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What is Relational Psychoanalysis?

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Introduction

Relational psychoanalysis is a school of psychoanalysis in the United States that emphasizes the role of real and imagined relationships with others in mental disorder and psychotherapy. ‘Relational psychoanalysis is a relatively new and evolving school of psychoanalytic thought considered by its founders to represent a “paradigm shift” in psychoanalysis’.

Relational psychoanalysis began in the 1980s as an attempt to integrate interpersonal psychoanalysis’s emphasis on the detailed exploration of interpersonal interactions with British object relations theory’s ideas about the psychological importance of internalised relationships with other people. Relationalists argue that personality emerges from the matrix of early formative relationships with parents and other figures. Philosophically, relational psychoanalysis is closely allied with social constructionism.

Drives versus Relationships

An important difference between relational theory and traditional psychoanalytic thought is in its theory of motivation, which would ‘assign primary importance to real interpersonal relations, rather than to instinctual drives’. Freudian theory, with a few exceptions, proposes that human beings are motivated by sexual and aggressive drives. These drives are biologically rooted and innate. They are ultimately not shaped by experience.

Relationalists, on the other hand, argue that the primary motivation of the psyche is to be in relationships with others. As a consequence early relationships, usually with primary caregivers, shape one’s expectations about the way in which one’s needs are met. Therefore, desires and urges cannot be separated from the relational contexts in which they arise; motivation is then seen as being determined by the systemic interaction of a person and his or her relational world. Individuals attempt to re-create these early learned relationships in ongoing relationships that may have little or nothing to do with those early relationships. This re-creation of relational patterns serves to satisfy the individuals’ needs in a way that conforms with what they learned as infants. This re-creation is called an enactment.

Techniques

When treating patients, relational psychoanalysts stress a mixture of waiting and authentic spontaneity. Some relationally oriented psychoanalysts eschew the traditional Freudian emphasis on interpretation and free association, instead emphasising the importance of creating a lively, genuine relationship with the patient. However, many others place a great deal of importance on the Winnicottian concept of “holding” and are far more restrained in their approach, generally giving weight to well formulated interpretations made at what seems to be the proper time. Overall, relational analysts feel that psychotherapy works best when the therapist focuses on establishing a healing relationship with the patient, in addition to focusing on facilitating insight. They believe that in doing so, therapists break patients out of the repetitive patterns of relating to others that they believe maintain psychopathology. Noteworthy too is ‘the emphasis relational psychoanalysis places on the mutual construction of meaning in the analytic relationship’.

Authors

Stephen A. Mitchell has been described as the “most influential relational psychoanalyst”. His 1983 book, co-written with Jay Greenberg and called Object Relations in Psychoanalytic Theory is considered to be the first major work of relational psychoanalysis. Prior work especially by Sabina Spielrein in the 1910s to 1930s is often cited, particularly by Adrienne Harris and others who connect feminism with the field, but as part of the prior Freud/Jung/Spielrein tradition.

Other important relational authors include Neil Altman, Lewis Aron, Hugo Bleichmar, Philip Bromberg, Nancy Chodorow, Susan Coates, Jody Davies, Emmanuel Ghent, Adrienne Harris, Irwin Hirsch, Irwin Z. Hoffman, Karen Maroda, Stuart Pizer, Owen Renik, Ramón Riera, Daniel Schechter, Joyce Slochower, Martha Stark, Ruth Stein, Donnel Stern, Robert Stolorow, Jeremy D. Safran and Jessica Benjamin – the latter pursuing the ‘goal of creating a genuinely feminist and philosophically informed relational psychoanalysis’. A significant historian and philosophical contributor is Philip Cushman.

Criticisms

Psychoanalyst and philosopher Jon Mills has offered a number of substantial criticisms of the relational movement. Mills evidently thinks this “paradigm shift” to relational psychoanalysis is not exclusively due to theoretical differences with classical psychoanalysis but also arises from a certain group mentality and set of interests: “Relational psychoanalysis is an American phenomenon, with a politically powerful and advantageous group of members advocating for conceptual and technical reform” from a professional psychologist group perspective: “most identified relational analysts are psychologists, as are the founding professionals associated with initiating the relational movement”.

From a theoretical perspective, Mills appears to doubt that relational psychoanalysis is as radically new as it is touted to be. In its emphasis on the developmental importance of other people, according to Mills, “relational theory is merely stating the obvious” – picking up on “a point that Freud made explicit throughout his theoretical corpus, which becomes further emphasized more significantly by early object relations therapists through to contemporary self psychologists.” Mills also criticizes the diminishing or even the loss of the significance of the unconscious in relational psychoanalysis, a point he brings up in various parts of his book Conundrums.

Psychoanalyst and historian Henry Zvi Lothane has also criticised some of the central ideas of relational psychoanalysis, from both historical and psychoanalytic perspectives. Historically, Lothane believes relational theorists overstate the non-relational aspects of Freud as ignore its relational aspects. Lothane maintains that, though Freud’s theory of disorder is “monadic,” i.e. focused more or less exclusively on the individual, Freud’s psychoanalytic method and theory of clinical practice is consistently dyadic or relational. From a theoretical perspective, Lothane has criticised the term “relational” in favour of Harry Stack Sullivan’s term “interpersonal”. Lothane developed his concepts of “reciprocal free association” as well as “dramatology” as ways of understanding the interpersonal or relational dimension of psychoanalysis.

Psychoanalyst and philosopher Aner Govrin examines the heavy price psychoanalysis paid for adopting postmodernism as their preferred epistemology. He posits that only analysts who thought they “know the truth,” created classical, interpersonal, self-psychology, ego psychology, Kleinian, Bionian, Fairbairnian, Winiccottian and other schools of thought. While the relational tradition had made extraordinary and positive contributions to psychoanalysis, and its postmodern epistemology is indeed moderate, as a political movement the American relational tradition had unwanted psychological and sociological effects on psychoanalysis. This led to a severe decline in the positive image of knowledge that is crucial for the building of new theories. Led by the relational movement, but influenced by a much broader movement in western philosophy and culture, this impact has greatly influenced international psychoanalysis. It has led not only to the disparagement of the school era but also to the devaluation of any attempt to know the truth.

Adopting a more sympathetic line of criticism, Robin S. Brown suggests that while relational thinking has done much to challenge psychoanalytic dogmatism, excessively emphasizing the formative role of social relations can culminate in its own form of authoritarianism. Brown contends that the relational shift has insufficiently addressed the role of first principles, and that this tendency might be challenged by engaging analytical psychology.

What was the Rosenham Experiment?

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Introduction

The Rosenhan experiment or Thud experiment was an experiment conducted to determine the validity of psychiatric diagnosis. The participants feigned hallucinations to enter psychiatric hospitals but acted normally afterwards. They were diagnosed with psychiatric disorders and were given antipsychotic medication. The study was conducted by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science in 1973 under the title “On Being Sane in Insane Places”. It is considered an important and influential criticism of psychiatric diagnosis, and broached the topic of wrongful involuntary commitment.

Rosenhan’s study was done in two parts. The first part involved the use of healthy associates or “pseudopatients” (three women and five men, including Rosenhan himself) who briefly feigned auditory hallucinations in an attempt to gain admission to 12 psychiatric hospitals in five states in the United States. All were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they no longer experienced any additional hallucinations. As a condition of their release, all the patients were forced to admit to having a mental illness and had to agree to take antipsychotic medication. The average time that the patients spent in the hospital was 19 days. All but one were diagnosed with schizophrenia “in remission” before their release.

The second part of his study involved a hospital administration challenging Rosenhan to send pseudopatients to its facility, whose staff asserted that they would be able to detect the pseudopatients. Rosenhan agreed, and in the following weeks 41 out of 193 new patients were identified as potential pseudopatients, with 19 of these receiving suspicion from at least one psychiatrist and one other staff member. Rosenhan sent no pseudopatients to the hospital.

While listening to a lecture by R.D. Laing, who was associated with the anti-psychiatry movement, Rosenhan conceived of the experiment as a way to test the reliability of psychiatric diagnoses. The study concluded “it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals” and also illustrated the dangers of dehumanisation and labelling in psychiatric institutions. It suggested that the use of community mental health facilities which concentrated on specific problems and behaviours rather than psychiatric labels might be a solution, and recommended education to make psychiatric workers more aware of the social psychology of their facilities.

Pseudopatient Experiment

Rosenhan himself and seven mentally healthy associates, called “pseudopatients”, attempted to gain admission to psychiatric hospitals by calling for an appointment and feigning auditory hallucinations. The hospital staff were not informed of the experiment. The pseudopatients included a psychology graduate student in his twenties, three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife. None had a history of mental illness. Pseudopatients used pseudonyms, and those who worked in the mental health field were given false jobs in a different sector to avoid invoking any special treatment or scrutiny. Apart from giving false names and employment details, further biographical details were truthfully reported.

