“What Is the Function of the Brain?” by Laura K. Kerr

reblogged from Trauma’s Labyrinth

If you haven’t checked out Trauma’s Labyrinth yet, DO IT.  Its curator, Laura Kerr is a psychologist specializing in trauma and her blog is a must-read for anyone in the process of recovery. Her writing is academic but accessible, a great balance of scientific evidence and artistic/literary sensibility. Go read it, please.

Based on her ethnographic study of psychiatric residency programs, anthropologist T.M. Luhrmann concluded psychiatry is “of two minds”: one “mind” emphasizes the role of neurochemistry, while the other “mind” places more importance on the context of our suffering, including relationships past and present.

Identifying the origins of mental illness likely depends on both interpretations. There is an undeniable organic component to mental illness, just as psychological and social conditions are inexorably linked to mental well-being. But like the Democrats and Republicans, these two approaches are often pitted against one another, often leading to that old, tiresome nature versus nurture debate.

Unfortunately, in a world of limited resources, including limited time, the implicit guiding question — Where should we place our focus? — naturally divides our attention. Is it helpful to explore genes and neurobiology in our efforts to reach best outcomes? Or is it better to explore the social conditions that contribute to mental disorders? Unfortunately, much like U.S. politics, the treatment of mental illness often is derailed when such questions become fodder for polarizing arguments that serves allegiances and professional agendas more than persons in the throes of mental suffering.

Instead of worrying if nature is more influential than nurture, perhaps it would be more helpful to identify what counts as optimal functioning for the brain. Perhaps we could then focus on the value of combining information, thus leading to better outcomes rather than increased competition (and often, market share). I think the significance of function often gets overlooked because we aren’t adept at looking at any issues from multiple levels. Although the term biopsychosocial was coined to address the issue of scale and focus in the treatment of mental illness, it often feels piecemeal in approach.

How might we identify the causes of mental illnesses in ways that address their biological, psychological, and social aspects without parodying the impact of any of them?  Furthermore, what stands in the way of answering such a seemingly straightforward and important question?

More than any other arena of healthcare, the mental health field is paralyzed by politics, disciplinary boundaries, and financial stakes competing to define the disorders it treats and studies. I have wondered what it would be like for all of us who either work in the field or receive treatment for a mental disorder (a Venn diagram of these two groups would show a big overlap) to restart our quest for mental health and well-being with the very simple question:

What is the function of the brain?

With this question, I think we might begin treating the brain like any other organ of the body, and not according to its current exalted status. Appropriate treatment would “simply” mean returning the brain to its optimally functioning state. I believe this question could also encapsulate the complex relationship between biology, self, and society that complicates understanding the nature of mental illness as well as identifying best treatments.

Typically, something is perceived as a disease or trauma when it interferes with an organ’s proper functioning. By knowing the function of an organ of the body, it follows that healing that organ involves returning it to its homeostatic, functional state. Thus, what counts as disease or trauma are those things that interfere with normal functioning. For example, we know the function of the heart is to repeatedly and continually pump blood through the blood vessels, and anything that interferes with this process would be identified as disease or trauma. Similarly, the functions of the stomach include storing food during a meal and breaking down food particles into molecules small enough to be absorbed by the small intestine.  Whatever interferes with these functions is treated as disease or trauma.

We can identify the functions of every major organ of the body — the lungs, the skin, the intestines, the skeleton, the immune system — and with this knowledge, both diagnose and treat the causes of disease or the effects of trauma. Whereas there may be many paths to the cure, there is nevertheless a shared understanding of how the organ is meant to function. This simple approach seems to evade the mental health sciences, and I wonder if this is because there is a lack of agreement about the function of the brain.

We know the brain is part of the central nervous system, which functions like a command center for the rest of the body as well as gathering sensory information from the environment. The neurochemical model of mental illness relies heaviest on this understanding of brain functioning, particularly given its focus on neurotransmitters. Having a well-functioning central nervous system certainly seems central to mental well-being, yet it is also likely only one contributor to mental illness, and cannot adequately account for the psychological and social impairment also associated with mental illnesses. Although this model of mental disorders is not necessarily wrong, it nevertheless is too limited in scope to grapple with the myriad phenomena we associate with mental disorders.

