Dr. X's Free Associations

Psychology, Mind and Neuroscience Roundup For Friday

The links below do not necessarily reflect Dr. X's opinions, either in whole or in part, unless Dr. X otherwise says so.  For one reason or another I found these posts to be interesting reads and recommend them to my readers.

• Stephen Soldz on problems associated with physicians sharing personal anecdotes with patients.

• Shrinkwrapped on U.S. health care.

• Disembedded discusses a Paris Hilton sketch.

• Michael Merzenich discusses some potential hazards associated with psychotherapy following traumatic events.  (Dr X comments: This is an important post, in my opinion. I had intended to write more about trauma and PTSD this week, but held off because of the very complicated nature of a subject that does not lend itself well to blog bites, particularly with the somewhat controversial designation C-PTSD rolled into the discussion. I'm not going to touch that one right now other than to say that controversy related to the conceptualization of psychopathology in general and the significance of neuroscience in understanding PTSD (and psychopathology), coupled with controversies surrounding psychiatric nomenclature left me feeling that I would do better to let this subject stew for a time.  I might take a go at it at some later time, but do hope Dr. Merzenich will write more on the subject.) 

Fit of Phat?

Language Log reviews some backronymic interpretations of phat here.

NY Times Misleading On Big Pharma Payments To Vermont Psychiatrists

Yesterday, The NY Times reported that drug company payments to psychiatrists in Vermont doubled last year to over $45,000 on average.  In a climate of widespread worry about the nefarious influence of drug company payments on prescribing practices, the Times report only adds fuel to the fire.

... Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.

After digging a little deeper into the matter, it appears that The Times reporter has gotten the facts wrong.  The report issued by Vermont officials indicates that an average payment of $45,692 was made to just 11 of the state's psychiatrists who were among the top 100 recipients of pharmaceutical company payments to prescribers in all specialties.  The Times article says nothing about the $45,000 figure referring only to the state’s top 11 recipients of drug company payments.  Click on the table below to see a summary.

The Vermont report also indicates that, among the 11 psychiatrists who top the list, the median payment was $27,000.  The large difference between the average and median figures suggests a trend in the way payments are distributed.  It appears that a few psychiatrists receive very large payments with the rest recieving far less.  Looking only at the average among the top 11 recipients yields an average figure that would be shocking, indeed, if it represented the average or even the median payment to all psychiatrists in Vermont.  It does not, but this is the false impression created by the Times article.

Although the Vermont report doesn't provide information on the average payment for psychiatrists who are not among the top 11 recipients in the state, we can extrapilate from the available data and come up with what I believe is a reasonable estimate of payments/gifts a typical psychiatrist practicing in Vermont might see.

The state's report indicates that prescribers from all specialties received a total of $2,033,000 from drug makers.  Of that total figure, $1,550,000 (76%) went to the state's top 100 recipients, leaving about $500,000 payed to all prescribers who were not among the state's top 100.  I don't have a recent figure for the number of psychiatrists working in Vermont, but the USDHHS reported that there were 116 psychiatrists practicing there in 1998. 

The Vermont report also indicated that 22% of payments to the top 100 recipeints went to psychiatrists.  If the that distribution rate holds up for all of the state's prescribers, then roughly $110,000 (22% of $500,000) in payments were divided between approximately 105 psychiatrists who were not among the state's top 100 list.  That would amount to about a $1 thousand payment per psychiatrist for those not among the top 11 recipients of drug company money — a far cry from the Times' figure of $45,000 per psychiatrist in the state.

Even when we include the top 11 recipients in calculating the average, the figure would be closer to $4 thousand per psychiatrist.  Given the lopsided distribution of payments, I suspect that the median value of payments would still fall somewhere in the neighborhood of $1,000.  Again, I'm assuming that the 22% distribution rate seen among the top 100 recipients holds up for all providers in the state.  The figure might be higher or lower.

