All morning we hike the upland meadows,

 through devil’s paintbrush, poison sumac,

 and the heady smell of wild apples rotting

 in the pale fall sun. Palm warblers twitch

 their yellow rumps like strung out coke-heads,

 and cedar waxwings sing drinking songs

 as they eat fermented berries from the high

 branches. Two yellow feathers and a skull

 drop from the sky and fall on the brown

 scar of trail, a sharp-shinned hawk on a dead

 branch watching us walk, his brown speckled

 belly and slate gray wings reflecting the sun.

 He considers us, and without a flap

 opens his wings to the wind and is gone.

Articles

Two yellow feathers and a skull. . . drop from the sky and fall on the brown . . . scar of trail, a sharp-shinned hawk

Sharp-Shinned Hawk

Unfortunately, brilliant psychiatrists continue to put on display their ignorance of the Second Amendment and its history. The Second Amendment is not about hunting or even defending your home from armed intruders, although that is certainly a fringe benefit. The founders of this great nation came here to escape tyranny and religious persecution. So, not surprisingly, the First Amendment to the Constitution is about religious freedom and the Second Amendment, about the defense against tyranny.

The situation in a Colorado movie theater was tragic and heartbreaking. However, when individuals “go off,” they kill people in the dozens; when governments “go off,” they kill people in the millions.

Between 50 million and 100 million people were killed in the 20th century after being disarmed by their own governments in the name of gun control, the most famous being Germany. Germany was the most educated and technically advanced country in the world at the time and yet murdered 20 million of its own people after disarming them less than 70 years previously.

Today people are being murdered all over the globe, people who have no ability to fight back. As far-fetched as it may seem to some, it can happen here because we are neither more moral nor more civilized than the Germans in the 1940s. People in government are people, and not automatically more trustworthy than your neighbor. The best way to stop tragedies like the one in Colorado is an armed citizenry, because the only thing that will stop a bad man with a gun is a good man with a gun. Not coincidentally, all mass shootings in this country have occurred in “gun-free zones.”

Ronald Pies, whom I greatly respect, asked attorney Joshua Horwitz to respond to my comments on the history of the Second Amendment. Why ask a member of a well-known left wing advocacy group, the Coalition to Stop Gun Violence, whose mission is to advance victim disarmament laws? I haven’t heard much from this group regarding the “Fast and Furious” operation in which government guns killed innocent people. How about a commentary from a respected researcher, such as David Kopel, Gary Kleck, or John Lott?

We can trade statistics all day. Often, the murder rates in the US that are gun-related are compared with gun-related murder rates in other countries. This is misleading, since the overall murder rate is often much higher in the foreign country but other means are used besides guns. Also, most of the violent crime in the US is related to the drug trade and won’t be affected by new laws. The reality that can’t be ignored is that the murder rate is declining in the US despite record numbers of people who buy guns. John Lott’s More Guns, Less Crime: Understanding Crime and Gun Control Laws provides data from the US and many other countries. These data show an inverse relationship between gun ownership and violent crime. It is safer to live where law abiding citizens are armed. How is that working in Chicago, which has the strictest gun laws in the nation and a higher murder rate than Afghanistan?

Another purpose of the Second Amendment is to allow protection not just against isolated intruders, which happens thousands of times a year, but also against mobs during times of societal breakdown. The only shop owners who saved their businesses during the LA street riots in the 1960s were armed with AR-15 semi-automatic assault rifles. People who were armed after Hurricane Katrina were surprisingly not looted or mugged.

How can we know with absolute certainty that there will never be a terrorist attack on US soil causing social unrest, another natural disas-ter such as a major earthquake, or Greece-like riots in response to an economic disaster? When it is up to me to protect my family-and I’ll need adequate fire power to do so-I have an absolute God given right to that.That right is not a gift from government.

Dr Thomas Sowell summed it up this way, “There are no solutions, only painful trade-offs.” If ordinary people have guns, some of them will be misused, such as in the massacre in Colorado. Since guns exist, a gun-free society is impossible. If ordinary people are disbarred firearm ownership, then only criminals and people in government will have guns. Are we safer with an armed citizenry or disarmed victims? I know where the data fall.

This argument almost always breaks down along political lines. There are people who think we should all be dependent on government, from health care to day care to protecting us from each other. The hard truth is, protecting yourself and your family is your responsibility. The government will not be there when you most need it.

For the "Counterpoint" to this debate, please click here

Unfortunately, brilliant psychiatrists continue to put on display their ignorance of the Second Amendment and its history.

POINT: The Case for Gun Control

When the patient comes, I say: “I know it is not easy to start talking about oneself to a stranger, but what can you tell me that would be helpful for me to understand you?” I see how they begin and I notice the content, but I also pay attention to the defense mechanisms, the avoidances, to what they don’t want to talk about. I let them know that it is important to say everything that occurs to them. “Free association” is really our basic tool . . . it yields insights that the patient does not censor.

So after I come to some conclusion, I say: “From what you tell me, I understand the following . . .” Then, I judge their capacity for insight. With some people, you can go deeper faster; with others, it is extremely delicate. You learn whether you have to watch your words very carefully, depending on how suspicious, disturbed, or trustful the patient is.

So you gradually create within yourself an image of the person and then you communicate out of your image. As you get to know the patient, the image becomes more articulate. In all of this, I am not focused on change. I am trying to understand what the patient is about and allowing him or her to develop the goal of his or her own changing.