During their initial psychiatric assessment, the pseudopatients claimed to be hearing voices of the same sex as the patient which were often unclear, but which seemed to pronounce the words “empty”, “hollow”, or “thud”, and nothing else. These words were chosen as they vaguely suggest some sort of existential crisis and for the lack of any published literature referencing them as psychotic symptoms. No other psychiatric symptoms were claimed. If admitted, the pseudopatients were instructed to “act normally”, reporting that they felt fine and no longer heard voices. Hospital records obtained after the experiment indicate that all pseudopatients were characterized as friendly and cooperative by staff.

All were admitted, to 12 psychiatric hospitals across the United States, including rundown and underfunded public hospitals in rural areas, urban university-run hospitals with excellent reputations, and one expensive private hospital. Though presented with identical symptoms, seven were diagnosed with schizophrenia at public hospitals, and one with manic-depressive psychosis, a more optimistic diagnosis with better clinical outcomes, at the private hospital. Their stays ranged from 7 to 52 days, and the average was 19 days. All but one were discharged with a diagnosis of schizophrenia “in remission”, which Rosenhan considered as evidence that mental illness is perceived as an irreversible condition creating a lifelong stigma rather than a curable illness.

Despite constantly and openly taking extensive notes on the behaviour of the staff and other patients, none of the pseudopatients were identified as impostors by the hospital staff, although many of the other psychiatric patients seemed to be able to correctly identify them as impostors. In the first three hospitalisations, 35 of the total of 118 patients expressed a suspicion that the pseudopatients were sane, with some suggesting that the patients were researchers or journalists investigating the hospital. Hospital notes indicated that staff interpreted much of the pseudopatients’ behaviour in terms of mental illness. For example, one nurse labelled the note-taking of one pseudopatient as “writing behaviour” and considered it pathological. The patients’ normal biographies were recast in hospital records along the lines of what was expected of schizophrenics by the then-dominant theories of its cause.

The experiment required the pseudopatients to get out of the hospital on their own by getting the hospital to release them, though a lawyer was retained to be on call for emergencies when it became clear that the pseudopatients would not ever be voluntarily released on short notice. Once admitted and diagnosed, the pseudopatients were not able to obtain their release until they agreed with the psychiatrists that they were mentally ill and began taking antipsychotic medications, which they flushed down the toilet. No staff member reported that the pseudopatients were flushing their medication down the toilets.

Rosenhan and the other pseudopatients reported an overwhelming sense of dehumanisation, severe invasion of privacy, and boredom while hospitalised. Their possessions were searched randomly, and they were sometimes observed while using the toilet. They reported that though the staff seemed to be well-meaning, they generally objectified and dehumanised the patients, often discussing patients at length in their presence as though they were not there, and avoiding direct interaction with patients except as strictly necessary to perform official duties. Some attendants were prone to verbal and physical abuse of patients when other staff were not present. A group of patients waiting outside the cafeteria half an hour before lunchtime were said by a doctor to his students to be experiencing “oral-acquisitive” psychiatric symptoms. Contact with doctors averaged 6.8 minutes per day.

Non-Existent Impostor Experiment

For this experiment, Rosenhan used a well-known research and teaching hospital, whose staff had heard of the results of the initial study but claimed that similar errors could not be made at their institution. Rosenhan arranged with them that during a three-month period, one or more pseudopatients would attempt to gain admission and the staff would rate every incoming patient as to the likelihood they were an impostor. Out of 193 patients, 41 were considered to be impostors and a further 42 were considered suspect. In reality, Rosenhan had sent no pseudopatients; all patients suspected as impostors by the hospital staff were ordinary patients. This led to a conclusion that “any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.”

Impact

Rosenhan published his findings in Science, in which he criticised the reliability of psychiatric diagnosis and the disempowering and demeaning nature of patient care experienced by the associates in the study. In addition, he described his work in a variety of news appearances, including to the BBC:

I told friends, I told my family: “I can get out when I can get out. That’s all. I’ll be there for a couple of days and I’ll get out.” Nobody knew I’d be there for two months … The only way out was to point out that they’re [the psychiatrists are] correct. They had said I was insane, “I am insane; but I am getting better.” That was an affirmation of their view of me.

The experiment is argued to have “accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible”.

Many respondents to the publication defended psychiatry, arguing that as psychiatric diagnosis relies largely on the patient’s report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. In this vein, psychiatrist Robert Spitzer quoted Seymour S. Kety in a 1975 criticism of Rosenhan’s study:

If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition.

Kety also argued that psychiatrists should not necessarily be expected to assume that a patient is pretending to have mental illness, thus the study lacked realism. Rosenhan called this the “experimenter effect” or “expectation bias”, something indicative of the problems he uncovered rather than a problem in his methodology.

In The Great Pretender, a 2019 book on Rosenhan, author Susannah Cahalan questions the veracity and validity of the Rosenhan experiment. Examining documents left behind by Rosenhan after his death, Cahalan finds apparent distortion in the Science article: inconsistent data, misleading descriptions, and inaccurate or fabricated quotations from psychiatric records. Moreover, despite an extensive search, she is only able to identify two of the eight pseudopatients: Rosenhan himself, and a graduate student whose testimony is allegedly inconsistent with Rosenhan’s description in the article. In light of Rosenhan’s seeming willingness to bend the truth in other ways regarding the experiment, Cahalan questions whether some or all of the six other pseudopatients might have been simply invented by Rosenhan.

Related Experiments

In 1887 American investigative journalist Nellie Bly feigned symptoms of mental illness to gain admission to a lunatic asylum and report on the terrible conditions therein. The results were published as Ten Days in a Mad-House.]

In 1968 Maurice K. Temerlin split 25 psychiatrists into two groups and had them listen to an actor portraying a character of normal mental health. One group was told that the actor “was a very interesting man because he looked neurotic, but actually was quite psychotic” while the other was told nothing. Sixty percent of the former group diagnosed psychoses, most often schizophrenia, while none of the control group did so.

In 1988, Loring and Powell gave 290 psychiatrists a transcript of a patient interview and told half of them that the patient was black and the other half white; they concluded of the results that “clinicians appear to ascribe violence, suspiciousness, and dangerousness to black clients even though the case studies are the same as the case studies for the white clients.”

In 2004, psychologist Lauren Slater claimed to have conducted an experiment very similar to Rosenhan’s for her book Opening Skinner’s Box. Slater wrote that she had presented herself at 9 psychiatric emergency rooms with auditory hallucinations, resulting in being diagnosed “almost every time” with psychotic depression. However, when challenged to provide evidence of actually conducting her experiment, she could not. The serious methodologic and other concerns regarding Slater’s work appeared as a series of responses to a journal report, in the same journal.

In 2008, the BBC’s Horizon science programme performed a similar experiment over two episodes entitled “How Mad Are You?”. The experiment involved ten subjects, five with previously diagnosed mental health conditions, and five with no such diagnosis. They were observed by three experts in mental health diagnoses and their challenge was to identify the five with mental health problems solely from their behaviour, without speaking to the subjects or learning anything of their histories. The experts correctly diagnosed two of the ten patients, misdiagnosed one patient, and incorrectly identified two healthy patients as having mental health problems. Unlike the other experiments listed here, however, the aim of this journalistic exercise was not to criticise the diagnostic process, but to minimise the stigmatisation of the mentally ill. It aimed to illustrate that people with a previous diagnosis of a mental illness could live normal lives with their health problems not obvious to observers from their behaviour.

What is the Seasonal Pattern Assessment Questionnaire?

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Introduction

The Seasonal Pattern Assessment Questionnaire, or SPAQ, is a simple, self-administered screening test for Seasonal Affective Disorder, first developed in 1984. Though some aspects of its accuracy have been questioned since then, it is widely used today, especially by SAD researchers.

Background

The SPAQ is a screening instrument for seasonal affective disorder (SAD), a recurrent major depressive disorder that typically affects its victims during the fall and winter months. It was first developed by American psychiatrist Norman E. Rosenthal and his National Institute of Mental Health colleagues in 1984, and continues to be widely used. It is a self-administered paper-and-pencil test that is freely available in the public domain. The SPAQ can be downloaded.

The questionnaire asks subjects to score the amounts of seasonal changes they have experienced in sleep, socialization, mood, weight, appetite and energy. A global score between 0 and 24 is gotten by adding up the scores on each of these items. Subjects also specify the months during which these changes are greatest and least. Subjects are also asked rate their overall seasonal impairment from “no problem” to “disabling”.

Subjects are often taught how to interpret their scores, and cautioned that a self-assessment can never substitute for a clinical evaluation. If their score on the SPAQ is high, they are advised to consult their physician.