An alternative model of the brain has emerged with research into the neurobiology of trauma as well as research into the different regions of the brain. With this model, the brain is understood more in terms of the functions of its components and adaptation to environmental conditions, especially the environments created through our relationships with significant people in our lives. This is an important change in scope from the biochemical model of mental illness that seems to rest on the “command, control, communicate” metaphor that has dominated information systems thinking since World War II.

In contrast, the neurobiology of trauma model examines how specific areas of the brain — often depicted as three primary regions: the cortex, limbic system, and brain stem — take part in the process of gathering information from the body and the environment, synthesizing this information, and then acting in accordance with often implicit needs or desires. In particular, two dominant action tendencies are thought to organize how the brain functions, which also correlate with two dominant environmental conditions:

• conditions of attachment and normal daily activities, and
• conditions requiring defense (i.e., fight, flight, freeze, submit, cling).

From the perspective of the neurobiology of trauma, sociality, and the capacity to engage with others in meaningful and pleasurable ways, is inversely related to the amount of traumatic stress a person experiences. Too little of the conditions that contribute to sociality, along with too many of the conditions that activate defense responses (including low levels of chronic stress), lead to poor mental functioning. And yet both functions — surviving in states of peace and in states of defense — are necessary functions of a healthy brain. (Thus an added benefit of the neurobiology of trauma model is that it replaces notions of pathology with notions of adaptation.)

The neurobiology of trauma model of the brain can also incorporate the functions of the central nervous system associated with the biochemical model of mental disorders, especially when the primary function associated with the brain is this concept of sociality. When the brain is seen as primarily a “social” organ, it seems to have two main functions:

1. to communicate with the rest of the body in the creation of a coördinated response to stimuli (creating an ‘internal’ society of sorts); and
2. to communicate with the world in the creation of a self among others selves.

When the primary function of the brain is seen as sociality — both within our own psyches & bodies and with other people — mental illness could then be simplified to include

• interference with the capacity for internal communication that contributes to authentic self-care;
• interference with the ability to be a self among others, and thus feeling relaxed and safe in the presence of others; and
• interference with the capacity to maintain meaningful and supportive relationships.

Just as there are many ways for the heart, stomach, or any organ to be diseased or traumatized, there are many ways for the brain to lose functionality. Impairment does sometimes result from genetic predispositions, although typically in combination with physiological stressors such as exposure to toxins, exposure to bacteria and/or viruses, poor diet, high levels of stress, and injuries that alter the physiology of the organ or impairs its normal development. Also included in these physiological environmental stressors are traumas such as adverse childhood experiences, assault, combat, and other situations where people hurt people, thus not only overly activating defense responses, but also altering the capacity to function as social beings.

Both nature and nurture are undoubtably contributing causes to mental disorders. But perhaps we should think of them as either less or more relevant depending on which lens best helps people regain functionality — both in terms of their inner and outer sociality.

Another way of thinking about this would be in terms of integration. Feeling internally integrated lessens the sense of internal fragmentation. And integration is central to mental well-being. Feeling internally fragmented demands a lot of energy and attention, and often leads to isolation and limited integration with the larger community, hence also limiting the capacity for sociality.

Lacking the capacity for sociality seems central to the suffering associated with mental disorders, irrespective of the cause. And isn’t the reason we have any type of healthcare is to help people overcome suffering? Sometimes when overloaded with competing theories, professional agendas, and the potential for large profits, we lose sight of this otherwise straightforward goal. Yet if we can agree on the primary function of the brain, I think we can also be more astute in our choices about what counts as best treatments.

Insomnia, my old frenemy

Insomnia. I gave up on sleep after two hours of lying awake in bed. I tried to counteract it with Benadryl and Valerian root, but no dice. I usually wake up at 5 AM to make my husband breakfast and see him off to work. This morning I’ll just stay up until then. I’ll crash sometime later in the morning. The day will be a wash, but luckily I’ve nothing on my agenda that can’t be rescheduled.

My brain often speeds up at night. I start lighting on insights and deconstructing everything, and snatches of songs I’ve listened to during the day play in my head in a relentless loop. I used to feed it. Now I fight it. Being a restless night owl works better when you’re in your twenties.

My depression and mood swings are more manageable when I’m on a 9-5 schedule, but I often feel like I’m fighting my nature. My frosted side whines: why shouldn’t I follow my inclinations to stay up all night writing, watching Game of Thrones, and bopping around online? It’s fun. It feels good.

