What we can learn from a PLOS Medicine study of antidepressants and violent crime

Update October 1 7:58 PM: note the inaccuracy that I correct in response to a comment by DJ Jaffe, for which I am thankful.

An impressively large-scale study published in PLOS Medicine of the association between antidepressants and violent crime is being greeted with strong opinions from those who haven’t read it. But even those who attempt to read the article might miss some of the nuances and the ambiguity that its results provide.

2305701220_0fc3d01183_bIn this issue of Mind the Brain, we will explore some of these nuances, which are fascinating in themselves. But the article also provides excellent opportunities to apply the critical appraisal skills needed for correlational observational studies using administrative data sets.

Any time there is a report of a mass shooting in the media, a motley crew of commentators immediately announces that the shooter is mentally ill and has been taking psychotropic medication. Mental illness and drugs are the problem, not guns, we are told. Sprinkled among the commentators are opponents of gun-control, Scientologists, and psychiatrists seeking to make money serving as expert witnesses. They are paid handsomely to argue for the diminished responsibility for the shooter or for product liability suits against Pharma. Rebuttals will be offered by often equally biased commentators, some of them receiving funds from Pharma.

every major shoorting

This is not from the Onion, but a comment left at a blog that expresses a commonly held view.


What is generally lost is that most shooters are not mentally ill and are not taking psychotropic medication.

Yet such recurring stories in the media have created a strong impression in the public and even professionals that a large scientific literature exists which establishes a tie between antidepressant use and violence.

Even when there has been some exposure to psychotropic medication, its causal role in the shooting cannot be established either from the facts of the case or the scientific literature.

The existing literature is seriously limited in quality and quantity and contradictory in its conclusions. Ecological studies [ 1, 2,]  conclude that the availability of antidepressants may reduce violence on a community level. An “expert review” and a review of reports of adverse events conclude there is a link between antidepressants and violence. However, reports of adverse events being submitted to regulatory agencies can be strongly biased, including by recent claims in the media. Reviews of adverse events do not distinguish between correlates of a condition like depression and effects of the drug being used to treat it. Moreover, authors of these particular reviews were serving as expert witnesses in legal proceedings. Authorship adds to their credibility and publicizes their services.

The recent study in PLOS Medicine should command the attention of anyone interested in the link between antidepressants and violent crime. Already there have been many tweets and at least one media story claiming vindication of the Scientologists as being right all along  I expected the release of the study and its reaction in the media would give me another opportunity to call attention to the entrenched opposing sides in the antidepressant wars  who only claim to be driven by strength of evidence and dismiss any evidence contrary to their beliefs, as well as the gullibility of journalists. But the article and its coverage in the media are developing a very different story.

At the outset, I should say I don’t know if evidence can be assembled for an unambiguous case that antidepressants are strongly linked to violent crime. Give up on us ever been able to rely on a randomized trial in which we examine whether participants randomized to receiving an antidepressant rather than a placebo are convicted more often for violent crimes. Most persons receiving antidepressant will not be convicted for a violent crime. The overall base rate of convictions is too low to monitor as an outcome a randomized trial. We are left having to sort through correlational observational, clinical epidemiological data typically collected for other purposes.

I’m skeptical about there being a link strong enough to send a clear signal through all the noise in the data sets that we can assemble to look for it. But the PLOS Medicine article represents a step forward.

stop Association does not equal causation

From Health News Review

Correlation does not equal causality.

Any conceivable data set in which we can search will pose the challenges of competing explanations from other variables that might explain the association.

  • Most obviously, persons prescribed antidepressants suffer from conditions that may themselves increase the likelihood of violence.
  • The timing of persons seeking treatment with antidepressants may be influenced by circumstances that increase their likelihood of violence.
  • Violent persons are more likely to be under the influence of alcohol and other drugs and to have histories of use of these substances.
  • Persons taking antidepressants and consuming alcohol and other drugs may be prone to adverse effects of the combination.
  • Violent persons have characteristics and may be in circumstances with a host of other influences that may explain their behavior.
  • Violent persons may themselves be facing victimization that increases the likelihood of their committing violence and having a condition warranting treatment with antidepressants.

Etc, etc.

The PLOS Medicine article introduces a number of other interesting possibilities for such confounding.

Statistical controls are never perfect

Studies will always incompletely specify of confounds and imperfectly measure them. Keep in mind that completeness of statistical control requires that all possible confounding factors be identified and measured without error. These ideal conditions are not attainable. Yet any application of statistics to “control” confounds that do not meet these ideal conditions risks producing less accurate estimate of effects than simply examining basic associations. Yet, we already know that these simple associations are not sufficient to indicate causality.

The PLOS Medicine article doesn’t provide definitive answers, but it presents data with greater sophistication than has previously been available. The article’s careful writing should make misinterpretation or missing of its main points less likely. And one of the authors – Professor Seena Fazel of the Department of Psychiatry, Oxford University – did an exemplary job of delivering careful messages to any journalist who would listen.

Professor Seena Fazel

Professor Seena Fazel

Professor Fazel can be found explaining his study in the media at 8:45 in a downloadable BBC World New Health Check News mp3.

Delving into the details of the article

The PLOS Medicine article is of course open access and freely available.

Molero, Y., Lichtenstein, P., Zetterqvist, J., Gumpert, C. H., & Fazel, S. (2015). Selective Serotonin Reuptake Inhibitors and Violent Crime: A Cohort Study. PLoS Med, 12(9), e1001875.

Supplementary material are also available from the web [1, 2, 3] for the study including a completed standardized STROBE checklist of items  that should be included in reports of observational studies, additional tables, and details of the variables and how they were obtained.

An incredible sample

Out of Sweden’s total population of 7,917,854 aged 15 and older in 2006, the researchers identified 856,493 individuals who were prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant from 2006-2009 and compared them to the 7,061,361 Swedish individuals who were not been prescribed this medication in that four year period.

SSRIs  were chosen for study because they represent the bulk of antidepressants being prescribed and also because SSRIs are the class of antidepressants to which the question of an association with violence of the most often raised. Primary hypotheses were about the SSRIs as a group, but secondary analyses focused on individual SSRIs – fluoxetine, citalopram, paroxetine, sertraline, fluvoxamine, and escitalopram. It was not expected that the analyses at the level of individual SSRI drugs have sufficient statistical power to explore associations with violent crimes. Data were also collected on non-SSRI antidepressants and other psychotropic medication, and these data were used to adjust for medications taken concurrently with SSRIs.

With these individuals’ unique identification number, the researchers collected information on the particular medications and dates of prescription from the Swedish Prescribed Drug Register. The register provides complete data on all prescribed and dispensed medical drugs from all pharmacies in Sweden since July 2005. The unique identification number also allowed obtaining information concerning hospitalizations and outpatient visits and reasons for visit and diagnoses.

crime sceneThese data were then matched against information on convictions for violent crimes for the same period from the Swedish national crime register.

These individuals were followed from January 1, 2006, to December 31, 2009.

During this period 1% of individuals prescribed an SSRI were convicted of a violent crime versus .6% of those not being prescribed an SSRI. The article focused on the extent to which prescription of an SSRI affected the likelihood of committing a violent crime and considered other possibilities for any association that was found.

A clever analytic strategy

Epidemiologic studies most commonly make comparisons between individuals differing in their exposures to particular conditions in terms of whether they have particular outcomes. Detecting bona fide causal associations can be derailed by other characteristics being associated with both antidepressants and violent crimes. An example of a spurious relationship is one between coffee drinking and cardiovascular disease. Exposure to coffee may be associated with lung cancer, but the association is spurious, due to smokers smoking Confoundinglighting up when they have coffee breaks. Taking smoking into account eliminates the association of coffee and cardiovascular disease. In practice, it can be difficult to identify such confounds, particularly when they are left unmeasured or imperfectly measured.

So, such Between-individual analyses of people taking antidepressants and those who are not are subject to a full range of unmeasured, but potentially confounding background variables.

For instance, in an earlier study in the same population, some of these authors found that individuals with a full (adjusted OR 1.5, 95% CI 1.3-1.6) or half (adjusted OR 1.2, 95% CI 1.1-1.4) sibling with depression were themselves more likely to be convicted of violent crime, after controlling for age, sex, low family income and being born abroad. The influence of such familial risk can be misconstrued in a standard between-individual analysis.

This article supplemented between-individual analyses with within-individual stratified Cox proportional hazards regressions. Each individual exposed to antidepressants was considered separately and served as his/her own control. Thus, these within-individual analyses examined differences in violent crimes in the same individuals over time periods differing in whether they had exposure to an antidepressant prescription. Periods of exposure became the unit of analysis, not just individuals.

The linked Swedish data sets that were used are unusually rich. It would not be feasible to obtain such data in other countries, and certainly not the United States.

The results as summarized in the abstract

Using within-individual models, there was an overall association between SSRIs and violent crime convictions (hazard ratio [HR] = 1.19, 95% CI 1.08–1.32, p < 0.001, absolute risk = 1.0%). With age stratification, there was a significant association between SSRIs and violent crime convictions for individuals aged 15 to 24 y (HR = 1.43, 95% CI 1.19–1.73, p < 0.001, absolute risk = 3.0%). However, there were no significant associations in those aged 25–34 y (HR = 1.20, 95% CI 0.95–1.52, p = 0.125, absolute risk = 1.6%), in those aged 35–44 y (HR = 1.06, 95% CI 0.83–1.35, p = 0.666, absolute risk = 1.2%), or in those aged 45 y or older (HR = 1.07, 95% CI 0.84–1.35, p = 0.594, absolute risk = 0.3%). Associations in those aged 15 to 24 y were also found for violent crime arrests with preliminary investigations (HR = 1.28, 95% CI 1.16–1.41, p < 0.001), non-violent crime convictions (HR = 1.22, 95% CI 1.10–1.34, p < 0.001), non-violent crime arrests (HR = 1.13, 95% CI 1.07–1.20, p < 0.001), non-fatal injuries from accidents (HR = 1.29, 95% CI 1.22–1.36, p < 0.001), and emergency inpatient or outpatient treatment for alcohol intoxication or misuse (HR = 1.98, 95% CI 1.76–2.21, p < 0.001). With age and sex stratification, there was a significant association between SSRIs and violent crime convictions for males aged 15 to 24 y (HR = 1.40, 95% CI 1.13–1.73, p = 0.002) and females aged 15 to 24 y (HR = 1.75, 95% CI 1.08–2.84, p = 0.023). However, there were no significant associations in those aged 25 y or older. One important limitation is that we were unable to fully account for time-varying factors.

