Spooky

"One can smile, and smile, and be a villain."

Hamlet

The political and literary parallels between Nathaniel Hawthorne (1804-1864) and Barack Obama are uncanny. Okay, perhaps I exaggerate. But I have been reading the former's short stories and the latter's Dreams From My Father, and they both tempt and test my ability to connect seemingly disparate characters. For one thing, the moral hazards of Hawthorne's fictions, no less than the pre-Election Day dread of some appalling Republican upset, demonstrate that there are far worse things to fear than goblins this Halloween.

Literary Hawthorne and political Obama strive to overcome two related bugbears: alienated apartness on the one hand and radical distrust on the other. And Hawthorne was more political than most fiction writers, while Obama is more genuinely a writer than most politicians. Both explore the dark regions of the soul, although Obama has had to suppress this inclination in favor of "sweetness and light" for the general election.

Compared to the very dark materials of his fictions, and compared with some of his famously eccentric contemporaries--Poe, Dickinson, Thoreau--Hawthorne was outwardly conventional, happily married and raising three children. He got into politics by penning a campaign biography of his college friend Franklin Pierce, who unfortunately turned out to be one of the worst presidents ever. Pierce was followed by James Buchanan, who was apparently just as bad, but Lincoln came next. If history were to repeat itself, we would have to endure another mediocrity before getting someone exceptional. Hmmm...

For Hawthorne isolation is both blessing and curse, the progenitor of both creativity and suffering. In a preface he wrote of his early years: "I sat down by the wayside of life, like a man under enchantment, and a shrubbery sprung up around me, and the bushes grew to be saplings, and the saplings became trees, until no exit appeared possible, through the entangling depths of my obscurity."

This may sound somehow magical and comforting, almost uterine. But at the end of "Wakefield," a disturbing story about a man's escape from domestic life, we read: "Amid the seeming confusion of our mysterious world, individuals are so nicely adjusted to a system, and systems to one another, and to a whole, that, by stepping aside for a moment, a man exposes himself to a fearful risk of losing his place forever. Like Wakefield, he may become, as it were, the Outcast of the Universe." For Hawthorne, human solidarity is so precarious that even momentary inattention or carelessness can send one spinning into the void, as it were.

Another anathema for Hawthorne's protagonists, yet always a temptation, is the prideful manipulation of humanity. This is termed the Unpardonable Sin in "Ethan Brand," and manifests itself as an overweening impatience with human imperfection in "The Birthmark." A witch seems to mock human beings by animating a scarecrow in "Feathertop," while magic fails to overcome human folly in "Dr. Heidegger's Experiment."

But reconciliation with the human race does not come easily in Hawthorne. The reason is the corrosive human propensity for iniquity and deception. The protagonist of "Young Goodman Brown" is devastated to learn the secret lives of those he previously put trust in, while "The Minister's Black Veil" is Junior High symbolism for hypocrisy. For Hawthorne as for Hamlet, the real zinger is not the fact of Evil itself, but the fact that it can hide so effectively from sight. The isolated individual withers, while solidarity is threatening.

The first part of Obama's Dreams From My Father eloquently yet without self-pity describes his childhood dismay at having to straddle black and white cultures (actually "brown" as well as the book puts it, with respect to the time he lived in Indonesia). He came to know alienation intimately. He tried to overcome this in part in his years as a community organizer in Chicago, but he was brought up short again and again by the brutal realities of human oppression, complacency, and corruption. It is the same "can't live with them, can't live without them" quandary.

In one telling dialogue, Obama describes his half-sister, Auma, expressing her dislike of politics. The reason? "People always end up disappointed" (p. 209). To me, this captures the fundamental political dilemma. In politics one is thrown together with others who may have radically different value systems and different points of view, and yet some kind of workable coexistence, or even better, consensus must be reached. One must overcome both alienation and distrust, and to my mind it is one of the harder things we attempt to do. Obama's story is a willed perseverance through both psychological and cultural obstacles in an attempt to reconcile with a society that he had every reason to be at war with. McCain's military courage and sense of honor are admirable, but Obama exhibits a moral resilience that originates in murkier psychological regions. Happy Halloween, and here's hoping for an illuminating Election Day and dispersal of our recent gloom.

Twilight Zone

"O, let me not be mad, not mad, sweet heaven,

Keep me in temper: I would not be mad."

King Lear

When a patient says, spontaneously and early in an interview, "I am not delusional," it could be either a good or a bad sign, prognostically, but it does portend an interesting session. Patients with schizophrenia or bipolar disorder are often in denial, but not typically in such an explicit and articulate fashion. Delusional Disorder is something of an oddity, a diagnostic stepchild. Patients suffering from it often have well-preserved cognitive and behavioral function, such that they are less likely to come to clinical attention than other psychotic patients. Age of onset is somewhat later, often middle age, and in my experience at least, women are more commonly affected.

In many cases of psychotic disorder the pathology hits you in the face, figuratively speaking; the question is primarily how to manage it, how to try to rebuild. If schizophrenia is a half-demolished city block, then delusional disorder is an outwardly unremarkable one: a little faded, perhaps, and somewhat deserted, but seemingly intact. Then suddenly you walk around a corner and nearly fall into a gaping sinkhole; picking up a volume of Thomas Mann, you open it and instead find a Kafka story. Or maybe it's more like stepping into an Escher print--no matter how far you seem to walk, you always end up where you started.

