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Sunday, April 23, 2006

PTSD May Persist in Combat Veterans for Decades

The April 2006 edition of the American Journal of Psychiatry has an article about the longitudinal course of .  The abstract is here; the full version is here, but requires a subscription.  Additionally, there is a Medscape article based upon the original paper, here (free registration required).  From the Medscape synopsis:
The study was done with Israeli soldiers who served in the 1982 war with Lebanon.  The results are at least vaguely consistent with my own observations of soldiers in the US who served in Viet Nam, but one would need to be cautious about generalizing the results.
The Israeli investigators compared PTSD symptoms exhibited at 1, 2, 3 and 20 years after the war among 131 veterans diagnosed with combat stress reaction and 83 soldiers in the same units who did not develop an acute stress reaction. The researchers note that the two groups did not differ significantly in their premilitary screening of physical and psychiatric symptoms. [...]

At year 1, subjects in the combat stress reaction group had a 10.57-fold higher odds of meeting PTSD criteria than the comparison subjects. At years 2, 3 and 20, the odds were reduced to 5.15, 5.41, and 3.09, respectively.

Those with a combat stress reaction also had significantly more PTSD symptoms at all four time points.

The authors observed that 19.8% of the combat stress reaction group and 61.4% of the comparison group did not meet PTSD criteria at any of the four tests. However, members of the comparison group were more vulnerable to delayed onset.

What they did was to divide the soldiers into two groups: those who had shown "combat stress reaction" immediately during or shortly after combat, and those who did not have obvious symptoms in the immediate aftermath of combat.  Note that they used DSM-III criteria, since the DSM-IV did not exist in the early '80s.  If they had used the DSM-IV, they probably would have used the term .  (Acute Stress Disorder was not defined in DSM-III.)

There are a few key points here.  One is that, in this study, they did not find premorbid psychological factors that were associated with the subsequent development of combat stress reaction.  Another is the unsurprising observation, that the persons who had the most symptoms early on, also had more symptoms over time.  

Perhaps the more interesting finding is that the soldiers who did not have combat stress reaction were more susceptible to delayed onset of PTSD.  That is, some soldiers deal with the stress well on an acute basis, but then are more vulnerable to have problems later on.  
"Our findings suggest that (war veterans) need long-term monitoring and professional attention," the investigators conclude.
I hope that the people in charge of disability determinations for the VA system are paying attention.  Often, veterans who turn up years after war, claiming disability for PTSD, are greeted with skepticism.  That merely adds insult to injury.  The situation is already difficult enough for veterans who have delayed-onset PTSD.  For them, one of the most vexing things about the condition is that it seems inexplicable to them, to have done well acutely, but to develop problems later on.  When they take note of that apparent paradox, they tend to ascribe meaning to it.  These faulty attributions usually are self-deprecating.

Delayed-onset PTSD can occur also in civilians, although a quick Medline search did not turn up very much information of this.  There might be articles out there that I did not find, but if not, I would think this would be an important question to look into more thoroughly.

(update here.)


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Friday, April 07, 2006

Candidate's Forum

This is a quick report on the Washtenaw County Democracy for America Candidates Forum, held on April 5, 2006, at the Superior Township hall. The purpose of the Forum was to have Democratic Party candidates for State of Michigan offices answer questions about themselves and their campaigns.  This forum was small; there were three candidates there, two for the Attorney General spot, and one for the Secretary of State (SoS).  They invited three attorney general candidates, but only two agreed to come.  Scott Bowen is the one who did not come. Amos Williams and Alexander "Sandy" Lipsey did come.  Geoffrey Fieger also may be running, but nobody even mentioned him.  For reference, here are their campaign sites:

http://www.bowen4ag.com/
http://www.amoswilliams.com/
http://www.citizensforalexanderlipsey.com/
http://www.fiegerlaw.com/

Actually, Fieger's site is not a campaign site, it is the general site for his law practice ("the nation's premier law firm").

Scott Bowen apparently is Grandholm's pick for the AG spot.  The two who were there were asked if they knew why Bowen did not come.  Williams said that the rumor is that Bowen is on vacation in South Carolina.  I don't think anyone knew for sure.  

At the end of the Forum, I found that someone had placed little fliers under the windshield wipers of all the cars.  It was a notice that said that Scott Bowen in pro-life.

Ron Suarez is making a podcast of the Forum; a link should be posted here soon (or here).

I enjoyed the candidate's forum.  Both candidates for attorney general were impressive; I would have no trouble supporting either of them.  Sandy Lipsey is currently a State Representative.  Amos Williams is an attorney, a retired cop, and a military veteran.  Both name civil rights as important issues, although Williams was a little more vocal about that topic.  Both are strongly pro-choice. Lipsey talks a little faster, and gives a better global impression, but Williams comes across as more thoughtful.  He sometimes ran out of time while responding to questions (all candidate's responses were limited to two minutes.)  Both candidates often drew applause from the audience.  Both seem intelligent and well-educated.  Lipsey has a bachelor's degree in physics, graduated for the Kennedy School of Government, and Michigan Law.  Williams graduated from the FBI National Academy, and Detroit College of Law.  Both make an issue of consumer protection.  Both characterized the current AG, Mike Cox, as being excessively pro-business and weak on consumer protection.  They characterized Cox as being a man of little action.  They claim that his centerpiece accomplishment -- the increased aggressiveness in collection of child support -- as an unnecessary duplication of efforts already carried out by individual counties.

The SoS campaign is less interesting.  The site, http://www.uselections.com/mi/mi.htm, lists Mary Waters as the only active Democratic candidate for SoS.  She is hoping to unseat the incumbent, Terri Lynn Land.  She mentioned that one of the reasons she is running, is that people asked her to run.  The other reason she gave is that the current SoS had an important position in Bush's campaign, which is a conflict of interest.  Waters currently is a State Rep, and has asked for legislation that would prevent such conflicts of interest.  The main concern that she expressed was that the SoS in the chief elections officer in the State, and it is important to have someone with no conflicts of interest.  She exhibited some awareness of the current concerns about the integrity of the voting process.  However, I would have preferred to hear from her a greater understanding of the complex issues involved.  