Reliability, Validity, and Specificity

Numerous studies have been done to assess the usefulness of the test. In general, it has been found to be reliable (in that it yields consistent measurements) and valid (in that it measures what it purports to measure). It has also been found to have low specificity (in that people who have other forms of depression can score as if they have SAD). This could give misleadingly high estimates of the prevalence of SAD.

Some studies have questioned the overall validity of the SPAQ, and even the concept of SAD itself.

In spite of its shortcomings, the SPAQ is still a very popular screening tool in SAD research. This is true because of its early development, historically wide dissemination, and the absence of better-validated alternatives.

What is Substance-Induced Psychosis?

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Introduction

Substance-induced psychosis (commonly known as toxic psychosis or drug-induced psychosis) is a form of psychosis that is attributed to substance use.

It is a psychosis that results from the effects of chemicals or drugs, including those produced by the body itself. Various psychoactive substances have been implicated in causing or worsening psychosis in users.

Signs and Symptoms

Psychosis manifests as disorientation, visual hallucinations and/or haptic hallucinations. It is a state in which a person’s mental capacity to recognise reality, communicate, and relate to others is impaired, thus interfering with the capacity to deal with life demands. While there are many types of psychosis, substance-induced psychosis can be pinpointed to specific chemicals.

Transition to schizophrenia

A 2019 systematic review and meta-analysis by Murrie and colleagues found that the pooled proportion of transition from substance-induced psychosis to schizophrenia was 25% (95% CI 18%-35%), compared with 36% (95% CI 30%-43%) for brief, atypical and not otherwise specified psychoses.

Type of substance was the primary predictor of transition from drug-induced psychosis to schizophrenia, with highest rates associated with cannabis (6 studies, 34%, CI 25%-46%), hallucinogens (3 studies, 26%, CI 14%-43%) and amphetamines (5 studies, 22%, CI 14%-34%). Lower rates were reported for opioid (12%), alcohol (10%) and sedative (9%) induced psychoses.

Transition rates were slightly lower in older cohorts but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up.

Substances

Psychotic states may occur after using a variety of legal and illegal substances. Usually such states are temporary and reversible, with fluoroquinolone-induced psychosis being a notable exception. Substances whose use or withdrawal are implicated in psychosis include the following:

International Classification of Diseases

Psychoactive substance-induced psychotic disorders outlined within the ICD-10 codes F10.5-F19.5:

  • F10.5 alcohol:
    • Alcohol is a common cause of psychotic disorders or episodes, which may occur through acute intoxication, chronic alcoholism, withdrawal, exacerbation of existing disorders, or acute idiosyncratic reactions.
    • Research has shown that excessive alcohol use causes an 8-fold increased risk of psychotic disorders in men and a 3 fold increased risk of psychotic disorders in women.
    • While the vast majority of cases are acute and resolve fairly quickly upon treatment and/or abstinence, they can occasionally become chronic and persistent.
    • Alcoholic psychosis is sometimes misdiagnosed as another mental illness such as schizophrenia.
  • F11.5 opioid:
    • Studies show stronger opioids such as Fentanyl are more likely to cause psychosis and hallucinations.
  • F12.5 cannabinoid:
    • Some studies indicate that cannabis may trigger full-blown psychosis.
    • Recent studies have found an increase in risk for psychosis in cannabis users.
  • F13.5 sedatives/hypnotics (barbiturates; benzodiazepines):
    • It is also important to this topic to understand the paradoxical effects of some sedative drugs.
    • Serious complications can occur in conjunction with the use of sedatives creating the opposite effect as to that intended.
    • Malcolm Lader at the Institute of Psychiatry in London estimates the incidence of these adverse reactions at about 5%, even in short-term use of the drugs.
    • The paradoxical reactions may consist of depression, with or without suicidal tendencies, phobias, aggressiveness, violent behaviour and symptoms sometimes misdiagnosed as psychosis.
    • However, psychosis is more commonly related to the benzodiazepine withdrawal syndrome.
  • F14.5 cocaine.
  • F15.5 other stimulants:
    • Amphetamines; methamphetamine; and methylphenidate.
    • Refer to stimulant psychosis.
  • F16.5 hallucinogens (LSD and others).
  • F18.5 volatile solvents (volatile inhalants):
    • Toluene, found in glue, paint, thinner, etc. See also toluene toxicity.
    • Butane.
    • Gasoline (petrol).

F17.5 is reserved for tobacco-induced psychosis, but is traditionally not associated with the induction of psychosis.

The code F15.5 also includes caffeine-induced psychosis, despite not being specifically listed in the DSM-IV. However, there is evidence that caffeine, in extreme acute doses or when taken in excess for long periods of time, may induce psychosis.

Medication

  • Fluoroquinolone drugs, fluoroquinolone use has been linked to serious cases of toxic psychosis that have been reported to be irreversible and permanent, see adverse effects of fluoroquinolones. The related quinoline derivative mefloquine (Lariam) has also been associated with psychosis.
  • Some over-the-counter drugs, including:
    • Dextromethorphan (DXM) at high doses.
    • Certain antihistamines at high doses.
    • Cold Medications (i.e. containing Phenylpropanolamine, or PPA)
  • Prescription drugs:
    • Prednisone and other corticosteroids.
    • Isotretinoin
    • Anticholinergic drugs.
      • Atropine.
      • Scopolamine.
    • Antidepressants.
    • L-dopa.
    • Antiepileptics.
  • Antipsychotics, in an idiosyncratic reaction.
  • Antimalarials.
  • Mepacrine.

Other drugs illicit in America

Other drugs illegal in America (not listed above), including:

  • MDMA (ecstasy).
  • Phencyclidine (PCP).
  • Ketamine.
  • Synthetic research chemicals used recreationally, including:
    • JWH-018 and some other synthetic cannabinoids, or mixtures containing them (e.g. “Spice”, “Kronic”, “MNG” or “Mr. Nice Guy”, “Relaxinol”, etc.).
    • Various “JWH-XXX” compounds in “Spice” or “Incense” have also been found and have been found to cause psychosis in some people.
  • Mephedrone and related amphetamine-like drugs sold as “bath salts” or “plant food”.

Plants

  • Hawaiian baby woodrose (contains ergine).
  • Morning glory seeds (contains ergine).
  • Jimson weed (Datura, angel’s trumpet, thorn apple).
  • Belladonna (deadly nightshade).
  • Salvia divinorum.

Nonmedicinal Substances

Substances chiefly nonmedicinal as to source:

  • Carbon monoxide, carbon dioxide, and carbon disulfide.
  • Heavy metals.
  • Organophosphate insecticides.
  • Sarin and other nerve gases.
  • Tetraethyllead.
  • Aniline.
  • Acetone and other ketones.
  • Antifreeze – a mixture of ethylene glycol and other glycols.
  • Arsenic and its compounds.

Reference

Murrie, B., Lappin, J., Large, M. & Sara, G. (2019) Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis. Schizophrenia Bulletin. 46(3), pp.505-516. doi:10.1093/schbul/sbz102.

On This Day … 25 May

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People (Births)

  • 1860 – James McKeen Cattell, American psychologist and academic (d. 1944).
  • 1941 – Uta Frith, German developmental psychologist.
  • 1947 – Catherine G. Wolf, American psychologist and computer scientist.

James McKeen Cattell

James McKeen Cattell (25 May 1860 to 20 January 1944), American psychologist, was the first professor of psychology in the United States, teaching at the University of Pennsylvania, and long-time editor and publisher of scientific journals and publications, most notably the journal Science. He also served on the board of trustees for Science Service, now known as Society for Science & the Public (or SSP), from 1921-1944.

At the beginning of Cattell’s career, many scientists regarded psychology as, at best, a minor field of study, or at worst a pseudoscience such as phrenology. Perhaps more than any of his contemporaries, Cattell helped establish psychology as a legitimate science, worthy of study at the highest levels of the academy. At the time of his death, The New York Times hailed him as “the dean of American science.” Yet Cattell may be best remembered for his uncompromising opposition to American involvement in World War I. His public opposition to the draft led to his dismissal from his position at Columbia University, a move that later led many American universities to establish tenure as a means of protecting unpopular beliefs.

Uta Frith

Uta Frith (née Aurnhammer; born 25 May 1941) is a German developmental psychologist working at the Institute of Cognitive Neuroscience at University College London. She has pioneered much of the current research into autism and dyslexia, and has written several books on the two subjects arguing for autism to be considered a mental condition rather than being caused by parenting. Her book Autism: Explaining the Enigma introduces the cognitive neuroscience of autism. She is credited for creating the Sally-Anne test along with fellow scientists Alan Leslie and Simon Baron-Cohen. She also pioneered the work with child dyslexia. Among the students she has mentored are Tony Attwood, Maggie Snowling, Simon Baron-Cohen and Francesca Happé.