I find it uncanny at times to be with patients like this. It is as if our respective realities only partially overlap; the person seems only halfway within "my" usual epistemological universe. We witness the same states of affairs, in a literal sense, but we make totally different inferences from them. With other psychotic patients I don't really get this sensation. They may hear voices or they may think they're Jesus Christ, but they're either with me or they're not (in a metaphysical, not a moral, sense); patients with delusional disorder are half with me, half not, sort of like the Nazgul in Middle Earth (but without sinister implication). Maybe it's a bit like confronting a hologram--it seems like you could just reach out and connect, but you miss every time.

I thought of this for some reason the other day when I read a fascinating, and inexpressibly sad, profile (encountered by way of Arts and Letters Daily) of a family who perished in the Jonestown mass suicide in Guyana. If loving parents cannot get through to an only daughter in the grip of delusion, then who could? Fanaticism of all stripes as well as cult behavior provokes the same experience with me, the disconcerting feeling that some people may be physically next door but, in another sense, inhabiting parallel, and shocking, universes.

I Will Please (or Not)

I thought I'd weigh in on the doctors-prescribing-placebos story that caused some media stir at the end of last week. While some might view this issue as yet more evidence of the conspiratorial perfidy of the medical profession, I find it a fascinating window onto the dynamics of the clinical encounter, based on converging expectations of both physician and patient. It does, granted, reflect the persistent ethical naivete of doctors as well as an attitude carried over from a millenia-old tradition of paternalism.

The phenomenon is most relevant to the vast and--somewhat like the deep ocean, insufficiently explored--symptom pool of vague and recalcitrant complaints, unassignable to definite diagnosis, that constitutes much of primary care. No, I do not do primary care, but I live in close domestic proximity to an ER physician, and a good deal of ER practice these days is de facto primary care.

As the linked article implies, doctors are not generally prescribing true placebos, i.e. substances known to have no therapeutic activity such as sugar pills or IV saline solution. Rather, they are offering drugs, ranging from vitamins to antibiotics, that they themselves are skeptical will have a direct physiological (as opposed to psychological) effect.

I'm guessing that these interventions are not being made for clear-cut diagnoses with clearly indicated treatments, but rather for amorphous and mercurial syndromes for which no definitive clinical path is clear. If you're hopelessly lost in the woods and feel that you have nothing to guide you--no cell phone, no compass, no stars even--then you feel a need to pick some direction and start walking. Just step carefully and make sure you watch out for cliffs.

At some point in this age of technological overstretch, someone came up with the medical saying "Don't just do something, stand there." That is, sometimes inaction--watchful waiting--really is the best strategy. But it is one thing to do this in risky, high-tech, and acute situations and quite another to do it with chronic relapsing conditions in which people keep coming back again and again in search of relief. Paradoxically, "There is nothing more I can do for you" may be easier to say in cases of terminal illness than in cases of fibromyalgia, chronic back pain, or other long-term afflictions. In some particularly tough cases doctors desperately want to do something, and patients desperately want to get something, such that these expectations are mutually reinforcing.

I think there is no excuse for using non-indicated drugs that could have significant side effects, including antibiotics which could increase bacterial resistance in general. But consider the speculative case of a doctor prescribing a multivitamin for, say, chronic pain or fatigue. If pressed on whether the pill specifically targets the pathophysiology in question he would have to say, "I don't know" (if only because in many of these conditions the pathophysiology isn't really known). But he could honestly say that the pill has been helpful for others he has given it to (if only due to the placebo effect, a classic and potentially virtuous case of the self-fulfilling prophecy), and he could honestly say that a vitamin could decrease pain or fatigue by virtue of its overall effects on health or the immune system.

As some have mentioned, this practice, even when it does not (as in the case of multivitamins) involve significant side effects, does promote the general "pill culture" as a response to distress. But in this many bear culpability: doctors, patients, drug companies, marketers, the list goes on. Doctors need to be much more willing in general to say, "I don't know."

I don't know that this placebo trend has a counterpart in psychiatry, although it might if one includes it in the general category of the longshot. That is, with particularly chronic and refractory cases, I think a psychiatrist will sometimes resort to psychotropic medications that are not inappropriate, per se, but that he deep down has little confidence in, particularly in the difficult case in question. The side effects of this type of drug are generally quite minor, and seem a small price to pay to keep hope of relief alive. And the latter is not impossible--as with all hail Mary passes, "miracles" can happen.

The Best of Times...

"He knew what this thing was--hysteria, a snake whose scales are tiny mirrors in which the dead world takes on a semblance of life."

Miss Lonelyhearts

One of my early fascinations with psychiatry was the question of whether the problems we face are primarily "the thousand natural shocks that flesh is heir to" or whether they are largely of our own making. Of course, inasmuch as we are natural creatures, our soiling of our own nest is merely another "natural shock," but while this may be a cosmic comfort, the serenity prayer codifies our belief that wisdom is knowing what we can alter and what we can't. And the parallel question of perennial controversy is whether psychiatry itself makes things better or worse overall.