For reference, the current SoS, Terri Lynn Land, was interviewed previously by Jack Lessenberry (1 2).  She has the idea of having picture ID voter registrations, that could be swiped in a machine at the voting precinct.  Her idea is that all of those machines would be connected together, so that all could be machine-verified, and no voter ID could be used more than once on a given day.  That sounds like an expensive proposition to combat voter fraud, when we all know that election fraud is the real problem.

After hearing the interview with Land, I wondered how anyone could propose to set up hundreds of nodes in a secure network on Monday, and expect it all to work at 7AM on Tuesday.  It is one of those things that is a nice idea, but anyone who has tried to set up any large network, not even a secure network, would probably tell you it would be foolish to expect it to work right away.  To expect to be able to set it up and have it be secure, and then to verify the security and functionality, in a short period of time, seems nutty to me.  It might work, but it might not, and what do you do if it doesn't work?  (Not that I am an expert, but I think I know enough to be able to say that much.)   Sure, you could set it up weeks ahead of time, but that gives it more time to fail, and creates a problem of how to make sure no one tampers with it in the meantime.

Is it strange to have two opposing candidates, one named Land, the other Waters?


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Wednesday, April 05, 2006

Collateral Damage in the War on Terrorism
Medical Ethics in Inaction

This post is about the case of a patient with Duchenne Muscular Dystrophy, whose life-prolonging medication was intercepted at the border by Homeland Security agents.  The post includes a long excerpt from the Grand Rapids Press.  I would not ordinarily excerpt so much of an article, but I think the article will disappear behind a firewall in a couple of weeks.
Boys' medicine held up by Homeland Security
Monday, April 03, 2006
By Pat Shellenbarger
The Grand Rapids Press

Tyler Fehsenfeld's doctors said the 6-year-old needs a drug from a company in England to delay his deterioration from muscular dystrophy.

The U.S. Department of Homeland Security said he couldn't have it.

Only after U.S. Rep. Vern Ehlers' office intervened last week did the U.S. Food and Drug Administration release it.

Tyler's parents, Anessa and Scott Fehsenfeld, of Rockford, were relieved but perplexed the federal agencies blocked a medication vital to their son's health.

"I'm choosing to give this drug to my son that a doctor says he needs, and my country says he can't have it," Anessa Fehsenfeld said. "As if the diagnosis isn't bad enough, and then you have this to deal with."

She ordered the drug, Deflazacort, in late January after Tyler's doctor prescribed it to slow rapid muscle decline and perhaps prolong his life. On March 6, the couple received a letter from Homeland Security's border protection division saying it confiscated the medicine because it is not approved by the FDA.

"I was shocked," Fehsenfeld said, frantic that her son soon could lose his ability to walk. "You think of sneaking it over the border. You're willing to do whatever you have to."

Several other parents of boys with an aggressive form of muscular dystrophy called Duchenne received the same form letter. In November, Customs began cracking down on shipments of prescription drugs from outside the United States.

While Deflazacort is available in Canada and throughout Europe, the company that makes it has not sought FDA approval to sell it here. The reason, some doctors and advocates for muscular dystrophy patients believe, is because it is an "orphan drug," with a market too small to be profitable.

An estimated 12,000 U.S. children have Duchenne, which affects only boys, said Pat Furlong, president of nonprofit Parent Project Muscular Dystrophy. [...]

Margaret Wilkinson, of Spring Lake, said she was notified Dec. 23 that the Deflazacort she ordered for her 14-year-old son, Jeffery, was confiscated. The FDA released it a month later after she called U.S. Rep. Pete Hoekstra's office. [...]

Without the drug, Duchenne patients typically lose their ability to walk between the ages of 6 and 12, said Marianne Knue, a nurse practitioner who works with Wong. Since the disease also affects the heart and breathing muscles, they often die in their teens.

"But with Deflazacort, we are finding boys are able to ambulate much longer, well into their teens," Knue said, adding she has patients on the drug still living in their late 20s.

Knue said she has heard from several parents whose Deflazacort orders were impounded. She began calling Customs and the FDA.

"They wouldn't give me a straight answer," she said.

Ehlers had better luck. After a Press reporter called his Washington office this week, a staff member contacted the FDA on the Fehsenfelds' behalf.

Tyler Fehsenfeld is the grandson of Press Publisher Dan Gaydou. [...]
In the USA, a drug can be sold only if it is approved by the FDA.  The approval process is excruciatingly complex, and costs millions of dollars to do.  And the longer the clinical trials take, the more expensive it is.  Because MD develops so slowly, the trials for this drug, in this disease, would take many years.  In order for it to be worthwhile getting the approval, the potential profits from the drug sales would have to be greater that the profits that could be gotten merely by investing those same millions of dollars for the same number of years.  Evidently, the analysis of the potential profits failed that test, so approval was never sought here.

Now, obviously, nobody would have thought that this kind of outcome, bizarre and inhumane as it was, would come from the Global and Perpetual War on Terrorism.  Call it collateral damage.  Still, in any massive, complex undertaking, there are bound to be unanticipated consequences.  

The thing is, intercepting unapproved drugs really has nothing to do with terrorism.  In this case, the War on Terrorism was merely a cover for another part of the Administration's agenda.  The Department of Homeland Security surely has better things to do than confiscating some terminally-ill patients medication.  It is difficult to figure out exactly how this fits in with their mission.  Sure, stopping some overseas drug shipments might protect pharmaceutical industry profits, but that clearly does not apply here, even though it would be consistent with the mission of our current Administration.  Likewise, stopping shipments of abusable drugs would fit in with their puritanical notions, but that clearly does not apply in this case.   No, this case was the result of a mindless power struggle.  

All ethical questions eventually boil down to the central question: who gets to make the decision?  That is, who is in charge here?  Who has the power?  Clearly, the Administration has decided that it has the power.  Not the doctor.  Not the patient.  Rather, some nameless Customs agent who has no idea what the drug is for, or why it is being imported, or whose lives will be affected by the confiscation.  None of that matters.  The only thing that matters is that it is that the Administration has to be in control of all things, at all times.  The War on Terrorism is used to justify this power grab.

In this case, the patient was the grandson of a newspaper publisher.  He eventually got the drug, but you have to wonder what would have happened if he hadn't had such an influential relative, and a Congressman had not gotten involved.  