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Psychiatrist Shrink Rap characterizes some of the reporting as sensationalist as he discusses his experience with pharmaceutical reps and his own prescribing practices.  He has not received payment other than pens, pads and a few sandwiches for clinic staff during in-office presentations.   Of the higher rates of anti-psychotic prescriptions for Medicaid patients, he notes:

It's hard to get Medicaid, you have to be sick. An episode of depression treated with Prozac doesn't do it. To get Medicaid, at least in Maryland, you have to be chronically ill (and even that isn't always enough), so a bad psychiatric illness, chronically, probably one that you need a chronic, expensive, antipsychotic medication to get. No wonder antipsychotics are a high percent of the Medicaid budget.

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Recall Of Childhood Sexual Abuse In Psychotherapy

Is psychotherapy sometimes a factor in the creation of false memories of childhood sexual abuse (CSA)?  The authors of this study found that spontaneously recollected memories of childhood sexual abuse were corroborated just as often as continuous (never "forgotten") memories of childhood sexual abuse (both corroborated 37% of the time), except when spontaneous recall occurred during psychotherapy.  In a starling finding, the authors report that no cases of childhood sexual abuse could be corroborated for memories spontaneously recovered during psychotherapy.

ABSTRACT – Although controversy surrounds the relative authenticity of discontinuous versus continuous memories of childhood sexual abuse (CSA), little is known about whether such memories differ in their likelihood of corroborative evidence.   Individuals reporting CSA memories were interviewed, and two independent raters attempted to find corroborative information for the allegations.    Continuous CSA memories CSA memories and discontinuous memories that were unexpectedly recalled outside therapy were more likely to be corroborated than anticipated discontinuous memories recovered in therapy.   Evidence that suggestion during therapy possibly mediates these differences comes from the additional finding that individuals who recalled the memories outside therapy were markedly more surprised at the existence of their memories than were individuals who initially recalled the memories in therapy.  These results indicate that discontinuous CSA memories spontaneously retrieved outside of therapy may be accurate, while implicating expectations arising from suggestions during therapy in producing false CSA memories.

Psychotherapy entails a complex interplay between the conscious and unconscious worlds of both the therapist and the patient such that each deeply influences the internal experience of the other during the therapy session.  Psychotherapists who are not deeply attentive to these mutual influences can exert malign effects on patients who are enlisted to meet conscious and unconscious pathological needs of the therapist.

A particularly egregious example of malign influence on patient recollections occurred in the case of Chicago psychiatrist Bennett Braun who was, at one time, a professional icon in Multiple Personality Disorder (MPD) circles.  Braun made quite a name for himself during the 1980s and 1990s despite deep skepticism and concern about both his claims and his motives.  The very damaging effects of Braun's work were eventually exposed.  In a compromise with the Illinois Department of Professional Regulation, Braun surrendered his license for two years and received five years of probation — light consequences, in my opinion, for the harm he did to those who placed their trust in him.  Besides the damage done directly to patients under his care, one insidious effect of cases like Braun's is that it provides ammunition to those who are, for a variety of reasons, invested in denying the prevalence of childhood sexual abuse — victimizing the victims yet again.

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Photo Of The Day: Men Need Rubber (1942)

Hazard, KY (1942).  Click photo to view full-size.

Collecting rubber for the war effort.

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Post Traumatic Stress and Lateral Dominance

On Friday, I linked to a post by Dr. Bliss who finds PTSD a suspect diagnostic construct.  One commenter mistakenly assumed that I shared her suspicion about the disorder.  Although PTSD holds potential for abuse in legal proceedings and disability claims, I do not doubt either the existence or seriousness of the condition.

More on PTSD:

Dr. Merzenich at Positscience reports on a PTSD study that yielded a fascinating finding: combat veterans with a high degree of mixed-handedness were 5 times as likely to suffer post traumatic stress as individuals with strong single hand dominance.  Science Daily has more on the study.

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Psychology, Mind and Neuroscience Roundup For Friday

• Dr. Bliss at Maggie's Farm says that Post Traumatic Stress Disorder "is on its way to becoming a legal scam, in my opinion. In fact, the entire movement to create new diagnoses, and to label more folks "disabled," is destructive to human dignity."

