Providentia

Are There Different Types of Problem Gamblers?

Although pathological gambling (PG) is regarded in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders as a unitary diagnostic construct, it is likely composed of distinct subtypes. In a report published in the December 2009 issue of Psychological Assessment, the authors used cluster analyses of personality traits with a non-treatment-seeking community sample of gamblers and identified 3 PG subtypes. Gamblers partitioned into a simple PG cluster, characterized by low rates of associated psychopathology and trait scores near the normative mean; a hedonic PG cluster, characterized by moderate rates of associated psychopathology and a proclivity for excitement seeking and positive affect; and a demoralized PG cluster, characterized by high rates of associated psychopathology and a propensity toward negative affect, low positive emotionality, and disinhibition.  Hedonic and demoralized problem gamblers were found to be significantly more impulsive that simple problem gamblers (who didn't differ significantly from non-PG controls in impulsivity).  While the authors recognized the limitation of the study (especially in terms of the small sample size used with thirty individuals in each group, the findings provide preliminary support for an empirically based typology of gamblers, distinguishable in terms of personality structure, which may reflect different etiologies.

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Human Rights Watch Report Condemns Compulsory Drug Detention Centers in China

A new report from Human Rights Watch titled "Where Darkness Knows No Limits" describes a disturbing new trend in China for dealing with the estimated 5 million opium addicts in that country.  In June 2008, China passed its first comprehensive narcotics control law to replace the former draconian system of dealing with drug users.  The new Anti-Drug Law was initially hailed as an enlightened measure which called for drug rehabilitation rather than the harsh criminal penalties that drug users previously faced.   Since the law's passage however, drug users have been typically incarcerated in what Human Rights Watch refers to as "compulsory drug detention centers" which are basically Reeducation Through Labor (RTL) camps under a different name. 

Under the new legislation, the Chinese government has been placing individuals suspected of drug use into the centers -without trial or judicial oversight- for periods of up to seven years.  According to the report, suspected users caught in the system are subjected to routine beatings, forced labour of up to 18 hours a day, no medical care, no skills training for reintegrating them into society, and no actual substance abuse treatment.  Many former detainees have told Human Rights Watch that the abuses have led to a number of deaths while in detention. 

The Chinese government is also promoting more progressive policies including harm reduction programs as well as community-based methadone and needle exchange programs to combat the spread of HIV/AIDS.  In a March 2009 statement by a high-ranging government official declared that "The Chinese Government maintains that drug treatment and rehabilitation should proceed in a people-oriented way.”   Despite the involvement of national and international treatment organizations, the use of punitive measures undermines the public statements concerning voluntary and human community-based drug treatment.  While previous drug legislation allowed for incarceration of six to twelve months, the new Anti-Drug Law now calls for a minimum of two years.  The vague definitions of clinical terms such as "addiction", "treatment" and "community rehabilitation" in the legislation allows local authorities extremely broad powers over who they can detain, and for how long.  The legislation also allows police wide discretionary powers in searching for drugs and administering drug tests with little or no oversight by judicial or medical authorities.  The detention centers are run by local police and managed by the Public Security Bureau. 

Former inmates describing their stay in these centers report a total lack of drug treatment, frequent drug use, and release being based solely on arbitrary decisions made by the authorities running the centers.  According to one detainee, "There is absolutely no support for quitting drugs inside detoxification centers; factory work is all there is.”  While incarceration is often justified in terms of forced "detoxification", there is no medical supervision involved.

Even after their release from the centers, former detainees report tremendous stigma surrounding their incarceration which makes reintegration into the community almost impossible.  Under the Anti-Drug Laws, convicted drug users are unable to register at a hotel, apply for a job, or register for drug treatment without the police being informed.  The frequent unemployment, poor health, and lack of community support virtually guarantees that former detainees return to drugs and incarceration in a vicious circle.  