This case arose from a longstanding problem with the FDA approval process.  The thing is, the system has been broken for a long time, and it still is broken.  It's just that for decades, doctors and their patients acted in accordance with common sense.  The government, rather than fix the broken system, simply looked the other way.  That was a fair solution, until some ideologically-driven zealots decided that they would not look the other way.  Instead, they now insist that the rules be followed, even thought the rules don't make any sense.


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Sunday, March 26, 2006

Blogworthy Articles in NEJM

The most recent (3/25/06) issue of the New England Journal of Medicine contains several items that deserve a mention here at Corpus Callosum.  It is worth noting that there are three items related to psychopharmacology; this degree of attention is unusual in a general medical journal.  All require a subscription for the full text.

There are two papers that report on results from the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) project.  One study shows what happens when patients are switched from one antidepressant that is not working for them, to a different one.  The other shows what happens when a second drug is added to the first one.  

The significance of these studies stems from the fact that it is a common decision point in the application of psychopharmacology, to have a patient who has not responded to the first drug tried.  The question then comes up: Is it better to stop drug A, and try drug B (switch); or, to stay on drug A, and add drug B (add)?  Although the studies do not provide a really definitive answer to the question, they at least provide some useful information.

One of the studies examined the question of what happens when the drugs are switched (Bupropion-SR, Sertraline, or Venlafaxine-XR after Failure of SSRIs for Depression).  Briefly, the result is that about 25% of the patients achieve remission.  It did not matter which f the three drugs was chosen:
Results Remission rates as assessed by the HRSD-17 and the QIDS-SR-16, respectively, were 21.3 percent and 25.5 percent for sustained-release bupropion, 17.6 percent and 26.6 percent for sertraline, and 24.8 percent and 25.0 percent for extended-release venlafaxine. QIDS-SR-16 response rates were 26.1 percent for sustained-release bupropion, 26.7 percent for sertraline, and 28.2 percent for extended-release venlafaxine. These treatments did not differ significantly with respect to outcomes, tolerability, or adverse events.
A few observations are in order.  First, conventional practice has been to switch from one family of drugs to another family, when employing the switch strategy.  In this study, all of the patients had not responded to an SSRI, citalopram.  It did not matter if they were switched to another SSRI, or a similar class (SNRI), or a completely different class (buproprion).  Note that the "conventional practice" was never based upon empirical evidence; up until now, there simply wasn't much empirical evidence to go on.  Second, the study does not tell us which patients would be better off with one drug over another.  We are still waiting for that study.

The second study examined what happens when a second drug is added (Medication Augmentation after the Failure of SSRIs for Depression).  Briefly, the study took a group of patients similar to those who enrolled in the other study; they all had not improved sufficiently on citalopram.  Briefly, about 30% attained remission:
Results The sustained-release bupropion group and the buspirone group had similar rates of HRSD-17 remission (29.7 percent and 30.1 percent, respectively), QIDS-SR-16 remission (39.0 percent and 32.9 percent), and QIDS-SR-16 response (31.8 percent and 26.9 percent). Sustained-release bupropion, however, was associated with a greater reduction (from baseline to the end of this study) in QIDS-SR-16 scores than was buspirone (25.3 percent vs. 17.1 percent, P<0.04), a lower QIDS-SR-16 score at the end of this study (8.0 vs. 9.1, P<0.02), and a lower dropout rate due to intolerance (12.5 percent vs. 20.6 percent, P<0.009).
Note that the bupropion group did somewhat better.  This is interesting.  In common practice, it is much more common for psychiatrist who employ the add strategy to add bupropion, even though there previously was no specific empirical guidance for this:  
Background Although clinicians frequently add a second medication to an initial, ineffective antidepressant drug, no randomized controlled trial has compared the efficacy of this approach.
The common practice was guided by intuition, more or less.  In this case, the intuition appears to have been correct.  

The third psychopharmacology paper in the NEJM issue is a "Perspective" piece on the cardiovascular safety of stimulants used in the treatment of ADHD.  That paper is available only as a (180KB) PDF download.  Their conclusion:
Although the committee recognized that there are important potential benefits of these drugs for certain highly dysfunctional children, we rejected the notion that the administration of potent sympathomimetic agents to millions of Americans is appropriate. We sought to emphasize more selective and restricted use, while increasing awareness of potential hazards. We argued that the FDA should act soon and decisively.
This sounds a bit harsh to me, but I would still take it seriously.  It may be that we need to start systematically monitoring blood pressure in all patients who are getting these drugs.  The number of deaths reported was extremely small, given the millions of patients who receive these drugs.  Even allowing for vast underreporting, it still means the risk is small.   But since the potential consequences are great, and the monitoring is so easy, it would make sense to do it.


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Monday, March 06, 2006

On The Authenticity Of Human Personality

I am just an amateur at this kind of thing, but sometimes I just blurt things out.  One argument that people sometimes raise, against the use of psychotropic medications, is that the state of mind that results from the use of such substances is somehow not authentic.  Part of this argument is seen in the controversy about so-called enhancement technologies, in which people argue about the propriety of using technology to make people "better than well."  That phrase seems to be used particularly in the context of persons using medical technologies when they are not ill, in order to enhance some functional capacity.

It has been reported that some nondepressed  persons taking SSRI antidepressant medication become better than well.  Some may argue that there is a problem with such a mental state.  One of the arguments is that such a mental state is not authentic, and thus it is to be avoided.  It turns out, though, that for the vast majority of persons, any such enhancement is subtle.  In fact, it is barely measurable.  Certainly, no one has documented any large flux of nondepressed persons flocking in to their doctors, trying to get prescriptions for SSRIs.  Granted, there is no reliable way to prove that it isn't happening, but it is hard to base an argument on evidence that does not exist.  Could it happen? Sure: it would not be difficult for someone to read up on the symptoms of depression, and go in to get a prescription.  Moreover, someone could order such medications over the Internet, without a prescription (which I don't recommend, by the way.)  Having said that, I am fairly sure that the majority of physicians would not expect this to happen.  The most likely outcome, if a person were to try this, would be for the person to take the medication for a few weeks, maybe months, then stop.  Any changes probably would be so small that they would not be apparent to casual observation.  In order to see the changes, one would have to do careful studies of various parameters, and take averages among a large group.  The changes in any one individual probably would be so small as to be clinically insignificant.  

