Shrink's Views

ramblings of an unknown psychiatrist

Archive for the ‘statistics’ Category

Love – Feeling, Reason and Choice: a story

Posted by Dheeraj Kattula on September 19, 2010

Background:

This is continuation of the story “Rights and Love”. If you have not read it, you could find it by clicking this. It was a story about a lawyer called James. His wife Agnes suffered with Schizophrenia. Under the influence of some delusions she attempted to murder him. He recovered and then took care of her. Despite all care she had not improved much. He continued to care for her despite the risk of harm that he could suffer. He surprised everyone with his love.

Love: feeling, reason and choice

It was nearly six months since Tab Clozapine was started. James reported that Agnes was doing well. She was not suspicious as before. She had started working again two weeks ago. She had put on some weight, but she got back the smile that she always had. As Agnes waited in the queue to get her medicines from the Pharmacy, James was called back by Dr Manas to the consultation room.

Dr Manas said “Mr James, I was glad to hear that Agnes is doing well. I wanted to tell you something. Do you have few minutes?” James was so happy that Agnes has improved so much. His eyes filled with tears as he said, “Of course doctor, you are always there for us. Please go ahead.”

“I have resigned my job here and I am moving to Kolkata. So I have transferred the care of Mrs Agnes to Dr Gurupreet Kaur. You have seen her during the in-patient stay. She is a fine doctor”, Dr Manas said as he looked away from James and stared into the empty sky through the window. He did not notice the crushed look on James’s face, as he nodded his head. James liked Dr Manas. He was a good doctor.

Suffering is not new to Dr Manas. He saw it every day. He was used to it. Despite his heroic efforts, his patients continue to succeed in suicidal attempts; they go off medications and relapse into full blown illness episodes. This was part of his life, but there was some suffering different about the case of Agnes and James that touched him.

“Mr James, I have seen many families with mental illness. They all care. If they did not care, the patients would not have been brought here or the family member would not have come here. I have seen people get beaten in episodes of rage. I have seen domestic violence exist in chronic form, but I have never seen one who had a brush with death because of an attempted homicide by a wife, care for his assaulter with so much of dedication and persistence. I admire you, Mr James. How do you do it? Is your marriage a love marriage?” Dr Manas inquired.

James smiled and replied, “I do not know if you could call it a love marriage. I guess you could. Agnes and I went to the same Church in Bangalore. Her parents had passed away in a road accident in her childhood. Her grandfather brought her up. He was a retired railway employee. They lived on his pension. He had multiple strokes and developed dementia. Agnes took good care of him. She used to bring him for the mass regularly. She was also active in the Sunday school.

I liked the way she behaved with children and elderly people. She was simple and had a simple lifestyle. I was interested in providing legal aid to poor people in Mumbai. I wanted to marry a girl who could fit in. I reasoned Agnes could be the right girl. I discussed this with the Church father. He was very happy. Agnes agreed to marry me. We got married after she finished her graduation. In the meantime her grandfather passed away. Then we moved to Mumbai.”

“Oh I see. Looks like you took a logical decision. Isn’t it?” Dr Manas asked.

James replied, “Yes sir. It was a 100% rational decision. I never had any flutter in my heart seeing Agnes nor did I miss sleep. In fact I have not had the feelings for Agnes that I once had for a girl…(smiles)

I had this feeling of being in love when I was in my 3rd year in the Law College. Permit me to leave her unnamed. She was the only daughter of a top criminal lawyer in Bangalore. She was obviously going to take over her father’s practice. Her father defends crimes done by politicians and their goons. She would have to do the same.

I desired a just society. If I married her, I would be aligning myself with enemies of truth and justice. I knew she was not the right girl for me.

Trust me; this knowledge did not help me lose feelings for her. I would get energized as if I had two cups of chai, if she were to just say a hello. I just cannot explain it. This ‘love’ seemed real, as I could feel it strongly. It lasted a year till she started going around with a minister’s son.” He smiled and added, “Thank God for that match! My emotions left. ”

“You said that you never had strong feelings for Agnes, but you seem to demonstrate love that I have not seen before. How is that?” Dr Manas asked inquisitively.