The Human Rights Watch report concludes by calling on China to abide by international agreements and provide proper community-based drug treatment that is both humane and effective.  Whether the Chinese government will acknowledge the abuses outlined in the report may well depend on international pressure. 

For more information.

Human Rights Watch report

Filling The Asylums (Part 2)

Continued from Part 1

Although the psychiatric profession often receives the blame for the incredible rise in the number of mental patients during this era, the real responsibility likely rests with the public policy makers who made the asylum system possible. Psychiatrists still acted as the gatekeepers who oversaw admissions (and the far rarer discharges) as well as being the final authority for how patients were treated in the asylums.  There was also a self-fulfilling prophecy at work on the part of psychiatrists in dealing with the chronic mental patients in their charge:  since these patients were considered largely incurable, the extent to which their conditions deteriorated while in the asylum simply reinforced the medical preconceptions about the unlikelihood that any psychotic patients could truly recover from their illness.

The perception that mental patients were a burden on society had fatal consequences in many countries.  Not only were they a prime target for the eugenics movement in terms of sterilization, but Nazi Germany specifically targeted mental patients and other "undesirables" in Aktion T4 leading to the deaths of thousands of patients at the start of World War II.  Even in more "civilized" countries, psychiatrists weren't afraid to try radical methods to treat mental patients.  The serious overcrowding in psychiatric hospitals and the financial burden that governments faced in supporting them provided ample incentive.  From psychosurgery to ECT, these new treatments always began with a flourish of optimism that mental illness would finally be curable and that psychiatry would take its proper place with the other, more scientifically oriented, medical professions.  Suffice it to say, they were often disappointed.

While the more primitive treatments methods failed to live up to their early promise, the rise of psychiatric medications finally began the deinstitutionalization movement in the late 20th century.  Beginning with the antibiotics that prevented syphilis from proceeding to the devastating neurosyphilis stage, the serious overcrowding that characterized asylums at the beginning of the 20th century slowly began to be reversed.  Despite medical problems associated with long-term psychiatric medication use (including tardive dyskinesia and neuroleptic malignant syndrome), newer medications have been developed to avoid these devastating side-effects (albeit with some controversy over safety issues).  While mental illness continued to be viewed as incurable, many chronic mental patients are successfully managed in the community.  Unfortunately, early enthusiasm over deinstitutionalization was disastrous for many mental patients who had spent their entire lives in psychiatric hospitals and lacked the resources to cope on their own

As for the psychiatric hospitals, those that couldn't be converted into short-term acute care units were usually closed and abandoned hospitals became common in many jurisdictions.  Despite efforts to preserve many of these old hospitals for their historic value, most have been either demolished or converted to other uses.  These derelict buildings have a strange cultural fascination due to their sinister reputation and have often been used as sets for horror movies and television shows. 

As community-based mental health clinics became established in most metropolitan settings, basic problems in reintegrating formerly "incurable" mental patients into society remained.  Not only was the stigma surrounding mental illness as strong as ever, but policy makers continued to be reluctant in recognizing the need for funding community initiatives properly.   For all that community health program continues to be touted as a viable alternative to institutionalization, they often don't have the necessary resources to provide adequate support for patients.  Once again, the problem often lies with public policy makers who fail to take the actual needs of psychiatric patients into consideration when drafting mental health legislation.  

Legal battles also continue to be fought over basic issues such as forced institutionalization and medical treatment of mental patients.  The rise of the psychiatric survivor movement and anti-psychiatry activists (including Thomas Szasz and the Church of Scientology) of the past several decades has attempted to curb what they considered to be human rights abuses perpetrated by mental health professionals and pharmaceutical companies.  Civil rights legislation has largely restricted forced psychiatric treatment which, paradoxically, has meant that more mental patients than ever are now finding their way into prison systems and homeless shelters around the world.  If psychiatric institutions are seen as poorly suited for dealing with mental patients, these alternatives are even less so.

