Explaining OCD and Involuntary Psychiatric Care to a Denialist

There is a certain anonymous anti-psychiatry commentator who imaginatively goes by the name of Stop.Psychiatry (henceforth S.P.). He has been IP banned twice on this blog because of engaging in irresponsible character assassination, spamming, and repeating same old canards over and over without addressing counterarguments. Predictably, this person has started his own blog, from which he spews his pseudoscience on anti-psychiatry by compiling personal anecdotes, emotional manipulation and arguments that have been refuted thousands of times before. He has made a couple of posts, but most of them are just linking to videos on other websites without much original content. Two posts contain more written text; one of them called “My story” and the other called “Anti-psychiatry is not denialism”.

Let’s critically examine these blog entries and see if they have any merit.

1. The uniting feature of OCD: obsessions and compulsions

The first interesting section of the first entry comes when S.P. talks about his own mental condition:

During most of my adult life I have struggled with a condition that was diagnosed as Obsessive Compulsive Disorder, OCD. The funny thing is that psychiatry dumps into this disorder all kinds of different types of mental distress. In my case it’s an exaggerated fear of contracting HIV through usual contact. However, psychiatry dumps under the same umbrella thinks [sic] such as repeated task checking or number counting. How is that these things are related escapes my understanding.

I empathize with S.P’s situation. Having a mental condition is a serious matter and should not be ignored, mocked or stigmatized. He is brave to talk about his situation. Furthermore, HIV is a virus with potent capabilities for harm, so it makes sense to be fearful of contracting HIV. It makes sense to use protection during sex and screen blood donations for HIV. However, as I have understood the situation, S.P. had or has an exaggerated fear of contracting the virus through usual contact. He does not specify what usual contact he was concerned about or what steps he took to avoid those forms of contact. These details are vital for an accurate understanding of the situation and I wish that he did not leave them out. Perhaps he will discuss them in a later blog post when he feels more comfortable talking about his condition in public.

So what is the connection between repeated task checking, number counting and an exaggerated fear of getting HIV? An OCD condition generally consists of two components (although it is possible for either to occur alone): obsessions (cognitive component) and compulsion (behavioral component). Here is how the Mayo Clinic describes the condition (Mayo Clinic, 2010):

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by unreasonable thoughts and fears (obsessions) that lead you to do repetitive behaviors (compulsions). With obsessive-compulsive disorder, you may realize that your obsessions aren’t reasonable, and you may try to ignore them or stop them. But that only increases your distress and anxiety. Ultimately, you feel driven to perform compulsive acts in an effort to ease your stressful feelings.

Obsessive-compulsive disorder often centers around themes, such as a fear of getting contaminated by germs. To ease your contamination fears, you may compulsively wash your hands until they’re sore and chapped. Despite your efforts, thoughts of obsessive-compulsive behavior keep coming back. This leads to more ritualistic behavior — and a vicious cycle that’s characteristic of obsessive-compulsive disorder.

On the symptom page, they describe it like this:

OCD obsessions are repeated, persistent and unwanted ideas, thoughts, images or impulses that you have involuntarily and that seem to make no sense. These obsessions typically intrude when you’re trying to think of or do other things. […] OCD compulsions are repetitive behaviors that you feel driven to perform. These repetitive behaviors are meant to prevent or reduce anxiety related to your obsessions.

Now we can see how these different things tie together: they share in common a pattern of obsessions and compulsions. A common obsession is the fear of being contaminated with germs (e. g. contracting HIV from usual contact) and a common corresponding compulsion is washing hands until raw or inflamed. Another obsession may be having this in order, which may be tied to the compulsion of cleaning. There does not even have to be a logical connection between the obsession and the compulsion: the obsession may be to hurt a person and the compulsion may be to count numbers. This clearly demonstrates the heterogeneity of mental conditions, an important finding we shall return to later.

2. No medical testing is 100% accurate

As the vast majority of people, before I suffered the abuse, I had a neutral position on the whole field of psychiatry. I assumed that it was just like any other branch of medicine, tested and confirmed by the scientific method to be 100% accurate both in diagnosis and prediction.

This is a fairly naive view of medical diagnosis and testing. No medical test is 100% accurate. This may be because of the intrinsic features of the condition itself (such as heterogeneity) or simply the limitations of the test. Since the second blog post tells me he accepts the consensus position that HIV causes AIDS, I will pick an example from this area.

ELISA is a fast and reasonably accurate antibody test. However, it has about a 1% chance of a false positive. That means that, on average, 1 in 100 patients will show up as HIV seropositive on ELISA while not having HIV. You can do another ELISA, a western blot or a PCR analysis to make sure that the person actually is seropositive, but there will never become 100% accurate. A person who has recently been infected with HIV may not give a positive ELISA test until after three months. So these people, who are infected with HIV, will give a false negative. You can go and get tested again in three months if you want to, but then that only says that, as far as the doctor can tell, you where not infected three months ago. Depending on your activities, you may have gotten infected between the two tests.