“Dr Manas, I have decided to love my wife Agnes. However she is, whatever she does, I will love her. I mean I would act in her interest. I might not have feelings like I had in college. I might not be as rational as when I had decided to marry Agnes. Love here is a choice I make.

In College years my feelings of love were not even in line with reason. They felt most real, but they were most deceptive. These feelings just evaporated. Imagine trusting those feelings and taking life decisions. My reason was stronger than my feeling when I decided to marry Agnes. If the situations did not change, reason would have been sufficient cause for a lasting marriage.

But things changed. You know it. I could have started a new life without her. Getting her out of prison and living with her in the same house with no one else, when she was still suspicious of me goes against sound reason. It was a choice I made to love Agnes that mattered. I thought in her interest. I had risk. I had fear. I faced it. It was ultimately a choice I made.”

“Mr James, I like the choice you made. I respect it. I appreciate it. In fact, you have inspired me to make such a choice. I normally don’t discuss my personal life with patients or their families, but I think you are different and I thought I could share this with you.

Let me first tell you that I hate Kolkata. I am a Bengali .I believe anyone who wants to work hard and grow cannot do so in Bengal. So, I always wanted to move out of Bengal.

I was involved in research which was being done in collaboration with the Indian Statistical Institute in Kolkata. I fell in love with a mathematician there. She was beautiful, brilliant and a Bengali. I had all reasons and all the feelings to get married. We married and were happy for few months. I then noticed that she was drawing closer and closer to her equations and was distancing herself from me. I do not suspect her for having an affair or any thing, but I felt she was not contributing to our relationship. I felt she was not valuing our relationship. Her equation was not an equality.

I got an opening here in Mumbai. I came here thinking that the distance would make her realize my absence and seek me. It did not work out. A couple of months ago I sent a divorce notice to her. Then I saw you. I saw what you were giving after having tasted what you had received. I knew this transcended reason and feelings. I thought I too should choose to love my wife.

Last month I called her and asked her forgiveness. I told her that though I hate Kolkata, I am willing to join her in Kolkata because I choose to love her. To my surprise, she wept. She felt sorry. She felt ashamed to call me and was desperately waiting for me to call. She too asked for my forgiveness as she had not been concerned for me.

She has requested a transfer to Indian Statistical Institute in Bangalore, with the idea that I can join NIMHANS. It is a matter of time that this would come through. I am glad I made the right choice. If I chose freedom as a right, we both would have lost. As I chose love, we both have gained.”

“I am so glad for you, sir. May God bless your marriage.” James blessed as a matter of fact.

Dr Manas held the hands of James and thanked him. Agnes came to the door after buying her medicines. They bid good bye to the doctor. Wiping his tears, the psychiatrist wondered when love as a choice is so beautiful and worthy, why we humans are so reluctant to choose it.

Posted in challenge, distress, drug therapy, emotion, ethics, fiction, love, marriage, psychiatry, schizophrenia, social, statistics | Tagged: , , , , , , , , | 11 Comments »

‘Agreement’ among Psychiatrists and Legal proffessionals:Towards better Mental Healthcare and Justice

Posted by Dheeraj Kattula on October 12, 2009

Consider a psychiatrist who diagnoses ‘severe depressive disorder with psychotic features’ in a patient. He makes diagnoses like this everyday. How can we be sure that he is making a right diagnosis? How do we judge? Usually this would be based on his qualifications and training. Isn’t it? What is training? How does training help?

A psychiatrist learns a set of criteria based on which he makes the diagnosis. He learns this process by observing senior psychiatrists till he begins to identify signs and symptoms just like them. This happens to every student of psychiatry. So at the end of a long period of training every student would probably make same diagnosis on seeing the same patient. Practically this does not happen in all cases. It would be in ‘typical’ cases but not all cases. When two doctors see a patient separately and diagnose a patient to have an illness or clear him as not having an illness, we can say they are in ‘agreement’. When one diagnoses a illness and another clears the same patient as not having an illness, we can say they are in ‘disagreement’.