It is a time of extremes (a "bipolar" time indeed). Every generation in history has probably thought of itself as exceptional in some way, but we are different because we really are exceptional (ha). Our 63-year-old awareness that civilization as we know it could end in minutes (see Cormac McCarthy's The Road, but not if you're depressed) has been broadened to the increasingly visceral knowledge of the planet's potential environmental depletion and degradation. And yet by many other measures those who live today, excepting the billion or so of the absolute poor (a dreadful exception I know), enjoy greater comforts and advantages than most who have ever lived on the planet.

The current fascination with happiness and "positive psychology" suggests that we increasingly wonder whether we're better or worse off than our ancestors. It is interesting to me how many patients have brought this up spontaneously over the years. "Are more people stressed out these days?" I answer that many people wonder the same thing, but that no one really knows.

Pysch Central among many others reported on the recent 5% increase in the suicide rate in the U.S. between 1999 and 2005, an uptick that surprisingly occurred chiefly among middle-aged white men and women. Speculative causes that I read about included increased abuse of opiate pankillers (no longer a specialty of the young), the decrease in estrogen use after its risks were shown, and increased depression and PTSD among war veterans. It is discouraging that psychiatry's efforts in this respect make such a modest impact.

Psychiatrist Peter Whybrow, M.D. is reported as opining that our contemporary consumerist lifestyle has hijacked evolutionary drives that were once advantageous but may be no longer (sort of like cotton candy). Much as cocaine affects dopamine systems that were naturally selected for other purposes, our endless craving for more stuff (stoked of course by overheated, and I dare say underregulated, capitalism) only leaves us crashing, empty and wanting more. It is an interesting idea, even if the title of the linked article, "American Dream an Impossibility, Neuroscientist Says," sounds like a headline from The Onion.

Dear Abby has been around for a long time, but recent years have seen a proliferation of celebrity advice-givers and counsellors (for a while there Dr. Phil seemed to be everywhere), who constitute an "alternative" treatment within psychiatry every bit as much as St. John's Wort. One advice-giver I enjoy following is Dear Prudence (Emily Yoffe) at Slate, who almost always is, in fact, as wise as one would wish a therapist to be. Many of the stories people write in with, naturally, are (often ludicrous) family situations, but this week's entry contains a woman who asks for help with "self-loathing" unrelieved by conventional psychotherapy and medication.

To some degree the trend of alternative "therapy" represents dissatisfaction with mainstream psychiatry or even imperfect access to the same, but in a wider sense it could reflect a popular discontent, a feeling that our once common cultural bearings and guideposts are being lost. The most devastatingly satirical look at this phenomenon that I know of is Nathanael West's novella Miss Lonelyhearts, written interestingly in the 1930's (his Day of the Locust was a similarly spot-on treatment of celebrity culture). It is satire as transcendence; if Obama is our FDR (ha), who is our Nathanael West (who died young in a car accident)? Maybe David Foster Wallace? If his Infinite Jest (confessedly, as yet unread by me) could have been compressed to short-novel length, perhaps it could have had the white heat of Miss Lonelyhearts. But where is Wallace when we need him?

Annals of the Prodigious

Here's a post from last night's news just for fun: the recent discovery of the longest known uninterrupted avian flight, by the bar-tailed godwit. The 7200+ mile journey from Alaska to New Zealand, which took eight days in the air without sleeping, eating, or drinking, beat the previous known migration record by over 3000 miles (not to stop even in Hawaii for a snack and a nap--that's impressive). Apparently it reflects an efficiency of energy production unsurpassed by any known vertebrate physiology. Can the godwit reduce our dependence on foreign oil? It is, alas, from Alaska.

What could it possibly be like to be a godwit, suspended above the sea for eight days and nights? It brought to mind, of course, a Dickinson poem:

A Route of Evanescence
With a revolving Wheel --
A Resonance of Emerald --
A Rush of Cochineal --
And every Blossom on the Bush
Adjusuts its tumbled Head --
The mail from Tunis, probably,
An easy Morning's Ride --

Big Spenders

Financial excess is certainly in the air these days--Wall Street, Vice-Presidential garb, and a topic for today, health care. This week's issue of The New England Journal of Medicine features two very straightforward and useful summaries of health care's systemic problems and potential solutions. Here are some take-away points as I understand them:

1. The most dire problem is not the uninsured, but rather the unsustainable growth of health care expenses.

2. Rising expenses are due largely to technical (and very costly) medical advances, although inefficiencies of care delivery play a role as well.

3. Resistance to change comes not only from partisan points of view, and from traditional American opposition to government administration, but also from the fact that the health care industry is itself a massive part of the economy. Millions of health care workers (including yours truly) depend on the status quo for their livelihood.

Potential solutions:

4. An independent oversight organization (such as Great Britain and other nations have) to assess effectiveness and cost-effectiveness of medical interventions.

5. Greater governmental involvement in the system to mandate efficiency, including wider use of electronic records.

(Basically, in order to have a system we can afford that provides adequate treatment for everyone, there is no avoiding elements of both rationing and (financial) compulsion).