Not only have psychiatric hospitals seen a rise in more violent cases (due to placement in hospitals by the courts), they have also seen a rise in patients who really have no business being in psychiatric hospitals at all.  This is especially true with the growing use of civil commitment legislation for indefinitely holding convicted sex offenders in psychiatric hospitals in many US states.  While some jurisdictions are starting to segregate sex offender and psychiatric populations, the potential conflict between these populations is making psychiatric institutions more problematic than ever.  Worldwide, the trend towards using psychiatric hospitals to hold political prisoners seems as strong as ever.  Human rights organizations such as Amnesty International has protested the use of forced hospitalization of dissidents in countries such as China, North Korea, Russia (before and after the breakup of the Soviet Union), and Turkmenistan.  Despite widespread condemnation, the practice is likely to continue.

Psychiatric hospitals has come a long way since their asylum days although they are still in a state of flux.  As for what the next phase of their long history will bring, that's anybody's guess.

International Clashes Delay Relief for Haiti

Despite rapid mobilization of international aid following the devastating earthquake that struck Haiti on January 12, medical and rescue teams have reported slow progress in reaching the victims.  The partial destruction of Haiti's capital city of Port au Prince as well as other cities such as Leogane and Jacmel has led to a widespread collapse of the country's infrastructure.  International aid organization such the International Committee of the Red Cross (ICRC) and Doctors Without Borders (MSF) have reported inability to land planes carrying humanitarian staff and supplies at Port au Prince airport.  While the Haitian government placed the airport under the control of American forces, international condemnation over how evacuation and relief flights to and from Haiti's capital continues to grow. 

Dozens of French nationals have crowded the airport following the cancellation of an emergency flight to take them to the nearby island of Guadaloupe.  Rumours that the American forces are favouring the evacuation of U.S. nationals are adding to the tension and has led to official complaints lodged against the US by Brazilian and French diplomatic personnel.  The U.S. embassy defended the American response by stressing that the small airport was up and running within one day following the earthquake despite damage to the airport's one control tower.  As the only international airport in Haiti, the Toussaint Louverture Airport has become the principal means of bringing in relief aid and the airport has become quickly swamped as a result.  With only one runway, humanitarian flights must continuously circle the airport or else be diverted to other airports nearby, most of which cannot accommodate large aircraft.   Due to extensive damage to Port au Prince's seaport facilities, large ships are being turned away forcing all aid to be brought in by air. 

Due to lack of coordination at the airport, arrival of aid flights has led to supplies being left at the airport with no notification for aid organizations preventing supplies from being distributed as needed.  In a rare show of cooperation between Cuba and Washington, Cuba has been allowing US military craft to overfly their territory enabling aid from Miami to arrive more quickly.  While progress is being made, questions remain about how aid is being mobilized.

For more information.

Please contact your local Red Cross branch to make a donation to help Haitian earthquake victims.

American Red Cross

Canadian Red Cross

International Committee of the Red Cross

Providentia: Year Three

January 17 marks the third anniversary of this crazy blog of mine.  It also marks another milestone since I recently completed my 500th post.  I suppose milestones are important to keep track of how I'm doing overall.   According to Google Analytics, I had visitors for over 154 countries around the world and my Technorati score seems to be rising nicely as well.  Er, not that I spend all that much time obsessing over site statistics (that would be strange). 

Still, I seem to be plugging along and I'm certainly open to any comments you nice people might have.  If there are any suggestions about future topics that you might want to see me write about, feel free to let me know either through the comments or by email.  Otherwise, just keep on tuning in as I come up with new material for you.

Filling The Asylums (Part 1)

Michel Foucault called it "The Great Confinement".

In his provocative writings about the history of madness, Foucault argued that the period which he termed the "long eighteenth century" (from approximately 1660 to 1800) showed a radical shift in how society dealt with "problem" individuals who were considered insane.  While specialized facilities for housing the mentally ill existed in Islamic counties since the 9th century A.D., European countries were slow to follow this example.  In Europe, families  dealing with mentally incompetent family members often resorted to the time-honoured solution of locking them up in parts of their home (attics and basements by preference).  Monasteries or cloistered nunneries were also favoured by many families although "madhouses" or insane asylums became increasingly common for dealing with the problem. The actual numbers of mental patients housed in these asylums are hard to estimate since basic statistics weren't available (epidemiology was unknown in those days). 