The criteria for diagnosis are formulated in such a way that agreement of responses is made possible to the maximum extent. For example, we can study two psychiatrists by making them assess 100 patients among whom there are few patients with depressed mood. Each psychiatrist is asked to evaluate for depressive symptoms. At the end of the study usually psychiatrist A and psychiatrist B would have agreed on certain people to have depressive symptoms and certain to not have depressive symptoms. There would be certain people whom A would have said to have depressive symptoms which B would have cleared them off as not having depressive symptoms. There would be another set of people whom B would have said to have depressive symptoms which A would have cleared them off as not having depressive symptoms.

If B was a 10 year old boy who would toss a coin and call all ‘heads’ as ‘depressive symptoms’ and all ‘tails’ as ‘no depressive symptoms’, there would still be some agreement between A and B. This is because of chance. Isn’t it? We can adjust for chance ‘agreement’ and find ‘true agreement’ by calculating a statistic called Kappa. If Kappa is high, it means that level of agreement is high.

Lately, I have found many lawyer friends. I discuss legal issues with them. I have been learning much from them. I also bore them with theoretical questions like this one- what is the level of agreement among judges while sentencing convicts?

For example there are 100 convicts. How would Judges A and B sentence them? There would be few to who both might give strict punishment. There would be few for who both would give liberal punishment (not so strict). There would be few, for whom one would give a strict punishment and another would give a liberal one.

Judge A

Punishment strict

Punishment liberal

Judge B

Punishment strict

🙂

😦

Punishment liberal

😦

🙂

Intuitively the level of agreement ought to be high, if one were to have faith in the legal system. The smiley in the table indicates that there is no problem when there is agreement.The sad face reflects feelings when a person could possibly be getting the wrong sentence.

To my surprise, many of my lawyer friends felt that agreement would probably be less. I was also shocked to see that they were comfortable with this lack of ‘clarity’. I sensed how other doctors perceived the low agreement levels in few of the psychiatric diagnosis. But ‘psychiatric diagnosis’ is of less significance than a ‘sentence’ in court. A disagreement in psychiatry might mean a patient might take a medicine for few extra months. Whereas a disagreement in a court of law might mean a death sentence for someone!!! How can lawyers be comfortable with this sort of system?

There is another principle which operates in the legal system. That principle allows a party to ‘appeal’ to a higher court. Just in case a party feels justice was not delivered in a court of law, then the party could appeal to a higher court. The higher court would look at evidence again and pass a fresh judgement. Courts are organized in such a way that there are 3-4 levels till which a case can be taken up. How on earth does this help? Let us see it- statistically!

Let us assume an average Judge has 90% accuracy in making his judgements. If he were to sentence 1000 people, he would have 900 correct decisions and 100 errors. If these 100 go to a higher court, 90 sentences would be corrected and only 10 errors would remain. If these 10 go to an even higher court 9 would be corrected and only 1 would end up getting a wrong sentence. This model assumes that every judge has 10 % error in judgements. The truth is that as we move to the higher courts there would be judges with less error rates. This is because higher courts have judges with more experience and better track records. This ensures that justice does get served.

Hmmm… Now I know realize why they were comfortable. It reminds me of what I do when I have a diagnostic dilemma in an atypical case. I would ask my peers to see the patient. If we ‘agree’ I assume that we are right. Something like this happens when courts use a ‘jury’. What do I do when my peer and I ‘disagree’? We ask a senior’s opinion. It would be usually someone with more experience and knowledge. Hey…That is like an ‘appeal’ to a higher court in the legal system. What can be done if the agreement among judges at higher courts is low? Make the law more comprehensive and clear! This is similar to what psychiatric researchers do, while revising the diagnostic criteria.

