experienced trauma fitting DSM-IV criteria.

If PTSD arose from trauma, the patients with PTSD symptoms should have histories of trauma, and those with trauma should show more PTSD. It was not so. Although the symptom screens rated 70 of the 90 patients positive for PTSD, the trauma screens found only 54 who had suffered trauma: the diagnosed PTSD “cases” outnumbered those who had experienced traumatic events. Things got worse when Bodkin compared the diagnoses one on one. If PTSD required trauma, then the 54 trauma-exposed patients should account for most of the 70 PTSD-positive patients. But the PTSD-symptomatic patients were equally distributed among the trauma-positive and the trauma-negative groups. The PTSD rate had zero relation to the trauma rate. It was, Bodkin observed, “a scientifically unacceptable situation.”

This does not necessarily mean the people are lying, but may simply be attributing true symptoms to an unlikely source.

It’s a wonderfully thought-provoking article that’s sure to ruffle a few feathers.

The writer, David Dobbs, has also put a load of background material and links to the relevant studies on his blog, so you can get a more in-depth perspective if it sparks your interest in the area.

Link to article ‘Soldiers’ Stress: What Doctors Get Wrong about PTSD’.
Link to David Dobb’s background material for the article.

The Economist has an excellent piece on crowd psychology and why group behaviour is essential in calming down street confrontations before they turn violent.

Crowds are often associated with senseless aggression, and perhaps the most widely quoted, and most colourful example, is from Gustave Le Bon’s 1895 book The Crowd.

He wrote that crowds showed several special characteristics such as “impulsiveness, irritability, incapacity to reason, the absence of judgment and of the critical spirit, the exaggeration of the sentiments, and others besides – which are almost always observed in beings belonging to inferior forms of evolution – in women, savages, and children, for instance”.

You can imagine how he went down at parties.

Nevertheless, this association between crowds and violence has remained a research focus for many years. Concepts such as deindividuation – a reduction in the feeling of personal identity and responsibility – are invoked to explain why ‘bad things’ supposedly happen when people congregate in groups. This also typically includes explaining why ‘bad things’ are allowed to happen without people intervening – the so-called bystander effect

The Economist article is interesting because it looks at research which seems to turn these assumptions on their head.

It discusses the work of psychologist Mark Levine, who studies crowd behaviour and has found that crowds actually act to reduce violence in many situations.

He has been analysing CCTV footage of incidents that control room operators thought might turn violent, not all of which did.

His first observation was that bystanders frequently intervene in incipient fights. The number of escalating gestures did not rise significantly as the size of the group increased, contrary to what the bystander effect would predict. Instead, it was the number of de-escalating gestures that grew. A bigger crowd, in other words, was more likely to suppress a fight.

Some incidents did end in violence, of course. To try to work out why, Dr Levine and his colleagues constructed probability trees to help them calculate the likelihood that a violent incident such as a punch being thrown would occur with each successive intervention by a bystander. Using these trees, they were generally able to identify a flashpoint at which the crowd determined which way the fight would go.

Judging the fight to begin with the aggressor’s first pointing gesture towards his target, the researchers found that the first intervention usually involved a bystander trying to calm the protagonist down. Next, another would advise the target not to respond. If a third intervention reinforced crowd solidarity, sending the same peaceful message, then a violent outcome became unlikely. But if it did not—if the third bystander vocally took sides, say—then violence was much more likely.

It’s a really eye-opening piece that’s well worth reading in full as it overturns both some common popular assumptions and some well-worn psychological clich√©s.

Link to Economist on ‘The kindness of crowds’.

There is a small but fascinating medical literature on delusional pregnancy that reports cases of people who, in the context of psychotic mental illness, come to believe they are expecting a child. Interestingly, the cases are not solely women of child bearing age – delusional pregnancy has also been reported in men and the elderly.

In fact, almost as many cases of delusional pregnancy have been reported in men as in women. Unfortunately, no studies have been done on how common this delusion is or what it is associated with, so it’s not clear whether men are equally as likely to have a delusions of pregnancy, or whether it’s just because these cases seem more unusual and is more likely to be published.

Below is one of the cases from a classic 1994 article on delusion of pregnancy from The British Journal of Psychiatry:

B was a 39-year-old, single, female schizophrenic patient with treatment-resistant psychotic symptoms including delusions of pregnancy of 20 years’ duration and amenorrhoea for the previous 18 years. On examination she was convinced that she had a triplet pregnancy – two boys and a girl – of four months gestational age. She reported that they moved about inside her abdomen and also talked to her.