Hazard ratios (HRs) are explained hereand are not to be confused with odds ratios (ORs) explained here. Absolute risk (AR) is the most intuitive and easy to understand measure of risk and is explained here, along with reasons that hazard ratios don’t tell you anything about absolute risk.

Principal findings

  • There was an association between receiving a prescription for antidepressants and violent crime.
  • When age differences were examined, the 15-24 age range was the only one from which the association was significant.
  • No association was found for other age groups.
  • The association held for both males and females analyze separately in the 15 – 24 age range. But…

Things not to be missed in the details

Only a small minority of persons prescribed an antidepressant were convicted of a violent crime, but the likelihood of a conviction in persons exposed to antidepressants was increased in this 15 to 24 age range.

There isn’t a dose-response association between SSRI use and convictions for violent crimes. Even in the 15 to 24 age range, periods of moderate or high exposure to SSRIs were not associated with violent crimes any more than no exposure. Rather, the association occurred only in those individuals with low exposure.

A dose response association would be reflected in the more exposure to antidepressants an individual had, the greater the level of violent crimes. A dose response association is a formal criterion for a causal association adequate evidence of a causal relationship between an incidence and a possible consequence.

In the age bracket for which this association between antidepressant use and conviction of a violent crime was significant, antidepressant use was also associated with an increased risk of violent crime arrests, non-violent crime convictions, and non-violent crime arrests, using emergency inpatient and or outpatient treatment for alcohol intoxication or misuse.

Major caveats

The use of linked administrative data sets concerning both antidepressant prescription and violent crimes is a special strength of this study. It allows a nuanced look at an important question with evidence that could not otherwise be assembled. But administrative data have well-known limitations.

The data were not originally captured with the research questions in mind and so key variables, including data concerning potential confounds were not necessarily collected. The quality control for the administrative purposes for which these data were collected, may differ greatly from what is needed in their use as research data. There may be systematic errors and incomplete data and inaccurate coding, including of the timing of these administrative events.

Administrative data do not always mesh well with the concepts with which we may be most concerned. This study does not directly assess violent behavior, only arrest and convictions. Most violent behavior does not result in an arrest or conviction and so this is a biased proxy for behavior.

This study does not directly assess diagnosis of depression, only diagnosis by specialists. We know from other studies that in primary and specialty medical settings, there may be no systematic effort to assess clinical depression by interview. The diagnoses that are recorded may simply be only serve to justify a clinical decision made on the basis other than a patient meeting research criteria for depression. Table 1 in the article suggests that only about a quarter of the patients exposed to antidepressants actually had a diagnosis of depression. And throughout this article, there was no distinction made between unipolar depression and the depressed phase of a bipolar disorder. This distinction may be important, given the small minority of individuals who were convicted of a violent crime while exposed to a SSRI.

Alcohol-and-Anti-DepressantsPerhaps one of the greatest weaknesses of this data set is its limited assessment of alcohol and substance use and abuse. For alcohol, we are limited to emergency inpatient or outpatient treatment for alcohol intoxication or misuse. For substance abuse, we have only convictions designated as substance-related. These are poor proxies for more common actual alcohol and substance use, which for a variety of reasons may not show up in these administrative data. Substance-related convictions are simply too infrequent to serve as a suitable control variable or even proxy for substance. It is telling that in the 15-24 age range, alcohol intoxication or misuse is associated with convictions for violent crimes with a strength (HR = 1.98, 95% CI 1.76–2.21, p < 0.001) greater than that found for SSRIs.

There may be important cultural differences between Sweden and other countries to which we want to generalize in terms of the determinants of arrest and conviction, but also treatment seeking for depression and the pathways for obtaining antidepressant medication. There may also be differences in institutional response to drug and alcohol use and misuse, including individuals’ willingness and ability to access services.

An unusual strength of this study is its use of within-individual analyses to escape some of the problems of more typical between-individual analyses not being able to adequately control for stable sources of differences. But, we can’t rely on these analyses to faithfully capture crucial sequences of events that happen quickly in terms of which events occurred first. The authors note that they

cannot fully account for time-varying risk factors, such as increased drug or alcohol use during periods of SSRI medication, worsening of symptoms, or a general psychosocial decline.

Findings examining non-fatal injuries from accidents as well as emergency inpatient or outpatient treatment for alcohol intoxication or misuse as time-varying confounders are tantalizing, but we reached the limits of the administrative data in trying to pursue them.

What can we learn from this study?

Readers seeking a definitive answer from the study to the question of whether antidepressants cause violent behavior or even violent crime will be frustrated.

There does not seem to be a risk of violent crime in individuals over 25 taking antidepressants.

The risk confined to individuals aged between 15 and 25 is, according to the authors, modest, but not insignificant. It represents a 20 to 40% increase in the low likelihood of being convicted of a violent crime. But it is not necessarily causal. The provocative data suggesting that low exposure, rather than no exposure or moderate or high exposure to antidepressants should give pause and suggest something more complex than simple causality may be going on.

This is an ambiguous but important point. Low exposure could represent non-adherence, inconsistent adherence, or periods in which there was a sudden stopping of medication, the effects of which might generate an association between the exposure and violent crimes. It could also represent the influence of time-dependent variables such as use of alcohol or substances that escaped control in the within-individual analyses.

There are parallels between results of the present study what is observed in other data sets. Most importantly, the data have some consistency with reports of suicidal ideation and deliberate self-harm among children and adolescents exposed to antidepressants. The common factor may be increased sensitivity of younger persons to antidepressants and particularly to their initiation and withdrawal or sudden stopping, the sensitivity reflected in impulsive and risk-taking behavior.

The take away message

Data concerning links between SSRIs and violent crime invite premature and exaggerated declarations of implications for public health and public policy.

At another blog, I’ve suggested that the British Medical Journal requirement that that observational studies have a demarcated section addressing these issues encourages authors to go beyond their data in order to increase the likelihood of publication – authors have to make public health and public policy recommendations to show that their data are newsworthy enough for publication. It’s interesting thata media watch group  criticized BMJ for using too strong causal language in covering this observational PLOS Medicine article.

I’m sure that the authors of this article felt pressure to address whether a black box warning inserted into the packaging of SSRIs was warranted by these data. I agree with them not recommending this at this time because of the strength of evidence and ambiguity in the interpretation of these administrative data. But I agree that the issue of young people being prescribed SSRIs needs more research and specifically elucidation of why low dose increases the likelihood of violence versus no or medium to high dose.

The authors do make some clinical recommendations, and their spokesperson Professor Fazel is particularly clear but careful in his interview with BBC World New Health Check News. My summary of what is said in the interview and in other media contacts is

  • Adolescents and young adults should be prescribed SSRIs should be on the basis of careful clinical interviews to ascertain a diagnosis consistent with practice guidelines for prescribing these drugs and that the drug be prescribed at therapeutic level.
  • These patients should be educated about the necessity of taking these medications consistently and advised against withdrawal or stopping the medication quickly without consultation and supervision of a professional.
  • These patients should be advised against taking these medications with alcohol or other drugs, with the explanation that there could be serious adverse reactions.

In general, young persons may be more sensitive to SSRIs, particularly when starting or stopping, and particularly when taken in the presence of alcohol or other drugs.

The importance of more research concerning nature of the sensitivity is highlighted by the findings of the PLOS Medicine article and the issues these findings point to but do not resolve.

Molero Y, Lichtenstein P, Zetterqvist J, Gumpert CH, Fazel S (2015) Selective Serotonin Reuptake Inhibitors and Violent Crime: A Cohort Study. PLoS Med 12(9): e1001875. doi:10.1371/journal.pmed.1001875

The views expressed in this post represent solely those of its author, and not necessarily those of PLOS or PLOS Medicine.

Category: antidepressants, Conflict of interest, depression, epidemiology, selective serotonin reuptake inhibitor, SSRis, violence | Tagged , , , , , , | 11 Comments

Promoting a positive psychology self-help book with a Wikipedia entry

to mama with loveThis edition of Mind the Brain continues an odd and fascinating story of an aggressive promotion of a positive psychology self-help book. In this chapter, I tell how the promotion is being aided by the author’s son creating a laudatory Wikipedia entry.

 The story can simply be appreciated as amusing. Or it can be used to raise the consciousness of readers concerning just what is involved in the promotion of sciencey self-help books. The story could raise readers’ level of skepticism about what they might have previously seen as a spontaneous outpouring of enthusiasm for the launch of books.

 The story can also be used to raise questions about the blurry lines between science, self-promotion of persons who traffic in the label of being a scientist, and commercial profitability.

 Is the science behind positive psychology self-help books being shaped and even distorted in the way it appears in the peer-reviewed literature and social media in order to make books and other commercial products like workshops and training for coaches more profitable? Do we need more routine declarations of conflicts of interest in scientific publications of persons writing self-help books?