If we agree that any such changes are small, does that make the ethical concern go away?  In my view, it does.  For those who still wonder, consider the following study on nonpharmaceutical compounds, as noted on the blog, Crumb Trail:
Omega 3 fatty acids influence mood, impulsivity and personality, study indicates

DENVER, March 3 – Omega-3 polyunsaturated fatty acids may influence mood, personality and behavior, according to results of a study presented today by University of Pittsburgh School of Medicine researchers at the 64th Annual Scientific Meeting of the American Psychosomatic Society in Denver.

In a study of 106 healthy volunteers, researchers found that participants who had lower blood levels of omega-3 polyunsaturated fatty acids were more likely to report mild or moderate symptoms of depression, a more negative outlook and be more impulsive. Conversely, those with higher blood levels of omega-3s were found to be more agreeable.

"A number of previous studies have linked low levels of omega-3 to clinically significant conditions such as major depressive disorder, bipolar disorder, schizophrenia, substance abuse and attention deficit disorder," said Sarah Conklin, Ph.D., a postdoctoral scholar with the Cardiovascular Behavioral Medicine Program in the department of psychiatry at the University of Pittsburgh School of Medicine. "However, few studies have shown that these relationships also occur in healthy adults. This study opens the door for future research looking at what effect increasing omega-3 intake, whether by eating omega-3 rich foods like salmon, or taking fish-oil supplements, has on people's mood." [emphasis added]
Note that the study participants were identified as "healthy volunteers," so presumably none had a diagnosable mood disorder (See this link for more detail on the study).  The study is suggestive (although not conclusive) in that it does not tell us for sure whether a healthy person could become better than well by deliberately increasing the intake of omega-3 fatty acids.  Although not conclusive, the study raises the question: if deliberate dietary supplementation with an ordinary food can cause a person to be better than well, is that better-than-well mood state inauthentic?  Or is the enhanced mood state inauthentic only if it is produced by an artificial chemical?  If there seems to be a difference in authenticity, why does the source of the chemical matter?

Credit goes to aspazia for the inspiration for this post, as well as some of the background information.


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Saturday, February 25, 2006

Early Hurricane Season in Florida

Those of us who have been following the news about global warming are worried about the upcoming hurricane season.  But now another storm is brewing in Florida, and it has nothing to do with global warming.  

The storm is being generated by Black Box Voting, which describes itself as "a nonpartisan, nonprofit, 501c(3) organization. We are the official consumer protection group for elections, funded by citizen donations."  They have released a report of their inspection of voting machine logs from Palm Beach, Volusia, and Broward County, used in the November 2, 2004 elections.  Their report shows that the logs contain over 100,000 error messages.  In addition, the logs show many votes were recorded in October 2004, even though the specific machines were not used for early elections.  
After investing over $7,000 and waiting nine months for the records, Black Box Voting discovered that the voting machine logs contained approximately 100,000 errors. According to voting machine assignment logs, Palm Beach County used 4,313 machines in the Nov. 2004 election. During election day, 1,475 voting system calibrations were performed while the polls were open, providing documentation to substantiate reports from citizens indicating the wrong candidate was selected when they tried to vote.

Another disturbing find was several dozen voting machines with votes for the Nov. 2, 2004 election cast on dates like Oct. 16, 15, 19, 13, 25, 28 2004 and one tape dated in 2010. These machines did not contain any votes date-stamped on Nov. 2, 2004. [...]

The Palm Beach County Supervisor of Elections, Arthur Anderson, said that his staff had looked into the problem and that the votes were normal, it's just that the dates somehow changed.  [...]
"The votes were normal, it's just that the dates somehow changed."  If that was intended to be reassuring, I would say Anderson failed rather miserably.  If, as he says, his staff looked into it, then there should be a written report.  Anderson should say to the journalist, "We prepared a report, and I would be happy to send you a copy," or something like that.

Google News lists about 100 news articles that reference the Black Box Voting article.  Most of these are reprints of an Associated Press article dated 2/23/2006, by Brian Skoloff.  The AP article was picked up mostly by small organizations, although some of the big media outlets, such as The Washington Post, also printed it.  A couple of conservative sites printed it as well, including Town Hall and The Conservative Voice.  Another news article on the subject appeared in the South Florida Sun-Sentinel, dated 2/24/2006, by Kevin Connolly.  

Both news articles are disappointing, although they live up to the usual journalistic standards.  

The AP writer, in a superficial effort to be fair and balanced, contacted the spokesperson for the manufacturer of the voting machines, and asked for a reply:
Sequoia spokeswoman Michelle Shafer disputed the findings, saying the company's machines worked properly. Sequoia's machines are used in five Florida counties and in 21 states.

"There was a fine election in November 2004," Shafer said.

She said many of the errors in the computer logs could have resulted from voters improperly inserting their user cards into the machines. The remaining errors would not affect the vote results because each unit has a backup system, she said.
The problem with that, is that there is no analysis of the adequacy of Sequoia's response.  The Black Box Voting article indeed does cite voting card errors, but that is only one type of error that they document.  There are many more kinds of error reported, and most of them have nothing to do with the voting cards.  Furthermore, a reasonably inquisitive reporter could wonder how it is that the machines handle these card errors, and what the procedures are for responding to the errors.  One might wonder why the logs do not show what was done to correct the error.  Furthermore, the respons that "The remaining errors would not affect the vote results because each unit has a backup system" is inadequate.  How does that address the problem of incorrect date stamps?  

Many such errors that Black Box Voting reported simply are not addressed in the AP article.  For eample:
Polls closed and results report messages would be expected to appear on every voting machine at the end of the voting cycle, but these revealed problems with poll worker training and procedures at the administrative/training level. Some logs reported one report printed, some two, three, four or five, and several not only had no results tape printed but showed no closing of the polls. (Closing the polls tells the voting machine not to accept any more votes).

Card encryption bad and Card read fail errors also appeared, with the encryption error message the more frequent of the two.
Some logs show that no results were printed, indicating that there is no paper record of the votes that the machine recorded.  Some show that the machine was not properly shut down at the end of the polling session.  That would not neceassirly be a problem, if all the votes had reliable date stamps; and vote recorded after the polls were closed could be discarded.  But as we have seen, the date stamps are not reliable.  I would like to think that a vigilant reporter would notice this, and ask about it.

