Jared Loughner, Sarah Palin, DSM and Interesting Contradictions

At the party, Frances and Carpenter began to talk about “psychosis risk syndrome,” a diagnosis that Carpenter’s group was considering for the new edition. It would apply mostly to adolescents who occasionally have jumbled thoughts, hear voices, or experience delusions. Since these kids never fully lose contact with reality, they don’t qualify for any of the existing psychotic disorders. But “throughout medicine, there’s a presumption that early identification and intervention is better than late,” Carpenter says, citing the monitoring of cholesterol as an example. If adolescents on the brink of psychosis can be treated before a full-blown psychosis develops, he adds, “it could make a huge difference in their life story.”
http://www.wired.com/magazine/2010/12/ff_dsmv/3/

There is a great debate to be had about this, once everyone stops debating whether Sarah Palin incited Jared Loughner to his massacre in Arizona.

(Ok, very quickly….I think some people on the left, as well as my favorite conservative blogger Andrew Sullivan—who, to put it very mildly, is not a fan of Sarah’s—jumped on this a little too fast and a little too hard. Which doesn’t excuse Palin, whose rise to prominence is a symptom of severe dysfunction in American politics; I can’t help thinking that some of the “respectable” conservative types, like George Will, who defend Palin, do so only because they take great delight in how utterly crazy she drives the opposition. Well, that kind of delight is bad for the soul, and conservatives and the Republican Party may come to rue the day they ever heard of Sarah Palin. Too bad for them; they created, tolerated--and almost allowed within a heartbeat of the Presidency--this public fraud; let them choke on their creation.)

But back to business….One of the really serious debates that is being raised about the new DSM manual being produced has to do with the possible inclusion of a syndrome for designating people—invariably adolescents---who are at risk for psychosis, but who may not yet be psychotic. Critics like Allen Frances have  a legitimate point: there is real potential for drug companies to seize on a new market for kids who might in another day have been considered “eccentric” or “creative.”

But there is also real science behind the early identification of individuals at risk for psychosis.   “The risk syndrome criteria we are proposing for DSM-V have already proven capable of identifying a clinical entity within a help-seeking population in which 1 out of 3 individuals develops a bona fide DSM-IV psychotic disorder within two and a half years,” says psychiatrist Thomas McGlashan. “This amounts to a true positive rate of 33 percent.” McGlashan said that compares favorably with the predictive power of hypertension for stroke or of hyperlipidemia for a coronary event.  (http://pn.psychiatryonline.org/content/44/16/5.1.full).

Psychosis is not a bad case of depression or anxiety. And it’s not a matter of being “eccentric” or “creative.” People with schizophrenia are often incapable of working, typically have few friends, create enormous havoc and heartbreak within their families, are a costly burden to the healthcare system and society at large, and die earlier than the general population. Untreated, they can be violent; sometimes they go off to the shopping center and shoot up congresspersons and nine-year-old girls.

Jared Loughner didn’t go to bed one night perfectly normal and wake up the next morning with paranoid schizophrenia. Just as a heart attack is the end stage result of a long train of cardiovascular complications over what may be a period of years, so a “psychotic break” is the end stage result of a long, possibly slow descent into ilness. Some people with schizophrenia report having first heard voices as early as junior high school; they may have lived with these voices for many years before their illness came to anyone’s attention. The possibility of identifying, diagnosing and treating people before they become psychotic is a prospect with enormous public health potential. There is also the potential for mischief. And the debate about this will make for some interesting politics: some of the conservative voices today who are saying that Sarah Palin (or the general poisonousness of the political climate) should not be blamed for the Arizona massacre because Jared Loughner was a delusional madman who lived in his own twisted world, have in the past also been quick to jump on the theme about "drugging our children” and the overuse of medication.

It’s always interesting when people’s contradictions become too obvious for them to ignore.