I wonder how many people have ever thought of inventing a term and having a Wikipedia entry written for it in order to appropriate – claim personal credit for – a cherry picked literature. Having redefined the relevant scientific literature, such a clever person can then select and scrub the literature so that shines brilliantly with positive findings, excluding a considerable amount of negative findings and work done by others? All in the service of promoting a self-help book. Clever or crass?

Staking a claim on a piece of the scientific literature as your own.

eqd_natg_day_4__staking_her_claim_by_samueleallen-d5a0uziAppropriating an area of research under your new label, such as mental contrasting  or grit  allows you to choose to take charge of what studies to include as relevant and what to exclude. Others outside of your laboratory who take your appropriation seriously will miss a potentially larger relevant literature when they attempt a search with standard electronic bibliographic source like Google Scholar or Web of Science using the existing terms that are being replaced by a new one. They are not searching your concept, only the old one.

Naïve PhD students who were inspired to investigate the renamed, appropriated concept will need to cite the author’s work. Critics who are motivated to challenge the confirmatory bias included under the rubric of the new term will be faced with the problem that they did not actually investigate it, only an alternative topic for which they are trying to claim relevance.

Step1: Appropriate the literature, with a novel renaming of a corner of the scientific literature.

Step2: Write a self-help book.

Step3: Get your son to write an entry for Wikipedia promoting the concept. A loving son who will please his mom by citing her for 19 of the 20 citations included in the Wikipedia entry.

Some background.

I was persuaded by an extraordinary publicity campaign to purchase a self-help book, Rethinking Positive Psychology. With stories in prominent media outlets titled like

 The Case Against Positive Thinking

I thought I was buying a long overdue critique of positive psychology. Instead, the book represents a clever repackaging of the familiar wild claims of positive psychology gurus that life transformations await anyone doing their exercises. In the case of Rethinking Positive Psychology, the pitch is made that positive fantasies are not enough, but one only needs a simple and superficial consideration of the obstacles involved in achieving them and what could be done. Rather than any elaborate process of problem definition and consideration of coping options, the book calls for a swift application of a WOOP exercise – (Wish, Outcome, Obstacle, Plan).

stop thinkI quickly saw that WOOP is just a reheating of common old stuff in the self-help and clinical literature, like, for instance, the familiar Stop and Think of problem-solving therapy.

I read the book to the end on a long train ride, but from the outset I found that it was being misrepresented as being evidence-based. Over a series of blog posts at I am exploring the book’s promotion and the bad science in which it is grounded

Some of what is claimed as the science behind this book is not peer peer-reviewed. Readers have no opportunity to go to an outside source and decide for themselves whether claims are valid, bolstered in their confidence that the sources at least survived peer review. Some of what passes for the science behind the book likely predates the conception of the book and any deal with publishers. But some papers that are cited have a distinct quality of being experimercials concocted as part of the creation of a marketing advantage of the book as more sciencey than its competitors. We’ll come back to that in a later blog post.

The author of the book coined the term mental contrasting and the acronym WOOP to selectively appropriate and represent parta of a larger literature concerning implementation of intentions and positive fantasies. Relying on the author’s work alone, along with that of her husband, one would get the impression that they have together developed a whole literature that has produced results uniformly consistent with their theory and supportive of their self-help products.

Checking with Wikipedia

Only late in my investigation did I come across a Wikipedia entry for mental contrasting.

The Wikipedia entry prominently displays an exclamation point with a warning and a plea:

exclaimThis entry contains content that is written like an advertisement. Please help improve it by removing promotional content and inappropriate external links, and by adding encyclopedic content written from a neutral point of view. (April 2015).

The entry stakes out the self-help book author’s claim of the invention:

Mental contrasting (MC) is a problem-solving strategy and motivational tool that leads to selective behavior modification.[1] It was introduced by psychologist Gabriele Oettingen in 2001.[2]

There are 20 references included for the entry. Nineteen are to the work of the author of the self-help book.

How the Wikipedia entry got there was a matter of mystery and speculation until it occurred to me to click on the View History link for the entry.

keep you are my hero momIt revealed that the entry had been created by Anton Gollwitzer, described as a contributor who does not have a Wikipedia user page. He happens to have the same last name as the husband of the author of the self-help book. [*] Anton created his entry just at the time the self-help book was published.

Clicking on the talk link  for him, we immediately comes to a warning:

exclaimSpeedy deletion of “Woop (Scientific Strategy)”

A page you created, Woop (Scientific Strategy), has been tagged for deletion, as it meets one or more of the criteria for speedy deletion; specifically, you removed all content from the page or otherwise requested its deletion.

You are welcome to contribute content which complies with our content policies and any applicable inclusion guidelines. However, please do not simply re-create the page with the same content. You may also wish to read our introduction to editing and guide to writing your first article.

Thank you. — Rrburke (talk) 17:55, 27 October 2014 (UTC),

This was followed by another entry:

Your contributed article, WOOP (scientific strategy)

Which began

Hello, I noticed that you recently created a new page, WOOP (scientific strategy). First, thank you for your contribution; Wikipedia relies solely on the efforts of volunteers such as you. Unfortunately, the page you created covers a topic on which we already have a page – Mental contrasting. Because of the duplication, your article has been tagged for speedy deletion. Please note that this is not a comment on you personally and we hope you will continue helping to improve Wikipedia. If the topic of the article you created is one that interests you, then perhaps you would like to help out at Mental contrasting – you might like to discuss new information at the article’s talk page.

It was then followed by another entry:

Managing a conflict of interest

That began:

Hello, AntonGollwitzer. We welcome your contributions to Wikipedia, but if you are affiliated with some of the people, places or things you have written about on Wikipedia, you may have a conflict of interest or close connection to the subject.

All editors are required to comply with Wikipedia’s neutral point of view content policy. People who are very close to a subject often have a distorted view of it, which may cause them to inadvertently edit in ways that make the article either too flattering or too disparaging. People with a close connection to a subject are not absolutely prohibited from editing about that subject, but they need to be especially careful about ensuring their edits are verified by reliable sources and writing with as little bias as possible.

If you are very close to a subject, here are some ways you can reduce the risk of problems:

Avoid or exercise great caution when editing or creating articles related to you, your organization, or its competitors, as well as projects and products they are involved with.

Avoid linking to the Wikipedia article or website of your organization in other articles (see Wikipedia:Spam).

Exercise great caution so that you do not accidentally breach Wikipedia’s content policies.

This is getting more embarrassing. And then comes another entry:

exclaimNomination of WOOP (scientific strategy) for deletion

A discussion is taking place as to whether the article WOOP (scientific strategy) is suitable for inclusion in Wikipedia according to Wikipedia’s policies and guidelines or whether it should be deleted.

The article will be discussed at Wikipedia: Articles for deletion/WOOP (scientific strategy) until a consensus is reached, and anyone is welcome to contribute to the discussion. The nomination will explain the policies and guidelines which are of concern. The discussion focuses on high-quality evidence and our policies and guidelines.

Users may edit the article during the discussion, including to improve the article to address concerns raised in the discussion. However, do not remove the article-for-deletion notice from the top of the article. DGG ( talk ) 04:11, 29 March 2015 (UTC)

I can’t wait to see where all this is going. But is anyone else offended by this misuse of Wikipedia?


*I was wrapping up this blog post when I did a Google Scholar search did I should have done earlier. I found that when I entered the names Anton Gollwitzer and Gabriele Oettingen, the first citation was

Gollwitzer, A., Oettingen, G., Kirby, T. A., Duckworth, A. L., & Mayer, D. (2011). Mental contrasting facilitates academic performance in school children. Motivation and Emotion, 35(4), 403-412.

Angela Duckworth provided a wildly enthusiastic endorsement of the book.

I was once asked by educators to identify the single most effective intervention for improving self-control. Every scientist I spoke to referred me to the work summarized here – masterfully in with incompatible insight and warmth. Read this brilliant book and then go out and do what Gabriele Oettingen recommends. No changes the way you think about making your dreams come true.”

Duckworth has her own contract for a self-help book. Similar to Oettingen, she appropriated an existing literature under her term grit. Maybe Oettingen will return the favor of Duckworth’s endorsement and do the same for her. What a wonderful mutual admiration society the positive psychology community is.




Category: Conflict of interest, happiness, hype, positive psychology | Tagged , , , , | 7 Comments

Do positive fantasies prevent dieters from losing weight?

Want to WOOP yourself into amazing shape, and fulfill your wildest dreams? Then get a self-help book telling you how through the Association for Psychological Science or the British Psychological Society Division of Health Psychology…Well not really, save your money.

I was like woopIn this issue of Mind the Brain, I discuss my tracking back into the scientific literature claims about positive fantasies and weight loss made for a self-help book promoted as science-based. I locate the study in which the claims supposedly arose. I find no basis for misleading and highly unrealistic claims. Rather than disseminating any science of positive psychology, the marketing effort for the book promotes unrealistic assumptions about what can be accomplished by dieters trying to lose weight. People who take these claims seriously can be demoralized by unrealistic expectations and encouraged to blame themselves when they can’t achieve what is presented as so simple. This promotion holds out the unwarranted promise that if people want to lose weight, they just need to buy this book, and integrate its simple exercises into their everyday life. If they have failed in the past, they can now succeed. Dieters are being exploited and made to feel bad.

Rethinking Positive Psychology  and an associated WOOP app were highlighted in a featured book signing at the annual convention of Association for Psychological Science. If you missed that opportunity, you still get to a site promoting the book through links at advertisements for the British Psychological Society Division of Health Psychology Annual Meeting.