The consensus on the campaign seems to be that neither candidate's plan seriously addresses these fundamental problems. Obama's is more generous but cannot realistically be paid for, while McCain's threatens to increase the numbers of the uninsured by undermining traditional employer-based coverage without providing reliable and affordable substitutes.

It all makes me glad I brought an apple for lunch.

Doctoring

"Everyone complains of a poor memory, no one of a weak judgment."

De La Rochefoucauld

Two psychiatry posts caught my eye yesterday, one by Peter Kramer, M.D. on the vagaries of prescribing, the other by Richard Friedman, M.D. on the strange phenomenon of patient-blaming. Between them they capture much of the art of the profession: balancing reported evidence against individual idiosyncrasy, and exercising patience leavened by humility.

Kramer points out that unless or until we have a much more advanced understanding of the genetics of drug metabolism, we will remain unable to predict how an individual will respond to any given drug with respect to both side effects and therapeutic effects. Doctors are guided by recommended ranges of doses, but patients vary wildly in their tolerance and reaction. One patient sleeps 24 hours after 25 mg of Seroquel, while another patient doesn't blink after 1000 mg. As someone somewhere said, the only difference between a medicine and a poison is the dose.

Many patients openly state they don't want "to be a guinea pig," but in a sense each singular clinical interaction must involve some "guinea pig" element because that particular constellation of factors--the doctor, the patient, the drug, the time, the diet, the other medications taken--have never occurred before in the history of the universe (and never will again). Of course, medications have been tested on large groups of other people such that we do have useful guidelines; we pretty much know that the person taking it won't drop dead 15 minutes later, and we know a lot more besides. But those large groups of other people are not exactly this person, so the potential for serendipity is considerable.

In choosing a medication we are hypothesizing that the range of remotely likely outcomes of taking it is preferable to the range of remotely likely outcomes of not taking it. We do not, of course, really know what will happen in either case; life is like that. A crystal ball would be a tremendous conversation piece in the office, but it would convey exactly the wrong idea (and of course few would get the irony anyway).

-----

Friedman delivers a message psychiatry seems in need of again and again: because of persistent crucial gaps in our knowledge we usually err in blaming patients for not getting better. It is true that factitious disorders and "secondary gain" exist, but these are vastly outnumbered by the cases in which people do not get better (or "fail" to get better, a frequently encountered word choice that itself speaks volumes) for physiological reasons we do not yet understand.

This is so problematic in psychiatry because we do not yet have access to the physical pathology involved. In other areas of medicine we can, via testing and imaging, witness the metastasizing tumor, the high blood sugar, the positive blood cultures. But in psychiatry all we usually have to go on is subjective report and observed behaviors. As Friedman describes, the bipolar who becomes refractory easily becomes, in the eyes of clinicians, the borderline.

Of course we also can't just treat people as physical phenomena; we must engage them as responsible agents as well. And the gray areas are fascinating: hysteria, personality disorders, addictions. We think now that addictions have a strong biological component, but what about willingness to attend AA or other appointments, or willingness to take medications? How do we decide when we are dealing with the illness and when we are dealing with the (accountable) person? We tack back and forth, I think, trying to find a fair and just middle way. But psychiatry teaches nothing if not humility, so when in doubt, which is often, it seems wise to spare the person and not the illness. I try not to be gullible either, but I'd rather be a little gullible than a little (or a lot) cynical--I seem to sleep better that way. Oh, and I try not to be sanctimonious either...

Department of Clarifications

I found the additional Obama commentary I was thinking of yesterday; it is an essay by Simon Critchley in this month's Harper's (his piece is not available electronically unfortunately so far as I can tell). Critchley likens Obama's intellectual embrace of the political common good to what he sees as Obama's diffidently willed allegiance (if there can be such a thing) to Christianity. Maybe, but at any rate the former is a "will to believe" I can go along with.

Critchley is always worth reading though--he also happens to be a favorite philosopher of mine because of his interest in Wallace Stevens.

We're All Psychoanalysts Now

"Only connect."

E. M. Forster

It may be hard to get some psychiatrists to think beyond the DSM-IV, but one reason for that may be that dynamic formulations have been farmed out to the mainstream media for a long time now. Ever since our Iraq adventure began pundits have been analyzing George W. Bush's policies as an Oedipal situation stemming from his father's frustration in 1992. This is apparently dramatized in Oliver Stone's current W. (as yet unseen by me); the fact that a quasi-biography of a still-sitting president has caused relatively little stir only shows how accustomed we have become to reflexivity and reflectivity. The couch is very rarely in evidence in the shrink's office these days, but metaphorically it sits prominently amid our cultural furniture.

The pundits have found Barack Obama a tough diagnostic nut to crack, however (don't worry, the point of this post is not to attempt it here). His atypical demeanor, ranging from chilly diffidence to masterly calm, is the last thing we expect from politicians. But is that good or bad?

A friend of mine once commented to me, about a mutual acquaintance that he was unsure about, "I don't know what motivates him." That stuck with me because it seemed to capture what we most seek to know about others: what drives them, what values they hold dear. Inscrutability in others alternatively attracts and dismays us when we don't know what they, ultimately, need or desire.