When she was 19, her dancing partner kissed her and she believed that he had been repeatedly impregnating her by means of the same kiss. Regarding her previous pregnancies she believed that their father did not want her to deliver them and hence he ‘withdrew’ them. She did not have any physical symptoms of pregnancy other than amenorrhoea and attributed this to the ‘supernatural nature’ of the pregnancy.

In a curious twist, a recent article reported on a patient who had the delusional denial of pregnancy – where she was clearly heavily pregnant but had the delusion that she was not.

It’s important to note that these cases are not the same as ‘phantom pregnancies’, something medically named pseudocyesis, where a women can show the signs of expecting a child (swollen breasts, enlarged abdomen etc) without actually being pregnant.

This is not a delusion, as the patient can be well aware that they are not actually pregnant or will accept the possibility that they are not when the results of medical tests come though.

Indeed, ‘phantom pregnancy’ can be due to clear disturbance to the hormones – one case was due to a brain tumour that disrupted the endocrine system – but other cases seem to be related to the strong desire to be pregnant.

However, even this has its male equivalent. Couvade syndrome is where men experience some of the physical effects of pregnancy (morning sickness, aches, weight gain) in response to their partner’s pregnancy.

Link to classic 1994 paper on delusion of pregnancy.

The Boston Herald has an interesting article on perfectionism – a pathological pursuit of usually unobtainable high standards that is strongly linked to anxiety, depression and eating disorders.

Perfectionism is variously described as a personality trait or a type of dysfunctional assumption where people feel their self-worth is dependent on 100% or perfect success.

It can be quite hard to shift, owing to the fact that some people find it hard to see why doing something perfectly isn’t a useful goal to aim for. However, when a desire for perfection is over-applied it tends to lead to harsh self-criticism and is self-defeating – ironically, people often perform worse as a result.

Psychologists Roz Shafran and Warren Mansell published an influential article on the role of perfectionism in mental illness in 2001, that really opened many people’s eyes to the importance of understanding perfectionist tendencies in psychopathology.

The Boston Globe article is a little more of a gentle introduction, but does a great job of succinctly describing the personal impact of perfectionism, some of the research in the area, and current approaches to treating the problem:

“Perfectionism is a phobia of mistake-making,” said Jeff Szymanski, executive director of the Obsessive Compulsive Foundation, which is based in Boston. “It is the feeling that ‘If I make a mistake, it will be catastrophic.’ “

Striving for perfection is fine, said Smith College psychology professor Randy Frost, a leading researcher on perfectionism. The issue is how you interpret your own inevitable mistakes and failings. Do they make you feel bad about yourself in a global sense? Does a missed shot in tennis make you slam your racket to the ground? Do you think anything less than 100 percent might as well be zero?

Link to ‘When perfectionism becomes a problem’.
Link to review article on perfectionism and psychopathology.
Link to PubMed entry for same.

There’s a brief but interesting case study in the General Hospital Psychiatry journal of a patient who is described as having ‘extremely grotesque somatic delusions’.

The case was a 54-year-old man. He had no past history or family history of psychiatric disorders. His social and occupational histories were quite normal. In August of 2005, he felt that “something has stuck between under front teeth.” From September, he felt that “there is another lower jaw with teeth between the real upper jaw and real lower jaw, and there is another tongue between the false lower jaw and the real lower jaw”; “the teeth on the false lower jaw are growing steadily”; “I try to cut the false teeth off with the real teeth, but the false teeth do not stop growing”; “the false teeth melt into holes in the false lower jaw, but later grow again from those holes”; “something like spaghetti is coming into and going out from the holes” and “the false lower jaw rolls up and is coming into the throat.” Because of these annoying sensations, he had mild depressive symptoms such as depressed mood, decrease in appetite, restlessness and fatigue. Despite these symptoms, he was able to continue working.

The patient was treated with the antipsychotic drug risperidone and reportedly recovered well.

As part of his assessment he was also given a SPECT brain scan, that found reduced blood flow in the temporal and parietal lobes.

Although still not well studied, various other single case studies have found that delusions concerning body size, shape or transformation correlate with changes in parietal lobe function.

Owing to the role of the parietal lobe in maintaining our ‘body image’, it is thought that problems in this area could lead to unusual experiences of body distortion which could, in part, spark delusional beliefs.

Link to case study.
Link to PubMed entry for same.