The book/app package is organized around a simplistic idea. From the book’s preface:

Rethinking Positive Thinking presents scientific research suggesting that starry eyed dreaming isn’t all it’s cracked up to be. The book then examines and documents the power of a deceptively simple task: juxtaposing our dreams with the obstacles that prevent their attainment. I delve into why such mental contrasting works, particularly available via subconscious minds, and introduce specific planning process that renders even more effective. In the book’s last two chapters, apply the method of mental contrasting 23 areas of personal change – becoming healthier, nurturing better relationships, and performing better at school and work – I offer advice on how to get started with the method in your own life. In particular, I present a four step procedure based on mental contrasting called WOOP – Wish, Outcome, Obstacle, Plan – that is need to learn, easy to apply to short-and long-term wishes, and is scientifically shown to help you become more energized and directed.

From the outset, the author tries to convince us that positive thinking or, more precisely, positive fantasies by themselves lead to negative outcomes. The research that is cited is almost entirely the author’s own and often consists of contrived laboratory studies with weak findings. A large body of null and contradictory findings from others is shoved aside. This is not about translating scientific findings into practical life strategies, it’s about selling a self-help product as more sciencey than the rest. Buyers beware.

Like me, you probably figure from everyday life experience, that positive fantasies are rather harmless (*) Asked the question, “Are positive fantasies good or bad, helpful or destructive?” we would probably answer “It depends.” By themselves, positive fantasies can have little or no effect, and when they do, effects can be positive or negative.

wOOP i got chicken soupCertainly we don’t want to get caught up in unrealistic fantasies, but who does succumb to them? Maybe you get suckered, if you have been taken in by Chicken Soup for the Soul or a Tony Robbins seminar and think that you can dream yourself to health and wealth. Of course, it helps to be realistic and have a workable plan, but we don’t need a self-help book to tell us that. This book provides very little useful advice about how we should cope with the obstacles we encounter.

Way back when I was in graduate school, there was a lot of excitement about using positive fantasies elicited from people as a way of predicting achievement motivation. Interest in the idea waned when it was shown that such assessments were generally unreliable. Any predictive value disappeared when IQ or productivity was taken into account. Keep that in mind as you read on: why should we think that fantasies elicited in contrived exercises should have much predictive value about things off in the future and subject to lots of other influences? Why would we presume that a fantasy elicited at the beginning of a weight loss program would predict what was actually lost a year later?

But the author is selling a book making a strong case that having positive fantasies are destructive of getting your goals achieved. An impressive publicity campaign hit major media outlets with a mind-numbing repetition of the same message. You could find it in pretty much the same thing being said in the Wall Street Journal, USA Today, the New York Times Sunday Magazine, the New Yorker, The Guardian, the Atlantic, Psychology Today, Huff Post, etc. etc.

le woopThere were also impressive endorsements from celebrity positive psychology gurus. Like the media coverage, these endorsements had a certain sameness suggesting the endorsers  were coached, if not outright provided with a script. Typical of these endorsements, Angela Duckworth, the author’s labmate and sometimes co-author back in Seligman’s lab gushed:

I was once asked by educators to identify the single most effective intervention for improving self-control. Every scientist I spoke to referred me to the work summarized here – masterfully in with incompatible insight and warmth. Read this brilliant book and then go out and do what Gabriele Oettingen recommends. No changes the way you think about making your dreams come true.”

I wanted to track some wild claims in the book and promotion back into the scientific literature and see if they held up. A recurring claim about weight loss triggered my skepticism.

In USA Today: Positive thinking? It’s not enough to reach your goals


One of Oettingen’s earliest studies showed that positive thinking alone can backfire when it comes to losing weight. In that study, women in a one-year weight loss program who had the most positive fantasies about future slimness lost an average of 24 pounds less than women with less rosy visions.

In the Wall Street Journal: The Case Against Positive Thinking

In one of Dr. Oettingen’s studies, obese participants who fantasized about successfully losing weight lost 24 pounds less than those who refrained from doing so.

A difference of 24 pounds in a weight loss program is huge. Consult a 2015 meta-analysis  of weight loss in self-help programs. You will see that at six months participants in weight loss programs are typically better off than those in the control condition by only 1.85 kg or 4.78 pounds. At 12 months, any benefit of being in the self-help program has disappeared.

Another meta-analysis evaluated commercial weight-loss programs like Weight Watchers, Jenny Craig, and Nutrisystem. Available evidence was limited and of poor quality, plagued by short follow-up periods of generally less than a year, high dropout rates, and the evaluation of outcome not being blinded to which participants had been assigned to the active weight loss program or a control condition.

Nonetheless, the review suggested that at 12 months, Weight Watchers achieved 2.6% more weight loss then education/control comparison treatments. Jenny Craig had 4.9% greater weight loss. Nutrisystem did 3.4% better than education/control groups. These figures are long way from a difference of 24 pounds.

Harriet Brown on Obesity

Harriet Brown on Obesity

In an exceptionally evidence-based recent Slate article, Harriet Brown argued that it was time to stop telling fat people to become thin. Even when dieters lose weight in the short-term, 97% of them regain everything they lost in three years. The article criticizes studies evaluating weight loss programs because they typically have too short a follow up period.

I was also skeptical too about the disadvantages the author of the self-help book attached to the positive fantasies that dieters have. Most participants in weight loss programs  have unrealistic fantasies about how much weight they will lose. But the fantasies do not strongly predict the modest amounts of weight they actually lose. So, there is no argument for targeting unrealistic expectations and fantasies if the intent is only to improve weight loss.

I started my search for the evidence behind the claims in press releases that women with positive fantasies lost 24 pounds less than women with less positive fantasies. Using the author’s name and “weight loss” in Google Scholar, I immediately came to the article to which I could eventually tracked the claim.

Oettingen, G., & Wadden, T. A. (1991). Expectation, fantasy, and weight loss: Is the impact of positive thinking always positive?. Cognitive Therapy and Research, 15(2), 167-175.

But I couldn’t immediately see its relevance and so I kept looking. I stumbled upon a non-peer-reviewed chapter by the author made available on the Internet .

The chapter cited the same 1991 weight reduction study with Tom Wadden at Penn. But the chapter made a claim that was not obvious in the original paper:

After one year, patients with high expectations lost about 12 kg more than subjects with negative fantasies. After two years, the respective differences were 15 and 12 kg. These patterns of results stayed on change when subjects’ weight loss aspirations, as well as subjective incentives to reach their spy weight loss, were covariates. The findings that supported our assumption that optimistic expectations and positive fantasies a different types of optimistic thinking, and they have differential effects on motivation and action. Apparently, images of getting slim and resisting food temptations he did weight loss. Subjects seem to daydream that weight loss had occurred without their having to make any effort.

jesus saysAnd then I stumbled upon a later peer-reviewed overview article that also reviewed the 1991 Oettingen and Wadden study. It converted the kilograms to pounds and elaborated:

Participants with positive expectations about losing weight (i.e., ‘‘It is likely that I will lose the indicated amount of weight’’) lost on average 26 pounds more than those with negative expectations (i.e., ‘‘It is unlikely that I will lose the indicated amount of weight’’). However, participants with positive fantasies (e.g., those who imagined shining when going out with the friend and easily resisting the temptation of the leftover box of doughnuts in the lunch room) lost on average 24 pounds less than participants with negative fantasies (e.g., those who imagined having disappointed the friend and having a hard time resisting the leftover box of doughnuts in the lunch room). In short, while positive expectations predicted successful weight loss, positive fantasies predicted little success in reaching one’s desired weight.

So I gave the 1991 paper a closer look.

The abstract stated

We investigated the impact of expectation and fantasy on the weight losses of 25 obese women participating in a behavioral weight reduction program. Both expectations of reaching one’s goal weight and spontaneous weight-related fantasies were measured at pretreatment before subjects began 1 year of weekly group-treatment. Consistent with our hypothesis that expectation and fantasy are different in quality, these variables predicted weight change in opposite directions. Optimistic expectations but negative fantasies favored weight loss. Subjects who displayed pessimistic expectations combined with positive fantasies had the poorest treatment outcome. Finally, expectation but not fantasy predicted program attendance. The effects of fantasy are discussed with regard to their potential impact on weight reduction therapy and the need for further studies of dieters’ spontaneous thoughts and images.

From the method section I learned

  • Subjects weighted average of 106.4 kg with a BMI of 39.1. The recruited with advertisements seeking women at least 25 kg overweight.
  • 13 subjects were randomly assigned to a very low calorie diet and 12 were assigned to a balanced-deficit diet.

Such a small randomized trial can’t reliably give effect sizes for anything. At best it can only suggest the feasibility of doing such a trial of a larger scale. Weight related fantasies were not manipulated, but they were measured:

Weight-Related Fantasy. Each subject was asked to vividly imagine herself as the main character in for hypothetical weight-and food-related scenarios. Two stories were designed to elicit fantasies about the subject’s weight loss, worse to others describing cows were tempting foods. Each story led to an unspecified outcome with subjects were asked to complete (in writing) by describing the stream of thoughts and images that occurred to them. Care was taken to make the scenarios open ended in order to elicit a variety of responses. One of the scenarios is described below:

You’re just completed Penn’s weight loss program. Tonight you have made plans to go out with an old friend whom you haven’t seen in about a year. As you wait for your friend to arrive, you imagine

Subjects rated the positivity, negativity, and intensity of their responses to each scenario, as well as their imagined body shape (using seven-point scales; 1 = low, 7 = high). After completing one scenario, they proceeded to the next. Scores were averaged across all four studies to form positivity, negativity, intensity, and body shape scales.

The study also assessed participants’ expectations of reaching their goal weight with three related questions:

(1) “How likely do you think it is that during this weight reduction program you’ll lose the amount of weight (that you have specified)?”; (2) “you feel that you will be successful in the weight loss program?” and (3) “how confident are you that after this program is completed, you will watch the amount of weight you indicated in question 1?” Questions were answered using 7-point scales (1 = low, 7 = high).


The results suggested this exceptionally strict and long-term weight reduction program yielded some significant losses for both groups.