I also use metaphors. Let’s say a patient is upset that he is not making any progress, then I might tell the following story. “Two men meet in Tel Aviv, and their conversation goes like this: ‘I haven’t seen you in a while!’ ‘Of course not, I was in South Africa.’ ‘What were you doing there?’ ‘I was on a safari.’ ‘The whole year?’ ‘Yes, the whole year. I was hunting lions.’ ‘How many lions did you get?’ ‘How many did I get? None!’” When it comes to lions, none is quite a bit!

I tell this vignette when a patient complains. It conveys the idea that some goals are difficult to attain. Like Alice in Wonderland, it takes all the running you can do, just to stay in the same place. That would be a similar idea.

I have been an analyst for 50 years, and if there is anything that I still find astonishing, it is that 

 patient has something new to communicate. Some have so much new to say that it’s bewildering.

It is as if an analyst is not only living his own life but also the lives of countless other people. So I think I am making a bargain with death. I am cheating. I am living more than one life.

Being a Therapist features intimate portraits of psychotherapists in their own work spaces. An excerpt of his interview with Dr Martin S.

Intimate Portrait: Martin S. Bergmann, PhD

Contemporary psychoanalysts know that behavior is a form of communication.

Treatment Resistance and Patient Authority: The Austen Riggs Reader,

edited by Dr Eric Plakun, describes the work being done at the Austen Riggs Center, a psychodynamic institution in Stockbridge, Mass. Specializing in work with treatment-resistant, usually highly comorbid, and often high-risk patients, the Center’s intensive multimodal psychoanalytic treatment program considers the most passive, disturbed, or disturbing behavior of treatment-resistant patients as cause for hope rather than pessimism.

Treatment resistance, defined as a failure to respond to customary psychiatric treatment, is now considered a fairly common occurrence that can involve substantial suffering and disability. Almost all mental health professionals have had contact with complicated, severe cases that tax resources and discourage clinicians. Given the magnitude of the problem of treatment resistance, the impact on patients and those who care about them, and the consumption of health care resources, the subject of this book is very important indeed.

To explain the practicalities of treatment resistance, the authors of each chapter describe contemporary psychoanalytic work and transmit the attitude required for this work. Furthermore, they keep in mind an audience that may be accustomed to approaching difficult clinical problems with a very different state of mind.

Aptly titled a “reader,” the book seems designed for the ongoing development and use of certain basic skills. Like the best of “readers,” it contains elements for the ambitious student. “The Third,” for example, which is discussed throughout the book, is a term currently at the cutting edge of psychoanalytic theory. Therefore, its inclusion may be a drawback for the inexperienced or less ambitious scholar.

The text is well organized with take-home messages set apart in boxes. The phenomenon of treatment resistance is reviewed, as are data that support the positive results obtained at the Riggs Center. A variety of issues are addressed, including negative transference; the transmission of trauma; psychodynamic psychopharmacology; and working with suicidality, family resistance, and psychotic disorders.

We are urged to look beyond the phenomenon of “acting out” toward the notion of “enactment,” which implies clinician participation in the unfolding treatment-resistant behavior. From this point of view, treatment pivots around the empowering concept of authority-the patient as author of an engaged relational narrative previous-ly carried in action (and inaction) rather than in words.

The book is worth reading by all mental health professionals. Of particular interest is the chapter “What is psychodynamic psychopharmacology? An approach to pharmacological treatment resistance,” by Drs Mintz and Belnap. The 2 main subjects in this chapter are deserving of book-length treatment. These are “resistance 

medications” (including the nocebo effect) and “resistance 

 medications,” wherein use of medications and the medical model contribute psychologically to treatment resistance.

Another notable chapter is “System pressures, ethics, and autonomy,” by Marilyn Charles, PhD. Dr Charles emphasizes that for treatment-resistant patients, “the standard of care is a floor, not a ceiling.” She describes how various types of fear on the part of the clinician often create a tendency toward oversimplified thinking in the treatment of these patients.

The only shortcoming of this excellent book is its minimal discussion of the issues involved in applying its understandings to less intensive clinical settings. The reader feels this as an aching need. One is left with the disquieting implication that much of current treatment with some patients, because it is “deaf” to the communication in their behavior, may actually further entrench treatment resistance.

Contemporary psychoanalysts know that behavior is a form of communication. This book describes the work being done at the Austen Riggs Center, a psychodynamic institution in Stockbridge, Mass.

Treatment Resistance and Patient Authority: The Austen Riggs Reader

Childhood ADHD is a major public health problem, with prevalence estimated to be over 5 million children in the US alone. Of particular concern is the recent increase in diagnosis of the disorder. In 2011, the CDC estimated that nearly 9% of children in the US (1 of 11 children between the ages of 5 and 17) have ADHD; the diagnosis is made in approximately twice as many boys as girls.

 Moreover, ADHD rarely exists alone. In most children with ADHD (75% to 80%), a second (or even third) psychiatric disorder develops at some point in their lives.

While the overall prevalence of ADHD among children and adolescents has increased in the past 10 years, diagnosis among girls appears to have increased more rapidly. In the 1990s, the male to female ratio for ADHD was estimated to be about 9 to 1 in clinical settings and 3 to 1 in the general population.

 More recently, however, a large epidemiological study of 3907 children found that of the 8.7% who met DSM-IV-TR criteria for ADHD, 51% were boys and 49% were girls.

