Richmond Times

February 24, 2009

Sometime in the near future, modern psychiatry’s unborn holy book, the DSM-V, the Diagnostic and Statistical Manual of Mental Disorders, will arrive. In fact, an early draft of the fifth edition of this guidebook of diagnostic criteria for mental disorders, which mental health professionals, researchers, health insurance companies, and pharmaceutical companies use as the basis for their work, is expected to be released later this year for comment.

The bad news is that DSM-V, as its heritage, is cursed with the same bad genes that handicapped modern psychiatry during the past century: a paucity of science.

All scientific arguments must be transparent and open to scholarly scrutiny. If that is true, why have the gurus who are revising the guidebook — the American Psychiatric Association — mandated that the revision process be carried out in secret? Psychiatrists working on the new fifth edition have been required to sign a confidentiality agreement. The total secrecy surrounding the birth of DSM-V is blatantly unscholarly.

The bigger concern, however, is the great likelihood that DSM-V will be an improved version of a system that has already proven to be broken. Regardless of how much improvement can be generated, it is not possible to upgrade DSM-V into a workable guidebook as long as it is based upon a descriptive approach to the definition of very complex neuropsychiatric disorders.

IT IS AS IF a bunch of high school students were to write a diagnostic manual on “how to fix cars”: The book says if the smoke is too black or too thick and comes from the left side, this may suggest a flat left front tire. But there is no discussion about the visual, manual, or mechanical evaluations of different body parts and not even a suggestion that someone must at least lift the hood to check the engine.

Thanks to advances in neuroscience, there are plenty of tests that are crucial in psychiatric diagnosis, including neuroimaging studies (PET or MRI scans of the brain) or laboratory studies.

DSM-IV never included any diagnostic tests. This itself presents a huge problem for modern psychiatry. That is, according to the guidelines of DSM-IV, a psychiatric diagnosis is made without any logical discussion about neuroanatomy, neurophysiology, or highly complex and relevant neurotransmitters such as serotonin, dopamine, glutamate, histamine, acetylcholine, or testosterone that influence human mood and behavior and hence all neuropsychiatric conditions.

The result seems devilish and intellectually impossible. How can a scientific discipline declare a mother and father guilty of inflicting consciously or unconsciously a horrific misery, “depression,” or “schizophrenia” as modern psychiatry did throughout the 20th century?

The very people who came up with the absurd ideas of blaming bad mothers and fathers for psychiatric disorders were also the same people who came up with DSM-I, II, III, and IV — and are now getting ready for V. How long and how many centuries will it take for American psychiatry to take corrective action to catch up with science? Is this a measure of progress for psychiatry or medicine? And if it is, what is progress? How could it be justified or still defended that modern psychiatric terminology does not have any connection to neuroanatomy, neurophysiology, and neurotransmission? How can American psychiatry get away with such nonsense and at the same time promote the idea that until the new holy book is born, secrecy is the best thing? And how can American psychiatry name various psychiatric disorders with pejorative terms such as “borderline personality?”

THE BEST REASON to declare the current DSM system dead is that it is a barrier to progress in the treatment of serious neuropsychiatric disorders. The difference or conflict between modern psychiatry and scientific knowledge partly explains why progress in neuroscience, for example in the treatment of schizophrenia, has been excruciatingly slow when compared with other equally destructive and progressive disorders, such as AIDS, tuberculosis, syphilis, diabetes, or hypertension.

Many schizophrenic symptoms can be logically explained consistent with our current knowledge of brain physiology and neuroanatomy — e.g., symptoms such as hallucinations, paranoia, delusions, agitation, or intellectual decline. Science says such symptoms are rooted in neurotransmitter dysfunction of specific brain regions such as amygdala, hippocampus, hypothalamus, or the brain cortex. But none of these relevant data can be found anywhere in the DSM system.