At weeks 17 and 52, weight losses for the very low calorie diet participants were 17.1 kg and 16.1 kg, respectively. Losses for the BDT balanced-deficit diet participants were 11.1 kg and 14.8 kg.

But where does the extraordinary claim about fantasies get support? That is really not clear from anything presented.

Weight-related fantasy predicted weight loss in week 17 (r = -.34, p = .05) but not in 52 weeks ( r = -.31, p = .09). But these numbers demonstrate the problem: with such a small number of participants, something can be significant at .34, but not at the trivially different .31. Beam me up, Scotty, nothing interesting happening here.

The authors then undertook multiple regression analyses that were inappropriate for a number of reasons. [Warning! Briefly getting technical ahead] First, with so few subjects, the equation was overfit with too many independent variables: initial weight, fantasy, and expectation were entered simultaneously in the first step; the interaction between fantasy and expectation in the second. Weight at weeks 17 and 52 were dependent variables of the two analyses, respectively. The second issue is that with expectations and fantasy correlated .45, entering both of these variables simultaneously would lead to misleading results, probably different than if they were entered alone.

In these dubious complex analyses, positive fantasies were not significant at 17 weeks, but were at 52 weeks. If anyone is still taking these analyses seriously, these are contradictory results. But who cares?

The authors then furthered their illusion by graphing the interaction effect, crossing fantasies with expectations. Think of it: they only had 25 patients and they nonetheless graphed participants after creating three groups (low, medium, high) based on fantasy scores and then 3 groups based on expectations(low, medium, high). We can’t take these results seriously.

So, I can find no basis in this study for the claim that women having positive fantasies lost 24 fewer pounds versus those having less positive fantasies. There was no randomization with respect to fantasies and no results justifying such an astonishing claim. We’ve got numbers, but not science here, and no basis for claiming that this self-help book is more sciencey than its competitors. But citing numbers is impressive, particularly when it’s so hard to find out from where they came.

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So we have the reality of most people who try to lose weight won’t succeed and certainly they won’t succeed in keeping it off. And probably at some point during that time, they fantasize about what would be like to be slimmer. We should give them a break. Instead, the author gives them reason to feel bad about themselves by suggesting that somehow WOOP could have saved them. Weight loss is that much under their control. And they can still save their dignity by buying this book. And if they don’t succeed in losing such weight, they just haven’t integrated the exercises of the book into the lives enough.

Okay, the author was capitalizing on a 1991 study that she’d probably completed long before she even thought about the book – Dare I say, before she fantasized about the book? – And the idea to try to turn the article into a promotion of the book was not a good one.

welcome to woop woopBut in a forthcoming blog, maybe not my next, I will critique another study that she published when she was working on the book. It serves as an experimercial in promoting the book. The study claims that a drop of only 1 mmHg in systolic blood pressure in women told to have positive fantasies about how they will look in high heels represents a serious sapping of energy that can be generalized to real world situations. Yep, experimercial . I’m going to introduce a new and very useful term to link the packaging together and publication of weak studies when they serve the promotion of commercial products. That’s a lot more of what positive psychology is about then we recognize.

Finally, why are supposedly scientific organizations like British Psychological Society Division of Health Psychology hawking a self-help book with a weak relationship to science that is likely to mislead consumers with its pitch?


(*) British Psychological Society President-elect, Peter Kinderman says he is frightened by his positive fantasies of “winning Nobel prizes, winning Pulitzer prizes, being elected to this and that, being awarded knighthoods,” but he’s an odd bird.


Category: dieting, evidence-supported, happiness, hype, obesity, positive psychology, self-help | Tagged , , , , , | 6 Comments

The National Vietnam Veterans Longitudinal Study (NVVLS) and the implications for the science and practice of PTSD: An interview with Dr. Charles Marmar

soldier-294476_640The National Vietnam Veterans Readjustment Study (NVVRS) was conducted in 1983 as a response to a congressional mandate for an investigation of PTSD and other postwar psychological problems among Vietnam veterans. More than 25 years after the original NVVRS study was conducted, researchers reassessed more than two thousand of the original study participants for symptoms of PTSD. What made this research unique was that the long-term course of PTSD in military personnel had not previously been evaluated in a nationally representative sample. This follow up study, called the National Vietnam Veterans Longitudinal Study (NVVLS), found a current prevalence of PTSD in 4.5% of male and 6.1% of female combat Vietnam era veterans. Extrapolating these figures suggests that more than a quarter of a million Vietnam veterans still struggle every day with the consequences of PTSD forty years after that war ended.

The study was led by Charles R. Marmar, MD, the Lucius N. Littauer Professor  and chair of the department of Psychiatry at NYU Langone Medical Center and director of its Steven and Alexandra Cohen Veterans Center, a leading program in the study of PTSD. A pioneer in the field of PTSD research, his work has led to breakthroughs in our understanding of PTSD through the study of police officers, soldiers in combat, veterans, and civilians who have been exposed to sudden, usually life-threatening, events.

Recently, I spoke to Dr. Marmar about the implications of the NVVLS study and about his 40 year career as a PTSD researcher.

Dr. Jain: For my first question, can you start by commenting on the large percentage of Vietnam veterans you and your team studied that has never suffered from PTSD linked to war? I feel sometimes that percentage gets lost in some of the headlines and media coverage of PTSD research.

Dr. Marmar: Yes. It is a little difficult to give a precise overall estimate, but if you look across our data from both the first wave of our study (collected between ’84 and ’88) and then the second wave (collected between 2011 and 2013), it is roughly a 75% and 25% split. Of course it depends precisely on how you define PTSD, and that has changed over the years, but you could say that approximately 3/4 of Vietnam veterans who served in the warzone never developed significant levels of stress, anxiety, or depression related to their military service. They were relatively resilient. Now, that is only an average across all 3.1 million men and women who served. There is a lot of variability depending on who you were, how old you were, how many times you were deployed, and what your service duties entailed. In a warzone deployment, there are three broad roles: combat, combat support, and service support. All three roles come under the definition of a warzone, but the number of people who are actually repeatedly at the tip of the sword is a smaller percentage, and that factors in to the individual risk calculation.

Dr. Jain: Yes. Actually as you talk, something comes into my mind about recent returnees from the conflicts in Afghanistan and Iraq. Military rank appears crucial. Lower ranking military members are exposed to higher doses of trauma and are therefore more vulnerable. Is that something that you looked at in the Vietnam study or is that something you can offer some feedback on?

Dr. Marmar: In general, older, more educated war fighters of higher rank are able to tolerate the intensity of combat and are more resilient. Also, as you indicated, in general, their levels of repeated combat exposure are lower if they were squad leaders rather than squad members.

Dr. Jain: Dr. Hoge’s editorial that accompanied the article described your research as “methodologically superb.” Can you comment a little bit from a researcher’s perspective on the strength of your study and how it is different to previous efforts to document the prevalence or course of PTSD in this population?

Dr. Marmar: Firstly, we believe it is the only study in the world (with the possible exception of studies conducted by Solomon et al with the Israeli Defense Force) which followed, in an epidemiologically sound way, a representative sample of every man and every woman who served in a major conflict. The study was not done by recruiting people from VA hospitals and clinics or by advertising on Craig’s list, etc. So it takes into account the differences between community samples and VA seeking patients, as these are two very different groups. This study was drawn top down from military records. It included people from all 50 states, Guam, and Puerto Rico, and it included urban, suburban, rural, and extremely remote veterans. So, for example, we have included participants from the remote aspects of the Big Island of Hawaii, all the way to Manhattan. It is a truly representative sample in this regard. Secondly, we oversampled for women and minorities. This gave us more statistical power to look at these populations too. Thirdly, the study is exceptionally successful in its implementation. We had zero contact with our cohort for 25 years. We never contacted a single one of them on a single occasion and still retained just under 80% of them for the follow up 25 years later. The study has many excellent features, but the most important features are that it has true representational sampling, over representation of women and minorities, and its high retention rate over 25 years.

Dr. Jain: That’s what makes it a very important piece of science in our understanding of the prevalence and course of PTSD.

Dr. Marmar: It also tells you something profound about the participants’ commitment to the research. Another thing is it is very deep, because we have up to 5-hour household interviews, survey interviews, and 3-hour clinical interviews on a sub-sample. For this follow up study, we had a 1-hour self-report package, 1 to 2-hour interview by professional survey interviewers, and 3 to 5-hour clinical interviews done by my team at NYU. We used a team of highly qualified PhD clinical interviewers, and they were able to interview people by telephone so that we could sample, in the clinical interview, people from all over the country. It is very hard to do that if you ask participants to come into regional medical centers.

Dr. Jain: Can you talk a little bit about sub threshold (or partial) PTSD? Clinicians see that all the time—patients who might not meet the diagnostic criteria, but that does not mean they do not have symptoms that have a significant impact on their quality of life. Sub threshold (partial) PTSD is something I believe you chose to measure in the study. Can you tell us a little bit about your findings?

2012-04-05-ptsd1Dr. Marmar: What we do know is that roughly as many Vietnam veterans have partial PTSD today as have full PTSD. We define partial PTSD very strictly. We had a very well-defined algorithm of what constitutes partial PTSD. The important things to note are that the overall symptom levels are relatively high in the partial group, and their functioning difficulties in work and love are also high. In fact in our work, and in some prior publications, the levels of dysfunction are quite similar in people with partial and full PTSD. Levels of medical comorbidity may be quite similar, too. So partial PTSD is very important. The other thing we found is that roughly 5% of the Vietnam veterans alive today, who served in the war, meet full criteria for PTSD, but an equal number meet partial criteria. We also found that roughly 1/3 of Vietnam combat veterans with PTSD today also have full current comorbid major depressive disorder. That is almost identical to the rate of comorbid major depression that we found in the partial group. You can see that there is a heavy burden of symptoms, comorbidities, and dysfunction in the partial group. A big study about partial PTSD, published in 2001 in the American Journal of Psychiatry, reported similar findings.

