Bob Schwartz

Category: Health

DSM-5: Paranoia

DSM-5

I did not think that I would be returning to the DSM quite so soon after my recent post.

The caveat in my last post about the DSM bears repeating. Mental health is a serious issue. Using diagnostic tools and terminology merely for entertainment and “pop psychology” can be careless. On the other hand, these tools can help provide insights that may be useful, particularly when the subject and the subject matter are very important or even critical.

Non-professionals talk loosely and colloquially about paranoia. The DSM approaches this clinically and scientifically:

Paranoid Personality Disorder

Diagnostic Criteria

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
  3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
  4. Reads hidden demeaning or threatening meanings into benign remarks or events.
  5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
  6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
  7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

Diagnostic Features [selected]

They suspect on the basis of little or no evidence that others are plotting against them and may attack them suddenly, at any time and without reason.

They are preoccupied with unjustified doubts about the loyalty or trustworthiness of their friends and associates, whose actions are minutely scrutinized for evidence of hostile intentions.

They may refuse to answer personal questions, saying that the information is “nobody’s business.”

They read hidden meanings that are demeaning and threatening into benign remarks or events. For example, an individual with this disorder may misinterpret an honest mistake by a store clerk as a deliberate attempt to shortchange, or view a casual humorous remark by a co-worker as a serious character attack.

They may view an offer of help as a criticism that they are not doing well enough on their own.

Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received.

Minor slights arouse major hostility, and the hostile feelings persist for a long time.

Because they are constantly vigilant to the harmful intentions of others, they very often feel that their character or reputation has been attacked or that they have been slighted in some other way.

They are quick to counterattack and react with anger to perceived insults.

DSM-5: Antagonism and Narcissistic Personality Disorder

 

DSM-5

Mental health is a serious matter and mental health practitioners are serious professionals. These are not to be treated lightly and off-handedly.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the “bible” of the mental health profession: “a classification of mental disorders with associated criteria designed to facilitate more reliable diagnoses of these disorders.” It is not a reference to be thrown around and used casually by non-professionals.

The DSM can nonetheless be fascinating, especially when certain strong behavioral traits observed in others seem to closely match the traits and possible related disorders referenced in the DSM.

With the above caution and caveat, here are selections from DSM-5 about the Personality Trait Domain of Antagonism. More from the DSM about the way this may or may not relate to Narcissistic Personality Disorder will follow in a subsequent post.

Personality trait: A tendency to behave, feel, perceive, and think in relatively consistent ways across time and across situations in which the trait may be manifest.

Personality trait facets: Specific personality components that make up the five broad personality trait domains in the dimensional taxonomy of Section III “Alternative DSM-5 Model for Personality Disorders.” For example, the broad domain Antagonism has the following component facets: Manipulativeness, Deceitfulness, Grandiosity, Attention Seeking, Callousness, and Hostility.

Antagonism: Behaviors that put an individual at odds with other people, such as an exaggerated sense of self-importance with a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings, and a readiness to use others in the service of self-enhancement. Antagonism is one of the five broad personality trait domains defined in Section III “Alternative DSM-5 Model for Personality Disorders.”

Manipulativeness: Use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends. Manipulativeness is a facet of the broad personality trait domain Antagonism.

Grandiosity: Believing that one is superior to others and deserves special treatment; self-centeredness; feelings of entitlement; condescension toward others. Grandiosity is a facet of the broad personality trait domain Antagonism.

Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events. Deceitfulness is a facet of the broad personality trait domain Antagonism.

Attention seeking: Engaging in behavior designed to attract notice and to make oneself the focus of others’ attention and admiration. Attention seeking is a facet of the broad personality trait domain Antagonism.

Callousness: Lack of concern for the feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others. Callousness is a facet of the broad personality trait domain Antagonism.

Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. Hostility is a facet of the broad personality trait domain Antagonism.

Healing and Magic: We Are Not Alone

White Tara

All of our religious traditions—Judaism, Buddhism, Christianity, and all others—include an element of healing. Healing of body, heart and mind. The Gospels, for example, contain many important stories about healing, from curing chronic illness to reversing death itself.

We invoke the power to heal in various ways. In Judaism, the Mi Shebeirach is recited:

May the one who blessed our ancestors, Abraham, Isaac and Jacob, Sarah, Rebecca, Rachel and Leah, bless and heal those who are ill. May the Blessed Holy One be filled with compassion for their health to be restored and their strength to be revived. May God swiftly send them a complete renewal of body and spirit, and let us say, Amen.