What modern psychiatry faces today is not much different from Galileo Galilei’s conflicts with the church during the dark ages. How can we address problems with a complex illness like schizophrenia without offending the established powers of APA, NIMH, and even the judicial system, which heavily relies on DSM-based diagnoses incompatible with science?

The good news is there is no reason to delay progress. It is possible to develop a simple and biologically sound system that will be the premise for defining psychiatric disorders. Basically, the mental health professions should adopt a medical approach.

The truth is, we have all the knowledge to be able to do it, yet our current bureaucratic and institutional systems must be ready for a paradigm shift. The truth is also that until the world of psychiatry changes its approach to diagnosis of mental disorders, we will still be locked in the dark ages of science and medicine.

Alen J. Salerian, a psychiatrist, is the medical director of the Washington Center for Psychiatry. Contact him at (202) 244-3815 or rcolbert@salerianbrain.com .

March 11, 2001

By Alen J. Salerian, MD

In the mid-1990s, the FBI sent me to a Southern city to do a psychological evaluation of one of its undercover agents. The reason: The agent was having an affair with a member of the criminal organization he was investigating.

I spent about a week there, talking with the agent in various restaurants and bars, my back always to the entrance so he could keep an eye on who came through the door. During our meetings, the agent seemed quite calm, unfazed by either his dangerous assignment or the firestorm his behavior was causing at headquarters.

He was remarkably candid about what motivated his reckless sexual conduct: anger. Behind his cool exterior he was seething, because he believed the exceptional caliber of his undercover work was not fully appreciated by his superiors. And this unnecessarily risky escapade was his way of punishing the uncaring agency.

Luckily, our work had a successful ending. The agent was gradually extricated from the assignment without arousing suspicion, and he soon retired from the bureau. His final words to me were: “I know I crossed the line and was going to do more. Thank God you came along.”

I have been thinking of that agent and what “more” he might have done since the headlines first appeared about Robert Hanssen, the FBI agent accused of betraying his country beginning in 1985. Were there signals that a professional evaluation would have picked up? Could a psychiatrist have identified Hanssen as a possible threat years before a double agent fingered him as a spy?

Very likely, the signals were there. But very likely they wouldn’t have been picked up — because the FBI doesn’t require regular psychological evaluations of its agents. This is a painfully obvious lack in bureau security. When personnel are hired, they go thorough physical and psychological screenings. After that, however, only the physical exams are routine, even though these employees are subject to stresses and pressures far beyond what most people experience. The FBI keeps regular tabs on its agents’ weight and blood pressure — but not their emotional stability.

It’s not that the bureau doesn’t believe in the usefulness of psychology — consider, for example, its use of extensive profiling to understand and identify serial criminals. And in crises involving its agents, it often relies on the tools of modern psychiatry. From 1992 to 1997, in fact, I worked regularly with the FBI; I helped develop and was medical director of the bureau’s Mobile Psychiatric Emergency Response Team. I trained many counselors and went out on assignments myself, working with agents everywhere from U.S. embassy compounds abroad to Waco, Tex. Not all the agents I have worked with were undercover, but I have evaluated dozens of men and women with secret missions and double lives.

So, while I don’t know Hanssen or pretend to understand his particular case, I understand a great deal about undercover agents. And I believe that regular evaluation of all agents might help expose threats and prevent security disasters.

Let me be clear about something: The overwhelming majority of the bureau personnel I have met are tough, intelligent and stable, with an unswerving dedication to their work. And the bureau itself is, in my view, a singularly well-managed and effective organization. My only concern here is identifying the rare potential problem.

Most secret agents I have met have two signature traits: fearlessness and a high tolerance for anxiety. Whether because of biological factors, such as an elevated level of the mood-enhancing neurochemical serotonin, or because of the influences of their early lives, these people seem to be extreme risk takers who can tolerate and manage worry, tension and stress with natural ease. Not surprisingly, their steely nerves are often perceived by others as aloofness or arrogance.