Dr. Jain: From your findings it is definitely something we need to be more aware of and on the lookout for to make sure these patients are also getting services where indicated or having their symptoms addressed.

Dr. Marmar: Absolutely. I think this is an important and potentially underserved group. They probably function a little better, maybe overall, than those with the full, more severe form, but there is still a heavy burden of illness. We have statistical models which examine the extent to which full PTSD is a risk factor for medical comorbidity and premature death. An important follow up question would be: Does carrying a diagnosis of chronic partial PTSD over years to decades shorten your life? I think physicians should be very concerned about the physical and medical problems of veterans with partial PTSD: cardiovascular risk, stroke risk, metabolic load, diabetes, and cancer.

Dr. Jain: Right. Yes. There is this whole other body of literature that is emerging that really fleshes out this sensitive relationship between PTSD and physical illness.

Dr. Marmar: In a study we did that was published in JAMA in 2009, my colleague Beth Cohen and I downloaded the VA national database and looked at 250,000 OEF/OIF veterans enrolled in VA healthcare nationally. We asked a simple question: If you compare veterans with no current mental health diagnosis, what do these medical risk factors look like in those with PTSD alone, depression alone, and comorbid PTSD and depression? At that time, around 2009, we had these pretty young, recently returning Iraq and Afghanistan veterans, and we found huge, two to three times increases in levels of dyslipidemia, type 2 diabetes, obesity, and other problems in those with psychiatric illness.

Dr. Jain: One of the wonderful things about working in the VA is that, as a system, it cares about PTSD. It funds not only clinical programs, but many research efforts too. In addition to that, there is political and societal motivation to support the funding of studies such as yours. As a physician, I am well aware that PTSD is not just an issue for veterans. It is an issue across our culture, across our society. It is an issue globally. Because so much cutting edge research on PTSD is done in veteran populations, it can contribute to a societal myth that PTSD is only a veteran issue. Your study offers a much needed contribution to advancing the science of PTSD, but it raises another question in my mind: Would the results be that different in a civilian population?

Dr. Marmar: It is difficult to say. War fighters are repeatedly exposed to personal life threat. It is somewhat less common in a civilian world. War fighters not only had their own life in danger, but they are required, by their service to their country, to take the lives of other people. This adds a different dimension to trauma than say, being a sexual assault survivor (which, of course, is horrible), or a vehicle accident or national disaster survivor. Killing is different than just having your life in danger. This has been written about more recently as the “moral injury” of war. In general, clinically, I think you would agree that there are easier cases that are more easily treated, and more difficult cases that are more difficult to treat. That is true in every aspect of the practice of medicine. In trauma, people who are repeatedly exposed to trauma early in life and who perpetuate violent acts, as part of the trauma experience, actually are different, and they have a different form of PTSD that is more complex, more chronic, and, generally, more treatment refractory.

Dr. Jain: Jonathan Shay wrote about the specific plight of Vietnam veterans in his 1994 book, Achilles in Vietnam: “such unhealed PTSD can devastate life and incapacitate its victims from participation in the domestic, economic, and political life of the nation. The painful paradox is that fighting for one’s country can render one unfit to be its citizen.” Shay’s anecdotal observations seem prophetic when considered in the light of your recent study. Can you comment about what your research showed about the quality of life of Vietnam veterans who still have combat related PTSD?

Dr. Marmar: I would say the effect on quality of life is very profound. Think, by analogy, about the study of the effects of psychotic symptoms among patients with the schizophrenia spectrum disorders. As you know, early on when the concept of schizophrenia was being developed, the focus initially was on the rather dramatic positive symptoms: delusions, hallucinations, the jumbled thinking, and so on. But actually as you begin to analyze what is related to functional disability, it is often more the negative symptoms of schizophrenia: the amotivational syndrome, apathy, detachment, dysphoria, and depression. I would say, in some ways, that is true for PTSD. The nightmares and flashback, the startle reactions—these positive symptoms are very disturbing. But the negative symptoms, which include numbing, detachment, inability to express and receive affection, erosion of the ability to enjoy things, and so on—those negative symptoms are very devastating to function. They often lead to withdrawal, fractured family, and alienation, and they are often associated with heavy alcohol and drug misuse. The negative symptoms are very important.

Dr. Jain: Right. That has a knock-on effect on capacity to work, capacity to parent, and capacity to engage in social relationships. In that way, I think it really speaks to how PTSD as a disease entity that goes beyond the individual human and their own biology and really extends and infiltrates our society.

Dr. Marmar: Yes. Very very much so. I mean, for every war fighter who is traumatized, there are 10 to 20 people in their lives that are part of their social fabric that are affected to varying degrees: parents, siblings, spouses, children, grandchildren. That is a huge network. They are all affected.

Dr. Jain: Again, coming back to your JAMA study, I feel like someone who is thinking both from the perspective as a clinician and researcher. I think intuitively, a lot of clinicians have been seeing this type of picture for decades, but what is validating is to have an excellent, well-designed, very rigorous scientific study which gives us that support for what we have been seeing on the ground. In my understanding, that is what your study has done. Can I ask how many years you been doing PTSD work?

Dr. Marmar: I have more than 40 years of experience as a trauma clinician and researcher. In a way, my professional history parallels that 40-year Vietnam study. I am probably more energized and passionate about my trauma research today than when I started 40 years ago.

Dr. Jain: Why do you think that is?

Dr. Marmar: It took a long time to really grasp the depth of what this subject was really about. We did not have all the tools. We did not have the sophisticated epidemiological studies. We did not have advances in translational neuroscience to probe the neurocircuitry, neuroendocrinology, or the neurogenetics for the illness of PTSD. I am very excited that the world is captivated by PTSD, and we have the tools now to make very dramatic advances, for example, to develop panels of blood and brain imaging biomarkers that would definitively say who does not have PTSD, who has partial PTSD, who has regular PTSD, etc. We will crack that code in your academic lifetime. It is an exceptionally rich and open field, and there is an opportunity to make huge contributions.

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The Holocaust intrudes into conversations about psychiatric diagnosis: Godwin’s rule confirmed

peter_kinderman_140x140The President-elect of the British Psychological Association drops the N word and invokes the Holocaust in denouncing mental health professionals who embrace the biomedical model.

The conversation concerning Understanding Psychosis and Schizophrenia  (hereafter UPS) took another wrong turn with extended references to Nazism and the Holocaust in a blog post by Peter Kinderman, Me, my brain and baked beans. Goodwin’s rule is once again confirmed.

please removePeter Kinderman is one of the main spokespersons for the British Psychological Society UPS document. The blog further identifies him as a Professor at University of Liverpool, and the President-elect of the British Psychological Society.

Godwin’s Rule or Godwin’s Rule of Nazi Analogies is “As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches 1.“ Michael Godwin elaborates on it in I Seem To Be A Verb: 18 Years of Godwin’s Law:

I created Godwin’s Law and began to repeat it in online forums whenever I encountered a silly comparison of someone or something to Hitler or to the Nazis…. My feeling is that “Never Again” loses its meaning if we don’t regularly remind ourselves of the terrible inflection point marked in human culture by the Holocaust. Sure, there has been genocide before that point and genocide after it, but to see an advanced, highly civilized nation warp itself into something capable of creating such a horror—well, I think Nazi Germany does count as a first in that regard. And to a great extent, our challenge as human beings who live in the period after that inflection point is that we no longer can be passive about history—we have a moral obligation to do what we can to prevent such events from ever happening again. Key to that obligation is remembering, which is what Godwin’s Law is all about.

Those horrified by the Holocaust as a unique historical event see invoking it casually in political or professional rivalries as a “gross misappropriation of the past and an obscene misuse of history.”

The continued misuse  and trivialization of the word prompted Elie Wiesel, Nobel laureate and chronicler of the Holocaust, to discontinue using it. “Whatever mishap occurs now, they call it ‘holocaust,'” Wiesel said. “I have seen it myself in television in the country in which I live. A commentator describing the defeat of a sports team, somewhere, called it a ‘holocaust.'”

This will be a long read edition of PLOS Mind the Brain because of extensive direct quotes from BPS President-elect Kinderman. His statements strain all credibility. I don’t want any ambiguity as to whether I made them up.

Readers are encouraged to retrieve Kinderman’s blog post and see for themselves. It is posted at the anti-psychiatry blog, Mad in America.

A résumé of what his blog reveals

  1. President-elect Kinderman has unusual psychological experiences which he traces to growing up in a family environment with a harsh, unloving mother.
  2. In ways that frighten him, he fantasizes about winning Nobel or Pulitzer prizes and being awarded knighthood. And “I lurch forwards and jump to conclusions in my mental logic.” He is prone to tangential connectivity and abstract, ‘clang’ associations.
  3. He believes that these experiences would have caused him to be castrated if the Nazis had won World War II.
  4. He believes that those who adhere to what he terms a disease model of psychological disorder are essentially following the Nazis.
  5. He believes the connection is obvious to friends and colleagues, who consider him brave in making it public.
  6. He makes extensive references to the Holocaust in developing his argument.
  7. Kinderman is particularly frightened by advocates of this disease model because of the rise of right-wing political parties in Europe.
  8. He ends with a plea “don’t use the ‘disease-model’ as a framework.”