 The prevalence of ADHD is reportedly higher in women than in girls, which suggests that ADHD may be underdiagnosed in girls or, alternatively, that the developmental onset of impairing symptoms occurs later in girls than in boys.

The rise in diagnosis of ADHD among girls contributes to the changing face of the disorder. For example, although there are few reported sex differences in problem behavior in infancy and early childhood, sex differences appear to emerge by age 4 years, with boys showing more aggressive and impulsive behaviors.

Two hypotheses have been posited to explain this apparent “remission” of symptoms in young girls. The first is that girls are more likely to channel their problem behavior into internalizing behaviors. In females, ADHD appears to be associated more with anxiety and depression-two-thirds of women with ADHD have comorbid depression.

The second hypothesis is that the change in behavior among girls is a function of more rapid neurobiological, cognitive, motor, and social development.

On one hand, this more rapid rate of development among girls may be protective against the manifestation of some ADHD symptoms in childhood; on the other hand, the onset of pubertal increases in estrogen and subsequent increases in dopamine receptors lead to an acceleration of symptoms in adolescence.

ADHD is nevertheless associated with significant risks for adverse outcomes. Longitudinal studies suggest that individuals with ADHD are far more likely than those without the disorder to drop out of school, to have few or no friends, to underperform at work, to engage in antisocial activities, and to use tobacco or illicit drugs. Also, youths with ADHD are more likely to experience teen pregnancy and sexually transmitted diseases, to drive too fast and have multiple car accidents, and to experience other psychiatric conditions as adults.

What is already known about ADHD in boys and girls? 
? ADHD is a neurodevelopmental disorder in which symptoms begin (most often) in preschool years and persist into adulthood. ADHD is more commonly diagnosed in boys than in girls; however, the rate of diagnosis among girls is rapidly increasing.

What new information does this article provide? 
? Boys with ADHD can present with different cognitive and behavioral patterns than girls with ADHD. These differences may be because of the types of comorbid conditions, earlier maturation among girls, and failure to identify the more subtle patterns of symptoms in girls. Despite these factors, girls with ADHD remain at significant psychosocial risk into adulthood.

What are the implications for psychiatric practice? 
? Up to 75% of persons with ADHD have at least one other psychiatric disorder, which often makes treatment more challenging. Assessment for and diagnosis of ADHD in girls are more complicated than in boys, because of later onset, more subtle clinical manifestations, and wording in many popular ratings scales that emphasizes behaviors seen more commonly in boys. Children who are young for grade in school tend to be rated as having more symptoms of ADHD than those who are older for grade, leading to greatest rates of ADHD diagnosis among children whose birthday is just before the cutoff for school entry. Given the proposed changes for ADHD diagnostic criteria in DSM-5, it is likely that rates of diagnosis among girls will continue to increase.

The sex paradox posits that the sex in which a given disorder is less prevalent should show greater levels of impairment than the sex in which the disorder is more prevalent.

While initial studies suggest that girls with ADHD have better adolescent and adult outcomes than boys with ADHD, more recent findings indicate that girls with ADHD have considerably more functional impairment, including an increased risk of internalizing disorders (eg, depression, suicide), and eating pathology than girls without ADHD.

These observations occur despite the fact that with age, symptoms of hyperactivity/impulsivity decline more in girls than in boys.

In fact, a recent study found that by adolescence, only 16% of girls with ADHD showed adequate social adjustment compared with 86% of girls without ADHD.

 Another 5-year follow-up of 6- to 17-year-old females with ADHD found that by age 16, ADHD persisted in 71% of the sample.

 Girls who have a diagnosis of ADHD in childhood continue to show deficits in executive functions as adults, even if their symptoms have remitted to a nondiagnosable level.

Early studies that compared neuropsychiatric function in boys who had ADHD with that of girls who had ADHD may have been confounded by group differences in proportion of ADHD subtype, since among school-aged children with ADHD, girls routinely present more often with the inattentive subtype, while boys are more likely to present with the combined subtype.

 Not surprisingly, an early meta-analysis that examined sex differences in ADHD found that boys with ADHD had greater levels of hyperactivity symptoms and externalizing behaviors, which were associated with reduced academic skills.

More recent neuropsychological studies suggest that when samples of boys and girls with ADHD are matched on subtype, girls are often just as impaired as boys, and in some functional areas (eg, planning skills), more impaired than boys.

 Other studies found that individuals with the subtype less common for their sex (ie, boys with the inattentive subtype and girls with the combined subtype) are at increased risk for cognitive dysfunction.

The diagnosis of ADHD in girls is more complicated than in boys because of the later age of onset, more subtle clinical manifestations, and limitations associated with the DSM-IV diagnostic schema and nomenclature.

 One concern has been that the wording of DSM-IV diagnostic criteria for ADHD and the majority of rating scales are geared toward the manifestation of ADHD in boys. Some have argued that there is a subset of girls who present with symptoms of ADHD and are rated by parents and teachers as having elevated scores when sex-specific norms are used, yet they do not meet DSM-IV criteria for the disorder.

 Parents tend to rate behaviors in boys (ie, inattention, hyperactivity, aggression) as more problematic than behaviors in girls (ie, relational aggression and other “feminine” behaviors).

A Dutch study found that while mothers reported similar levels of disruptive behavior in boys and girls, teachers reported higher levels of concern with attention and aggression among the boys in the same sample.