Catherine G. Wolf

Catherine Gody Wolf (25 May 1947 to 07 February 2018) was an American psychologist and expert in human-computer interaction. She was the author of more than 100 research articles and held six patents in the areas of human-computer interaction, artificial intelligence, and collaboration. Wolf was known for her work at IBM’s Thomas J. Watson Research Center in Yorktown Heights, NY, where she was a 19-year staff researcher.

In the late 1990s, Wolf was diagnosed with Amyotrophic lateral sclerosis (ALS), better known as Lou Gehrig’s disease. Despite a rapid physical deterioration, Wolf was still able to communicate with the world via electronic sensory equipment, including a sophisticated brain-computer interface. Remarkably, with almost no voluntary physical functions remaining, she published novel research into the fine-scale abilities of ALS patients.

What is Trichotillomania?

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Introduction

Trichotillomania (TTM), also known as hair pulling disorder or compulsive hair pulling, is a mental disorder characterised by a long-term urge that results in the pulling out of one’s hair. This occurs to such a degree that hair loss can be seen. A brief positive feeling may occur as hair is removed. Efforts to stop pulling hair typically fail. Hair removal may occur anywhere; however, the head and around the eyes are most common. The hair pulling is to such a degree that it results in distress.

The disorder may run in families. It occurs more commonly in those with obsessive compulsive disorder. Episodes of pulling may be triggered by anxiety. People usually acknowledge that they pull their hair. On examination broken hairs may be seen. Other conditions that may present similarly include body dysmorphic disorder, however in that condition people remove hair to try to improve what they see as a problem in how they look.

Treatment is typically with cognitive behavioural therapy (CBT). The medication clomipramine may also be helpful, as will clipping fingernails. Trichotillomania is estimated to affect one to four percent of people. Trichotillomania most commonly begins in childhood or adolescence. Women are affected about 10 times more often than men. The name was created by François Henri Hallopeau in 1889, from the Greek θριξ/τριχ; thrix (meaning “hair”), along with τίλλειν; tíllein (meaning “to pull”), and μανία; mania (meaning “madness”).

Brief History

Hair pulling was first mentioned by Aristotle in the fourth century B.C., was first described in modern literature in 1885, and the term trichotillomania was coined by the French dermatologist François Henri Hallopeau in 1889.

In 1987, trichotillomania was recognised in the Diagnostic and Statistical Manual of the American Psychiatric Association, third edition-revised (DSM-III-R).

Epidemiology

Although no broad-based population epidemiologic studies had been conducted as of 2009, the lifetime prevalence of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population. With a 1% prevalence rate, 2.5 million people in the US may have trichotillomania at some time during their lifetimes.

Trichotillomania is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age, and a notable peak at 12-13. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female. Among adults, females typically outnumber males by 3 to 1.

“Automatic” pulling occurs in approximately three-quarters of adult patients with trichotillomania.

Signs and Symptoms

Trichotillomania is usually confined to one or two sites, but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs. Some less common areas include the pubic area, underarms, beard, and chest. The classic presentation is the “Friar Tuck” form of vertex and crown alopecia. Children are less likely to pull from areas other than the scalp.

People who suffer from trichotillomania often pull only one hair at a time and these hair-pulling episodes can last for hours at a time. Trichotillomania can go into remission-like states where the individual may not experience the urge to “pull” for days, weeks, months, and even years.

Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape. Individuals with trichotillomania may be secretive or shameful of the hair pulling behaviour.

An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socialising, due to appearance and negative attention they may receive. Some people with trichotillomania wear hats, wigs, false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as “pulling”) whatsoever. This “pulling” often resumes upon leaving this environment. Some individuals with trichotillomania may feel they are the only person with this problem due to low rates of reporting.

For some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hair pulling causes painful isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hair pulling can lead to great tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.

Other medical complications include infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome, and gastrointestinal obstruction as a result of trichophagia. In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball (trichobezoar). Rapunzel syndrome, an extreme form of trichobezoar in which the “tail” of the hair ball extends into the intestines, can be fatal if misdiagnosed.

Environment is a large factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are conducive to hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic trichotillomania is found when some patients have been observed to pull their hair out while asleep. This is called sleep-isolated trichotillomania.

Causes

Anxiety, depression and obsessive-compulsive disorder (OCD) are more frequently encountered in people with trichotillomania. Trichotillomania has a high overlap with post traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or negatively reinforcing, as it is associated with rising tension beforehand and relief afterward. A neurocognitive model – the notion that the basal ganglia plays a role in habit formation and that the frontal lobes are critical for normally suppressing or inhibiting such habits – sees trichotillomania as a habit disorder.

Abnormalities in the caudate nucleus are noted in OCD, but there is no evidence to support that these abnormalities can also be linked to trichotillomania. One study has shown that individuals with trichotillomania have decreased cerebellar volume. These findings suggest some differences between OCD and trichotillomania. There is a lack of structural MRI studies on trichotillomania. In several MRI studies that have been conducted, it has been found that people with trichotillomania have more gray matter in their brains than those who do not suffer from the disorder.

It is likely that multiple genes confer vulnerability to trichotillomania. One study identified mutations in the SLITRK1 gene.

Diagnosis

Patients may be ashamed or actively attempt to disguise their symptoms. This can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure. If the patient admits to hair pulling, diagnosis is not difficult; if patients deny hair pulling, a differential diagnosis must be pursued. The differential diagnosis will include evaluation for alopecia areata, iron deficiency, hypothyroidism, tinea capitis, traction alopecia, alopecia mucinosa, thallium poisoning, and loose anagen syndrome. In trichotillomania, a hair pull test is negative.

A biopsy can be performed and may be helpful; it reveals traumatised hair follicles with perifollicular haemorrhage, fragmented hair in the dermis, empty follicles, and deformed hair shafts. Multiple catagen hairs are typically seen. An alternative technique to biopsy, particularly for children, is to shave a part of the involved area and observe for regrowth of normal hairs.

Classification

Trichotillomania is defined as a self-induced and recurrent loss of hair. It includes the criterion of an increasing sense of tension before pulling the hair and gratification or relief when pulling the hair. However, some people with trichotillomania do not endorse the inclusion of “rising tension and subsequent pleasure, gratification, or relief” as part of the criteria because many individuals with trichotillomania may not realise they are pulling their hair, and patients presenting for diagnosis may deny the criteria for tension prior to hair pulling or a sense of gratification after hair is pulled.

Trichotillomania may lie on the obsessive-compulsive spectrum, also encompassing OCD, body dysmorphic disorder (BDD), nail biting (onychophagia) and skin picking (dermatillomania), tic disorders and eating disorders. These conditions may share clinical features, genetic contributions, and possibly treatment response; however, differences between trichotillomania and OCD are present in symptoms, neural function and cognitive profile. In the sense that it is associated with irresistible urges to perform unwanted repetitive behaviour, trichotillomania is akin to some of these conditions, and rates of trichotillomania among relatives of OCD patients is higher than expected by chance. However, differences between the disorder and OCD have been noted, including: differing peak ages at onset, rates of comorbidity, gender differences, and neural dysfunction and cognitive profile. When it occurs in early childhood, it can be regarded as a distinct clinical entity.

Because trichotillomania can be present in multiple age groups, it is helpful in terms of prognosis and treatment to approach three distinct subgroups by age: preschool age children, preadolescents to young adults, and adults.

In preschool age children, trichotillomania is considered benign. For these children, hair-pulling is considered either a means of exploration or something done subconsciously, similar to nail-biting and thumb-sucking, and almost never continues into further ages.

The most common age of onset of trichotillomania is between ages 9 and 13. In this age range, trichotillomania is usually chronic, and continues into adulthood. Trichiotillomania that begins in adulthood most commonly arises from underlying psychiatric causes.

Trichotillomania is often not a focused act, but rather hair pulling occurs in a “trance-like” state; hence, trichotillomania is subdivided into “automatic” versus “focused” hair pulling. Children are more often in the automatic, or unconscious, subtype and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hair pulling, including seeking specific types of hairs to pull, pulling until the hair feels “just right”, or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies.

Treatment

Treatment is based on a person’s age. Most pre-school age children outgrow the condition if it is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behaviour modification programmes, may be considered; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other mental disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated.

Psychotherapy

Habit reversal training (HRT) has the highest rate of success in treating trichotillomania. HRT has also been shown to be a successful adjunct to medication as a way to treat trichotillomania. With HRT, the individual is trained to learn to recognise their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioural versus pharmacologic treatment, cognitive behavioural therapy (CBT, including HRT) have shown significant improvement over medication alone. It has also proven effective in treating children. Biofeedback, cognitive-behavioural methods, and hypnosis may improve symptoms. Acceptance and commitment therapy (ACT) is also demonstrating promise in trichotillomania treatment. A systematic review from 2012 found tentative evidence for “movement decoupling”.