A résumé of my commentary

  1. Kinderman sees his unusual experiences as giving him privileged status to condemn those who accept the biomedical model of psychopathology.
  2. He invokes the Holocaust and Nazi analogy to bolster his argument in what he sees as a turf war between his supporters and psychiatrists. Actually, the overwhelming majority of academic mental health professionals accept some version of a biomedical model.
  3. He has long been caricaturing psychiatric diagnosis in reductionist terms,  referring to the biomedical model as a “genetic disease” model. But by invoking the Holocaust and the Nazis, he is excluding himself from participation in any subsequent conversation.
  4. Until President-elect Kinderman apologizes to the larger community which accepts the need to protect the memory of Holocaust from such desecration, the credibility of the British Psychological Society remains damaged. The BPS Board of Trustees should condemn him or accept responsibility for having such a spokesperson.
  5. Kinderman indicates that his blog is “a slightly longer version” of an article published elsewhere. The earlier article lacked any reference to the Holocaust or Nazis and he expresses appreciation to Anne Cooke for editing the transition. She therefore shares responsibility with Kinderman for the references to the Holocaust and Nazis. She is similarly disqualified as a participant in any conversation in the social media until she apologizes.
  6. In place of scientific evidence, Kinderman’ frequently claimed the authority of personal eminence associated with his professorship. This is disallowed by his references to the Holocaust and Nazism, which place him outside of academic discourse.
  7. UPS was explicitly aimed at influencing mental health service users and policymakers. Vigorous debate should continue, but critics should not require the authors to engage them. After all, what do you expect from somebody who considers you a Nazi? And to get back into the conversation, the authors of Understanding Psychosis have to address Kinderman putting the Holocaust and Nazism on the table.

I hope that these résumés will inform, but do not satiate you. I  hope they encourage you to read further in what will prove a fascinating discussion. But regardless, begin asking yourself what responsibility the trustees of the British Psychological Society have in dealing with the situation that Kinderman has now created. Or does it really matter that the President-elect of this organization has written such things?

Kinderman’s Me, My Brain, and Baked Beans

beans_on_toast430x300Kinderman starts off with a statement of annoyance but gives no indication where he is going.

In mental health, resolving the relative contributions of our biology and genetics and how these interact with social and environmental factors (our parenting, peer-relationships, learning, and experiences of both abuse and nurturing) is more than an intellectual puzzle. I’m occasionally annoyed by what appears to be a rather simplistic suggestion that, if there’s a biological, even heritable, element, to a psychological phenomenon, then we’re inevitably discussing an illness, a disease.

A Difficult Childhood

He soon gets to depicting his early family environment and readers can again ponder ‘where is this taking us?’

After my mother’s death, we discovered that, when she had confessed to a religious mentor that she was in danger of loving her children more than God, there was a subsequent process of re-adjustment … she was encouraged to practice loving her children less. My parents rejected the material world as merely a stepping-stone to heaven (or hell) and paid little attention to worldly pursuits. I remember opening a letter from Cambridge University confirming an offer of a place as an undergraduate. I told my mother, whose reply was; “Very nice dear, now, do you want baked beans on toast for breakfast?”

Kinderman’s point seems to be that he and his siblings were not reared in a loving and accepting environment. His mother’s religiosity was pivotal. Kinderman discourages us from having any sympathy for the mother. But now that he has brought her up, we can nonetheless wonder about how she might have been suffering.

An astute reader with a sense of history might also wonder if we are being set up for a simplistic refrigerator mother explanation of psychological problems in offspring.

In the 1990s, Irish motivational speaker Tony Humphreys  drew upon his own adverse childhood experiences to extend a discredited theory of the refrigerator mothers of children with autism to explain schizophrenia and diabetes. He was subsequently censured by the Irish Psychological Society.

Humphreys was following up on the 1940s work of Leo Kanner  who coined the phrase in describing mothers of autistic children as “just happening to defrost enough to produce a child.”

refrigerator motherAs an antidote to this nasty mother bashing, I strongly recommend Refrigerator Mothers,  an hour-long movie freely available on the Internet. It provided an opportunity for mothers with autistic children to talk back against the stereotype of them.


Once isolated and unheard, these mothers have emerged with strong, resilient voices to share the details of their personal journeys. Through their poignant stories, Refrigerator Mothers puts a human face on what can happen when authority goes unquestioned and humanity is removed from the search for scientific answers.

Kinderman claims to be an expert by experience

Kinderman then describes his unusual psychological experiences and behavior.

So I am emotionally labile; my self-esteem and emotions are very fragile and very much dependent on what I imagine other people are thinking. Or, at least, I think I am; my observations of my own behaviour are themselves subjective, and it’s possible that others do these things as much as I do. I frighten myself (given my relative’s experiences) by fantasising about… winning Nobel prizes, winning Pulitzer prizes, being elected to this and that, being awarded knighthoods… and that’s frightening because I’ve seen self-referent fantasies ruin other people’s lives.

…And, perhaps most saliently, I lurch forwards and jump to conclusions in my mental logic. So, if you give me the sequence “A, B, C” and ask me to complete the sequence, I’ll say Z. Maybe that’s a bit of a joke (a pun on ‘complete’), and it’s unequivocally good for me in my academic career. A creative professor is a good professor. I also and simultaneously make abstract and surreal connections. It’s a recognised part of my teaching style – I’ll veer off on a tangent. Again, perhaps useful in an academic and possibly engaging or at least entertaining for students (if they can keep up…). But jumping to conclusions, tangential connectivity and abstract, ‘clang’ associations all have very interesting connotations in the field of mental health.

Too much information. What shall we to make of these deeply personal and out-of-place disclosures from the President-elect of the British Psychological Society? Kinderman claims benefit from it these experiences and does not want to discredit himself. Yet he is giving live ammunition to critics who have long been frustrated with his distinctive torrents of scrambled anecdata and pomposity. No worry, Kinderman is about to discredit himself more thoroughly.

But for a bit, Kinderman continues quite reasonably:

So I am very interested (and, I hope, open-minded) about what it is, if anything, that we inherit. How do I differ from other people? What proportion of the variance in these traits can be accounted for by genetic differences? What proportion of the variance in these traits comes from being brought up by repressed religious extremists? What proportion comes from being reinforced, through my childhood, for being academic? Which elements of my upbringing were different other people’s anyway?

Kinderman brings in the Nazis

Out of context, this appears a reconciliatory statement that invites agreement from critics. But there is a disaster ahead. Kinderman’s train of thought transports unknowing readers to the death camps of the Holocaust with contemporary psychiatrists branded Nazis. Kinderman apparently thinks his friends and colleagues will consider him brave for exposing this obvious connection.

…I think it’s perfectly possible to be intelligent and open-minded about the contribution of genetic and environmental factors in our mental health. We can intelligently and respectfully discuss how experiences and heritable traits can interact to produce the wonderful variety of human experience. This, I think, is a much more accurate and helpful way to conceptualise what’s going on than to say that some of us – but only some of us – have ‘mental illnesses’. Labels such as ‘schizophrenia’ not only suffer from the validity problems that we’ve discussed elsewhere, but also obfuscate these important considerations. I don’t think it’s helpful to consider how I have managed to avoid developing ‘schizophrenia’, or whether I have ‘attenuated psychosis syndrome’. To do that, to reduce these discussions to binary considerations of the presence or absence of disorders, necessarily constrains the scientific debate. It can also sometimes have frightening consequences in the real world. When I’ve mentioned some of these issues before in less public settings, friends and colleagues have often told me that I’m being brave, and that it’s a potentially risky topic of conversation. So why might that be?

The eradication of undesirable genetic traits

Part of the reason that people might be reluctant to talk about such issues is that we have a very poor track record in this area. This is a difficult topic, but I think it is important to remember the infamous 1933 Nazi Law for the Prevention of Genetically Diseased Offspring (Gesetz zur Verhütung erbkranken Nachwuchses). Arguments of genetic science not only led to the drafting of this law (which permitted the compulsory sterilisation of any citizens who were judged to possess a ‘genetic disorder’ which could be passed onto their children) but indeed led German-American psychiatrist Franz Kallmann to argue that such a policy of sterilisation should be extended to the relatives of people with mental health problems (in order to eradicate the genes supposedly responsible). The notorious Action T4 ‘eradication’ programme was the logical extension of these policies.

From Kinderman’s Me, my brain and baked beans.

Adolf Hitler’s order for the Action T4 programme

Adolf Hitler’s order for the Action T4 programme.

Reich Law Gazette on 25 July 1933: Law for the Prevention of Genetically Diseased Offspring













Kinderman accuses Franz Kallmann of being a war criminal. Kinderman should have spent more time at Google University learning about Kallmann who fled the Nazis in the 1936.

Considered a Jew by the Nazis although not by himself, he could not publish his work, and had to rely on friends at Munich to read his papers for him. He could only get his statistics into print by quotation in papers of others’ authorship.

… Despite of all obstacles, he succeeded in organizing the first research department in psychiatric genetics in the United States at the New York State Psychiatric Institute. This department became the main source of intellectual support of psychiatric genetic research in the U.S. for a generation.

Kinderman’s description of Kallmann as a “German-American psychiatrist” is used to smear all of contemporary psychiatry with the taint of Nazism.

At the Bath Conference on Understanding Psychosis, Kinderman refused to engage other members of the panel. It is too bad that the event was not recorded and that the BPS insisting on editing a journalist’s account. But those who were there will recall Kinderman closed with a rambling, incoherent rant about the horrors of mental health professionals telling psychiatric patients that they had a genetic disease.

Perhaps uncomfortable with having invoked the Nazis, in his blog he tries to shift to fascism. He introduces a non sequitur in claiming that if schizophrenia represents “a biological problem, we can dismiss any further troubling considerations.” Then he insists in a most extraordinary way on his privileged status talk of the Holocaust because of its personal relevance and threat.

Of course, a focus on biological aspects of mental health problems is not in any sense necessarily synonymous with fascism. But for many of us, there are echoes of blame, of stigma, when we identify the pathology within the genetic substrate of the person. I’m reminded of Eric Pickles’ notorious throw-away comment to a voter campaigning about the abuse she’d experienced that she should “adjust her medication”. If the pathology lies in the person, and particularly if it is a biological problem, we can dismiss any further troubling considerations.