The notion of publicly supported asylums came at a later date however.  Before the 19th century, most asylums tended to be privately-run hospitals that were either Church-sponsored or supported by fees provided by family members.  The conditions under which the mentally ill were kept and the type of treatment that they received varied widely since there were no formal guidelines for how these private institutions were run.  The oldest and most legendary of these hospitals had to have been the Bethlem Royal Hospital of London (a.k.a. "Bedlam").  The Bethlem Hospital dealt with mental patients since the 14th century although it  didn't become formally dedicated as a psychiatric hospital much later.  With separate wards for "curable" and "incurable" patients, the Bethlem hospital became legendary for the brutality with which patients were treated (spectators were allowed to bring sticks on visiting days to poke the patients).  Of course, more respectable hospitals were available for patients whose families could afford better care. 

Although psychiatric reformers such as Phillippe Pinel and Francis Willis among others encouraged more humane treatment for the mentally ill, the economic reality of the time and the growing influx of psychiatric admissions made these reforms hard to implement.  The fact that many mental patients were unable to afford the fees for the upscale hospitals and often had to depend on facilities such as Bedlam led to a push for reform. In the United Kingdom, the County Asylums Act of 1808 allowed local authorities to build asylums for those patients who were unable to afford private hospitalization, (a.k.a., the "pauper lunatics"). Whatever the intention of the early reformers, the hospitals that were established quickly became warehouses for those patients who couldn't function anywhere else.  Despite notable exceptions (including the Quaker-run Retreat at York), the ten asylums that were built in the following years quickly swelled to far beyond their planned capacity.  By the mid-1840s, the average asylum housed 300 patients but some asylums had far more.  By 1900, the average number of patients in each asylum had swelled to nearly 1000. 

So what was the cause for this influx in "certfied lunatics"?  While the total population in the U.K. more than doubled in the 19th century, the number of patients in lunatic asylums rose from 20.809 in 1844 to 117,200 in 1904 (a five-fold increase).  Cases of syphilis-related dementia certainly swelled the ranks of mental patients (neurosyphilis couldn't be treated or even reliably diagnosed until well into the 20th century), but the vast majority of psychiatric admissions were the "pauper lunatics" with no visible means of support.   They were also the patients who were most likely to be considered "incurable" by asylum superintendents.  Given the reality of the time, that meant that "incurable lunatics" would spend the rest of their lives in the vast warehouses that psychiatric hospitals had become.  Even after their deaths, pauper lunatics were often buried in unmarked graves ensuring that they would be as forgotten in death as they were in life.

The trend towards institutionalizing mental patients in large hospitals was hardly limited to the U.K. however.  Virtually every industrialized nation showed a similar rise in numbers during the 19th century.  With the economic changes brought on by the Industrial Revolution and the rising concentration of populations in cities, lower class families became less able to care for marginal individuals unable to support themselves.  It was hardly a coincidence that changes in the English Poor Laws that were passed in 1834 meant that more paupers than ever were placed in public asylums.  While the workhouse system allowed the more high-functioning mentally ill to support themselves (at least for a time), those paupers who were too low functioning really had nowhere else to go except into an asylum.  As the condition of mentally ill paupers in workhouses deteriorated (which it often did), they would be placed into asylums as well.  By then, the mentally ill paupers had usually exhausted any other support they might have had and their conditions were considered too chronic to be curable.  