Medication

The United States Food and Drug Administration (FDA) has not approved any medications for trichotillomania treatment.

Medications can be used to treat trichotillomania. Treatment with clomipramine, a tricyclic antidepressant, was shown in a small double-blind study to improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Naltrexone may be a viable treatment. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects. Behavioural therapy has proven more effective when compared to fluoxetine. There is little research on the effectiveness of behavioural therapy combined with medication, and robust evidence from high-quality studies is lacking. Acetylcysteine treatment stemmed from an understanding of glutamate’s role in regulation of impulse control.

Different medications, depending on the individual, may increase hair pulling.

Devices

Technology can be used to augment habit reversal training or behavioural therapy. Several mobile apps exist to help log behaviour and focus on treatment strategies. There are also wearable devices that track the position of a user’s hands. They produce sound or vibrating notifications so that users can track rates of these events over time.

Prognosis

When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required. In adults, the onset of trichotillomania may be secondary to underlying psychiatric disturbances, and symptoms are generally more long-term.

Secondary infections may occur due to picking and scratching, but other complications are rare. Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder.

Society and Culture

Support groups and internet sites can provide recommended educational material and help persons with trichotillomania in maintaining a positive attitude and overcoming the fear of being alone with the disorder.

Media

A documentary film exploring trichotillomania, Bad Hair Life, was the 2003 winner of the International Health & Medical Media Award for best film in psychiatry and the winner of the 2004 Superfest Film Festival Merit Award.

Trichster is a 2016 documentary that follows seven individuals living with trichotillomania, as they navigate the complicated emotions surrounding the disorder, and the effect it has on their daily lives.

What is the Tripartite Model of Anxiety and Depression?

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Introduction

Watson and Clark (1991) proposed the Tripartite Model of Anxiety and Depression to help explain the comorbidity between anxious and depressive symptoms and disorders.

This model divides the symptoms of anxiety and depression into three groups: negative affect, positive affect and physiological hyperarousal. These three sets of symptoms help explain common and distinct aspects of depression and anxiety.

The ability to distinguish between anxiety and depression with this model may help increase diagnostic accuracy and help eliminate the complications that occur with comorbidity. According to Clark, depressed patients have a comorbidity rate of 57% for any anxiety disorder. Other studies in youth have revealed comorbidity rates of anxiety and depression as high as 70%. There are many negative effects of anxiety-depression comorbidity. The negative effects of comorbidity include: chronicity, recovery and relapse rates, and higher suicide risk. Among youth samples, negative effects of anxiety-depression comorbidity include: increased substance abuse, more likely to attempt suicide, receive a diagnosis of conduct disorder, and are less likely to show favourable gains from treatment.

Factors

Negative Affect

Negative affect is the factor that is common to both anxiety and depression. Negative affect can be defined as, “the extent to which an individual feels upset or unpleasantly engaged, rather than peaceful”. It involves negative mood states such as subjective distress, fear, disgust, scorn, and hostility. Mood states that are specific to depression include sadness and loneliness that have large factor loadings on negative affect. Some common symptoms of negative affect include: insomnia, restlessness, irritability, and poor concentration.

There is a substantial amount of empirical research on negative affect (NA) and its role in the tripartite model. For example, the Mood and Anxiety Symptom Questionnaire (MASQ) was administered to a sample of college students and a sample of psychiatric patients. The correlations between the specific anxiety scale (anxious arousal) in the MASQ and NA were moderate (rs= .41 and .47), supporting that NA is specific to anxiety disorders, congruent with the tripartite model. Another study consisted of a sample of children (ages 7-14) diagnosed with a principal anxiety disorder. The children completed the Positive and Negative Affect Scale for Children (PANAS-C). The results showed NA was significantly associated with measure of anxiety and depression. A study by Chorpita in 2002, was consistent with the tripartite model. In a large sample of school-aged children, NA was positively correlated with all anxiety and depression scales.

Physiological Hyperarousal

Physiological hyperarousal is defined by increased activity in the sympathetic nervous system, in response to threat. Physiological hyperarousal is unique to anxiety disorders. Some symptoms of physiological hyperarousal include: shortness of breath, feeling dizzy or lightheaded, dry mouth, trembling or shaking, and sweaty palms.

Compared to negative affect and positive affect, physiological hyperarousal has been studied less. Chorpita et al. (2000), proposed an affect and arousal scale in order to measure the tripartite factors of emotion in children and adolescents. In this study, physiological hyperarousal was positively correlated with negative affect but not positive affect. This supports the tripartite model hypothesis, that physiological hyperarousal will distinguish anxiety from depression, which is related to positive affect. Another study by Joiner et al. (1999), analysed the construct validity of physiological hyperarousal. Data were collected from samples of psychotherapy outpatients, air force cadets, and undergraduate students. Confirmatory factor analyses showed that psychological hyperarousal is a reliable, replicable, valid, and discriminable construct.

Positive Affect

Positive affect is a dimension that reflects one’s level of pleasurable engagement with their environment. High positive affect is made up of enthusiasm, energy level, mental alertness, interest, joy, social dominance, adventurousness, and activeness. In contrast, a low level of positive affect, or absence of, is called anhedonia. Anhedonia is described as the loss of interest or the inability to experience pleasure when experiencing things that used to be pleasurable. Low levels of positive affect in the Tripartite Model characterise depression. Signs of low positive affect include fatigue, loneliness, sadness, and lethargy. Positive affect is important because it is a construct used in order to differentiate depression from anxiety.

Many studies were completed to evaluate the role of positive affect in the tripartite model. A sample of university students were administered the Positive and Negative Affective Schedule (PANAS), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). The results of this study were congruent with low Positive Affect predicting depression. A longitudinal study was completed with a sample of students in grade 6 and later grade 9. The students completed the Baltimore How I Feel (BHIF), a measure of anxious and depressive symptoms. This study confirmed the PA aspect of the tripartite model. A study with a sample of inpatient children/adolescents was consistent with the tripartite model as well. Findings from a study in 2006 of a community sample of youth supported the tripartite in youth and further supported that anxiety and depression do represent unique syndromes in youth based on differences found in positive affect. Many studies looked at samples of youth but studies were also done with older adult samples. A study consisting of psychiatric outpatients, ages 55-87, confirmed that positive affect was significantly more related to depression than anxiety symptoms.

Measures

PANAS

The Positive and Negative Affect Schedule (PANAS) was developed by Watson, Clark, and Tellegen in 1988. This scale is brief, easy to administer, and is used to measure positive affect and negative affect. The scale uses 20 adjectives that describe different moods ranging from excited to upset. There are 10 positive affect adjectives and 10 negative affect adjectives. Individuals are asked to rate each adjective on a 5-point scale (1 – very slightly or not at all to 5 – extremely) based on how they feel. The time frame in which they make these ratings varies based on the study.

MASQ

Watson and Clark established the 90-item Mood and Anxiety Symptom Questionnaire (MASQ). The MASQ consists of five subscales that measure: mixed general distress symptoms (GD: Mixed, 15 items), general distress depressive symptoms (GD: Depression, 12 items), general distress anxiety symptoms (GD: Anxiety, 11 items), anxious arousal symptoms (Anxious Arousal, 17 items) and anhedonic depression symptoms (Anhedonic Depression, 22 items). All individual items are rated on a scale 1 to 5, where 1 (not at all) indicates the individual has not felt this way at all during the past week and 5 (extremely) indicates that they have felt this way extremely.

On This Day … 24 May

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People (Births)

  • 1878 – Lillian Moller Gilbreth, American psychologist and engineer (d. 1972).

People (Deaths)

  • 2012 – Jacqueline Harpman, Belgian psychoanalyst and author (b. 1929).

Lillian Moller Gilbreth

Lillian Evelyn Moller Gilbreth (24 May 1878 to 02 January 1972) was an American psychologist, industrial engineer, consultant, and educator who was an early pioneer in applying psychology to time-and-motion studies.

She was described in the 1940s as “a genius in the art of living.” Gilbreth, one of the first female engineers to earn a Ph.D., is considered to be the first industrial/organisational psychologist.

She and her husband, Frank Bunker Gilbreth, were efficiency experts who contributed to the study of industrial engineering, especially in the areas of motion study and human factors. Cheaper by the Dozen (1948) and Belles on Their Toes (1950), written by two of their children (Ernestine and Frank Jr.) tell the story of their family life and describe how time-and-motion studies were applied to the organisation and daily activities of their large family. Both books were later made into feature films.