These characteristics, combined with stamina and the sharp intellect of a skilled chess player, are requirements for a profession distinguished by calculated risk taking in the face of constant danger. “It’s not about money or anything else,” the agent who “crossed the line” in that Southern city said. “It’s about the rush I get when I’m outsmarting them, having a quiet dinner with the enemy in his own home and slowly building the fire to burn him.”

“What about fear?” I asked.

He smiled. “My only fear is not building the perfect fire.”

Though unshakable on assignment, this agent nevertheless displayed a brittle self-esteem easily shattered by his superior’s disapproval or rejection. In this way, too, he was similar to many undercover agents I have known. They have an intense narcissism — the flip side of their confidence. They need constant positive input, and they can only get it from two sources. The first is self-esteem, which is provided by constant mastery of their roles; winning is very important. The second is feedback from their superiors, a need that makes them very vulnerable to real or perceived slights. Not merely criticism but the simple absence of praise can enrage them.

When most of us get angry at the people or system we work for, we vent our frustrations by talking with family or friends. If we get really angry, we might retaliate in straightforward fashion by turning against the boss or organization we perceive as abusive.

Spies, however, can’t vent about their work to their loved ones, because their profession demands absolute secrecy. Their necessarily lonely lives offer none of the safety valves that help the average disgruntled employee cope with stress.

Also, if they decide to take revenge, these people bring extraordinary knowledge, skill, intelligence and — perhaps most important — daring to their plans.

In 1996, the nation’s interest was caught by the case of Eugene Bennett, the former FBI agent who kidnapped his pastor in Northern Virginia. Bennett was angry with his estranged wife, who was intimately involved with crime novelist Patricia Cornwell. But his problems had been building long before he confronted his wife in the church where he had tied the pastor to a chair along with a phony bomb.

I know because, a few years earlier, Bennett had come to me for psychological counseling. It was a rare occurrence for an FBI employee to seek me out on his own, but Bennett clearly knew he was in trouble. Like any good spy, he had done his homework — checked out my background and security clearance, concluded that he could confide in me. Also true to form, he maintained outward control: When he called me, his voice was a monotone, his words cryptic. And during our meetings, his face would remain expressionless.

We met eight or nine times over a period of about six months. One day, something apparently spooked him, and he suddenly vanished into silence and never spoke with me again.

For ethical reasons, I cannot reveal what he told me during those meetings, or how I responded. But because his bizarre case was eventually part of the public record — he spent 12 months in federal prison on a fraud charge even before his conviction on charges including attempted murder and abduction — I can say he was a dangerously volatile character. By the time Bennett called me for help, he was already on administrative leave, in the midst of a publicly messy divorce and fraud investigation. The question is, could some kind of screening have spotted his problems while he was still working undercover in highly sensitive assignments?

It would be wrong to make my argument too simplistic — that certain agents get angry, have no outlet for their rage, and turn to violence and betrayal. These are complex people with paradoxical personalities. An inflated yet fragile ego is a highly combustible thing.

But that is exactly the challenge to the FBI: how to predict who is approaching meltdown and how to prevent that final explosion — or the hidden revenge of secret betrayal. There has been much discussion of lie detector tests, and I believe that regardless of their imperfections, such tests could help identify security risks. But they should be part of a broader, regular psychiatric evaluation.

I have been called to work with the bureau many times after an agent’s mental health was obviously in question. I remember a female agent who was beginning to get reckless and endanger her assignment. She turned out to be the only woman in a highly chauvinistic unit, repressing anger at superiors who merely urged her to “tough out” the harassment. And there was the counterterrorism expert based at a U.S. embassy in the Mediterranean, whose hidden frustrations only came to light when he became publicly abusive toward his wife and child.

Both cases had happy endings: The female agent was removed from the hostile environment and placed successfully in another assignment; the counterterrorism expert received extensive counseling and managed to keep his job. I was pleased and fortunate to be able to help an agency for which I have immense respect.