What does Obama want in general, and what does he want from being President? In a recent Op-Ed piece David Brooks argued that unlike the cases of, say, Bill Clinton or George W. Bush, who like most politicians craved love and acceptance, Obama's ambition does not derive from anything he lacks but rather is a kind of natural outgrowth of his identity. What this means, exactly, is unclear, but Brooks suggests that Obama may therefore be something of a dry and dull technocrat, which may be what the country is quite ready for after recent excitement. He mentions also that Obama does not seem, psychologically, to need the love of the masses, which some people find disconcerting, especially in a politician.

But in another online commentary I read recently (I can't remember where, and it's driving me up the wall), it was suggested that Obama, perhaps due to the family and geographical vicissitudes of his past, struggled with feeling detached, unrooted, and disconnected from people. The piece maintained that he pursued politics and the notion of the common good explicitly in order to forge connections with others (go into politics--that's a doozy of a psychotherapy homework assignment). We don't need psychiatry to pathologize everyday life anymore since the media does it already.

I think Obama is an unusual politician precisely because he is an intellectual. Endless ink has been spilled over what an intellectual is, for better or worse, but I would define it as someone who looks to ideas as a (significant, not sole) means of forging personal and social identity. Non-intellectuals (again, for better or worse) implicitly or explicity develop an individual and communal self based on family, geography, history, work or (often unfortunately) biology. I am oversimplifying for contrast; obviously intellectualism (?) exists on a continuum (I would suggest that more is sometimes, but by no means always, better).

Any intellectual has to begin with a sufficient degree of basic curiosity. Most people as teenagers have a dawning realization that humanity features a vast array of different, and often contradictory, belief systems involving morality, culture, and religion. The incurious are not deeply affected by this, or they implicitly decide that their personal way (and their family/tribe/country's way) is simply right and others are wrong. Recall that a perennial criticism of President Bush is basic incuriosity--he is an exemplar of the non-intellectual.

The budding intellectual arrives at the notion that through sheer study, thinking, and dialogues of ideas, useful consensus can be achieved amid the pandemonium of diverse human values. The holy grail is Truth, most ambitiously sought after in science and philosophy. We often do find Truth in science, but only about how things work, not how they should work, which is what we ultimately most care about. Philosophy aspires to such Truth in ethics, aesthetics, and the philosophy of religion, but results vary and are not always satisfactory, to put it mildly.

Many pundits have criticized Obama for political naivete, for his apparent notion that we can "come together" more helpfully than in the past, despite the myriad factors that divide us. These "realist" pundits point out that politics is the great clash of competing interests (power is everything, and it was not for nothing that war was famously described as "politics by other means"). And indeed any politician who thinks that the truth of some ultimate maxim will compel allegiance from diverse humanity would only remind us of Stalin or Mao. But short of being an ideologue, Obama has the intellectual's hope that we can unite not because of shared race, religion, or even history, but because of willingly embraced idea(l)s. Plato's philosopher-kings have been few and far between; are we ready for a distant, dry, but potentially transformative philosopher-President? Does Obama's need for a consensus of ideas complement our need for...what exactly?

The Doctor Will Insult You Now

"I have a certain alacrity in sinking."

Falstaff

Medical horror stories aren't hard to come by, but sometimes the seemingly minor ones are both most telling and most poignant (the ones about surgeons cutting off the wrong body part are more titillating but, fortunately, more exceptional).

I saw a morbidly obese woman who told me that the medical doctor she had seen in a small town free clinic called her a "fat ass." She is a bit acerbic in her manner, and maybe something she said rubbed the doctor the wrong way, but needless to say this sort of thing does not endear one to the medical profession. I'm glad for her sake that is was a free clinic--one would hate to have to pay out of pocket for that kind of treatment (adding insult to injury you know).

But then again, maybe the doctor was resorting to a little-used therapeutic tool: insult therapy. Granted, obese patients will often have received myriad insults from family, "friends," and acquaintances over the years, but such lay insults are less effective than those delivered by someone in a white coat. This is both a low-tech and a time-effective treatment--without any instrumentation at all, a callous, moralistic, and demeaning tirade of considerable detail may be delivered in less than five minutes.

Insult therapy has been inadequately studied, not least because it is difficult to devise a control condition for blinded studies. In fact, few are aware that insult therapy has not in fact been demonstrated, in rigorous random and controlled fashion, not to be effective for any number of conditions which could have a behavioral component. It reminds me somewhat of ultra-brief, one-time "get a life" psychotherapy, which is similarly underresearched.

Not having been trained in this sort of treatment, and somewhat lacking in general aptitude, I could only shake my head in wonder as my patient described her doctor's approach.

(For any literalists still out there, this was irony).

Infamous Scribblers

SCRIBBLER, n. A professional writer whose views are antagonistic to one's own.

Ambrose Bierce

Andrew Sullivan has some astute reflections on the nature and impact of blogging. Overall the blog, in its personal and omnivorous aspects, seems to have most in common with the essay, but it is so much more visceral and immediate than its print predecessor. A blog post is essentially a micro-essay, and can be either tasteless or witty, graceless or ponderous.