Jacqueline Harpman

Jacqueline Harpman (05 July 1929 to 24 May 2012) was a Belgian writer who wrote in French.

She was born on 05 July 1929, in Brussels, Belgium, and was later well known for her books written in French. She also worked as a psychoanalyst and lived in Etterbeek, Brussels. She died on 24 May 2012, in Brussels, Belgium, after having been severely ill for a long time. She was 82.

On This Day … 22 May

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People (Births)

  • 1932 – Robert Spitzer, American psychiatrist and academic (d. 2015).

Robert Spitzer

Robert Leopold Spitzer (22 May 1932 to 25 December 2015) was a psychiatrist and professor of psychiatry at Columbia University in New York City. He was a major force in the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Education

He received his bachelor’s degree in psychology from Cornell University in 1953 and his M.D. from New York University School of Medicine in 1957. He completed his psychiatric residency at New York State Psychiatric Institute in 1961 and graduated from Columbia University Centre for Psychoanalytic Training and Research in 1966.

Spitzer wrote an article on Wilhelm Reich’s theories in 1953 which the American Journal of Psychiatry declined to publish.

Career

Spitzer spent most of his career at Columbia University in New York City as a Professor of Psychiatry until he retired in 2003. He was on the research faculty of the Columbia University Centre for Psychoanalytic Training and Research where he retired after 49 years in December 2010. He has been called one of the most influential psychiatrists of the 20th century. The Lancet’s obituary described him as “Stubborn, sometimes abrasive, and always eager, Spitzer’s work was guided by a strong sense of ethical fairness”. A colleague at Columbia has described him as an “iconoclast” who “looked for injustice”.

Screening and Diagnostic Tools

Spitzer was a major architect of the modern classification of mental disorders. In 1968, he co-developed a computer program, Diagno I, based on a logical decision tree, that could derive a diagnosis from the scores on a Psychiatric Status Schedule which he co-published in 1970 and that the United States Steering Committee for the United States-United Kingdom Diagnostic Project used to check the consistency of its results.

Spitzer was a member on the four-person United States Steering Committee for the United States-United Kingdom Diagnostic Project, which published their results in 1972. They found the most important difference between countries was that the concept of schizophrenia used in New York was much broader than the one used in London, and included patients who would have been termed manic-depressive or bipolar.

He developed psychiatric methods that focused on asking specific interview questions to get at a diagnosis as opposed to the open-ended questioning of psychoanalysis, which was the predominant technique of mental health. He codeveloped the Mood Disorder Questionnaire (MDQ), a screening technique used for diagnosing bipolar disorder. He also co-developed the Patient Health Questionnaire (PRIME-MD) which can be self-administered to find out if one has a mental illness. The portions of PRIME-MD directed at depression (PHQ2 and PHQ9) have since become accepted in primary care medicine for screening and diagnosis of major depression as well as for monitoring response to treatment.

Position on the Diagnostic and Statistical Manual of Mental Disorders

In 1974, Spitzer became the chair of the American Psychiatric Association’s task force of the third edition of the Diagnostic and Statistical Manual of Mental Disorders the so-called, DSM-III which was released in 1980. Spitzer is a major architect of the modern classification of mental disorders which involves classifying mental disorders in discrete categories with specified diagnostic criteria but later criticised what he saw as errors and excesses in the DSM’s later versions, although he maintained his position that the DSM is still better than the alternatives.

In 2003, Spitzer co-authored a position paper with DSM-IV editor Michael First, stating that the “DSM is generally viewed as clinically useful” based on surveys from practicing professionals and feedback from medical students and residents, but that primary care physicians find the DSM too complicated for their use. The authors emphasized that given then-current limitations in understanding psychiatric disorders, a multitude of DSM codes/diagnoses might apply to some patients, but that it would be a “total speculation” to assign a single diagnosis to a patient. The authors rejected calls to adopt the ICD-9 because it lacked diagnostic criteria and would “[set] psychiatry back 30 years,” while the ICD-10, closely resembled the DSM-III-R classification.[14] In 2013, a definitive autobiography of Spitzer, The Making of DSM-III®: A Diagnostic Manual’s Conquest of American Psychiatry, was published by author and historian Hannah S. Decker.

Spitzer was briefly featured in the 2007 BBC TV series The Trap, in which he stated that the DSM, by operationalising the definitions of mental disorders while paying little attention to the context in which the symptoms occur, may have medicalised the normal human experiences of a significant number of people.

In 2008, Spitzer had criticised the revision process of the DSM-5 for lacking transparency. He has also criticised specific proposals, like the proposed introduction of the psychosis risk syndrome for people who have mild symptoms found in psychotic disorders.

On Homosexuality

Spitzer led a successful effort, in 1973, to stop treating homosexuality as a mental illness.

It was partly due to Spitzer’s efforts that homosexuality was “removed” (i.e. renamed as Sexual Orientation Disturbance) in 1974 DSM-II: “By withdrawing it from the manual, homosexuality was legitimized as a normal difference rather than a psychiatric behavior. This early powerful statement by institutional psychiatry that this is normal sped up the confidence of people in the movement.”

In 2001, Spitzer delivered a controversial paper, “Can Some Gay Men and Lesbians Change Their Sexual Orientation?” at the 2001 annual APA meeting; he argued that it is possible that some highly motivated individuals could successfully change their sexual orientation from homosexual to heterosexual.

Awards

Spitzer received the Thomas William Salmon Medal from the New York Academy of Medicine for his contributions to psychiatry.

What is the American Psychological Association?

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Introduction

The American Psychological Association (APA) is the largest scientific and professional organisation of psychologists in the United States, with over 122,000 members, including scientists, educators, clinicians, consultants, and students.

It has 54 divisions – interest groups for different subspecialties of psychology or topical areas.

The APA has an annual budget of around $115m.

Brief History

Founding

The APA was founded in July 1892 at Clark University by a small group of around 30 men; by 1916 there were over 300 members. The first president was G. Stanley Hall. During World War II, the APA merged with other psychological organisations, resulting in a new divisional structure. Nineteen divisions were approved in 1944; the divisions with the most members were the clinical and personnel (now counselling) divisions. From 1960 to 2007, the number of divisions expanded to 54. Today the APA is affiliated with 60 state, territorial, and Canadian provincial associations.

Dominance of Clinical Psychology

Due to the dominance of clinical psychology in APA, several research-focused groups have broken away from the organisation. These include the Psychonomic Society in 1959 (with a primarily cognitive orientation), and the Association for Psychological Science (which changed its name from the American Psychological Society in early 2006) in 1988 (with a broad focus on the science and research of psychology). Theodore H. Blau was the first clinician in independent practice to be elected president of the American Psychological Association in 1977.

Profile

The APA has task forces that issue policy statements on various matters of social importance, including abortion, human rights, the welfare of detainees, human trafficking, the rights of the mentally ill, IQ testing, sexual orientation change efforts, and gender equality.

Governance

APA is a corporation chartered in the District of Columbia. APA’s bylaws describe structural components that serve as a system of checks and balances to ensure democratic process. The organisational entities include:

  • APA President:
    • The APA’s president is elected by the membership.
    • The president chairs the Council of Representatives and the Board of Directors.
    • During his or her term of office, the president performs such duties as are prescribed in the bylaws.
  • Board of Directors:
    • The board is composed of six members-at-large, the president-elect, president, past-president, treasurer, recording secretary, CEO, and the chair of the American Psychological Association of Graduate Students (APAGS).
    • The Board oversees the association’s administrative affairs and presents an annual budget for council approval.
  • APA Council of Representatives:
    • The council has sole authority to set policy and make decisions regarding APA’s roughly $60 million annual income.
    • It is composed of elected members from state/provincial/territorial psychological associations, APA divisions and the APA Board of Directors.
  • APA Committee Structure, Boards and Committees:
    • Members of boards and committees conduct much of APA’s work on a volunteer basis.
    • They carry out a wide variety of tasks suggested by their names.
    • Some have responsibility for monitoring major programmes, such as the directorates, the journals and international affairs.

Good Governance Project

The Good Governance Project (GGP) was initiated in January 2011 as part of the strategic plan to “[assure] APA’s governance practices, processes and structures are optimized and aligned with what is needed to thrive in a rapidly changing and increasingly complex environment.” The charge included soliciting feedback and input stakeholders, learning about governance best practices, recommending whether change was required, recommending needed changes based on data, and creating implementation plans. The June 2013 GGP update on the recommended changes can be found in the document “Good Governance Project Recommended Changes to Maximize Organizational Effectiveness of APA Governance”. The suggested changes would change APA from a membership-based, representational structure to a corporate structure. These motions were discussed and voted upon by Council on 31 July 2013 and 02 August 2013.