My disappointment, though, is that too often my fellow counselors and I are called in only after events seem to be getting out of control and there is a possibility of real damage. This reactive response is not enough. As the bureau looks into what might have made Robert Hanssen “turn” in 1985, it should seriously consider a systematic, proactive program to monitor all its agents’ psychological well-being. Both the agents and the country deserve it.

By Alen J. Salerian, MD

I have a simple question for my 50,000 and some psychiatric colleagues who gathered in San Diego at the annual American Psychiatric Association’s meeting: Does it matter to say, “I’m sorry?”

The capacity to acknowledge past error is a reliable measure of human progress. Modern Germany acknowledged their wrong against Jews, Gypsies and homosexuals. Americans acknowledged past wrongs against Japanese Americans during World War II. Neither modern nor Turkey nor modern psychiatry ever said, “I am sorry”.

As a practicing psychiatrist in Washington, DC, I still feel guilty for my past errors, and in particular for the pain I caused as a young doctor pontificating to the parents of the mentally ill by suggesting that their parental failings handicapped their loved ones with schizophrenia, schizoaffective disorder or bipolar disorder.

At least until the mid-1980’s, myself and many of my colleagues believed that toxic parenting produced psychotic offspring. I am ashamed to recall that part of my message was subtle, unspoken yet powerfully conveyed: Had you done your job better, your son or daughter would not have developed schizophrenia or bipolar disorder.

Neuroscience has now proven that severe psychiatric disorders are almost always caused by highly complex genetic and environmental factors including psychological events, but rarely caused by parental failures. Since the mid-1980’s, neuroscience proved that it is bad genes and unlucky biology in combination with complex environmental factors including psychosocial forces that contribute to the development of severe psychiatric disorders.

Despite the certainty that bad parenting is not responsible for severe psychiatric disorders, APA has never publicly acknowledged our collective past failings.

Sadly, I had my own painful and unnerving experience with psychiatric colleagues who were ignorant of their own prejudicial attitudes toward families of the mentally ill. A few years ago I had my first encounter with modern psychiatry.

Soon after my book of cartoons “Honest Moments with Dr. Shrink” was published, I had become the target of an investigation by the Washington Psychiatric Society, the local chapter of the American Psychiatric Association. Dr. Shrink, my fictional arrogant, self-centered contemporary version of Archie Bunker attempting to expolse modern psychiatry’s failings, and myself, the creator of Dr. Shrink were accused of insanity.

The APA sent a polite, guarded, senior psychoanalyst to see the exhibition of my cartoons at the Watergate Gallery and to talk with me. He meticulously scrutinized every cartoon and then interrogated me personally. I still recall that blank flatness of his expression as he struggled to find any humor in the cartoons I had drawn.

One in particular depicted Dr. Shrink praying, “My Lord, forgive all analysts for torture, for abuse and the guilt-induced deaths of mothers of the insane.”

“I can not find any humor in your creative work, Dr. Salerian,” the visiting psychiatrist said, his eyes glued to Dr. Shrink and the cartoon where a patient was asking Dr. Shrink, “Are you really weird, Doc? Or do you only act weird when I see you in public?”

“Your sense of humor is beyond me,” he commented. “What is your point?”

Luckily in the end I, and maybe even Dr. Shrink were found sane by the APA representative.

As a member of the APA and as a psychiatrist, I am sorry for my failings, and I publicly want to say as much to all the family members of my patients whom I offended by suggesting that they were responsible for their relatives’ mental illness. I kindly request their forgiveness. I also request that my colleagues at the APA formally acknowledge their past wrongs and the harm they caused to millions of Americans with severe psychiatric disabilities and their families.

Any APA meeting, without an appropriate apology for past wrongs, will be a failure now or in the near future.