In Buddhism, White Tara, an important embodiment of compassion, is invoked:

The liberator of suffering shines light upon me to create an abundance of merit and wisdom for long life and happiness.

Is this magic we are engaged in? If you take magic to be a call to illegitimate and evil powers, as some traditions do, then this might have to be classified as something else. If you take magic to be the recognition of a seeming powerlessness in the face of things as they are and an attempt to borrow and employ the power we believe in, then magic it is.

This invocation of the power to heal—by ourselves, in a family, in a community—is a way of practicing that we are not alone. When healing is needed, that is something we want to know.

For JRK.

The Weird Randomness of Life

The Catcher in the Rye

I went to the gym this morning for my regular morning workout. The TV was on, but nobody was there. I saw that the remote control was gone. I climbed on a chair, pushed the power button and turned the TV off.

On further search for the remote, I discovered a handbag on the seat of stationery bike. I didn’t want to pry, but I peeked in to see if the remote had ended up there. Instead, I saw a copy of The Catcher in the Rye by J.D. Salinger.

Are people still reading The Catcher in the Rye? They should and apparently they are. It is a great and famous novel. Once upon a time controversial, when it was published in 1951, because Salinger included the word “fuck” multiple times.

After this novel, another novel, and a book of stories, Salinger disappeared, like the remote control. He is considered the most reclusive and mysterious of contemporary fiction writers. W.P. Kinsella included a character based on Salinger in his novel Shoeless Joe, which became a character in the movie version Field of Dreams. The character in the movie is played by James Earl Jones, a big black man with a booming voice. Salinger was a white Jewish man, as far as we can tell regular size and regular voice.

In high school, I wrote a book report on The Catcher in the Rye, one that was supposed to be read aloud. The English teacher was one of those young, hip women, so I thought it would be alright. I was a little concerned about some of the quotes, specifically the ones that included the word “fuck.” In that class was a girl who was a friend, not a girlfriend, who read it before class and urged me to read it just as it was. She was a popular and cool girl, but mostly I wanted to seem cool to her because she was pretty and had really big breasts.

So I read the report out loud. This is one of the passages I read. The confused and questioning adolescent Holden Caulfield says:

I went down by a different staircase, and I saw another “Fuck you” on the wall. I tried to rub it off with my hand again, but this one was scratched on, with a knife or something. It wouldn’t come off. It’s hopeless, anyway. If you had a million years to do it in, you couldn’t rub out even half the “Fuck you” signs in the world. It’s impossible.

I wasn’t particularly confused, but I was punished. Someone in the class took offense and told the principal. I was called down to his office, and despite his liking me a lot and despite my record as a star student, he believed some sort of sanction for my indiscretion was necessary. The sentence was that my entry into the National Honor Society was to be delayed one year.

If I had it to do all over again, I would know that none of this mattered. I read the book, still love it, and maybe my book report led someone else to read it. If I was somebody else, then or now, I might have said something to the principal that was clever and super-meta, such as “Go fuck yourself.” I didn’t and wouldn’t.

On the other hand, if I go down to the gym tomorrow, and still can’t find it, I might say to myself—only to myself and not out loud—“Where’s the fucking remote?”

Opiods and Heroin: Where Does It Hurt?

There is bipartisan agreement that we have a national problem of opiod and heroin addiction. But few politicos are willing to discuss the hard questions.

The political consensus is that we address the addicts and how to treat and end their addiction. Which is a good and humane objective.

But there are two other aspects the politicos are less willing to take on.

Supply chain

The old school war on drugs went for the top of the supply pyramid. Think El Chapo. In the case of opiods, that supply chain leads up from pharmacies to doctors to pharmaceutical companies. But if you listen to the grandstanding from Democrats and Republicans, you hardly if ever hear the legal producers of the drugs called to account. It is true that product makers are not unconditionally responsible for how people ultimately use their products—not alcohol makers, not cigarette makers, not gun makers. But at least those suppliers can be spotlighted as significant stakeholders.

Where does it hurt?

Pain killers are a blessing to those who suffer from chronic physical pain or from intermittent severe physical pain. That kind of pain is a damnable thing, and we should all be glad that we have developed such a solution.