Likewise, the South Florida Sun-Sentinel article is only a superficial report.  They quote a Volusia County official:
Volusia officials said the charges are groundless and questioned Harris' credibility.

"If you wish hard enough for a problem, your mind can imagine it," said former Volusia County Election Supervisor Deanie Lowe, who ran the 2004 election.

"I don't know of any election or of any voting system she has ever programmed, so she does not understand the situation. . . . She doesn't know what she's talking about."
I think it is fine to give the County officials a chance to respond, but the reporter could do better than that, by pressing for specifics.  Lowe's response is a sweeping rejection of all claims, based upon a vague dismissal of the credibility of the Balck Box Voting director, Bev Harris.  Vague ad hominem attacks tell us nothing.  I want to know what the county officials have to say about the individual error messages.  I want to know what happens when error messages occur while votes are being cast.  Are poll workers aware of the errors?  Is there a log kept by poll workers, showing when the errors occurred, what was done in response, and which poll workers responded?  Is there a policy and procedures manual that specifies how these situations are handled?  If so, how can citizens get access to that manual?  What does it say a poll worker should do, if, for example, a voting machine reports a card encryption error?  

Bloggers have been commenting on this, typically with a high degree of skepticism.  For example, an IT guy, Truthspew, writes:
Can a president elected through fraudulent means be tossed out?

Because Black Box Voting is really going gangbusters identifying serious election hanky panky.

For example, while I find the grammar and syntactical skills of the journalists at the Associated Press to be very disappointing, this article ineloquently states what the problems encountered happened to be.

Even during the 2000 Judicial Fiat we knew something was wrong. Same happened in 2004 and Dubya's plunging numbers only reinforce the notion that something is seriously rotten in Denmark.
Elisabeth, writing on Infomanic, picked up on the story, and got a useless comment:

Um, Elisabeth. We need to talk. The DUmmie FUnnies has LONG chronicled the foibles of the veracity challenged Bev Harris. Even the Democrat Underground has BANNED her from their leftwing site. Check out our December 2004 archivies of the DUmmie FUnnies and then do a search on the MANY references to Bev Harris and that should get you up to speed on the whole Black Box Voting thing.

The only thing Bev Harris and Black Box Voting are really good for is as a reliable source for comedy material and for that we thank her.---P.J.

Again, attacking Bev Harris may be interesting, but it is a different story.  We need to see an analysis of the specific claims made by Black Box Voting, and a credible explanation of each claim.  Harris provided the actual logs -- the raw data -- that were used by Black Box voting.  If someone wants to complain about her reporting, that person needs to look at the logs and explain what all those error messages mean, and show why they should be disregarded.    

Independent Report picks up on the story, and points out:
Does this sway the election results any? No, probably not. However, we find it curious that the voting machine manufacturers fought, kicking and screaming, against providing their source code or the machine's capabilities. "Trade secrets" they claimed, while also claiming the machines worked wonderfully well and could not be sabotaged. Well, we know they can be hacked pretty easily, and these irregularities point to some fishy business going on somewhere.
Bev Harris does not claim to know if election results would have been any different had these errors not occurred.  From the AP artiicle:
However, Harris said it was impossible to determine what information was altered or if votes were shifted among candidates.
That, in itself, is newsworthy.  The fact is, the results of the election cannot be verified, because the machines do a lousy job of telling us what actually happened on voting day.  As one comment states here:
I started reading the actual log files... as far as I can tell, it doesn't look like the numbers were manipulated to benefit a specific candidate. It does look like the company is totally inept, and isn't qualified to count jellybeans.
Some people read the Black Box voting article and concluded that there were problems, but the problems probably did not change the election results.  Others looked at the same article and concluded that the problems do indicate election fraud, such as this post at What a Mockery: Concrete Evidence that 2004 Vote was Rigged in Florida.  Some echo the report, and imply that the report indicates fraud, but do not state that explicitly; Ranting and Venting: Florida Voting Machine Logs Reveal Anomalies, by Mindwolf,  is an example of this approach.  
It seems like all this work the GOP is doing is just to make it easier to stage an election so they can seize power and make it look like it was legal.
Others merely report on the findings, without adding anything; presumably, they are content to let readers draw their own conclusions.  For example, Rob Galgano, at The Great Leap Forward, does exactly that.  In a way, that approach is preferable to the approach taken by news writers who provide a half-hearted attempt at being fair and balanced, but no analysis of their findings.

What I notice about this situation, is that the Black Box Voting article, and the news stories about the findings by the Black Box Voting (BBV) organization, both illustrate similar concepts.  What BBV found, is that one of the fundamental guarantors of our democracy -- accurate vote counting -- is no longer credible.  Similarly, another fundamental guarantor of our democracy -- good journalism -- suffers from a credibility problem.  Both of these problems are serious, but having the two together is especially bad.  Together, the lack of credible voting, and the lack of credible journalism, threaten to create a new storm system in our political ecosystem.


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Tuesday, February 21, 2006

Prozac OTC?

Aspazia left a comment with some questions, pertaining to my last post.  Since the response is way to long to fit into a comment box, I've responded here.  Note that the response might not make a lot of sense unless you first read the original post, and the comment, here.

Yes, the term hysteroid dysphoria is attributed to Donald Klein, from the late 60's. At this point (year 2006), it is more of historical and sociological interest, than medical interest. As for the question of whether MAOIs or Prozac would be better for treating rejection sensitivity, the answer is the predictable one: it depends on the patient, and to some extent, on the doctor.

I am confident that the magnitude of the therapeutic effect is greater with MAOIs, and that a higher percentage of patients will respond. But at least 30-35% will stop taking an MAOI because of adverse effects, compared to 10-15% with Prozac.  

From the psychiatrist's perspective, the judgment about which is "better" will depend upon a number of factors.  MDs who see a lot of young, relatively healthy patients, with clean diagnoses, and without a long history of multiple medication trials, will naturally see Prozac as the better choice for their typical patient.  MDs who see patients with multiple diagnoses (e.g. depression and panic disorder and PTSD), patients who have had multiple trials on modern antidepressants, will tend to think of MAOIs as better.  That's because there is no point in starting yet another trial of yet another SSRI in such a patient.  (If that was going to work, it would have worked already.)  