WUSA9.com

April 4, 2007

Alen J. Salerian, MD quoted

By Leslie Foster

(WUSA) — Parents taking their own children’s lives, then their own. It seems unthinkable. In just over a week, two communities and two families know all two well that it can happen. Last week, a Frederick father killed his four kids then himself. Tuesday, a Montgomery County father killed his two children in Boyds, Maryland. Psychiatrists say these kinds of deaths at the hands of a parents are a common occurrence. They call them mercy killings. “It’s a package deal of suicide and homicide,” says psychiatrist Dr. Alen Salerian. “But suicide is the real intent.” Salerian says the parents who’ve decided to take their own lives wonder about the kids they would leave behind. And, he says sometimes those killings are the result of someone who wants to settle a score. “There is the intent to punish somebody,” says Salerian. While some people may wonder how these horrific crimes could take place, Salerian says there is a logical answer: mental illness. “Mental illness, suicide, murder does not happen overnight. There are some frightening sounds that this person usually gives and very often the people around them ignore it.” Salerian says people need to educate themselves about mental illness and ways to prevent tragedy before it happens. He wonders who might have seen something in the cases involving the children killed in Frederick and those found in Boyds but never intervened. To learn more about the signs of mental illness and how to get help, check out the links attached to this story.

The Armenian Reporter International

October 1, 2005

(about Alen J. Salerian, MD’s reception of an award)

On Friday evening, August 19, 2005, Armenian psychologists convened at the Grand Hyatt Washington Hotel for the seventeenth gathering of the Armenian Behavioral Science Association (ABSA). This two-part gathering was part of the 113th annual convention of the American Psychological Association
(APA), and was chaired by Professors Harold Takooshian and Anie Kalayjian of Fordham University in New York.

The gathering began with a report on the activities of ABSA, which was formed in New York City in 1987. Participants at the meeting introduced themselves and gave a series of brief reports on their diverse groups and activities.

These included the American University of Armenia (www.auamirror.com), Meline Karakashian’s Hokeban (www.hokeban.com), Anie Kalayjian’s Armenian American Society for Studies of Stress and Genocide (www.meaningfulworld.com), the harrassment in Yerevan of the esteemed Dr. Carolann and George Najarian (www.najarian.info), Hayk Kaftarian’s Armenian American Health Association of Greater Washington, which was started after the 1988 earthquake in Armenia (www.aahagw.org), Jane Mahakian’s new Armenian Alzheimer’s Association (www.alzarmenia.org), and Samvel Jeshmaridian’s announcement of a new Armenian bookstore on-line (www.zangak.com).

The second part of the August 19 gathering was the ABSA awards presentation and gala reception. Over a festive buffet, 75 guests heard messages by two of the 2005 ABSA Distinguished Achievement Award, for outstanding contributions to the behavioral sciences.

Mark Krikorian, the longtime Executive Director of the Center for Immigration Studies, spoke about his extensive studies in Yerevan and the Middle East, which led to his becoming one of the most articultae experts in the USA on immigration reform.

Psychiatrist Alen J. Salerian, the Director of the Washington Center for Psychiatry and former Chief Psychiatric consultant to the FBI, offered a riveting presentation on his brilliant interdisciplinary work on “evidence-based history,” including a major new international project he is now completing, which may be ready for public announcement later in 2005. Redears can check salerianbrain.com.

Dr. Salerian is a noted psychiatris, who has earned national and international accolades for his treatment of psychiatric disorders, his pioneering work in forensic psychiatry and his research on a variety of topics, including President Franklin Roosevelt’s impaired state of mind during his last years in the presidency.

The popular, recently published book titled “Will’s Choice”, written by Gail Griffith, features Dr. Salerian as the psychiatrist who helped save Ms. Griffith’s depressed, suicidal son.

Dr. Salerian is also kown as a frequent contributor to medical journals such as the Lancet, The Journal of Clinical Psychiatry and numerous national newspapers such as The Washington Post, The Los Angeles Times and USA Today. He has appeared on news shows as an expert commentator on numerous occasions, including such programs as CBS’s “60 Minutes”, and “48 Hours”, and BBC’s “Panorama”. He is a regular analyst on the Washington, DC CBS affiliate WUSA.