Millions of those who use painkillers, prescription and otherwise, are not in physical pain. But many of them are in psychic pain, whether out of loss, desperation, frustration, purposelessness, difficult circumstances, or just boredom. It is convenient but not completely helpful to lump these into “mental Illness” for which increased funding and access could be made available. This kind of pain is not illness; it is just a response to a condition or injury, no different than the hurt that might come from being hit over the head really hard.

Politicos don’t want to talk about this. The solutions to this kind of pain involve changes in society and in people’s lives that require lots of self-awareness, lots of politically tricky analysis, lots of controversial proposals that go beyond better addiction services. And lots of hard questions that politicos don’t want to ask, let alone try to answer. Such as:

Where does it hurt?

NFL Priorities

NFL

Which of these three NFL issues deserves the deepest continuous attention by the league, by fans, by the media, and by the public?

1. Frequent on-field concussions that demonstrably lead to players having permanent brain damage, diminished quality of life, and premature death.

2. Frequent off-field antisocial and possibly criminal behavior by celebrated players.

3. A possibly deflated football.

Note: It is possible that more scientists have been covered talking about the football that New England Patriots quarterback Tom Brady may have had deflated than about the concussions in the NFL.

Ebola Stress Test

Kaci Hickox

Stress tests. We see them in medicine, in banking, in construction.

How well will the patient’s heart perform when he is on a treadmill? How sound are a bank’s finances in the worst case scenario? How will building materials stand up under maximum pressure?

Public crises are stress tests. So far, Ebola is the latest demonstration of the tendency for our civic infrastructure to crack—or show signs of it—under pressure.

Quietly, where no one can hear, some leaders and citizens are probably worried that if this was a real Ebola outbreak in the U.S., and not the thankfully tiny and so far isolated problem it is, we would fall apart. Utterly fail the test.

The latest episode concerns this weekend’s rapid response by multiple states to Craig Spencer, a doctor returning from West Africa and becoming sick with Ebola in New York City last week. In addition to New York and New Jersey, other states are now or may be requiring returning health care workers to be quarantined.

There is a problem: none of these states appear to have thought through any of it—most especially the practical aspects of whisking someone coming home from a heroic medical mission into isolation that is supposed to be comfortable, suitable, sensible, and sensitive under the circumstances. It now seems the scenario is act first, plan later.

Nurse Kaci Hickox is the first one caught in this trap. She is not sick and is showing no symptoms. Arriving at Newark Airport Friday night, she was taken to a tent behind a hospital, with a portable toilet, no shower, no television, and little cellphone reception. She castigated all involved, particularly Governor Chris Christie, who said she had symptoms and was sick, when she hadn’t and wasn’t. She plans a federal lawsuit challenging the quarantine.

“I also want to be treated with compassion and humanity, and I don’t feel I’ve been treated that way in the past three days. I think this is an extreme that is really unacceptable. I feel like my basic human rights have been violated.”

(Update: Governor Christie has relented, allowing her to return home to Maine, where, if you read between the lines, the message is that it will then be Maine’s problem to monitor her and where, if something goes wrong, it will be on their head.)

We seem to have forgotten how to solve problems, enthralled by our own voice either positing solutions, making points, or complaining. Or maybe it is that this is America, with a history of being bigger, stronger, smarter, and most of all, righter, in all circumstances. Even if that was ever true, politics—in the big sense of privileging positions over effective and thoughtful answers—has poisoned that well. Worthy questions and deliberate solutions are rejected out of hand because of the source, because they don’t fit some preconceived notion or program, or simply because they won’t help win or not lose elections.

Whether or not quarantine of heroic Ebola care givers returning from West Africa is a good idea, it is certainly a good idea to evaluate and plan exactly how you are going to practically handle it. Maybe, though, we shouldn’t be at all surprised. In recent years we did, after all, send hundreds of thousands of troops abroad, and when the promised rewards for their heroic service came due, we seemed unable to fulfill and, worse, were suddenly unenthusiastic about keeping the promise anyway.

If this is a war on Ebola, we better make sure we are committed to those who are sacrificing, part of which is actual planning and resourcing, not ignorant and reflexive pontificating and politicking. So far, this is looking too much like some of our other recent wars. Maybe we can use this as an opportunity to get better and be better at it.