Wow! Is it not amazing to see commonalities in approach of lawyers and psychiatrists? We also share a common desire for our clients. That is the client’s well being. But, it is funny that we don’t seem to understand each other in our arguements. We would…soon 🙂

Posted in law, psychiatry, statistics | Tagged: , , | Leave a Comment »

“Normal”, “Abnormal” and “Label”

Posted by Dheeraj Kattula on June 26, 2009

Warning:

The post might have a lot of jargon,which you might not enjoy. It might be written in a fashion, which may make you feel that author and his thinking is complicated. Don’t worry. He is ‘normal’ only. If you want to stop reading the post mid-way, It might be absolutely ‘normal’. So, no problems with that too. If you call this post bad, I would say you are a ‘label-er’ but not ‘abnormal’. If you say this is written splendidly in Sanskrit, it is only then I could consider you abnormal. Assuming normalcy of some sort I invite you to read the post:

“Normal”, “Abnormal” and “Label”

There would always be debates on defining, what is ‘normal’. There are many models to define what is abnormal.

‘Statistical infrequency’ is one of the models to define what is abnormal. If some thing is rare then it is abnormal. If that be the case gifted people are abnormal as they are rare!

‘Failure to function adequately’ is another model to help not labeling gifted individuals as abnormal. But, who defines what is adequate and what is functioning? Is there a consensus?

‘Deviation from social norms’ is another such model. Social norms vary with culture, context, situation, age, gender, development and historical context (time).

Identifying parameters that are abnormal, considering the possible causes and treating them is a part of routine medical practice. In psychiatry, the parameters are more behavioral in nature.

Is “normal” a dichotomous construct (yes/no), a continuous construct (0-fully dysfunctional, 100-Mahatma Gandhi), or a dimensional construct (Einstein- professionally a genius, politically eccentric, interpersonally deficient)?

If we observe, we might find ourselves in different areas of the normal curve in different aspects. For example when I dance (as I sometimes do), people don’t see me in awe but rather laugh in amusement :-/ ( not so sadly :-)) Dancing Dheeraj

Or when I play cricket, I know the timing of my shots is awful. I might discuss the physics behind ‘reverse swing’ but would never be able to read its trajectory and time a ‘square-cut’ to the boundary. This just shows that I probably am low in Body Kinesthetic Intelligence. A not so sophisticated ‘labeler’ might call me ‘Kinesthetically Retarded’! (Ops! I labeled him a ‘labeler’ :-)) .The more specialized psychiatrists have even a diagnosis for it ‘Developmental Coordination Disorder’. “Diagnoses for all by 2025” seems to be the motto of some psychiatrists.

It is interesting that though we draw clear lines and cut across the parameters as normal and abnormal, most parameters are distributed normally. There are individuals very close to the line drawn but on different sides of it. They end up with different labels/ diagnosis and probably different treatments. Is this not quite terrifying?

Not just that, if the line is drawn somewhere close to the mean, then we have more problems. Take for example Complicated grief, Atypical PTSD (Post Traumatic Stress Disorder), High-functioning Asperger’s syndrome, Developmental Coordination Disorder etc. Besides, some conditions that are abnormal in a majority of settings become desirable in very narrow contexts. For example Anti-Social Personality Disorder in politicians and businessmen, Histrionic Personality in actresses and performers, Schizoid Personality in mathematicians and physicists and so on.

Good news is that most medical researchers consider these statistical issues before formulating guidelines and are not keen on labeling everything and everyone as abnormal. Most Clinicians go by patterns of symptoms, signs, laboratory results and diagnostics not isolated laboratory findings. Clinicians are not bothered, so thankfully not confused about statistical issues!

A good doctor picks up most of the abnormal parameters in his history taking, clinical examination and diagnostic work up, logically thinks through and explains these with the most judicious explanation, considers rarer possibilities and tries to rule them out or in and treats appropriately covering for most possible causes and always tries to relieve symptoms and is less bothered about the ‘label’ he gives to his patients.

Posted in Diagnosis, grief, medicine, personality, psychiatry, statistics | 4 Comments »

Being caught on one side of the ‘cut-off’

Posted by Dheeraj Kattula on May 26, 2009

Have you wondered how marks of an exam are distributed? Normal Curve? Skewed to right? or left? Ok. All answers are accepted. But wait…

Who are the ones who fail? The ones below a “cut off” point.