It has always been the case that a physician or therapist has the right to openly share his or her views, not only about the profession, but about politics, literature, or whatever so long as the clinical commitment is not detrimentally affected. Before the Internet this could take the form of letters to the editor, academic or general articles, case reports, etc. No screen of anonymity should prevent a physician or therapist from publishing a memoir or book of poetry, again, so long as the rights and prerogatives of patients are not harmed. As I wrote the other day, it is not for me to question the anonymous blogging of others (the more voices the better), but it makes sense for me to drop the pseudonym.

Any argument that could be made against "open" medical blogging can be equally made against print publication in general. The same potential threats to patient privacy exist in both, and this privacy must be safeguarded above all. To be sure, no patient wants to feel that in seeing a doctor or therapist, he or she may be "merely" grist for the blogging mill, but the same concern could exist for a doctor in the habit of publishing books or articles. So long as privacy is not infringed upon, one can hope that the greater openness and dialogue generated by blogging, as by publication, will more than compensate for any awkwardness that could result from a doctor having a public voice. To be sure, such a public voice encroaches upon the blank screen or white coat of the therapist or doctor, respectively, but this pretended facelessness has been on the wane for a long time now.

So I will write openly, although to reiterate, despite the vaunted ease and casualness of blogging, I will convey only those matters that I would feel comfortable seeing above my name in a newspaper, journal, or book. That is, the matters can still be personal, and all kinds of subjects beyond psychiatry are fair game (with the understanding that in many cases it is personal and not expert opinion that is at issue), but I will not write in any identifiable detail about family, friends, or colleagues; their privacy matters as much as that of patients. In general I think that combining respectfulness with a critical and creative approach is more crucial than the exact medium, whether print or Internet.

I have listed my email in case anyone wishes to comment directly and not openly; as always anonymous comments are welcome, and I would not of course publicize the contents of any emails received. All I ask is that the basic respectfulness I mentioned be mutual.

What Psychiatry is Coming To

"Things are in the saddle, and ride mankind."

Emerson

The other day a friend of mine, as we say, saw a young man with garden-variety anxiety and depression, with some alcohol abuse thrown in. This fellow wasn't unpleasant exactly, but he had a kind of curt, impatient, and "Can't we just get this over with" manner.

They (my friend and this fellow) agreed that sobriety and AA were crucial to his success, and they came around to the question of medications for his affective and anxiety symptoms. His wariness was palpable, and the doctor certainly wasn't pushing for anything (too much substance rather than too little seemed the problem here).

Finally the fellow matter-of-factly announced that he and his wife would research some medications online and would be back in touch. "I would never let a doctor pick my medication," he declared, not in a hostile way and without any apparent awareness that the doctor in front of him might be a bit taken aback by this statement.

The doctor could only incline his head in mute understanding, feeling like a real-estate agent driving past a "For Sale by Owner" sign. How, indeed, could someone with his limited experience and qualifications be expected to advise a construction worker with an Internet link about psychotropic medications? The Protestant Reformation has permeated medicine at last--no intermediaries needed. What's next, neurosurgery at home in twelve easy steps?

Well, prescribing antidepressants isn't brain surgery--but that's the point isn't it? I've often wondered whether, if SSRI's were as safe and effective as, say, Claritin or Zantac are for allergies or reflux, they couldn't be sold over the counter. Wouldn't that rile up two opposing groups, psychiatrists (in need of work) and woeful "Prozac in the water" commentators? Actually, a psychiatrist's expertise isn't needed when the SSRI works (a 20-year-old pre-med major could manage SSRI's from a strictly medical point of view). Rather, the hard work of psychiatry begins when the SSRI (or the tenth antidepressant tried) doesn't work, and often this is as much a function of supportive, almost spiritual witness as it is a medical role. If antidepressants became overnight much more effective, this would not generate work for psychiatrists; quite the opposite, primary care physicians would take over the role.

I left out one detail. The patient mentioned that he had previously been on Effexor, which, as a previous psychiatrist had explained to him, is not "habit-forming." He proceeded to go through two weeks of hell while trying to get off of Effexor (notorious for its withdrawal symptoms for some people). So this fellow had a case of micro-PTSD, the trauma being inept psychiatric care. I keep running into ex-patients of that one Bumbling Psychiatrist out there who vitiates trust in the profession for the rest of us. Bumbling Psychiatrist: managing SSRI's is not brain surgery, so how do you keep screwing it up?

We all play up the virtues of the drugs and play down their side effects, and in most cases this is neither sinister nor even lazy. Like most people, we want to believe that what we do is effective and helpful for those we minister to, and if we have to deceive ourselves to do it, that's only human nature--but an aspect of human nature we must keep to a minimum. For we can't always assume patients will have read the package insert.

Breaking News--Ars Psychiatrica Renovation Considered!

"Would that all excellent books were foundlings, without father or mother, that so it might be, we could glorify them, without including their ostensible authors!"

Melville, "Hawthorne and his Mosses"

I'm hoping for some feedback--change may be in the air, but no demolition is planned. I've been at this hobby for over two months now, and I'm wondering where to go with it now. Specifically, for the half-dozen (I'm rounding up) or so of you who may read this blog now and then (you know who you are, even if I don't), I'd be curious to have any feedback regarding what you may have liked or not liked about the format and content.