Coming Out: How Cosmetic Surgery Is Like Being Gay

South Park - Tom Cruise

In case you haven’t noticed, the noise surrounding Renee Zellweger’s about face sounds just like the conversations we have about celebrities being gay: did she or didn’t she, is he or isn’t he?

There are three kinds of cosmetic surgery: the public kind that can be explained as the result of exercise and nutrition (body shaping and toning), the public kind that is hard to explain that way (obviously enhanced breasts), and the private kind that is (sort of) meant to be private (vagina rejuvenation, penis enhancement).

Questions about the public kinds can be met with a variety of replies, all of them valid:

Yes.
No.
No comment.
It’s none of your business.

This remarkably parallels the situation of those who are “suspected” of being gay. Sometimes it is made public, sometimes it is kept private, sometimes it is treated matter-of-factly: it is what it is, it’s my life, take it or leave it, so what?

Admitting to plastic surgery is in many contexts (including and especially entertainment) as delicate as admitting to being gay—even if the fact is relatively obvious. One of the many reasons the late Joan Rivers was so beloved, why what was obnoxious in others was endearing in her, is that the fact of her many plastic surgeries was a prime subject of her own bits. As with other topics, she just gave you the finger, laughed, and had you laughing too.

In the scheme of all but the tiniest matters, Renee Zellweger’s face is inconsequential. But as with all the tongue wagging about the sexual preferences of some celebrity, it exposes unanswered and mostly unspoken questions about how people feel about certain things. Many people still don’t know exactly what they think about major or minor voluntary body mod, any more than they may have totally resolved their deepest puzzlement about homosexuality, no matter how genuinely progressive and tolerant they are.

For better or worse, we are actually seeing a bit of that in the Renee Zellweger situation: along with an avalanche of typically mindless chatter, there has been some useful discussion about the nature of celebrity, privacy, aging, feminism, and health. It is unfortunate that this has to fall on a single individual’s shoulders, with so much collateral and gratuitous hurt. But if we are careful, we might just learn something, mostly about ourselves. How rare and valuable an opportunity is that?

Illustration: The obvious illustration for this post would be yet another photo of Renee Zellweger, which neither the world nor she need. Instead, above is a frame from South Park, the 2005 episode called Trapped in the Closet. It is widely considered the show’s most controversial episode, which is saying something. In it, the fearless and brilliant and culturally incorrect Parker and Stone managed to skewer (eviscerate?) both Scientology and the rumored homosexuality of Hollywood stars. In this scene, Tom Cruise won’t come out of the closet (where he will ultimately be joined by John Travolta). Nicole Kidman, his then-wife, is trying to talk him out. As I said, culturally incorrect, and probably intolerant and spiteful in light of all that’s written above. But it is funny, and not surprisingly, it is the equally fearless and funny Joan Rivers who also took on the very same subject. Laughing and thinking. What a combo.

VA Health Crisis: Listen to IAVA

VA IG Report

We should listen to the Iraq and Afghanistan Veterans of America about this VA health system crisis.

As the name implies, IAVA represents the latest generation of American war veterans. They are in some ways the most attuned to the current realities and sensibilities of veterans’ issues in 2014. Not because they have been around the longest, but because they are native to the way things work, or don’t, here in the early 21st century in America.

Those realities regarding the health care crisis in the VA are shocking to some, but come as no surprise to those who have watched it happening, including Congress (both parties) and the President.

Is it fixable? What won’t fix it is political posturing, handwringing, or even the delayed but imminent departure of VA Secretary Shinseki.

What will fix it? Good policy well executed, without excuses or cover up. The IAVA can help with that.

In the wake of yesterday’s Inspector General Report about the Phoenix VA health system, IAVA CEO and Founder Paul Rieckhoff said:

The new IG report on the Phoenix VA is damning and outrageous. It also reveals the need for a criminal investigation. Each day we learn how awful things are in Phoenix and across the country. The VA’s problems are broad and deep – and President Obama and his team haven’t demonstrated they can fix it. As one of only two combat veterans, Senator John McCain’s call for Secretary Shinseki’s resignation is particularly impactful…

Today’s report makes it painfully clear that the VA does not always have our veterans’ backs. Even before this report came out, IAVA members were losing confidence in Secretary Shinseki and President Obama. At Memorial Day events across the nation, our members voiced outrage, anger, and impatience at the growing VA scandal. This new report only increases the belief that the promise to veterans has been broken. We are sharing this report now with our members and seeking their reaction. In the coming days, we will share the voices of our members with the President, VA leaders and those in Congress.