If the examiner feels only 50 % of the people should pass, the median would be the ‘cut off’ point. At different cut off points the percentage of people who pass and fail differs.

In Life, aren’t cut off points arbitrary? How is the person just above the cut-off better than the one just below it? Let us leave this for the moment and consider a cut-off point such that 40 students of a class of 100 students failed an exam as they got less than 30 marks.

Good news is that the school has ‘supplementary exams’. The exam can be taken again in 2 weeks time and people are given a chance to move on or they would have to repeat the course.

Hey!!! A naughty fellow is taking them for a 10 day trek into the woods. What do you think would happen, if this bunch of 40 students NEVER touched the book in 2 weeks and re-appear for the exam? Would all of them fail again? Remember, they were ‘failures’ in the first place and they wasted the time they got by enjoying themselves. They all ought to fail. Right?

Nope!!! Many of them passed. 35 of them! Only 5 failed again. How is that????

Let us confess that our performance is not stable at all times. We have our peaks and dips. In any exam the bright ones, whose dip would always be higher than the cut-off would always clear. Many average ones, when caught in the peak manage to clear the cut-off and when caught in the dip fail to do so.

Few of the ones who fail to do so, if given another chance through a supplementary exam would clear the cut-off. This happens by pure chance. It need not be due to preparation. If all 100 had re-written the exam may be a different set of 40 would have failed. The ones, who fail repeatedly, show that their preparation was inadequate that even in their peak moments they are not clearing the cut off.

Now if you have failed in your life. Don’t worry. Chance had caught you on the wrong side. There are many on the other side, who aren’t significantly different from you. They are there by chance alone. You will get to that side in a short-time with more trials. Don’t worry. Be patient.

If you have failed repeatedly, friend…you have to work harder. Your peak should go higher.

If you have passed this time and you think you are lucky, thank God. He is the one who made uncertainty a certainty. He favored you blindly as you played dice this time.

If you always pass, thank God again. You are too favored, my friend. You are on the extreme of normal curve of capability. You are here not by chance; you were designed to be here. Also be careful. Life is like a tennis match with many sets and many games. As you play more games, you will encounter dips…you might get caught below the cut off at one point. There is never a case when you need not be thankful and never a case when you need to give up.

Posted in challenge, philosophy, spiritual, statistics | 7 Comments »

“Lies, Damned Lies and Statistics”

Posted by Dheeraj Kattula on May 22, 2009

Warning:

If you cannot stand a bit of statistics/maths or dry humor please stop here. If you do not mind that then, please read the disclaimer.

Disclaimer:

The following research is purely fiction. The quotes are original. The author of the post believes there is some ‘truth’ in these quotes.

———————————————————————————————-

Benjamin Disraeli, the British politician said There are three kinds of lies: DisraeliLies, Damned Lies and Statistics.

It is interesting to know how one comes to such a conclusion. First collect data. Without data you cannot conclude any thing. Here you collect all statements which are ‘lies’. Lies- being defined as that which does not correspond to truth. Truth- being defined as that which corresponds to reality. ‘Lies’ are categories. Also define a continuous variable called ‘distance from truth’. So each lie is distant from truth by some degree.

A huge sample of ‘lies’ is collected. And the distance from truth is noted for each lie. The frequency distribution at each distance is seen.

Hey! You do not get a normal curve (with a single peak at the mean) in this as you get for most distributions. This is a trimodal curve. There are three peaks!!!

On analysis it was found that the ones with low distance from truth were uttered mostly by common people in the sample. These are Disraeli’s ‘lies’. The ones whose distance from truth was farther were mainly politicians. Their utterances were the ‘Damned Lies’.

The ones who were farthest from the truth were researchers, scientists and officials whose lies were officially ‘statistics’.

This is not to say that the scientific community has always got it wrong. It is just to remind ourselves that we have to be humble in science. We could be the ones farthest from truth if we ‘seek’ to find our pet conclusions. Let us remember the Nobel Laureate Ronald Coase’s adage “ If we torture data long enough, it will confess.

Posted in philosophy, science, statistics | 2 Comments »