Chief among the changes I'm considering is the whole anonymity thing--speaking for me personally, and without any implicit criticism of incognito bloggers (whose numbers are legion, and many of whose blogs I enjoy following), the mask hasn't really felt natural to me. To some degree this is because even apart from blogging, the Internet has forever limited physician privacy (well, everyone's privacy), particularly for those with any record in the public domain.

In my former job I published a dozen or so articles, mostly in fairly obscure academic journals. Before the Internet few non-academics would have had the misfortune to stumble upon those writings, but now any patient can Google my name and infer a good deal about my interests and points of view (these were not scientifically technical articles, but rather had to do with the ethics and humanities of psychiatry). And do I, personally, really want to place in the public domain anything that I would be ashamed to see in a newspaper or journal article?

Going cognito (?) would change the tone and approach somewhat, although not drastically. A couple of illustrations might vanish, and some flights of fancy may be a bit more disciplined (future ones--no retroactive editing here). But it needn't become drily professional either. Being a psychiatrist, therapist, or physician shouldn't prevent one from even personal or poetic self-expression in the public sphere so long as clinical care and patient privacy are inviolate.

No, I'm not imagining that this prospective self-disclosure is a matter of any particular excitement. But, again, as I consider a more straightforward approach, I solicit suggestions and recommendations. As I see it the 44 posts thus far can be broken down into these categories:

1. Examinations of literary works or figures with psychiatric ties or dimensions
2. Considerations of social and cultural trends and implications for mental disorders or psychiatry
3. Discussions of what the practice of psychiatry is like
4. Personal prose-poetic speculations, usually alarmingly bad and rather self-indulgent (these would probably decrease under the cognito plan)

Please let me know if anyone comes to this site hoping for more or less of any of these. Oh, and anonymous comments are welcome!

The Writing Cure

"Once more--for it is hard to be finite upon an infinite subject, and all subjects are infinite."

Melville, "Hawthorne and his Mosses"

An article today (astutely noted by Dr. X) describes the work of psychologist James Pennebaker, who is using textual analysis to examine the writings of those either suffering or recovering from mental illness. In short, he is looking at the prevalence of certain pronouns and other categories of words to try to get a quantifiable (always the holy grail it would seem) sense of a person's state of mind. Since narrative is such a hot paradigm these days, therapeutic writing is getting a closer look. While writing is virtually always a worthwhile endeavor, particularly if it aids recovery, I got to wondering whether any significant (in a narrowly literary sense) writing careers have originated primarily as a consciously therapeutic exercise. Only two came to mind: Anne Sexton and Kate Chopin, shown above (both women, alas, a fact I might get an earful/eyeful about).

Being the better known, Anne Sexton I mention only in passing. Apparently she had written some quality poems as a teenager, but any literary ambition went underground at least during her marriage and disastrous attempts at mainstream 1950's domestic life. After her breakdowns began, and under otherwise highly questionable therapeutic circumstances, Dr. Martin Orne saw her creative potential and suggested that she start writing. She was very reluctant and lacking in confidence at first, but she went to a poetry workshop, and the rest is literary history.

Kate Chopin (1850-1904) had also done some modest amateur writing as a young woman, but she put this aside in her 20's when she moved to Louisiana and bore five children. In the course of several years her husband's business ventures failed, he died in 1882, and then her mother died in 1885. Struggling with these losses and with the strains of single motherhood, she was advised by an obstetrician and friend to write. In the next fifteen years or so she wrote dozens of short stories, a number of which were published in national magazines. However, The Awakening, the short novel for which she is best known today, was critically panned at the time as both risque and generally without merit. For much of this century she was known if at all as a minor short story writer until around 1970, when feminism brought her overall work and especially The Awakening into higher esteem.

The Awakening takes place in a wonderfully recreated and languorous New Orleans. It is the story of Edna Pontellier, a middle-aged woman dismayed by her stultifying life with her husband, a financier of some type, who is often both geographically and emotionally distant. By the standards of the time, he is depicted as being only moderately chauvinistic, but I suppose the standards of the time may be the issue. But Mrs. Pointellier makes for an intriguing and not entirely sympathetic psychopathological study, and arguably her problems are more than feminist in scope; she struggles to connect with a number of people in her life, and while she initiates steps toward independence, she ultimately fails to decisively change her situation (in the way her author/creator succeeded in doing). Surprisingly for a quasi-feminist work, the end is tragic (or perhaps, from a sufficiently radical point of view, transcendent). But don't let that stop you--it is definitely worth a read (and it's not long).

John Stuart Mill famously recovered from a severe depression as a result of his encounter with English Romantic poetry (especially Wordsworth I believe), but I don't know that his own philosophical writing career was any direct outgrowth of that.

Obviously a great deal of writing (most? all?) is done for very good unconscious or implicit reasons, but I struggle to think of other well-known cases in which such writing began or really took off as a result of a medical recommendation. But I'm probably overlooking some obvious ones.

The Better Angels of Our Natures

Hamlet: (He) was a man, take him for all in all,

I shall not look upon his like again.

Horatio: My lord, I think I saw him yesternight.

Hamlet: Saw who?