In the IAVA 2014 Policy Agenda, the VA health system was just one of a number of initiatives offered for consideration. On that score, IAVA recommends this (excerpted):

I. Establish a Presidential Commission to end the VA claims backlog.

II. Transform the Veterans’ Benefits Administration’s (VBA) adversarial culture…

III. Reform VA’s work credit and productivity evaluation system for claims processor….

IV. Outline the VA’s responsibility about the requirements to substantiate a claim….

V. Adopt the “treating physician rule” for medical evaluations for compensation and pension…

VI. Require appeals form to be sent along with the Notice of Decision letters in order to expedite the appeals process.

VII. Evaluate the Segmented Lanes work initiative to continually assess whether it is meeting the goals of fast tracking…

VIII. Report the intake of new compensation and pension claims on the Monday Morning Workload Report.

IX. Report separated statistics on the intake and processing of supplemental and original claims in the Monday Morning Workload Report…

XIII. Continue to engage veteran stakeholders in updating the VA Schedule for Rating Disabilities (VASRD).

XIV. Require the VA to accept a PTSD diagnosis provided from a qualified private medical provider.

X. Establish a model to accurately project the claims workload and the resource and staffing requirements needed to meet the demand.

XI. Make all disability benefits questionnaires available to private medical providers.

XII. Simplify notification letters to provide easily digestible, specific and clear information about the reasons for rating decisions.

XV. Allow the VA to incentivize private medical providers to furnish medical health records to the VA for processing.

XVI. Clarify and report accuracy ratings for each regional VA….

This is an agenda, and if the President and the good people of Congress want to adjust or add, that is their prerogative and duty. But you have to start somewhere, with something on the table, and this is a good place for that. If these warriors are smart enough and capable enough and honorable enough to fight our wars, they are surely able to suggest the smart, honorable, and capable ways of treating them when those wars are over.

There Is Still a War in Syria

Paris Hilton As Miley Cyrus
When there was less to people’s news and info lives—a newspaper or two a day, a half-hour network news show, a couple of news magazines a week—there were stories that rose to the top and stayed there, depending on importance. This didn’t mean that second-tier or frivolous stories didn’t get coverage or traction. People always loved celebrities, always loved hearing gossip, and when man bites dog, that’s always news. The down side was a certain provincialism that came with a narrow channel and less worldly attitudes: if millions were suffering in a place nobody heard of, with people unlike us, most readers and viewers might have no idea.

Now we can know anything, though we don’t know everything, or care about everything. This has left news leaders in a delicate position. There are going to be stories that appeal to a journalist sense and a humanist sense, that deserve at least regular mention, if not coverage that might only say, “And in the misery of this place or that war, it’s still happening, with no end in sight.” The dual problem is that people can find and figure that out for themselves, without a multi-billion dollar media enterprise telling them, and those media consumers might just as well pay attention to something else.

Which is why, unlike its predecessors World War II, Korean War and Vietnam War, the Iraq War was not the top story every day of its ten years. Which is why the current violence in Iraq is barely covered, a turning away that in part must come from some profound but unspoken embarrassment.

For a few moments a few months ago, Syria was a bright shiny object. Red lines, chemical warfare, threats of military action, etc. After some erratic movement, slight progress is being made. But that progress does not include ending the civil war.

The New York Times, still possibly the world’s greatest news enterprise, has an ongoing section devoted to the Crisis in Syria. The increasing numbers stupefy: 6.5 million Syrians displaced from their homes, more than 2 million of them seeking refuge in other countries. Now we hear about a cluster of polio cases among Syrian children.

We have plenty of our own problems, individually and as a country. Some of those are not small at all. But there is no polio. And the entire population of the state of Tennessee or Indiana has not had to leave their homes behind, dodging mayhem, unsure if they will ever return, or if there will be anything to return to.

We shouldn’t expect ourselves to be exhausted or crushed by the miseries of the world; that’s what keeping track of all the problems all the time would do. So yes, you can argue that it is important to learn from the news today that Paris Hilton has spent $5,000 on Halloween costumes so that she can dress up as Miley Cyrus. But for a change of pace, a regular, maybe daily, reminder that there is still a war in Syria might be of value.