No medical test, or medical treatment, is 100% effective. An antibiotic might not work because of antibiotic resistance, a vaccine may not work because you where among the unlucky few % that did not develop antibodies to the antigen, the PSA test for prostate cancer can give false positives, a cancerous tumor may go into spontaneous remission, HIV may become resistant to treatment etc.

3. Involuntary psychiatric commitment

All that changed a few years ago when I was involuntarily committed to a psychiatric institution and forcibly drugged in the European country where my parents live for treatment of OCD. Unlike the laws of the United States, the laws of that country afford psychiatrists all-encompassing power to commit whomever they wish and to drug people against their will. So any psychiatrist can order to involuntarily commit and drug forcibly any patient in cases in which a psychiatrist determines it to be necessary, regardless of whether a finding that the patient’s life or a third party’s life is in danger exists. I was forcibly detained; tied up for almost one day and then forced to stay in 2 different mental institutions for several weeks. The psychiatrists I worked with during that time are amongst the most arrogant people I have met in my entire life, which shows that, if you give anybody such power, they will become inevitably corrupt. The humiliation that I endured will stay with me for the rest of my life. My parents asked the psychiatrists to commit me. […] Needless to say, the relationship with my parents has become strained as a result of the episode. In fact, it is nonexistent as I write this.

Becoming involuntary committed is probably always traumatic and it is unfortunate that the relationship between S.P. and his parents no longer exists. Since S.P. does not specify which European country he is talking about, I am unable to look up the relevant laws regarding involuntary psychiatric care in that particular country.

What I can do is to describe how it works in Sweden (Allgulander, 2008, pp. 67-74). This may not be representative for Europe as a whole, but it gives an insight into the situation. Before 1967, patients could be involuntarily committed to a psychiatric hospital whether they wanted it or not by a psychiatrist. Then, successive laws were passed to strengthen the legal rights of the patients and demanded stronger justifications for coercive psychiatric commitment. Today, a licensed general practitioner writes a certificate of care (“vårdintyg”). According to the law LPT 1991:1128, a patient can be involuntary committed only if the following three conditions apply: (1) the patient has a serious psychiatric disorder, (2) the patient either does not want to get treated voluntarily or is lacks the ability to make an informed decision and (3) he or she cannot be taken care of in any other way than around-the-cloak psychiatric care. This has to be justified in the certificate of care. As a special additional requirement, the coercion must be in proportion to the purpose of the action. Coercion cannot be used if other, non-coercive methods are available and coercion cannot be used above and beyond what is necessary to make the person comply.

The certificate of care has to be critically investigated within 24 hours by a specialist doctor. If it is approved, the patient can be committed for up to four weeks. If the time needs to be increased, this was to be demonstrated in a special court proceedings in which the patient has the right to council and legal help. The decision can be appealed all the way up to the Supreme Administrative Court of Sweden. The patient can be restrained in a bed with a large belt against his or her will if there is an imminent danger for the life of the patient or that of others. If the patient is instead in an institution for voluntary psychiatric care, the chief senior doctor can convert it to involuntary commitment, but a second doctor has to write the certificate of care and the decision has to be tried in court the next day at the latest.

To conclude this section, S.P. is probably withholding information on the severity of his OCD condition and his actions during the psychiatric intake. It seems highly unlikely that he was subjected to involuntary psychiatric intake and restraining just because he had an exaggerated fear of getting infected with HIV.

4. Can anyone say cum hoc / post hoc?

S.P. then discusses what he perceives to be side effects of antidepressants. He thinks that because changes in liver enzymes occurred after he started his medication and ended after he did not take his medication, there must be a simple cause-and-effect relationship between medication and changed liver function. While possible, more evidence is needed to avoid the conclusion of logical fallacy.

5. The joys of cherry picking

S.P. insists that scientists have not identified “single biological marker that can be reliably described as the cause of any mental disorder”. For this, he links a Wikipedia article that contains a statement from the American Psychiatric Association. However, neither the Wikipedia nor the statement support the overall anti-psychiatry position of S.P.

At the time of this writing, the relevant section of the Wikipedia article reads:

Current status in biopsychiatric research

Biopsychiatric research has produced reproducible abnormalities of brain structure and function, and a strong genetic component for a number of psychiatric disorders (although the latter has never been shown to be causative, merely correlative). It has also elucidated some of the mechanisms of action of medications that are effective in treating some of these disorders. Still, by their own admission, this research has not progressed to the stage that they can identify clear biomarkers of these disorders.