Some younger psychiatrists have little or no experience prescribing MAOIs, and would need to do their homework before doing so.  Some will do their homework, while others will not.

Psychiatrists vary considerably in their practice patterns, thus there are systematic differences in their patient populations.   It is important to keep this in mind when listening to a psychiatrist talk about his or her own experiences.  This is because it is impossible to know what conclusions can be drawn from those experiences, unless you know something about the population of patients among whom those experiences occurred.  

As for whether patients can pressure doctors into prescribing antidepressants, I would like to think that it would not happen very often.  It is pretty easy to say to someone, "Look, I know you think this would be best, but I really have to prescribe according to my own judgment..."

A bigger concern is that it is fairly easy for someone to come in and give all the correct answers, to manipulate the doctor into prescribing an antidepressant.  There is no good defense against that.  As a physician, one has to assume that the patient is acting in good faith, and the suspicion level is going to be low unless the patient seems to be fishing for a controlled substance.  

Make SSRI's available without a prescription?  First you would have to get a company that would be willing to sell them without a prescription, and I tend to doubt that anyone would do that in the USA; the liability issues would be horrendous.  But I realize that is a different issue.  Assuming that a company would do it, would it be advantageous for society?  The issues I see are these:

1. Selling antidepressants over the counter (OTC) might do something to destigmatize depression, and mental illness in general, and there could be benefit there.  

2.  It could trivialize mental illness, which would be bad.

3.  A lot of people who don't need them would end up taking them.  Most of those people would suffer no harm, except for the wasted money, and would stop taking them after a while.

4. Some people with bipolar disorder would became manic or hypomanic, and that would be a problem; in some cases, it would be a big problem.

5. Some people would try to abuse them.  Most of those people would get no appreciable effect, and would stop, no harm done.  Some would combine them with other substances, and that could be very dangerous.  

6. Some people report that antidepressants intensify the effect of alcohol.  That is not directly dangerous, assuming that the person does not intentionally overdose, but it can be hazardous because the person may not realize how much impairment there is.  (Of course, that can happen with alcohol alone, but it is more likely to happen with some kind of CNS drug involved.)

7. Some people who need treatment, but who for some reason will not see a doctor to get treatment, might end up getting beneficial treatment.  While not optimal, that would be more good than bad, except for #8...

8. Some people who are at risk for suicide would try to treat themselves in isolation.  Isolation is very bad for persons who are suicidal.  Self-treatment almost certainly would be a bad idea, and could have disastrous consequences.

Policy wonks may have some way of estimating the magnitude of those good and bad factors, and coming up with some kind of pronouncement about whether the good would outweigh the bad.  Personally, I would be highly skeptical of any such analysis.  So, to answer the question about whether SSRIs should be available OTC, I would not attempt a numerical analysis.  Rather, I would rely on the following kind of judgment:  
  • In general, it is a bad idea to make a radical change in how a medication is used, unless the likely consequences can be anticipated and quantified.
  • Selling antidepressants OTC would be a radical change in how they are used.
  • The likely consequences cannot be anticipated, nor quantified.
  • Therefore, it would be a bad idea.
I realize that that is a simplistic analysis, but even so, it pretty much sums up what I think about the idea.


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Monday, February 20, 2006

It Has Been Bugging Me All Day

Yesterday, ambling around the Internet, I read an article, and a blog post, that seemed to call for some kind of response.  The article is on The Nation's website: Brave Neuro World: The Ethics of the New Brain Science, by Kathryn Schulz; the blog post is Prozac Feminism?, by Aspazia.  What was bugging me, is that my intuition was telling me that there is some kind of important connection between the themes of the two pieces, but I could not quite put my finger on it.

Tonight, I am going to try to clarify for myself what the connection is.  This is not a post that was thought out before writing it.  Rather, I let my unconscious mind wrestle with it, and now I am going to sit down and start typing and see what comes out.  Ah, the joy of blogging!  

I will refer to the Schulz' article as BNW, and Aspazia's as PF, just as a kind of shorthand.

In BWN, Schulz poses a number of questions that are created by advances in neuroscience, and in our ability to control what the brain does.  Essentially, she points out that the prospect of enhancement technologies will pose ethical quandaries.  If enhancement is possible, to what extent will humans be free to make use of those enhancements?  Will it be possible, or proper, for anyone to coerce another to make use of such enhancements?  What are we to do about the inevitable unequal access to enhancement technologies?  

Schulz can no more answer these questions that anyone else.  Admittedly, I was sort of hoping that she would venture some answers, no matter how speculative or premature.  

Aspazia takes a different approach.  Not surprisingly, she ends up with different questions.  Rather than viewing Prozac as an enhancement technology, she views it as a means of promoting conformity to social expectations.  In that way, Prozac becomes a metaphor for the social pressures that promote conformity and compliance in women.Viewed in that way, Prozac is only an "enhancement" technology to the extent that conformity and subservience are improvements over the original.

I will leave aside the question of whether Prozac actually does that, or can do that.

What occurs to me first, is sort of an odd parallel.  I realize that understanding this requires some specialized knowledge, and that I am too impatient to expand on all of the prerequisites in sufficient detail, so I may loose some readers by not explaining things sufficiently.

In the 1950's, three particular new molecular entities were developed for the treatment of depression: phenelzine, isocarboxazid, and tranylcypramine.  These were marketed successfully as Nardil, Marplan, and Parnate, respectively.  All three are monoamine oxidase inhibitors (MAOIs).  Although there are highly effective, they were supplanted rather quickly by the tricyclic antidepressants (TCAs).  The reason is that all of them required that the patient follow a special diet, in order to avoid an interaction with a chemical found in certain foods.  (See the Wikipedia article for details.)  MAOIs also tended to cause weight gain, sexual dysfunction, and various other adverse effects.  

Although the MAOIs were supplanted by the TCAs, and the TCAs were supplanted by Prozac, they continue to excel in one respect.  MAOIs have particular efficacy for the treatment of atypical depression.  Atypical depression is characterized by a cluster of four symptoms: overeating, oversleeping, leaden fatigue, and rejection sensitivity.  Ordinary depression, in contrast, tends to involve loss of appetite, insomnia, intentional social isolation, and fatigue that does not have a peculiar somatic sensation associated with it.  MAOIs are particularly effective at reducing the symptom of rejection sensitivity, and thus are the preferred agents for treatment of Social Phobia.