The next day, however, feels awful. Today will not be fun. Today will be a mulligan. It’s just the way it is, and beating myself up about it isn’t productive. I’ll need to reset my clock: more Benadryl and Valerian root. Maybe a shot or two for good measure. Tequila agrees with me a hell of a lot more than Trazadone does. That shit gives me nightmares. And I don’t hit the bottle much. I haven’t done so much as a shot since the weekend before Halloween. I can finally justify buying a bottle of Espalón.

I know I don’t do enough. I don’t exercise enough. I rarely meditate. And I haven’t been eating well the past few days.  I admit it, I’ve been slacking.

When I was a child, I tried the conventional remedies that I gleaned from books and television. Warm milk didn’t do anything besides upset my stomach. I counted sheep well into the hundreds. When none of that worked, I often sneaked books out and read them by flashlight. It got to the point where I hid two or three flashlights because my parents started checking on me and confiscating them. I remember my father being roused by the noise from me playing in my rocking chair before dawn and dragging me back to bed. I remember him accosting me in the hallway late one night and telling me that if I couldn’t sleep, I should just lie there and rest. I resented him at the time, but now I’m grateful that they didn’t try to drug me with sleeping pills.

In high school, I stayed up writing frantically in my journal and purging the day’s pain with a crying jag, screaming sobs into my pillow and gulping  vodka filched from the kitchen cabinet. When I grew too restless, I’d creep out of the house and wander. I walked down back roads lined with stone walls built centuries ago by colonial farmers.  I walked through moonlit woods hallucinating that the trees were following me. I walked to the houses of boys I had crushes on. Cops would find me and put me in the back of their cruisers, lecture me while they drove me home, and deposit me at my door with empty threats of alerting my parents if they caught me out again.

Sometimes fatigue would set in on the walk back and I’d accept a stranger’s offer of a ride home. I’m incredibly lucky that I was never outright assaulted, that on the occasions I felt unsafe I was able to exit the vehicles and get away.

In college and grad school, I worked late into the night reading and writing. I loved it, but it wreaked havoc on my mood. I plan on going back to grad school and I’m not thrilled at the prospect of only working during the day and sticking to a schedule. Studying and writing in manic spurts has always been my M.O.

When I was emceeing and performing burlesque, I stayed up late doing shows and then winding down with other performers afterwards. Musicians and theater folk tend to keep late hours. I loved it, but again, not the best thing for my moods. It’s one of the primary reasons I gave up performing.

My brain functions differently at night. I feel more inspired, creative, and insightful. I do not enjoy fighting that.

I’m starting to fade. I’ll go back to bed after I make breakfast. Bring on the mulligan.

“What is Normal?” by Peter Kramer

Peter Kramer is a professor of psychiatry at Brown University. His article “What Is Normal,” first published in 2009, attempts to address concerns about the impending fifth edition of the Diagnostic Statistical Manual, primarily that expansions in psychiatric diagnostic labels and criteria would result in pathologization of “normal” human affect and behavior. You don’t have to subscribe to antipsychiatry to conclude that some of these concerns have been validated, an oft-cited example being the removal of the “bereavement exclusion” from the diagnostic criteria for major depressive disorder.

Still, Kramer offers a fresh perspective on the issue, arguing that expansions of psychiatric diagnoses not only have the potential to vastly improve people’s quality of life, but can  also alleviate isolation and stigma, provide insight into our sociocultural context, and enhance our understanding of the human condition. He also sheds light on some of these expansions’ epistemological origins.

I’ve included and emphasized what I consider the most salient excerpts from the article, which you can read in its entirety here.

 

I have been thinking a good deal about normality lately. It’s a concern in the medical world. The complaint is that doctors are abusing the privilege…to define the normal. Ordinary sadness, critics say, has been engulfed by depression. Boyishness stands in the shadow of attention deficits. Social phobia has engineered a hostile takeover of shyness.

….

The fate of normality is very much in the balance. The American Psychiatric Association is now revising its diagnostic and statistical manual—the next version, DSM-V, should preview in 2011 and become official the following year. It may, indeed, be that as labels proliferate, mental disorders will annex ever more territory. But claims of a psychiatric power grab are overstated. The real force behind a proliferation of labels is the increasing ability of technology to see us as we’ve never been seen before. Still, the notion of a shift in the normal invites unease: To constrain normality is to induce conformity. To expand diagnosis is to induce anxiety. Is anyone really well?