• Modern Psychoanalysis comments on causes of schizophrenia.

• PsyBlog reports on a notorious stuttering study conducted by MA student Mary Tudor under the supervision of speech pathologist Wendell Johnson in 1939.  PsyBlog comments: "it [the study] had extremely shaky (practically non-existent) ethical standards. Second its results were never published for fear it would be likened to experiments carried out by the Nazis (Rothwell, 2003). Finally, in historical context, its findings were dramatic."  Dr. Nicholas Johnson offers a defense of the study in historical context.

• Dr. Michael Merzenich writes: "We have intensively trained individuals who are in a pre-AD [Alzheimer's Disease] medical status, their cognitive decline appears be arrested — and, in fact, significant functional rejuvenation is recorded. These practical studies combined with a growing number of animal studies indicate that brain fitness exercises can, by themselves, prophylactically sustain brain health over an extended epoch."  Merzenich argues the advantages of brain training excercises over currently available drugs to delay/prevent onset of Alzheimers Disease.

• More on Alzheimer's Disease: neurophilosopher reports on a study suggesting that "the consumption of foie gras is potentially hazardous to those who are genetically predisposed to (i.e. have a family history of) amyloidogenic disorders.   Discounting the consumption of infected brain tissue (during, for example, the ritual of mortuary cannibalism), this is the first time that a dietary component has been implicated in the amyloidogenic diseases."

• David Brooks offers a surprisingly lucid discussion of the limitations of values education that is sure to inflame people on both sides of the cultural divide.  I wonder if he's ever read Stolorow and Atwood on prereflective unconscious structures?  I think Brooks overplays his hand in this discussion of the limitations of didactic influences on behavior, but it is a nice antidote to people who proceed from the more commonplace and naive assumption that values are acquired and behavior principally determined by a process of early childhood indoctrination.  We like to think we're in charge of ourselves and know exactly what we're doing far more than we really do.  Ideas to the contrary don't always set well with people.

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Dixie Insurgents Continue Their Assault On American Values

Hat tips to Ed Brayton and Pam's House Blend on this one.

Conservatives frequently decry the blindness of culturally-neutral, postmodernism to pathologies that threaten to undermine America's core social and political values.  As they correctly point out the dismal human rights record of tribal Muslim societies, they rail against multiculturalists who tiptoe around Muslim sensibilities.  Hear, hear!  Let's not tiptoe.

When it comes to their own backyard, however, some conservatives go PoMo blind while our highest values are assaulted again and again by a Southernist subculture that has arrogantly claimed to represent "true" American cultural values.  These are the same people who defiantly wave the confederate battle flag as a Southernist shibboleth while masquerading as a "states' rights" movement.  That movement amounts to nothing more than advocacy for an inanimate state's so-called "right" to deprive actual living human beings of their rights.

Post Traumatic Stress and Lateral Dominance

On Friday, I linked to a post by Dr. Bliss who finds PTSD a suspect diagnostic construct.  One commenter mistakenly assumed that I shared her suspicion about the disorder.  Although PTSD holds potential for abuse in legal proceedings and disability claims, I do not doubt either the existence or seriousness of the condition.

More on PTSD:

Dr. Merzenich at Positscience reports on a PTSD study that yielded a fascinating finding: combat veterans with a high degree of mixed-handedness were 5 times as likely to suffer post traumatic stress as individuals with strong single hand dominance.  Science Daily has more on the study.

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Deflecting Blame For Iraq

From Frank Rich (via Welcome-to-Pottersville):

"For the Bush White House, the real definition of victory has become "anything they can get away with without taking blame for defeat," said the retired Army Gen. William Odom, a national security official in the Reagan and Carter administrations, when I spoke with him recently. The plan is to run out the Washington clock between now and Jan. 20, 2009, no matter the cost."

And, Left End of the Dial expects the Dolchstoßlegende to escalate in coming months and years as the administration's supporters attempt to deflect blame for the Iraq failure.

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