 Mental health professionals may also display this bias. In a recent study, therapists were presented with 4 diagnostic vignettes: 3 vignettes illustrated some symptoms of ADHD, but not enough to diagnose the disorder according to DSM-IV criteria. Male and female versions of each vignette were created. In the male version of the vignettes, therapists diagnosed ADHD twice as often as they did with the female vignettes. This suggests that therapists do not adhere strictly to DSM-IV criteria, with consequent overdiagnosis of ADHD in boys and underdiagnosis (and undertreatment) in girls.

Developmental maturity also appears to play a part in the diagnosis of ADHD, and boys may be at increased risk for diagnosis because of their later development of self-control skills. A recent US study found that the rate of diagnosis of ADHD varied according to the month of the child’s birthday, relative to the cutoff date for entrance into kindergarten. For example, in approximately 8.4% of children born in the month before the cutoff, ADHD was diagnosed, compared with 5.1% of children born in the month after the cutoff.

 Similar findings were also reported in a Canadian study that showed higher rates of diagnosis (relative to sex-matched peers) for both boys and girls born in the month before kindergarten cutoff.

There are sex differences in incidence or nature of many CNS-related disorders. Human brains are approximately 8% to 10% larger in males than in females

; however, girls’ brains mature earlier and are on a different trajectory. These differences are observed at birth and may be driven by sex chromosome–specific pathways that underlie sexual dimorphism or even by differences in the presence of fetal testosterone.

 It has been estimated that at birth, girls are 3 weeks ahead of boys in physical maturation and by the time they enter school, girls are approximately 1 year ahead.

These findings are highly salient, since different maturation rates appear to be associated with different patterns of cognitive skills (eg, children identified as “late-maturing” performed better than early-maturing children of the same sex on spatial measures).

A recent meta-analysis identified sex differences in reward sensitivity-women were more sensitive to punishment than men but not more sensitive to reward; men showed higher rates of sensation-seeking than women.

 It has been argued that these patterns of behavior are related and may also have sexually dimorphic phenotypic expression of genes linked to ADHD.

Over the past 15 years, Giedd and colleagues at the NIMH have compiled normative growth curves for the brain. Their work reveals the heterochronous, regionally specific, and sexually dimorphic nature of brain development in which total cerebral volume is reached by age 10.5 in girls and age 14.5 in boys.

Of particular importance for understanding sex differences in ADHD are the patterns of growth in the frontal lobes and basal ganglia (both known to be anomalous in ADHD). Bush

 found that frontal lobe gray matter volume peaks at around 9.5 years in girls and 10.5 years in boys. The caudate nucleus peaks at 10.5 years in girls and at 14.0 years in boys.

By adulthood, a number of regions of the brain are larger in women than in men (after adjusting for total cerebral volume), including the frontal lobes and hippocampus.

 Given these observations, when considering neuropsychiatric development in boys and girls in whom ADHD is suspected, it may be best to make determinations of “impairment” on the basis of sex-specific comparisons and to consider the different developmental course of ADHD in males and females.

Early neuroimaging studies of ADHD have identified widespread cortical and subcortical volumetric reductions, including delayed cortical maturation, among school-aged children with ADHD.

 To date, the generalizability of many published MRI findings in children with ADHD to girls with ADHD has been questioned because most conclusions have been based on samples consisting primarily (or exclusively) of boys, with girls underrepresented in imaging studies of ADHD.

A recent meta-analysis of neuroimaging studies in ADHD found that only 20% of participants were female and only 50% of the ADHD samples included females.

 More recent brain mapping studies of ADHD suggest a more subtle pattern of neuroanatomic differences among girls that appears to parallel the earlier reduction in externalizing symptoms.

In a study that compared functional frontal lobe subdivisions in boys and girls with ADHD (aged 8 to 12 years), both boys and girls showed reductions in supplementary motor cortex. Conversely, boys (but not girls) showed reductions in dorsolateral prefrontal cortex, while girls (but not boys) showed reduced premotor cortex volumes. In both sexes, the differential reductions were associated with different patterns of executive dysfunction, but boys showed more relative problems with inhibitory control.

In a study that assessed basal ganglia volume and shape in boys and girls with ADHD (aged 8 to 13 years) and age-matched controls, compared with controls, boys with ADHD showed compression in several regions, including the left anterior and right ventral putamen, the bilateral mid-body of the caudate, and the left dorsolateral and right ventromedial head of the caudate.

 However, no differences were observed in girls with ADHD compared with controls.

The neuropsychiatric signature of ADHD in girls

The research literature has only begun to identify a signature pattern of brain anomalies and behavioral deficits associated with ADHD in girls, in part because girls “age-out” of many symptoms earlier than boys. For example, motor development follows an earlier-maturing developmental course in girls than in boys. The developmental status of the motor system in 144 typically developing children (72 boys and 72 girls, aged 7 to 14 years) was examined by Larson and colleagues.

 They found significant sex effects for atypical subtle signs (involuntary movements) and motor speed. In all cases, girls showed fewer subtle signs and were faster and more proficient than boys. Moreover, by age 7 years, many of the motor skills assessed reached “adult” level in girls, but not in boys.