As an historical aside, there is a disused term lurking in the dustbin of psychiatry: hysteroid dysphoria.  The term hysteroid was used in reference to an ancient (but not ancient enough) belief that certain emotional symptoms were caused by a wandering uterus.  (Really.  People actually believed that.)  It was thought that certain emotional symptoms tended to cluster together, along with rejection sensitivity.  That cluster was given the name hysteroid dysphoria.  In the 1980s, someone got around to analyzing the statistics, and it was found that the proposed symptom cluster had no validity.  The term has been abandoned since then.  In retrospect, it seems that it was merely a term of disparagement that was applied to women who had emotions that were inconvenient to men.  (As a part of the process of discarding pejorative terminology, the symptom of rejection sensitivity now is often referred to as mood reactivity.  The two are not exactly synonymous, but close enough for some purposes.)

Anyway, in the 1950's, the treatment of mood reactivity was hard: the patient had to memorize a list of foods to avoid, learn new recipes, get the family to accept a new menu, and scrupulously avoid dietary indiscretions.  Likewise, in the 1950's, housework was hard.  

Prozac changed the treatment of mood reactivity, sort of like the way the microwave oven changed housework.  Just push a button, and you're done.  Nothing hard about it.   That is the odd parallel that I referred to earlier in this insufferable stream of consciousness.

Both BNW and PF pose questions about bioethics.  Specifically, they ask how society should deal with the fact that we are developing new ways to alter brain function.  Both essays point out that there is a potential for coercion.  

BNW concludes with this:
If we fail to have that discussion, we risk winding up with a social policy for neuroscience based on tactical decisions, not ethical ones; benefiting the few, not the many; and obscuring the complex relationship between personal decisions about our minds and public decisions about our culture. That is a social policy we need like a hole in the head.
PF concludes with this:
What sort of culture do we become when we can gender engineer ourselves right into the sort of personality types that kick ass in business, that make us less sentimental about sex, and less overly sensitive to the needs of others?

Are we ready for this medically enhanced post-modern Feminism?
I think these issues are important.  What is important to note, though, is that society does not put people on medication.  Doctors put people on medication.  Society may exert unarticulated pressure on companies to develop products, on doctors to prescribe those products, and on people to go to their doctors to get those products, but ultimately it is the responsibility of the physician to be aware of those pressures, counteract them, and to make the prescribing decisions based on clinical grounds, with the patient's interest and value system in mind.  

I have mixed feelings about this.  On the one hand, many medical decisions are complex.  With that in mind, it seems that the need for a physician to sort out sociological and gender issues and consider them in the prescribing decision is no more complex than the decision about who should get bypass surgery.  On the other hand, the medical profession has a spotty record when it comes to that kind of thing.  It has been reported that women with heart disease have not gotten treated as aggressively, or as appropriately, as men.  There are other examples of bias in medical decision-making, such as racial or class biases.  I don't think the problem of potential biases is intractable, but I do think it requires some attention.

It is not something that worries me, really, because I do think that the medical profession is responsive when such biases are documented.  If we are paying attention, we should be able to avoid such biases, so hopefully they will not occur in the first place.  The authors are correct to point out the potential for such biases.


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Saturday, February 18, 2006

Why I'm No Good At Cryptography

One of my favorite stories from the World War II era is that of the cracking of the Enigma ciphers.  Individuals such as the Polish mathematician, Marian Rejewski, figured out how the Enigma machine worked to scramble information.  But even after that discovery, it was not simple to figure out how to decipher each message.  That is due to the fact that Nazis changed the key for the cipher every day.  Even knowing how the machine worked, it was necessary to figure out what key had been used, in order to decipher the message.

There are many interesting details to the story, but the main point is that the cryptanalysts working on the problem could not rely only on their math skills.  A certain amount of intuition was necessary.  For example, the keys were supposed to be combinations of letters that were chosen at random.  But people being what they are, it was common for non-random factors to intervene.  One such departure from randomness occurred when the Enigma machine operation would spontaneously make up a pseudorandom sctring by typing arbitraty keys.  But since the machine operators fingers generally started from the home positions on the keyboard, the home keys were much more likely to be pressed.  Furthermore, it was common for the operators to alternate keypresses between the fingers of the left and right hands.  

On the Enigma machine, the home keys are asdfghjk.  So an operator who is not careful might choose a-k-a as a key.  Cryptanalysts often used intuition to help them narrow down the list of possible keys.  Rudimentary computing devices could help, but the intuition of the cryptanalyst often resulted in saving a great amount of time in the process.  

Now that computers have become much more advanced, it might seem that there would be no place for intuition.  Just set up the computer to do a brute-force attack, trying every possible key in order to crack the cipher.   But that turns out to be wrong.  A good illustration of this comes from the story of the Chinese mathematician, Xiaoyun Wang.  She has been working on cracking the MD5 and SHA-1 hash functions.  From an article posted on MAA Online, Cracking the Code, by Keith Devlin:
Wang's approach was to input to the algorithm two strings that differ by just a few bits and look closely at what happens to them, step-by- step, as the algorithm operates on them. This led her to develop a "feel" for the kinds of strings that will result in a collision, allowing her to gradually narrow down the possibilities, resulting eventually in her developing a procedure to generate a collision. Others working in the field remark that her ability to intuit which of the many possible paths to follow, coupled with her tenacity, is remarkable. Commenting to the magazine New Scientist, which covered the story in its 17 December, 2005 issue, Charanjit Jutia, a cryptographer at IBM's Watson Research Center in Yorktown Heights, New York, described the challenge of cracking a hash function like SHA-1 as being "like a giant puzzle." Referring to Wang, he added, "Most people get tired and give up. She did not"
I don't want to spur a mass panic, by starting a rumor that SHA-1 has been cracked.  I know full well, what pandemonium would break out if that turned out to be the case.  So, I will clarify that, so far, Wang has only reduced the number of steps required to guess the key.  It had been thought that 2^80 steps were needed.  Wang found some shortcuts that got that down to 2^63 steps.  So SHA-1 still works to effectively obscure private information.  
Following the announcement at Crypto 04, Wang and Yu teamed up with Yiqun Lisa Yin, now an independent security consultant based in Greenwich, Connecticut, and started work on the crown jewel of current hash functions, SHA-1. This proved a much harder nut to crack, but to the general dismay (and admiration) of the computer security community, at the annual RSA security conference in San Francisco in February last year, they were able to announce that they had developed an algorithm that could generate two SHA-1 colliding files in just 2^69 steps.