Organisational Structure

APA comprises an executive office, a publishing operation, offices that address administrative, business, information technology, and operational needs, and five substantive directorates:

  1. The Education Directorate accredits doctoral psychology programmes and addresses issues related to psychology education in secondary through graduate education;
  2. The Practice Directorate engages on behalf of practicing psychologists and health care consumers;
  3. The Public Interest Directorate advances psychology as a means of addressing the fundamental problems of human welfare and promoting the equitable and just treatment of all segments of society;
  4. The Public and Member Communications Directorate is responsible for APA’s outreach to its members and affiliates and to the general public;
  5. The Science Directorate provides support and voice for psychological scientists.

Membership and Title of “Psychologist”

APA policy on the use of the title psychologist is contained in the Model Act for State Licensure of Psychologists: psychologists have earned a doctoral degree in psychology and may not use the title “psychologist” and/or deliver psychological services to the public, unless the psychologist is licensed or specifically exempted from licensure under the law. State licensing laws specify state specific requirements for the education and training of psychologists leading to licensure. Psychologists who are exempted from licensure could include researchers, educators, or general applied psychologists who provide services outside the health and mental health field.

Full membership with the APA in United States and Canada requires doctoral training whereas associate membership requires at least two years of postgraduate studies in psychology or approved related discipline. The minimal requirement of a doctoral dissertation related to psychology for full membership can be waived in certain circumstances where there is evidence that significant contribution or performance in the field of psychology has been made.

Affiliate Organisations

American Psychological Association Services, Inc. (APASI) was formed in 2018 and is a 501(c)(6) entity, which engages in advocacy on behalf of psychologists from all areas of psychology.

Awards

Each year, the APA recognises top psychologists with the “Distinguished Contributions” Awards; these awards are the highest honours given by the APA.

  • APA Award for Distinguished Scientific Contributions to Psychology.
  • APA Distinguished Scientific Award for the Applications of Psychology.
  • Award for Distinguished Contributions to Psychology in the Public Interest.
  • Award for Distinguished Contributions to Education and Training in Psychology.
  • APA Award for Distinguished Professional Contributions to Applied Research.
  • Award for Distinguished Professional Contributions to Independent Practice.
  • Award for Distinguished Professional Contributions to Practice in the Public Sector.
  • APA Award for Distinguished Contributions to the International Advancement of Psychology.
  • APA Award for Lifetime Contributions to Psychology (APA’s highest award).
  • APA International Humanitarian Award.

Publications

The American Psychologist is the Association’s official journal. APA also publishes over 70 other journals encompassing most specialty areas in the field; APA’s Educational Publishing Foundation (EPF) is an imprint for publishing on behalf of other organisations. Its journals include:

  • Archives of Scientific Psychology.
  • Behavioral Neuroscience.
  • Developmental Psychology.
  • Emotion.
  • Health Psychology.
  • Journal of Applied Psychology.
  • Journal of Comparative Psychology.
  • Journal of Experimental Psychology.
  • Journal of Experimental Psychology: Applied.
  • Journal of Family Psychology.
  • Journal of Occupational Health Psychology.
  • Journal of Personality and Social Psychology.
  • Psychological Bulletin.
  • Psychological Review.
  • Psychology and Aging.
  • Psychology of Addictive Behaviours.
  • Psychology of Violence.
  • School Psychology Quarterly.

The APA has published hundreds of books. Among these books are: the Publication Manual of the American Psychological Association (and a concise version titled Concise Rules of APA Style), which is the official guide to APA style; the APA Dictionary of Psychology; an eight-volume Encyclopaedia of Psychology; and many scholarly books on specific subjects such as Varieties of Anomalous Experience. The APA has also published children’s books under the Magination Press imprint, software for data analysis, videos demonstrating therapeutic techniques, reports, and brochures.

The Psychologically Healthy Workplace Programme

The Psychologically Healthy Workplace Programme (PHWP) is a collaborative effort between the American Psychological Association and the APA Practice Organisation designed to help employers optimise employee well-being and organisational performance. The PHWP includes APA’s Psychologically Healthy Workplace Awards, a variety of APA Practice Organisation resources, including PHWP Web content, e-newsletter, podcast and blog, and support of local programmes currently implemented by 52 state, provincial and territorial psychological associations as a mechanism for driving grassroots change in local business communities. The awards are designed to recognise organisations for their efforts to foster employee health and well-being while enhancing organisational performance. The award programme highlights a variety of workplaces, large and small, profit and non-profit, in diverse geographical settings. Applicants are evaluated on their efforts in the following five areas: employee involvement, work-life balance, employee growth and development, health and safety, and employee recognition. Awards are given at the local and national level.

APA Style

American Psychological Association (APA) style is a set of rules developed to assist reading comprehension in the social and behavioural sciences. Used to ensure clarity of communication, the layout is designed to “move the idea forward with a minimum of distraction and a maximum of precision.” The Publication Manual of the American Psychological Association contains the rules for every aspect of writing, especially in the social sciences from determining authorship to constructing a table to avoiding plagiarism and constructing accurate reference citations. “The General Format of APA is most commonly used to cite sources within the social sciences. General guidelines for a paper in APA style includes: typed, double-spaced on standard-sized paper (8.5″ x 11″) with 1″ margins on all sides. The font should be clear and highly readable. APA recommends using 12 pt. Times New Roman font.” The seventh edition of the Publication Manual of the American Psychological Association was published in October 2019.

Databases

APA maintains a number of databases, including PsycINFO, PsycARTICLES, PsycBOOKS, PsycEXTRA, PsycCRITIQUES, PsycTESTS, and PsycTHERAPY. APA also operates a comprehensive search platform, PsycNET, covering multiple databases.

PsycINFO is a bibliographic database that contains citations and summaries dating from the 19th century, including journal articles, book chapters, books, technical reports, and dissertations within the field of psychology. As of January 2010, PsycINFO has collected information from 2,457 journals.

Divisions

The APA has 56 numbered divisions, 54 of which are currently active:

  1. Society for General Psychology – the first division formed by the APA, in 1945, concerned with issues across the subdisciplines of psychology.
  2. Society for the Teaching of Psychology – provides free teaching material for students and teachers of psychology and bestows many awards.
  3. Society for Experimental Psychology and Cognitive Science.
  4. Currently vacant – initially the Psychometric Society, which decided against becoming an APA division.
  5. Quantitative and Qualitative Methods – previously named Evaluation, Measurement, and Statistics.
  6. Behavioural Neuroscience and Comparative Psychology.
  7. Developmental Psychology.
  8. Society for Personality and Social Psychology.
  9. Society for the Psychological Study of Social Issues (SPSSI).
  10. Society for the Psychology of Aesthetics, Creativity and the Arts.
  11. Currently vacant – initially Abnormal Psychology and Psychotherapy, which joined division 12 in 1946.
  12. Society of Clinical Psychology – established in 1948 with 482 members, in 1962 it created clinical child psychology as its first section.
  13. Society of Consulting Psychology.
  14. Society for Industrial and Organisational Psychology.
  15. Educational Psychology.
  16. School Psychology – originally formed as the Division of School Psychologists in 1945, renamed in 1969.
  17. Society of Counselling Psychology.
  18. Psychologists in Public Service.
  19. Society for Military Psychology.
  20. Adult Development and Aging.
  21. Applied Experimental and Engineering Psychology.
  22. Rehabilitation Psychology.
  23. Society for Consumer Psychology.
  24. Society for Theoretical and Philosophical Psychology.
  25. Behaviour Analysis.
  26. Society for the History of Psychology.
  27. Society for Community Research and Action: Division of Community Psychology.
  28. Psychopharmacology and Substance Abuse.
  29. Psychotherapy.
  30. Society of Psychological Hypnosis.
  31. State, Provincial and Territorial Psychological Association Affairs.
  32. Society for Humanistic Psychology.
  33. Intellectual and Developmental Disabilities / Autism Spectrum Disorder.
  34. Society for Environmental, Population and Conservation Psychology.
  35. Society for the Psychology of Women.
  36. Society for the Psychology of Religion and Spirituality.
  37. Society for Child and Family Policy and Practice.
  38. Health Psychology.
  39. Psychoanalysis.
  40. Clinical Neuropsychology.
  41. American Psychology-Law Society.
  42. Psychologists in Independent Practice.
  43. Society for Family Psychology.
  44. Society for the Psychological Study of Lesbian, Gay, Bisexual and Transgender Issues.
  45. Society for the Psychological Study of Ethnic Minority Issues.
  46. Media Psychology.
  47. Exercise and Sport Psychology.
  48. Society for the Study of Peace, Conflict, and Violence: Peace Psychology Division.
  49. Society of Group Psychology and Group Psychotherapy.
  50. Society of Addiction Psychology.
  51. Society for the Psychological Study of Men and Masculinities.
  52. International Psychology.
  53. Society of Clinical Child & Adolescent Psychology.
  54. Society of Paediatric Psychology.
  55. American Society for the Advancement of Pharmacotherapy.
  56. Trauma Psychology – addresses issues of trauma with projects, working groups and via collaborations.