So one way to understand these kinds of experiences is to diagnose some form of ‘subclinical’ syndrome, perhaps attenuated psychosis. If the Nazis had won the second world war, I would have been castrated as a first-degree relative of a ‘schizophrenic’. Disease-model, eugenic, thinking is a direct threat to me personally, especially given the recent rise of UKIP and other far-right parties in Europe. I am interested in whether the traits that make me a good professor may also be related to the traits I listed earlier, and on their impact on my emotions. I am interested in whether they may have emerged from a similar mix of genes and environment that led my relative to experience psychosis. I am very interested in the practical implications; I have always, for example, avoided certain classes of street drugs. It is absolutely possible to discuss gene × environment interactions, but – please – don’t use the ‘disease-model’ as a framework.

Why Peter Kinderman and Anne Cooke are excluded from further discussions of Understanding Psychosis until they publicly apologize.

“A good rule in most discussions is that the first person to call the other a Nazi automatically loses the argument.”  This has been elaborated in Godwin’s Law FAQ:

godwin faq

Nonetheless, gratuitous references to the Holocaust in Nazis regularly occur around the world, highlighting all the more the need to insist on them being obscene.

The memory of six million Jews and the eleven million other human beings who died in the Holocaust is too sacred for calculating politicians and their paranoid cheerleaders to be turned into a semantic missile.

Republican presidential candidate Mike Huckabee is incorrigible. In 2014 he said


If you felt something incredibly powerful at Auschwitz and Birkenau over the 11 million killed worldwide and the 1.5 million killed on those grounds, cannot we feel something extraordinary about 55 million murdered in our own country in the wombs of their mothers? Does that not speak to us?

Now Huckabee is being condemned by Israel for saying the Iran nuclear deal is “marching the Israelis to the door of the oven.”  Israel does not need that kind of support.

Why did Kinderman destroy his credibility by publishing this?

For the same reason that Mike Huckabee made the comparison between abortion and the Holocaust. He believes these things, he has bad judgment, and he thought he wouldn’t be caught.

Huckabee speech was captured on a videotape in 2014 and subsequently distributed by Right Wing Watch, a non-profit working to expose the Far-Right’s extreme and intolerant agenda. Otherwise most of us would not have learned of his statements.

Kinderman similarly may have thought that he was in a closed environment where he could express views that would resonate with an important part of his constituency. He surely would not have made them at an international scientific psychology gathering.

The long thread of comments Kinderman elicited at the blog site showed little indignation and tacit acceptance that psychiatrists are Nazis. He seems to have only tweeted once about this blog post and probably didn’t think it would come to the attention of the larger community.

He may be a professor at University of Liverpool and President-elect of the British Psychological Society, but he plays to a constituency that is neither academic nor professional.

Dealing with the offense to all comes first

Even before the references to the Holocaust and Nazis aside, there there have been many reasons be offended by Kinderman’s promotion of the BPS UPS.

  • Serious academics have been outraged by Kinderman’s arguments without evidence against diagnosis, his claim that antipsychotic medication is toxic and ineffective, his crass emotional appeals, and his slandering of the large other side on an important issue. UPS simply not does not adhere to academic standards in terms of logic and reference to evidence and would not pass independent peer review.
  • Mental health service consumers and their family members have been upset that issues that concern them are being framed in such a misleading and irrational way by a professional. They are unrepresented and silenced by the carefully selected clinical examples in the UPS. Treatment options have been misrepresented in ways intended to frighten them. They have legitimate concerns about having to be diagnosed or treated by psychologists who hold such warped views.
  • Many members of the British Psychological Society are embarrassed by the organization sinking to this level. They would not want to be asked in a public gathering if UPS represents solid science. Many UK psychologists who are not members of BPS are upset that the organization that supposedly speaks for them is associated with such ridiculous statements.

All who are offended should feel free to speak out. But the preemptive issue is before the larger community is that Kinderman has behaved in an unacceptable manner. Kinderman is out of the discussion. His license is revoked and he needs to reapply.

If Kinderman or Anne Cooke pop up in these discussions, they should simply be asked “Don’t you have a problem with desecrating the memory of the Holocaust?” and then ignored.

The dilemma facing the British Psychological Society

Kinderman blurs any distinction between his personal views and those of the organization with which he incessantly claims to speak, often in forums only available because he represents BPS. It’s incumbent upon the BPS to clarify where they stand on what is now a game-stopping issue. Do they condemn Kinderman or are they left implicitly condoning him?

Here is a list of members of the Board of Trustees and some of their email addresses I was able to obtain from the internet. Readers might want to individually and collectively inquire about where the board stands about Kinderman casually invoking the Holocaust and Nazism in a context where references to these historical events have no place.

  • President Professor Jamie Hacker Hughes CPsychol CSci FBPsS profjamiehh@gmail.com
  • Vice President Professor Dorothy Miell CPsychol FBPsS d.e.miell@ed.ac.uk
  • Honorary General Secretary Dr Carole Allan CPsychol Csci FBPsS Carole.Allan@glasgow.ac.uk
  • Honorary Treasurer Professor Ray Miller CPsychol FBPsS
  • Chair Education and Public Engagement Board Professor Catriona Morrison CPsychol AFBPsS c.morrison@hw.ac.uk
  • Chair Research Board Professor Daryl B O’Connor CPsychol AFBPsS D.B.O’Connor@leeds.ac.uk
  • Chair Professional Practice Board Dr Ian Gargan CPsychol AFBPsS
  • Chair Membership Standards Board Dr Mark Forshaw CPsychol CSci FBPsS FIHPE

It is fair game to raise the issue of Kinderman’s transgression when members of the BPS Board of Trustees appear at public gatherings. I intend to do so when Daryl B O’Connor shows up at the European Health Psychology Conference in Cyprus and encourage others to do so as well. “Hey Daryl, about Kinderman’s references to the Holocaust and Nazis…”

BPS President Jamie Hacker Hughes announced the launch of Understanding Psychosis on Twitter and then unsuccessfully tried to squelch discussion when it turned negative.

hacker huges exchangeIt was foolish for the BPS President to insist that conversation about a document that could not conceivably pass independent peer review be confined to venues gated by peer review. It would be a disaster for him to adopt this strategy in trying to squelch the conversation about what Kinderman has done.

The other authors of UPS and Kinderman’s bringing in the Holocaust and the Nazis

Anne Cooke is given credit for the transition for an earlier blog post by Kinderman that lack references to the Holocaust and the Nazis to the present one.

Acknowledgement: Thanks to Anne Cooke for helpful comments and advice on earlier drafts.

She also edited UPS. Some of the contributors  have expressed previously extreme anti-psychiatry sentiments in public. Now that Kinderman’s blog post is distributed, they need to get clear on where they stand on desecrating the memory of the Holocaust.

UPS Contributers

The conversation about Understanding Psychosis and Schizophrenia

From its launch, critics of Understanding Psychosis and Schizophrenia lots of abuse. Their own blog posts have been spammed with threats and demands the blog posts be taken. There have been hit and run attacks on blog comment threats and Twitter by pseudonymous commentators who morph and disappear from the internet. Often, outrageous comments are left and elicit responses, only to later be removed,leaving whole threads incoherence.

The day of the official launch of Understanding Psychosis and Schizophrenia, Keith Laws, Alex Langford, and Samei Huda posted a detailed critique that became one of the most viewed posts at Mental Elf ever. Angela Wilson Ursery posted a comment attacking the three as engaging in mutual masturbation and bragged about it on Twitter. The moderator at Mental Elf quickly edited her comment, but Kinderman retweeted her announcement and Anne Cooke favored it.

welcome circle jerk full

So, Kinderman has now gone from endorsing the views of UPS critics as masturbating each other, to expressing worries about being castrated, and now tying in the Holocaust and Nazis. Very strange for a President-elect of the BPS

At 1Boring Old Man  psychiatrist Mickey Nardo unflinchingly takes aim at NIMH Director Thomas Insel and American Psychiatric Association President Jeffrey Lieberman. Mickey approvingly quotes long statements from the Critical Psychiatry Network and engaging its representatives in long threads of comments on his blog posts. But he has grown frustrated trying to deal with the authors of UPS and their followers.

I’ve sort of stopped responding to comments myself because they focus on anything I say as evidence of my being some insensitive psychiatrist who holds people back and snows them with medication. I’m not that…The cases of psychotic illness I followed in my practice were treated much in the same way as the BPS Report suggests, though my attitude about medications changed over time because of frequent relapses.

But I don’t think the responders want to know what my objections really are, and would prefer to keep me in the bad guy role. I’m not interested in being defensive. If my writings about this aren’t clear, ask me a question. If you prefer to see me as some doom-sayer, that’s your call…

Well, now you know, Mickey, some of them think you are a Nazi.

The conversation about UPS must continue, without Kinderman and Cooke

BPS offered UPS as

A resource for people who work in mental health services, people who use them and their friends and relatives, to help ensure that their conversations are as well informed and as useful as possible. It also contains vital information for those responsible for commissioning and designing both services and professional training, as well as for journalists and policy-makers”.

UPS is chock-full of posturing in what its authors see as a turf war, misinformation, and simple nonsense. We should continue to provide mental health service uses, policymakers, and other professionals with evidence-based alternative information. From the first day of its launch, the UPS authors have not been keen on sustained evidence-based exchanges. We should continue without them, despite Kinderman having seriously damaged the debate.


DISCLAIMER: I am grateful for PLOS blogs providing me the space for free expression. However, the views I present here are not necessarily those of PLOS nor of any of my institutional affiliations.


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Category: antipsychotics, cognitive behavioral therapy, Holocaust, Psychiatry, psychosis, schizophrenia | Tagged , , , | 41 Comments