Unlike MD5, Wang and her colleagues have not (yet) cracked SHA-1, they have just produced a method that could crack it in far fewer steps than was previously believed possible. That number 2^69 is still sufficiently high to provide some degree of confidence in the system's security - for now. So too is the even lower number of 2^63 steps that Wang and other collaborators managed to achieve in the months following the February 2005 announcement.
A lot of computing power is still needed to get the key.  Even so, it is evident that successful cryptanalysis gets a boost from intuition.  And that is why I am not good at it: I don't have the right kind of intuition.


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Tuesday, February 14, 2006

Ann Coulter As Metaphor

Peter Westre, of Left in the Heartland, recently asked for some commentary about Ann Coulter, from a clinical perspective.  This is an interesting topic.  In fact, one could write a book about the subject.  

I am not going to write a book, but I will make a few comments.  

First, the requisite disclaimers.  I have never met Ann Coulter, and I cannot actually make a clinical diagnosis pertaining to someone I've never met.  Second, if I had met her in a clinical context, I neither could nor would say anything about it.  Third, the only information I have is what is available on the Internet, and I haven't read all of that.  What I can do, though, is use the public persona of Ann Coulter as a metaphor for the dark side of the Republican Party.  It would be appropriate for me to say that I do not think that Ms. Coulter is at all representative of members of he Republican Party.  Rather, I would say that the Party has been infiltrated and co-opted by mean-spirited persons who have sociopathic characteristics.  Thus, Ms. Coulter can be used as a convenient metaphor to describe this phenomenon.

Ann Coulter has made some remarks that could be taken as evidence that she is a sociopath.  Editor and Publisher picked up on a few in this article.  Max Blumenthal has more on Huffington Post.  Back in 2001, The Washington Monthly put together a decent collection of some of her earlier and more offensive comments.  Indeed, some of these are highly suggestive.
On Rep. Christopher Shays (d-CT) in deciding whether to run against him as a Libertarian candidate: "I really want to hurt him. I want him to feel pain."--- Hartford Courant 6/25/99
The thing is, in order for someone to be a sociopath, they have to actually do some bad things, not just talk about doing bad things.  Of course, I have no idea if Ms. Coulter ever has done bad things.  Probably not; surely the media would pounce on it if she had.  But the fact is, it is not normal for someone to state openly that they want someone else to feel pain.  The fact that she makes such statements openly is not normal.  It is not normal for someone to say openly, even in jest, that a Supreme Court Justice should be poisoned.  While not conclusive, diagnostically, for someone to make such statements does suggest the possibility of some kind of personality disorder.  

Technically, there are four types of personality disorder that might cause a predilection to make such statements.  If one cared to attempt to establish such a diagnosis, in a casual, armchair-musing kind of way, that could be done.  One would first read the general criteria for a personality disorder.  (The list of criteria can be found on Wikipedia, here.)  If the general criteria are met, one then would read the specific criteria for those personality disorders that tend to be associated with people doing bad things.  Those would be the Cluster B personality disorders: Antisocial, Narcissistic, Histrionic, and Borderline.  Antisocial Personality Disorder is the one that is most closely synonymous with sociopathy.

To meet criteria for Antisocial Personality Disorder, the person in question has to have a history of repeatedly doing bad things.  But what about someone who does not actually do those bad things, but does talk about them in public, repeatedly?      

Looking at the question from a clinical perspective, I would wonder about the Narcissistic and Histrionic personality disorders.  Narcissism can be understood as being pathologically self-centered.  Histrionic Personality Disorder can be thought of a being pathologically attention-seeking, especially if done in a theatrical manner.  

Narcissistic persons have a massive failure of empathy, but typically do not go out of their way to cause harm to others.  On the other hand, if they do happen to cause harm to others (say, by accidentally shooting them in the face with a shotgun), it is no big deal.  After all, it is just "collateral damage."

Histrionic persons tend to be so theatrical that they may, perhaps without really meaning to, cause great insult to others.  Like the narcissist, if they do happen to insult someone, they typically feel no shame; they may even take pride in it.  After all, it is "just a joke."

With those points in mind, now, ignore Ms. Coulter.  Instead, consider  the extent to which the Narcissistic and Histrionic personality disorders can be used, collectively, as a metaphor for the dark underside of a perverted political party.  

Here are the formal criteria for the two disorders:
Diagnostic criteria for 301.81 Narcissistic Personality Disorder
(cautionary statement)  

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) 

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love 

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) 

(4) requires excessive admiration 

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations 

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends 

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others 

(8) is often envious of others or believes that others are envious of him or her 

(9) shows arrogant, haughty behaviors or attitudes

Reprinted with without permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association


Diagnostic criteria for 301.50 Histrionic Personality Disorder
(cautionary statement)  

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 

(1) is uncomfortable in situations in which he or she is not the center of attention 

(2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior 

(3) displays rapidly shifting and shallow expression of emotions 

(4) consistently uses physical appearance to draw attention to self 

(5) has a style of speech that is excessively impressionistic and lacking in detail 

(6) shows self-dramatization, theatricality, and exaggerated expression of emotion 

(7) is suggestible, i.e., easily influenced by others or circumstances 

(8) considers relationships to be more intimate than they actually are

Reprinted with without permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association

Consider the question, of whether there are elements within the Republican Party that reflect these criteria for mental disorders.  Are there frequent instances of the Party have a grandiose sense of self-importance?  Has any member of the Party ever stood on an aircraft carrier, with a large banner proclaiming "Mission Accomplished?"  Do any of them ever seem preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love?  Well, forget the ideal love part, and think about the rest of it.

What about the third criterion for NPD?  Any hint of exclusivity in the statement about the "haves and the have-mores?"
“What an impressive crowd: the haves, and the have-mores. Some people call you the elite. I call you my base.”
I could go through most of these criteria, and find numerous suitable examples for each, but that merely would be feeding the vampire.  



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