It’s a short hop from critiquing narrowed normalcy to claiming that we are an overmedicated nation. As [Christopher Lane, author of Shyness: How Normal Behavior Became a Sickness] writes, “We’ve narrowed healthy behavior so dramatically that our quirks and eccentricities—the normal emotional range of adolescence and adulthood—have become problems we fear and expect drugs to fix.” Psychiatry’s critics also complain that doctors medicate patients who meet no diagnosis, who practice what I have dubbed “cosmetic psychopharmacology,” to move a person from one normal, but disfavored personality state, like humility and diffidence, to another normal, but rewarded state, like self-assertion.

Labels matter even when medication has no role in treatment. A wife complains that her husband lacks empathy. Does he have Asperger’s syndrome, a lesser variant of autism, or is he simply one of those guys who “don’t get it,” who simply don’t see social interactions as ordinarily perceptive women do?

Diagnosis, however loose, can bring relief, along with a plan for addressing the problem at hand. Parents who might have once thought of a child as slow or eccentric now see him as having dyslexia or Asperger’s syndrome—and then notice similar tendencies in themselves. But there’s no evidence that the proliferation of diagnoses has done harm to our identity. Is dyslexia worse than what it replaced: the accusation, say, that a child is stupid and lazy?

The question of normality creates strange paradoxes in the consulting room. Often it is relatively healthy people who feel defective. In psychotherapy, patients may perseverate over vague complaints, feeling off-balance and out of sync. The worriers may believe that they have too much or, more often, too little ambition, desire, confidence, spontaneity, or sociability. Their keen social awareness (a strength), when tinctured with obsessionality, causes them to fuss over glitches in the self. For them, a sense of abnormality precedes any diagnosis and may persist even when none is proffered.

In contrast, seriously ill patients may have no such concern. Those who manifest frank paranoia will insist on their normality; anyone would be vigilant in the face of plots directed at them. Anorexics and alcoholics may profess certainty that they’re fine; the degree of “denial” is something of a marker for severity of disorder.

People afflicted by disabling panic or depression may fully embrace the disease model. A diagnosis can restore a sense of wholeness by naming, and confining, an ailment. That mood disorders are common and largely treatable makes them more acceptable; to suffer them is painful but not strange.

In other words, in the clinical setting, the proliferation of diagnoses has diverse effects, making some people feel more normal, some less so, and touching others not at all. There is no automatic link between a label and a sense of abnormality.

Still, diagnosis can seem to confer stigma. I recall a patient, Roberta, who consulted me because her marriage was in trouble. Her husband resisted couples therapy. Might she see me alone?

In my office, Roberta was listless and slow of thought. Her memory was vague. Was the problem thyroid disease—or an occult cancer? Roberta willingly submitted to a workup by an internist. She was devastated when she was referred back for treatment of depression.

To Roberta, the mood disorder label confirmed her husband’s complaint that something was wrong with her as a person. To be called depressed rather than, say, anemic constituted double jeopardy: She was in pain and she was flawed, in judgment and in character. She was unloved—and, now, abnormal.

Despite her misgivings, I asked Roberta to consider psychotherapy, exercise, bright lights (for winter in New England), and medication. I wanted her to be functioning well quickly, before she made irreversible decisions about her marriage.

The case had a memorable outcome. Only when she was better did Roberta reveal that at her low point she had contemplated suicide. Her summary comment was, “The fights with my husband saved my life.” They caused her to be diagnosed—and treated.

When she first spoke with me, Roberta seemed to display normal sadness, that is, emotional disruption in the face of a life crisis. Psychiatry’s critics are right: Roberta experienced the diagnosis as stigmatizing, and it led to her taking medication. But the case also illustrates why, for doctors, making diagnoses and educating patients about them is not a matter of choice; diagnosis can be lifesaving.

Just where does the impetus to expand diagnosis originate? A recent public flap highlights how categories proliferate. Raymond DiGiuseppe, a psychologist who researches anger, made headlines last spring when, at a scientific meeting, he argued that the DSM should add anger disorders, to parallel depression and anxiety disorders. There is a point at which anger becomes harmful, he contends. When scholars immerse themselves in an area—carefully observing research subjects, making note of differences and attendant harm—new sets of diagnosis seem obvious and inevitable. It doesn’t matter whether treatment for the condition is medication or psychotherapy, or indeed, any treatment at all.