A pattern of prolonged motor dysfunction emerges in boys, but not in girls, with ADHD. In a study that examined age-related reduction in motor subtle signs (overflow, dysrhythmia) in 268 children aged 7 to 14 years, boys with ADHD had more overflow and dysrhythmia than controls, while girls with ADHD did not differ from controls. Also, during this age range, girls with ADHD showed significant reduction in overflow (associated) movements, while boys showed little change during this period. This suggests that the frontal-striatal and cerebellar brain systems implicated in motor overflow and dysrhythmia mature earlier in girls.

In a study that examined executive functions in school-aged children with ADHD, O’Brien and colleagues

 found that both boys and girls showed similar patterns of deficit on tasks involving response preparation and working memory; however, they manifested different patterns of executive dysfunction. On tasks related to response inhibition, boys were more impaired; on tasks related to strategic planning, girls were more impaired.

The well-established sexual dimorphism in human neurobiological development extends to the patterns of behavior observed along the developmental course of ADHD. Current research suggests that the prevalence of ADHD among females is approaching that of males. Given the proposed changes in the ADHD diagnostic criteria for DSM-5 (which will raise the required age of onset of symptoms from 7 to 12), it is likely that the rate of diagnosis among girls will continue to increase. Cross-sectional research that compared boys and girls with ADHD has yielded inconsistent findings, because adolescent girls are at a different point in their development than boys of the same age.

More recent longitudinal studies highlight the pattern of adolescent and adult risks associated with ADHD in females and bring to fo-cus the importance of making clinical judgments in assessment and treatment of ADHD on the basis of sex-specific comparisons. Continued work examining the sex differences in expression of ADHD from early childhood (ie, preschoolers) through adulthood is encouraged.

 Akinbami LJ, Liu X, Pastor PN, Reuben CA. Attention deficit hyperactivity disorder among children aged 5-17 years in the United States, 1998â2009. NCHS data brief, No 70. Hyattsville, MD: National Center for Health Statistics; 2011.


 Larson K, Russ SA, Kahn RS, Halfon N. Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. 

 Gaub M, Carlson CL. Gender differences in ADHD: a meta-analysis and critical review [published correction appears in 

 Froehlich TE, Lanphear BP, Epstein JN, et al. Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. 

 Pinkhardt EH, Kassubek J, Brummer D, et al. Intensified testing for attention-deficit hyperactivity disorder (ADHD) in girls should reduce depression and smoking in adult females and the prevalence of ADHD in the longterm. 

 Boys with ADHD can present with different cognitive and behavioral patterns than girls with ADHD. Despite these factors, girls with ADHD remain at significant psychosocial risk into adulthood.

Neuropsychiatric Differences Between Boys and Girls With ADHD

Gun violence continues to destroy families and communities in the US on a daily basis.

Dr Robertson offers the same Faustian bargain the National Rifle Association does. We are told that we must allow the massacre of innocent Americans-including children-with easily obtained firearms because “it is the price we must pay for freedom.” All those who have sworn the Hippocratic Oath to protect their patients should stand resolute against this radical and morally bankrupt idea.

The insurrectionist interpretation of the Second Amendment dominates the modern pro-gun movement. This view posits that individuals should be allowed to prepare for war with their government as a counterbalance should it one day become “tyrannical.” Citizens who care about our Constitution and the vast array of rights it affords us might think twice before adopting this flawed and treasonous interpretation as their own.

There is not one shred of evidence to suggest that the Second Amendment’s purpose was to safeguard an individual right of insurrection. The amendment’s author, Federalist James Madison, articulated that its purpose was to split the military power of the new nation between the states and the federal government. But he also made it clear that any opposition to federal tyranny would come from state militia forces “conducted by governments possessing their affections and confidence.”

Our Founders saw what insurrection looked like during acts of armed mob violence such as Shays’ Rebellion. It horrified them and was one of the chief reasons they gathered in Philadelphia to create a new system of government with a stronger, more capable federal government. Article 1, Section 8 of the Constitution makes it clear that the purpose of the militia is to “suppress insurrections,” not to foment them. Remember, what looks like “tyranny” to one man might look like “health care reform” to another.

The comparison of contemporary Americans to the Nazis is not valid. The experience in Germany before World War II, far from providing validation to the insurrectionist argument, instead shows the danger of allowing political violence to influence the political process. Before Hitler’s appointment as Chancellor, the Nazi party had a larger body of men under arms than the German military itself, and frequently used violence to intimidate and kill its political opponents. The Weimar Republic taught us that if a government cannot maintain its monopoly on the use of force, then individual rights can be neither protected nor vindicated.

The claim that governments with strong restrictions on firearms put citizens at risk for government genocide is entirely without basis. Dictators and strongmen kill their citizens. Democracies do not-regardless of their gun laws. A study by Davenport and Armstrong 

 found that “democratic political systems have been found to decrease political bans, censorship, torture, disappearances, and mass killing, doing so in a linear fashion across diverse measurements, methodologies, time periods, countries, and contexts.” Well-developed democracies remain the most effective means of preventing public and private violence.

Allowing individuals to arm for a potential war against our government serves only to increase the risk of civil war and diminish our cherished democratic institutions and rights as defined in the Constitution. Meanwhile, weak gun laws drafted and supported by insurrectionists are taking an enormous human toll, with more than 80 Americans dying daily from gunfire and another 200 suffering injuries. There is no other democracy on the face of earth that experiences this type of gun violence. We are the only free society that has yet to address this problem.