While the actual diagnoses given to these pauper inmates ranged from newly popular labels such as dementia praecox (later known as schizophrenia) to familiar standbys such as general paresis of the insane, the outcome was usually the same.  Reformers such as Dorothea Dix and Clifford Beers had some success in encouraging more humane treatment for mental patients.  Still, the sheer number of patients who needed to be accommodated and the chronic shortage of support staff meant that patients were often left to deteriorate due to the sheer monotony of their lives.  The stigma surrounding mental illness also typically meant that patients were deprived of whatever links to families or friends they once had.   It hardly seems surprising that the proportion of patients who were considered "curable" dropped steadily throughout the 19th and early 20th centuries. 

Continue to Part 2

Testing Homophobia

While investigations into acts of prejudice directed towards sexual minorities mostly rely on self-report questionnaires, using indirect, behavioral measures can provide better insight into the underlying factors shaping discrimination. The December 2009 issue of Social Psychology  presents the results of afield experiment that investigated helping in an everyday face-to-face situation as an indicator of discrimination. Researchers at the University of Portsmouth in the U.K. conducted their experiment at a car park in southern England.  A sample of 240 local residents (120 males and 120 females) were approached by a person asking for 10 pence for a parking meter. The requestor wore either a neutral or a pro-gay T-shirt. Additional independent variables in the study were the requestor’s and the target person’s gender. Participant responses were recorded either as helpful behaviour (providing change or polite refusal) or non-helpful behaviour (rudeness or ignoring request).  Results showed that a person perceived as being a visible lesbian or a gay man received much less help, especially from men, than the same person perceived as being heterosexual. The researchers discuss these findings in comparison with earlier studies involving either behavioral or self-report measures.  The researchers also discuss their results in terms of the apparent relationship between attitudes towards sexual orientation and how it affects helping behaviour.

For more information.

On Race and Schizophrenia

A new book released by a researcher at the University of Michigan has concluded that black men are five times more likely to be diagnosed with schizophrenia than white patients and that the trend dates back to the 1960s.  In his book, titled The Protest Psychosis: How Schizophrenia Became a Black Disease, Dr. Jonathan Metzl, an associate professor of Psychiatry and Women's Studies  and director of the University of Michigan's Program in Culture, Health and Medicine, provides an overview of his archival research examining decades of psychiatric admissions to the Ionia State Hospital  in Michigan's Ionia County.  Before its closure in 1972, the hospital (one known as the Michigan Asylum for the Criminally Insane) often housed the most severely disturbed psychiatric patients in the state, including offenders who had been found not guilty for reasons of insanity.

In presenting his conclusions , Dr. Metzl noted a dramatic shift over time in how schizophrenia was viewed by treating psychiatrists.  When the schizophrenia diagnosis was first introduced at the dawn of the20th century, psychiatrists often viewed schizophrenics as being primarily docile.  Until the 1940s, diagnosed schizophrenics were often white, middle-class females whose behaviour was deemed inappropriate by civil authorities or their own families.  During the 1960s , with the advent of the the civil rights era in the U.S., a redefinition of schizophrenia occurred leading to an increasing tendency to diagnose violent black men as suffering from the disease. The former perception of schizophrenics as being non-violent changed and schizophrenics were more likely to be seen by psychiatrists and the general population as being violent, unpredictable, and in need of psychotropic medication to control theirbehaviour .  This shift was reflected in the popular media with "mad slasher" films and newspaper accounts of violent psychosis becoming more prevalent.

Metzl also discussed psychiatric literature from 1968 relating to "protest psychosis": a supposed condition in which black men developed "hostility, aggression, and delusional anti-whiteness after listening to Malcolm X, joining the black Muslims, or engaging in Civil Rights protests".  Not surprising, the schizophrenia diagnosis became a handy way of dealing with black activists who were often sent to psychiatric hospitals and subjected to involuntary psychiatric treatment. According to Metzl's statistics, 88 percent of Ionia's post-1960 "US Negro" admissions- 9 6 percent of whom were male-were diagnosed with schizophrenia.  By comparison, only 44.6 percent of "U.S. White" admissions received the schizophrenia diagnosis.  Black schizophrenics were also more likely to be regarded as violent.  The book provides specific case histories which highlight the changes thatMetzl noted.