….

Critics of psychiatry complain that many patients fit no clear category and, at least on insurance forms, are given labels like “anxiety disorder not otherwise specified.” Such patients nevertheless often remain at risk for an array of bad outcomes, studies indicate—findings that tend to broaden diagnostic categories.

Research technology is transforming understanding of mental disorders. New, more finely grained ways of looking at brains, neurons, and even cell connections, as well as powerful computer models, correlate many observed variations in function with disease and disability. The nerve connections you form, the neurotransmitters you elaborate, the symptoms you suffer—each may be linked to vulnerability to disorder.

One way psychiatry has responded to expansionist pressures is to turn to the concept of dimensions. Imagine compiling a list of all the factors ever associated with depression: irritability, a metallic taste in the mouth, a variant of a relevant gene, a change in size of a part of the brain. The list grows to 300 factors—symptoms, personality styles, gene variants, gene configurations, family histories, protein elaboration, and anatomical differences. Say, you rate a person on each of them.

Then you identify clusters of factors (extreme irritability, mild complaints of “off” taste, moderate levels of brain abnormality) that predict recurring episodes of mood disruption. A computer could identify varying degrees of severity for each of the hundreds of factors, with differing prognoses and treatment options. And then at some point, it becomes logical to dispense with the discrete, categorical have-it-or-don’t-have-it view of depression.

In time, and in future manuals, dimensions may push categories aside. If for many of the factors, difference confers some degree of vulnerability to dysfunction, then we will find that we are all defective in one fashion or another. DSM-V may turn out to be conservative and postpone the inevitable, but it is hard to imagine a future in which abnormality is not much more prevalent than it is today. The shift in perception may become more marked as researchers identify subtle neuron- or gene-based variations with modest psychological consequences—increased risk for one or another condition—in the way that high blood pressure signals increased risk for stroke.

How will it feel to live in a culture in which few people are free of psychological defect? Well, we’ve been there before, and we can gain some clues from the past. The high-water mark for diagnosis occurred in the heyday of psychoanalysis. The Midtown Manhattan Study, the premier mental health survey of the 1950s, found that over 80 percent of respondents—more than triple our own abnormality rate—were not normal. “Only 18.5 percent of those investigated were ‘free enough of emotional symptoms to be considered well,'” the New York Times reported. It even cited a psychiatrist who reasoned that, since health includes awareness of conflict, subjects who express no neurotic anxiety must also be abnormal.

In a forthcoming book, Perfectly Average: The Pursuit of Normality in Postwar America, American Studies scholar Anna Creadick reports that the U.S. hungered for a return to normality in the wake of World War II. Articles asking, “Is Your Child Normal?” appeared regularly in the press.

But being deemed neurotic was hardly a cause for distress. If anything, the affliction seemed to signal opposition to mass culture, as if emotional sensitivity were a protest against Eisenhower-era dullness and conformity. Popular essays and books such as The Man in the Gray Flannel Suit made normal men and women out as saps.

The lesson of mid-century is clear: When everyone is abnormal, diagnosis loses its sting. I suspect that we are entering a similar period in which diagnosis (or dimensional defect) spreads—while its gravity, in terms of social stigma, diminishes. Or else we will redefine normal to include broad ranges of difference.

To some degree, that is already happening. The deaf, anorexics, people with Asperger’s syndrome—groups whose members might otherwise be considered impaired or deviant—have made vigorous claims to represent “the new normal.” The Hearing Voices Network advocates liberation, not cure, for those who hallucinate. Where once people pursued normality through efforts at self-reform, now they proudly redraw the map to include themselves. In this context, diagnostic labels confer inclusion in a community. Today, an emotional or behavioral state can be understood both as a disorder and a unique perspective.

As the experience of mid-century shows, we can hold two forms of normality in mind—normal as free of defect, and normal as sharing the human condition, which always includes variation and vulnerability. We may be entering a similar period of dissociation, in which risk and pathology become separated from abnormality—or an era in which abnormality is universal and unremarkable.