A number of studies have demonstrated that gun ownership makes an individual and his loved ones far more likely to be victims of gun-related homicides, suicides and accidental deaths. The data also show that states with comprehensive firearms regulations have consistently lower rates of gun death.

Psychiatrists need to ask themselves this important question: Does it benefit their patients’ health and safety to give them-or anybody else for that matter-easy access to all the firearms they want with few (if any) questions asked, or would they benefit from laws that require universal, thorough background checks and restrictions on military-style firepower?

In contemporary society-where grotesque shootings are a daily feature of American life-the answer is a matter of life and death.

For the "Point" to this debate, please click here

 Davenport C, Armstrong DA II. Democracy and the violation of human rights: a statistical analysis from 1976 to 1996. 

http://onlinelibrary.wiley.com/doi/10.1111/j.0092-5853.2004.00086.x/abstract

We are told that we must allow the massacre of innocent Americans--including children--with easily obtained firearms because "it is the price we must pay for freedom."

COUNTERPOINT: Gun Control and the Second Amendment

Social media can be intimidating to those who provide mental health care. Why? Privacy and liability concerns are probably the first things that come to mind. However, careful and creative use of social media Web sites, such as Twitter, Facebook, and LinkedIn, can enhance your professional profile, promote high standards of patient care, and facilitate collaboration among colleagues.

Social media encompasses a wide range of Internet-based activities, including blogs, microblogs, wikis-and social networks. Blogs can help educate patients and caregivers about mental health topics, such as recently approved treatments, and typically provide such content on a regular basis. Blogs reach a wide audience and provide easy links to other sources of information (eg, the FDA).

For psychiatrists, being aware of topics that generate interest on social media sites not only fuels ideas for your own “tweets” or blog posts but also helps you anticipate concerns raised by your patients.

Note, however, that this sort of social media activity does not 

Many social media sites are designed to facilitate conversations among users, thereby creating an interactive social network. This may be very useful, since you can share information with and respond to posts received from others on the site (eg, about medication efficacy studies). Social networking sites that provide secure and private access (such as the APA page on LinkedIn) can also promote professional collaboration.

Because a psychiatrist must not do anything to compromise a patient’s right to confidential communication, social networking that involves patients does not have much utility in clinical practice. Many patients invite their psychiatrist or other behavioral health provider to join a social network (eg, a Facebook “friend” request). If the clinician accepts the invitation, communication with the patient is by definition not confidential and could easily impede treatment.

Setting up an account for your practice on social media Web sites such as Facebook and Twitter is very easy. One caveat is to keep your practice account separate from any personal accounts you may have on the same sites. Also, many social media sites encourage or require you to sign up with “business” accounts. Such accounts often have more controls over which features your business wants to present on the social network. For example, Facebook allows you to turn off the ability for other Facebook users to write on your “wall” (the most publicly viewable part of any Facebook page).

With your newly created social media account, you can begin to follow other behavioral health professionals or start to write about mental health topics yourself. As your network increases in number and in breadth of discipline, you will find new material in new places-other clinicians, journal newsfeeds, and items from the popular press.

Social media and networking offers an amazing amount of information to patients and quickly spreads treatment resources to behavioral health care providers.

A strong social media presence also helps generate referrals. Often potential patients will use search tools built into the social networks or traditional search engines (eg, Google and Bing) to learn more about a condition or health care provider. What they find may lead them to your Web site . . . and into your office.

Networking with colleagues on sites such as LinkedIn may also generate direct referrals from those colleagues.

For more and more of us, social media is the primary way we use the Internet-and this trend has been growing for years. According to the Pew Research Center, for example, “As of February 2012, one-third (34%) of Internet users aged 65 and older use social networking sites such as Facebook, and 18% do so on a typical day.”

 According to Wikipedia, “If Facebook were a country, it would be the world’s third largest in terms of population, larger even than the USA.”

 And like any other technology, the more we use it, the more dependent on it we become.

Having even a basic idea of the potential-as well as of the perils-of social media is therefore not only important to good practice, but it may be essential to good practice.

 Zickuhr K, Madden M. Older adults and internet use. PewInternet. June 6, 2012. 

http://pewinternet.org/Reports/2012/Older-adults-and-internet-use.aspx

http://en.wikipedia.org/wiki/Social_media#cite_note-19

Having even a basic idea of the potential--as well as of the perils--of social media is therefore not only important to good practice, but it may be essential to good practice.

Social Media: A Key Component to the Psychiatrist's Practice

Nearly 50 years ago, psychiatric diagnosis was described as the “soft underbelly” of psychiatry because of poor inter-rater agreement.

 Historically, psychiatric diagnoses were interpretive and somewhat subjective. Relative to medicine as a whole, psychiatry has few laboratory markers or imaging data to confirm a preliminary diagnosis. However, subsequent iterations of DSM have aspired to more accurate, reliable diagnoses. Despite this, the inter-rater reliability of psychiatric diagnosis remains a challenge as American psychiatry prepares to welcome DSM-5.

Inter-rater (or intercoder) reliability is a measure of how often 2 or more people arrive at the same diagnosis given an identical set of data. While diagnostic criteria help establish reliable diagnoses, the methods of gathering and interpreting patient data have a tremendous effect on how likely it is that 2 examiners will come to the same diagnostic conclusion for a given patient. Here we review inter-rater reliability research, identify factors that threaten diagnostic reliability, and offer examples of assessment strategies that may provide increased diagnostic reliability in general clinical settings.