APA Internship Crisis for Graduate Students

The APA is the main accrediting body for US clinical and counselling psychology doctoral training programmes and internship sites. APA-accredited Clinical Psychology PhD and PsyD programmes typically require students to complete a one-year clinical internship in order to graduate (or a two-year part-time internship). However, there is currently an “internship crisis” as defined by the APA, in that approximately 25% of clinical psychology doctoral students do not match for internship each year. This crisis has led many students (approximately 1,000 each year) to re-apply for internship, thus delaying graduation, or to complete an unaccredited internship, and often has many emotional and financial consequences. Students who do not complete an APA accredited internships in the US are barred from certain employment settings, including VA Hospitals, the military, and cannot get licensed in some states, such as Utah and Mississippi. Additionally, some post-doctoral fellowships and other employment settings require or prefer an APA Accredited internship. The APA has been criticised for not addressing this crisis adequately and many psychologists and graduate students have petitioned for the APA to take action by regulating graduate training programmes.

Warfare and the Use of Torture

A year after the establishment of the Human Resources Research Organisation by the US military in 1951, the CIA began funding numerous psychologists (and other scientists) in the development of psychological warfare methods under the supervision of APA treasurer Meredith Crawford. Donald O. Hebb, the APA president in 1960 who was awarded the APA Distinguished Scientific Contribution Award in 1961, defended the torture of research subjects, arguing that what was being studied was other nations’ methods of brainwashing. Former APA president Martin Seligman spoke upon the invitation of the CIA on his animal experimentation where he shocked a dog unpredictably and repeatedly into total, helpless passivity. Former APA president Ronald F. Levant, upon visiting Guantanamo Bay, affirmed that psychologists were present during the torture of prisoners, arguing that their presence was to “add value and safeguards” to interrogations. Former APA president Gerald Koocher argued, referring to allegations of continuing systemic abuse by psychologists, that such allegations were originating from “opportunistic commentators masquerading as scholars”.

When it emerged that psychologists, as part of the Behavioural Science Consultation Team, were advising interrogators in Guantánamo and other US facilities on improving the effectiveness of the “enhanced interrogation techniques”, the APA called on the US government to prohibit the use of unethical interrogation techniques and labelled specific techniques as torture. Critics pointed out that the APA declined to advise its members not to participate in such interrogations. In September 2008, the APA’s members passed a resolution stating that psychologists may not work in settings where “persons are held outside, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the U.S. Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights.” The resolution became official APA policy in February 2009. However, the APA has refused to sanction those members known to have participated in and, in some cases, designed abusive interrogation techniques used in Guantanamo Bay, Iraq, and Afghanistan interrogation centres.

The APA directive was in contrast to the American Psychiatric Association ban in May 2006 of all direct participation in interrogations by psychiatrists, and the American Medical Association ban in June 2006 of the direct participation in interrogations by physicians. An independent panel of medical, military, ethics, education, public health, and legal professionals issued a comprehensive report in November 2013 that “charged that U.S. military and intelligence agencies directed doctors and psychologists working in U.S. military detention centers to violate standard ethical principles and medical standards to avoid infliction of harm”. One group of psychologists in particular, the Coalition for an Ethical Psychology, has been very harsh in its criticism of the APA stance on its refusal to categorically prohibit members from participating in any phase of military interrogations. They recently stated their continuing disagreement with APA leadership in an open letter posted on their website on 31 October 2012, in which they reiterated their condemnation of torture and enhanced interrogation techniques, and called for the APA to require its members to refuse participation in military conducted interrogations of any kind.

Amending the Ethics Code

In February 2010, the APA’s Council of Representatives voted to amend the association’s Ethics Code to make clear that its standards can never be interpreted to justify or defend violating human rights. Following are the two relevant ethical standards from the Ethics Code, with the newly adopted language shown in bold:
1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority

If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

1.03, Conflicts Between Ethics and Organisational Demands

If the demands of an organisation with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

In its 2013 “Policy Related to Psychologists’ Work in National Security Settings and Reaffirmation of the APA Position Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment the APA condemns the use of any of the following practices by military interrogators trying to elicit anti-terrorism information from detainees, on the ground that “there are no exceptional circumstances whatsoever, whether induced by a state of war or threat of war, internal political instability or any other public emergency, that may be invoked as a justification.”

Hoffman Report

In November 2014, the APA ordered an independent review into whether it cooperated with the government’s use of torture of prisoners during the George W. Bush administration, naming Chicago attorney David H. Hoffman to conduct the review. On 02 July 2015, a 542-page report was issued to the special committee of the board of directors of the APA relating to ethics guidelines, national security interrogations, and torture. The report concluded that the APA secretly collaborated with the Bush administration to bolster a legal and ethical justification for the torture of prisoners. Furthermore, the report stated that the association’s ethics director Stephen Behnke and others had “colluded with important Department of Defense officials to have the APA issue loose, high-level ethical guidelines that did not constrain” the interrogation of terrorism suspects at Guantanamo Bay. The association’s “principal motive in doing so was to align APA and curry favor with DOD.” An APA official said that ethics director Stephen Behnke had been “removed from his position as a result of the report” and indicated that other firings or sanctions might follow.

On 14 July 2015, the APA announced the retirement of its CEO, Norman B. Anderson, effective the end of 2015, and of Deputy Chief Executive Officer Michael Honaker, effective 15 August 2015, and the resignation of Rhea K. Farberman, APA’s executive director for public and member communication. Anderson had been CEO since 2003.

Ban on Involvement

For at least a decade, dissident psychologists within and outside the APA, including the group WithholdAPAdues, had protested the involvement of psychologists “in interrogations at CIA black sites and Guantánamo”. Prior to the release of the Hoffman report, which undermined the APA’s repeated denials and showed that some APA leaders were complicit in torture, the dissidents were ignored or ridiculed.

On 07 August 2015, just weeks following the release of the Hoffman report, the APA council of representatives met at the association’s 123rd annual convention in Toronto, Ontario. At that meeting, the APA council passed Resolution 23B, which implemented the 2008 membership vote to remove psychologists from settings that operate outside international law, and banning the participation of psychologists in unlawful interrogations. With 156 votes in favour and only one vote against, the resolution passed with the near unanimous approval of council members. The adoption of Resolution 23B aligned the APA’s policy with that of the American Psychiatric Association and that of the American Medical Association by prohibiting psychologists from participating in interrogations deemed illegal by the Geneva Conventions and the United Nations Convention against Torture.

IMPLEMENTATION OF THE 2008 MEMBERSHIP VOTE TO REMOVE PSYCHOLOGISTS FROM ALL SETTINGS THAT OPERATE OUTSIDE OF INTERNATIONAL LAW (NBI #23B)

Council is asked to approve the substitute main motion below that includes a revised resolution with a new title, Resolution to Amend the 2006 and 2013 Council Resolutions to Clarify the Roles of Psychologists Related to Interrogation and Detainee Welfare in National Security Settings, to Further Implement the 2008 Petition Resolution, and to Safeguard Against Acts of Torture and Cruel, Inhuman, or Degrading Treatment or Punishment in All Settings. This resolution further aligns the APA policy definition for “cruel, inhuman or degrading treatment or punishment” (in the 2006 and 2013 Council resolutions) with the United Nations (UN) Convention Against Torture and ensures that the definition applies broadly to all individuals and settings; offers APA as a supportive resource for ethical practice for psychologists, including those in military and national security roles; prohibits psychologists from participating in national security interrogations; clarifies the intended application of the 2008 petition resolution… and calls for APA letters to be sent to federal officials to inform them of these policy changes and clarifications of existing APA policy.

The ban will not “prohibit psychologists from working with the police or prisons in criminal law enforcement interrogations”.

Class Action Lawsuit by Members Claiming Deceptive Dues Assessments

In 2013 a class action lawsuit was brought against APA on behalf of approximately 60,000 of its 122,000 members who were licensed clinicians. Those members paid an additional $140 practice assessment fee as part of their membership dues every year beginning in 2001 to fund the lobbying arm of APA, the APA Practice Organisation (APAPO). The lawsuit accused APA of using deceptive means by representing that the assessment was mandatory for APA membership even though payment of the assessment was only required for membership in the APAPO. In 2015 APA settled the case by establishing a $9.02 million settlement fund to be used to pay claims made by members of APA who paid the practice assessment, as well as attorneys’ fees and certain other costs. APA agreed to change its policies to make clear that the APAPO membership dues are not required for membership in APA.