In his book, Metzl concluded that  "the transition of schizophrenia from a disease of white, feminine docility to one of black, male hostility resulted from a confluence of social and medical forces."  Whatever their actual mental status on admission to psychiatric hospitals, forced psychiatric treatment almost certainly led to their mental deterioration over the course of their hospitalization and after their release.

Whether or not you agree with Jonathan Metzl's conclusions (and I'm not entirely sure that I do), his provocative arguments concerning the role of cultural and political factors in psychiatric diagnosis and treatment are sure to trigger debate. We are still dealing with the consequences of this radical shift in psychiatric admissions even in the era ofdeinstitutionalization , both in terms of homeless mentally ill and treating diagnosed schizophrenics in the prison system.  Perhaps most of all, we are dealing with this legacy of the 1960s in terms of the persistent stigma thatstill surrounds mental illness and how people with psychiatric problems are treated.

For more information.

When the Nose Knows...

An article published in a recent issue of Experimental Psychology examines how humans recall pleasant and unpleasant odors across the lifespan.  While odor memory has been linked to the specific episodes in which the odor was previously encountered (also known as episodic memory), research into the specific qualities of odors that may trigger memory has been neglected. A sample of young (19–36 years), young-old (60–74 years), and old (75–91 years) adults (n = 202) rated a set of unfamiliar odors across a series of perceptual dimensions (i.e., pleasantness, intensity, and irritability). The overall results indicated that memory for unpleasant olfactory information was better than that for pleasant odors across the lifespan. Also, participants showed better retention for odors perceived with high intensity and irritability than for odors rated with low or medium scores. Interestingly, the old adults showed selective beneficial memory effects for odors rated as highly irritable.  Overall however, increasing age was associated with fewer hits, more false alarms, and lower overall memory performance.  No overall sex differences in episodic recognition for unfamiliar odors.  To the extent that perceptions of high irritability reflect an activation of the trigeminal sensory system, this finding suggests that older adults may use trigeminal components in odor information to compensate for age-related impairments in olfactory memory.

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Indian Boy Regains Sight Six Months After Torture

Six months after being left blind following torture by five policemen, a 15-year old boy has regained his vision.  The boy, known only as "Rohit" is a member of the Untouchable Dalit caste living in the Faizabad district in the Indian state of Uttar Pradesh.  On July 29 of this year, Rohit was accused of stealing cell phones from a shop in Ayodyhya and running away to Mumbai with the money.  After being returned to Ayodhya, Rohit was reportedly hanged upside down and repeatedly struck on his legs, neck, and forehead.  He was also subjected to electric shocks.  Rohit was later threatened to remain silent about the beatings on pain of death.  Although the boy confessed to the theft, locals maintain that the confession was obtained through torture. According to Rohit's father, Ram Dev, the police demanded money from him for his son's release and charges were laid when they were refused.  Ram Dev also reported that he had been tortured in custody several days before Rohit was arrested.

Following his beatings in police custody, Rohit was taken to hospital where his vision later worsened and he became completely blind.  After an assessment by opthalmologists and neurologists, the blindness was declared to be the result of "functional vision loss" (also known as conversion disorder) with no apparent organic basis.  He was later admitted to the children's Psychiatry ward of the Chhatrapati Shahuji Maharaj Medical University in Lucknow given the apparent psychiatric cause of his blindness resulting from trauma.  Although he has been declared medically fit, Rohit is still waiting for a court order to allow him to return to his family.

When interviewed by the press, Rohit stated that, “I can see now but at night my vision is hazy. I am learning tabla and harmonium here and I love singing. I know how to iron clothes. At least now I will be able to earn for my family,” said a cheerful Rohit, adding: “After the entire trauma I have faced, I will never engage in any wrong activities.”   After a public protest by the local Dalit community, the five police officers involved in the torture were later charged and have since been found guilty. 

For more information.