We are used to the concept of medical shortcomings; we face disappointing realizations—that our triglyceride levels and our stress tolerance are not what we would wish. Normality may be a myth we have allowed ourselves to enjoy for decades, sacrificed now to the increasing recognition of differences. The awareness that we all bear flaws is humbling. But it could lead us to a new sense of inclusiveness and tolerance, recognition that imperfection is the condition of every life.

“First Up, Mental Illness. Next Topic Is Up to You,” by Nicholas Kristof

Incidentally, in the aftermath of last year’s school shooting in Sandy Hook Elementary, the New York Times has been crushing it in advocating for people with mental health issues. They’ve published in-depth exposés on gaps and shortcomings in mental health coverage as well as think pieces about reducing stigma and the social costs of untreated mental illness. Kudos.

from The New York Times:

THOSE of us in the pundit world tend to blather on about what happened yesterday, while often ignoring what happens every day. We stir up topics already on the agenda, but we falter at calling attention to crucial-but-neglected issues.

So here’s your chance to tell us what we’re missing. I invite readers to suggest issues that deserve more attention in 2014. Make your suggestions on my blog, nytimes.com/ontheground. I hope to quote from some of your ideas in a future column.

My own suggestion for a systematically neglected issue: mental health. One-quarter of American adults suffer from a diagnosable mental disorder, including depression, anorexia, post-traumatic stress disorder and more, according to the National Institutes of Health. Such disorders are the leading cause of disability in the United States and Canada, the N.I.H. says.

A parent with depression. A lover who is bipolar. A child with an eating disorder. A brother who returned from war with P.T.S.D. A sister who is suicidal.

All across America and the world, families struggle with these issues, but people are more likely to cry quietly in bed than speak out. These mental health issues pose a greater risk to our well-being than, say, the Afghan Taliban or Al Qaeda terrorists, yet in polite society there is still something of a code of silence around these topics.

We in the news business have devoted vast coverage to political battles over health care, deservedly, but we don’t delve enough into underlying mental health issues that are crucial to national well-being.

Indeed, when the news media do cover mental health, we do so mostly in extreme situations such as a mass shooting. That leads the public to think of mental disorders as dangerous, stigmatizing those who are mentally ill and making it harder for them to find friends or get family support.

In fact, says an Institute of Medicine report, the danger is “greatly exaggerated” in the public mind. The report concluded: “although findings of many studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small.”

Put simply, the great majority of people who are mentally ill are not violent and do not constitute a threat — except, sometimes, to themselves. Every year, 38,000 Americans commit suicide, and 90 percent of them are said to suffer from mental illness.

One study found that anorexia is by far the most deadly psychiatric disorder, partly because of greatly elevated suicide risk.

Mental illness is also linked to narcotics and alcoholism, homelessness, parenting problems and cycles of poverty. One study found that 55 percent of American infants in poverty are raised by mothers with symptoms of depression, which impairs child rearing.

So if we want to tackle a broad range of social pathologies and inequities, we as a society have to break taboos about mental health. There has been progress, and news organizations can help accelerate it. But too often our coverage just aggravates the stigma and thereby encourages more silence.

The truth is that mental illness is not hopeless, and people recover all the time. Consider John Nash, the Princeton University mathematics genius who after a brilliant early career then tumbled into delusions and involuntary hospitalization — captured by the book and movie “A Beautiful Mind.” Nash spent decades as an obscure, mumbling presence on the Princeton campus before regaining his mental health and winning the Nobel Prize for economics.

Although treatments are available, we often don’t provide care, so the mentally ill disproportionately end up in prison or on the streets.

One example of a cost-effective approach employs a case worker to help mentally ill people leaving a hospital or shelter as they adjust to life in the outside world. Randomized trials have found that this support dramatically reduces subsequent homelessness and hospitalization.

Researchers found that the $6,300 cost per person in the program was offset by $24,000 in savings because of reduced hospitalization. In short, the program more than paid for itself. But we as a society hugely underinvest in mental health services.

Children in particular don’t get treated nearly often enough. The American Journal of Psychiatry reports that of children ages 6 to 17 who need mental health services, 80 percent don’t get help. Racial and ethnic minorities are even more underserved.

So mental health gets my vote as a major neglected issue meriting more attention. It’s not sexy, and it doesn’t involve Democrats and Republicans screaming at each other, but it is a source of incalculable suffering that can be remedied.

Now it’s your turn to suggest neglected issues for coverage in 2014. I’ll be back with a report.