Research has shown that serious neurobiological disorders such as schizophrenia reveal reproducible abnormalities of brain structure (such as ventricular enlargement) and function. Compelling evidence exists that disorders including schizophrenia, bipolar disorder, and autism to name a few have a strong genetic component. Still, brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group. Ultimately, no gross anatomical lesion such as a tumor may ever be found; rather, mental disorders will likely be proven to represent disorders of intercellular communication; or of disrupted neural circuitry. Research already has elucidated some of the mechanisms of action of medications that are effective for depression, schizophrenia, anxiety, attention deficit, and cognitive disorders such as Alzheimer’s disease. These medications clearly exert influence on specific neurotransmitters, naturally occurring brain chemicals that effect, or regulate, communication between neurons in regions of the brain that control mood, complex reasoning, anxiety, and cognition. In 1970, The Nobel Prize was awarded to Julius Axelrod, Ph.D., of the National Institute of Mental Health, for his discovery of how anti-depressant medications regulate the availability of neurotransmitters such as norepinephrine in the synapses, or gaps, between nerve cells.

— American Psychiatric Association, Statement on Diagnosis and Treatment of Mental Disorders

So it is strictly speaking true that there are no biomarkers found in all patients with a specific psychiatric condition and found in on person who does not have this condition. This is to be expected because of the heterogeneity of the conditions and because of human behavior and personality traits are spectra, rather than all-or-nothing. The same general principle can be applied to cancer. There is absolutely nothing that is unique for cancer cells that cannot be found in other non-cancer cells. In fact, we do not know precisely what causes things like breast cancer, but we know of various important risk factors. Does this mean there is no biological basis for cancer? That cancer does not exist? Of course not.

The trick that S.P. uses is the classical bait-and-switch tactic know as confusion whether with how. I wrote about this in my overview of common denialist tactics:

Tactic: Confusing Mechanism With Fact (or How with Whether).
Description: Involves shuffling the cards and trying to portray a genuine scientific debate on how something is occurring as the pseudoscientific notion that that scientists are still debating the merit of the idea. A classic example is creationists who falsely characterize the debate between the modes and mechanisms of evolution above the species level as if it questioned whether common descent was reasonable.
Countermeasure: Explain that scientists will always debate the details, but that every sane scientists in that debate accepts the fact, even though they may differ on precise mechanisms.

In this case, the Wikipedia article has already engaged the countermeasures for us. It says that despite the fact that no unique biomarkers exists, there still exists reproducible abnormalities of brain structure and function for certain mental conditions and that the neural circuitry involved in many others have been mapped and effective treatment developed. This is in stark contrast to the “no unique biomarkers implies no biological basis”.

Moving on to the second blog entry, it tries to claim that anti-psychiatry is not denialism. He repeats many of the same falsehoods that he has done elsewhere, so I will focus on the major points.

6. Comparing Anti-psychiatry with HIV/AIDS denialism is an apt analogy

S.P. writes that

I am very surprised that some antidenialism zealots [linking to my blog – E.K.] have a need to put us who are in the antipsychiatry movement in the same company as the nuts in the AIDS denialism movement. According to wikipedia, denialism means,

“Denialism is choosing to deny reality as a way to avoid an uncomfortable truth. Author Paul O’Shea remarks, “[It] is the refusal to accept an empirically verifiable reality. It is an essentially irrational action that withholds validation of a historical experience or event”

By this definition, it’s mainstream psychiatry in fact that practices denialism.

Unfortunately, this is a quote out of context. The article continues:

In science, denialism has been defined as the rejection of basic concepts that are undisputed and well-supported parts of the scientific consensus on a topic in favor of ideas that are both radical and controversial. It has been proposed that the various forms of denialism have the common feature of the rejection of overwhelming evidence and the generation of a controversy through attempts to deny that a consensus exists

This fits extremely well with anti-psychiatry and HIV/AIDS denialism, but not with psychiatry. His ultimatum to either reject HIV as the cause of AIDS or reject modern psychiatry similarly falls flat on it’s face: behavioral symptoms can be quantified, measured and compared with e. g. Beck Depression Inventory (analogous to comparing effects of HIV on CD4+) and people undergoing pharmacological treatment for depression with SSRIs are less likely to experience suicidality (analogous to people on HAART less likely to develop AIDS). There is no blood test for migraine, but migraine surely exists and can be treated with anti-migraine medications.

References and further reading

Allgulander, Christer. (2008). Introduktion till klinisk psykiatri (2nd edition). Studentlitteratur: Lund.
Isacsson, G., Holmgren, P., & Ahlner, J. (2005). Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: a controlled forensic database study of 14 857 suicides. Acta Psychiatrica Scandinavica, 111(4), 286-290.
Mayo Clinic Staff. (2010). Obsessive-compulsive disorder (OCD). Mayo Clinic. Accessed: 2012-05-20.