On this occasion Samvel Jeshmaridian, PhD, of Yerevan Ajarian University, sent the following congratulory email: “Greetings from Yerevan. My friends and colleagues in Armenia and Artsakh and I wish ABSA participants fruitful work. My congratulations to Mark Krikorian and Professor Alen J. Salerian.”

The gala reception was sponsored by admirers of Dr. Salerian, and organized by a special committee headed by Lynn Beavers and Shawntell Bell of Washington, DC.

The Baltimore Sun

2002

By Alen J. Salerian, MD

In the war on terrorism, we face a new enemy – suicidal killers who kill in the name of God and rejoice not just in the deaths of their victims, but in their own deaths. To fight these killers we must better understand how their minds work.

I have studied and treated suicidal killers extensively in my 25 years as a psychiatrist, including seven years as a consultant to the FBI. Based on available evidence, I believe the hijackers who killed more than 5,000 people at the World Trade Center, the Pentagon, and in Pennsylvania Sept. 11 were not mentally ill. Instead, they were sane men who trained themselves to imitate the behaviors of madmen.

Like almost all people who commit murder-suicide, these terrorists were motivated by three deeply held convictions: a determination to die; a belief that their victims were evil and must be killed; and a belief that death would give them a ticket to heavenly paradise or at least an exit from pain.

The same motivations drive Palestinian terrorists who have strapped explosives to their bodies and turned themselves into human bombs to kill as many Jews as possible in Israel.

Unlike people who become psychotic killers because they suffer from damaged or diseased brains, suicidal terrorists go through years of indoctrination in fanatical social, political and religious beliefs that glorify killing and suicide. This psychological conditioning enables the terrorists to kill not just with clear heads but with pride.

The Sept. 11 hijackers saw their victims as villains and considered the blood bath they initiated to be a ritual of holy purification that would pave their own paths to heaven. In fact, the hijackers saw their victims as subhumans who deserved to be exterminated. The same view was held by the Nazis who slaughtered 6 milion Jews, the Ottoman Turks who annhialated more than 1 million Armenians in 1915 and the Communist death squads that liquidated millions under Stalin, Mao and Cambodia’s Pol Pot.

In their own minds, the terrorists who attacked America were soldiers willing to die for God, in a tradition going back to ancient times.

Psychiatry offers no magic bullets to stop suicidal terrorists once they are committed to their deadly missions. Only real bullets and bombs, heightened security and improved intelligence can save us at that point. No one would suggest parachuting a battalion of psychiatrists into Afghanistan.

But we do have a chance to prevent the impressionable young people from falling under the spell of terrorist trainers like Osama bin Laden, who turn them into robotic killers. The key is to act early, before children and youths undergo years of indoctrination in schools where they are taught to hate, to glorify killing and to perpetuate ancient feuds.

The boy taught every day that Americans must be killed can grow into the young man willing to sacrifice his own life to kill Americans.

Tomorrow’s terrorists learn to worship at the altar of violence under the tutelage of groups like bin Laden’s al-Quaida, which thrive in dictatorships where they get sanctuary and support. A vast network of terrorists could never grow up in America with government approval and financial backing. Democracies arrest terrorists – dictatorships empower them.

From a psychological point of view, the best way to stop terrorism from taking root in young minds is to plant the seeds of democratic values: freedom of speech, freedom of religion, free elections and tolerance of others. When a nation embraces these values it presents a hostile environment for terrorists.

Only a utopian would believe that the spread of freedom and democracy would end terrorism, but it certainly would reduce the ranks of potential terrorists and make the world safer. This is why President Bush – though not a psychiatrist – is showing keen understanding of the human mind by emphasizing freedom and human rights as guiding values that we must spread around the world in our battle against terrorism.