Reliability of psychiatric diagnoses today

In diagnostic assessment, perfect inter-rater reliability would occur when psychiatric practitioners could always arrive at the same diagnosis for a given patient. When evaluating and interpreting inter-rater reliability, the measurement statistic used is kappa; the higher the kappa ranking, the stronger the degree of agreement is between raters. Indeed, no field of medicine is able to achieve perfect agreement-there are degrees of variance among diagnosticians in other specialties.

We are not saying that psychiatric diagnoses wholly lack objectivity, nor do we dismiss the “art” of psychiatry. Dependent on the skill of the rater and category of disorder, the inter-rater reliability of psychiatric diagnoses can be quite high and comparable to the kappas obtained for several diagnoses in other medical specialties. For example, Ruskin and colleagues

 demonstrated a kappa of 0.83 for 4 common psychiatric diagnoses. However, lacking some of the more objective measures enjoyed by other specialties, psychiatry faces additional challenges with inter-rater reliability.

Similar to goals of other fields of medicine, a central goal of psychiatric nosology is diagnostic reliability and consistency. Despite this goal, however, diagnostic reliability for some psychiatric disorders remains low. For example, studies have revealed a strong discordance among the diagnoses of psychotic disorders. McGorry and colleagues

documented 66% to 76% inter-rater reliability for this class of disorders and a corresponding discordance of 24% to 34%. Likewise, Maj and colleagues

 demonstrated a low kappa of 0.22 for the diagnosis of schizoaffective disorder.

Despite the ongoing revision of diagnostic criteria with each subsequent iteration of DSM, clinicians report concerns that diagnostic reliability generally remains poor. In a small-survey study in 2007, Aboraya 

 asked how clinicians’ attitudes and beliefs might explain low concordance in psychiatric diagnosis. In contrast to a similar study done in 1962, clinicians in the 2007 study attributed low inter-rater reliability more to individual clinician factors than to problems with nosology.

 Clinician-related factors that affect psychiatric diagnosis are heterogeneous, and the following is by no means a complete list.

Differences in clinical experience may affect knowledge about psychiatric phenomenology or alter the landscape of the clinical interview. For example, comfort and familiarity with diagnostic criteria, confidence in interviewing, and time management can each affect diagnostic conclusions. A loosening of the diagnostic criteria may occur if the clinician only asks about some of the diagnostic criteria. Availability of data (eg, collateral information) may also affect the ultimate diagnosis. Other important sources of inter-rater divergence are external pressures, such as different reimbursement practices by insurance companies, exposure to popular diagnoses through the media or pharmaceutical marketing, and the cognitive biases and heuristics that affect the practice of all medical specialties.

Clearly, interview styles vary widely and no single approach is the right one. Clinical interviews are often informal with variable structure. The aid of rating scales or structured instruments, therefore, can limit omissions or biases during history taking. While some validated structured instruments (eg, the Structured Clinical Interview for DSM Disorders-Clinician Version [SCID-CV]) require too much time for administration to be practical in everyday clinical work, others (eg, the Diagnostic Interview Schedule for Children [DISC]) may be successfully administered by lay providers or by computer, allowing the clinician to subsequently focus on one or more identified areas of concern.

 Similarly, systematic screening instruments are available for all major categories of psychiatric illness.

In light of these data, would an approach that offers more structure and objectivity increase the reliability of diagnoses? We offer 3 examples of approaches that may improve inter-rater reliability:

• A structured approach to collateral data

• The use of validated instruments to collect patient information

• A cognitive approach that anticipates critical challenges to diagnosis

The general clinician may not routinely seek outside information to test the accuracy and validity of a patient’s self-report, especially in outpatient settings. Yet clinicians should be cautious about obtaining most or all of the diagnostic data directly from the patient interview. Clinicians may empathize with patients even when they find a patient’s self-reported history to be implausible. In contrast, the regular, careful use of collateral information may reduce or limit biases. Opinions and diagnoses based on reviews of relevant outside material, interviews with people who know the patient and, at times, measures to screen for malingering or biased response style may provide a broader, more relevant and reliable history. If important data are missing, such as a drug screen, specifically noting diagnostic uncertainty created by the missing information will help shape the differential diagnoses.

Of course, patients who seek clinical care do not present with a box brimming with past records, and clinicians typically do not have time to sort through volumes of collateral data. Yet, in our experience, collateral data improve the reliability of diagnoses because they offset some of the problems associated with a patient’s recall and report of past events. For example, a patient may describe a past diagnosis of bipolar disorder from a recent hospitalization, but a review of past records might indicate that the patient’s discharge diagnosis was related to substances and that mood problems were characterized as a “rule out bipolar disorder versus substance-induced mood disorder.”

One practical solution is to structure the method for obtaining collateral information. Intake questionnaires are an opportunity to inquire comprehensively about current symptoms, obtain information on past treatment and hospitalizations, and obtain the names of a few people who know the patient well. Release of information forms and laboratory orders for screening tests may be paired with the intake questionnaires. Including past treatment records and laboratory results in the chart allows for a review before the follow-up appointment and critical reflection on the initial impressions from the patient’s self-report. Phone calls to the personal contacts, when consent is given, allow for further clarification, but always keep in mind the contacts’ own agendas or opportunities for secondary gain. If structured into the clinical routine, collateral information will increase the likelihood that a diagnosis is based on a full set of data.

The third approach is the mindset that anticipates a challenge to the diagnosis or scrutiny of review by an outside party. Child psychiatrists prepare reports that are scrutinized by parents, social services, juvenile justice professionals, and payers. Forensic psychiatrists prepare opinions with cross-examination in mind. As a diagnostic opinion is formulated, a number of questions arise:

• How good is the evidence that supports this diagnosis? What are the limits of the evidence?

• Is there another legitimate interpretation of the same data?

• Could the individual’s psychiatric symptoms be better accounted for by the use of substances?

• Was the individual (attorney or parent) invested in a particular diagnosis and could the self-report be biased?

• How does payer source affect the ways in which data were obtained and weighed?

Anticipation of these challenges counteracts bias and likely improves the probability of a reliable diagnosis.

DSM-5 presents psychiatry with a potential “reset button” for diagnostic reliability. Our field has an opportunity not only to revisit diagnostic criteria but also to revisit the ways clinicians can apply these criteria in the most valid and reliable fashion. Checklists have improved clinical outcomes in many other fields, but to date, psychiatry has not established a widely accepted or implemented checklist for screening and diagnosis.

 Perhaps the advent of DSM-5 and the studies of field reliability will lead to a new set of tools for the general psychiatrist’s toolbox. In the meantime, increasing collateral data, using validated screens, and using critical reflection on diagnostic evidence and influences may allow for increased confidence in diagnostic reliability and validity.

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 Ruskin PE, Reed S, Kumar R, et al. Reliability and acceptability of psychiatric diagnosis via telecommunication and audiovisual technology. 

 McGorry PD, Mihalopoulos C, Henry L, et al. Spurious precision: procedural validity of diagnostic assessment in psychotic disorders. 

 Maj M, Pirozza R, Formicola AM, et al. Reliability and validity of the DSM-IV diagnostic category of schizoaffective disorder: preliminary data. 

 Aboraya A. Clinicians’ opinions on the reliability of psychiatric diagnoses in clinical settings. 

 Ward CH, Beck AT, Mendelson M, et al. The psychiatric nomenclature. Reasons for diagnostic disagreement. 

 Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. 

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Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinician Version, User’s Guide

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 Shaffer D, Fisher P, Lucas CP, et al. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. 

DSM-5 presents psychiatry with a potential “reset button” for diagnostic reliability.

Inter-Rater Reliability in Psychiatric Diagnosis

Males conservatively make up approximate-ly 10% of anorexia nervosa and bulimia nervosa patients (bulimia nervosa is the more common disorder). The typical age range at presentation is adolescence to young adulthood.

 However, for binge eating disorder, rates for males are comparable to those for females, and at presentation, patients are typically adults. Binge eating disorder is often associated with obesity and the medical consequences of weight gain.

While the acute presentations of anorexia nervosa and bulimia nervosa in males and females tend to be the same and include weight loss and malnutrition and/or binge eating with compensatory behaviors, such as self-induced vomiting and calorie restriction, there are significant clinical differences between males and females who have eating disorders. Because of the growing awareness of males with eating disorders, this article addresses the similarities and differences between male and female risk factors, clinical presentations, and treatment.

The cause of eating disorders is multifactorial and typically manifests as idealizing dieting and weight loss. However, there are characteristics that are predictive of high risk for eating disorders in males.

Exercise and athletic competition, especially sports that require low body fat or extremes of weight loss, represent risks for disordered eating. A Norwegian study of elite athletes found that the rates of eating disorders in males were twice those of the general male population. For males who participate in antigravitation sports, such as high-jumping and pole-vaulting, the rates are particularly increased.

 The risk of eating disorders among triathletes also seems to be increased, as determined by increased scores on tests for abnormal eating.

 At least one study in male cyclists found that perfectionism may predict an increased likelihood of disordered eating.

Not only are rates of eating disorder diagnoses higher in homosexual men than in heterosexual men, but also scores on ratings of eating psychopathology and body image concerns, media influence, and body image–related anxiety are higher.

 Evidence suggests that younger, heavier gay men are at increased risk for eating disorders.

 Sexual identity disorders may also increase the risk of eating disorders.

 In addition, gay males experience higher levels of peer pressure to maintain a particular body type than do straight males, and higher levels of body dissatisfaction may account for higher levels of disordered eating.

Males who present for treatment are much more likely than females to have been subjected to weight-based victimization and to have a history of being overweight.

 Other factors that may increase the risk of an eating disorder in males include alcoholism and physical abuse.

 The article focuses on eating disorders in males and presents information on similarities and differences between males and females as they relate to risk factors, clinical presentation, and treatment.

Psychiatric Times Vol 29 No 10

Sharp-Shinned Hawk

POINT: The Case for Gun Control

Intimate Portrait: Martin S. Bergmann, PhD

Treatment Resistance and Patient Authority: The Austen Riggs Reader

Neuropsychiatric Differences Between Boys and Girls With ADHD

COUNTERPOINT: Gun Control and the Second Amendment

Social Media: A Key Component to the Psychiatrist's Practice

Inter-Rater Reliability in Psychiatric Diagnosis

Eating Disorders in Males

Irreversible Monoamine Oxidase Inhibitors Revisited

Are Psychiatric Disorders Inflammatory-Based Conditions?

Violence in the Media: What Effects on Behavior?