The pending bicentennial of Abraham Lincoln's birth in February of 2009 dovetails nicely with the current presidential season. He has long held a fascination for me (as for thousands of others I know), one which was reawakened when I recently got around to reading Joshua Shenk's book on Lincoln's battles with depression (an Atlantic Monthly article surveying some of this can be found here). One can quibble over exact diagnoses many decades after the fact, but it was plainly obvious to many around Lincoln that his was a depressive temperament, in marked contrast to the (high-functioning) narcissists typically attracted to politics.

What is so remarkable about Lincoln's legacy is the near unanimity of the reverence that he inspires (in The New Yorker Thomas Mallon looks at the Great Emancipator's career in the popular imagination since his martyrdom). Only he and Washington himself bear the mantle of true unity over division (tellingly, Washington was a far from typical politician as well). So when Obama talks of moving past the partisanship that has so poisoned the political process in recent years, there is a high bar to be crossed. But I reflect that for some of us, politics in this country has never been the same since the breaking of the Lewinsky scandal in early 1998. Ten years is a long time, and there is a tremendous hope and wish that someone can rise above the squalor of business as usual.

Even some of Obama's supporters seem to worry that expectations are too high, and are eager to remind us that he is all-too-human. In the current The New Republic David Samuels takes Obama to task, in an intriguing comparison to Ellison's Invisible Man, for refusing to shoulder the racial implications of his candidacy (whether Obama, had he done so, would enjoy even the prospect of possible victory that he appears to now, Samuels doesn't say). He also attempts a shrewd psychodynamic formulation in examining the effects upon Obama's character of a missing and disreputable father figure (this is the sort of thing psychiatrists used to do until they handed it off to reporters and critics in order to focus on meds).

Another Presidential storyline that has intriguing implications for Obama is the growing awareness of Thomas Jefferson's relationship with his mulatto slave Sally Hemings (yet another book demonstrating beyond a shadow of a doubt the existence of Jefferson's clandestine second family is reviewed favorably here). Jefferson was another of the Presidential greats who was an ambivalent and atypical politician, more interested in architecture, education, and myriad other ideas than in governing (and in many historians' opinions he wasn't actually so very effective as President). But his was a great mind, and if he was capable of such hypocrisy, we should not pride ourselves overmuch in our advances since his time.

The possibility of crushing disappointment still exists (President Palin?), but I for one am excited that at this late date that Obama remains viable at the very least, that a very different sort of President--different in heritage, temperament, and intellect from most--could show that there may still be "something new under the sun."

This opinion should be no surprise of course--studies have consistently shown the liberal (and agnostic) inclinations of most psychologists and psychiatrists (whenever some Republican derides the "liberal elites" I can't help thinking "Moi?"--while reaching for my wine or latte, as the case may be). For fear of diminishing whatever miniscule readership I might still enjoy at this point, I won't say this is as it should be, but it seems a natural result (for better or worse) of close acquaintance over time with both the vulnerability and irreducible complexity of human experience.

Singularity...Circularity

"Literature is news that stays news."

Ezra Pound

Fragments:

A six-year-old boy of my acquaintance was pestering me with questions the other day about the meaning of "infinity." He didn't get the idea from me (had I ever intended to raise a John Stuart Mill, I would have been disabused of the notion long ago); maybe it came from Toy Story (I suppose Buzz Lightyear's "To infinity and beyond!" was one of those Pixar witticisms meant for adults). "What do you add together to get infinity?" "No, what number is it?"

Like the idea of God, the idea of infinity occurs naturally to the human mind but defies practical understanding. Perhaps both of them can also be said properly to have no attributes apart from inscrutability. And both are known primarily by their absence in the world as we live it, by the shadow cast by a concept. If we could behold either of them directly, perhaps we would go mad. The perennial question, of course, is whether, in gazing at either infinity or God, we are looking through a window or into a mirror; whether we are seeing something real out there or merely a tic of our own consciousness; whether we are getting nourishment or merely a bit of our own tail; whether we are visited or haunted. At any rate, after unsuccessful attempts at clarification I suggested that the inquisitive one ask one of his teachers (and soon thereafter we were back to Spongebob). Getting through nightly first grade homework--that really does drive one mad.

-----

Some of the most acutely distraught patients I have ever seen have been men going through divorces and custody battles in which they have been deprived of access to their children (so much for evolutionary psychology, which stipulates that for men, offspring ought to come and go pretty cheaply); I have seen two such in the past week (maybe the economy is playing a role here). It brought to mind a recent insect documentary I saw which reminded me that the female praying mantis sometimes devours her partner after mating. Strange are the ways of love. Not that females (humans that is) have a monopoly on (emotional) cannibalism.

-----

Sometimes a passage pierces the heart of things. I was transfixed for some reason when I came upon this today from Nikolai Gogol's Dead Souls (translated by Richard Pevear and Larissa Volokhonsky):

Numberless as the sands of the sea are human passions, and no one resembles another, and all of them, base or beautiful, are at first obedient to man and only later become his dread rulers. Blessed is he who has chosen the most beautiful passion; his boundless bliss grows tenfold with every hour and minute, and he goes deeper and deeper into the infinite paradise of his soul. But there are passions that it is not for man to choose. They are born with him at the moment of his birth into this world, and he is not granted the power to refuse them. They are guided by a higher destiny, and they have in them something eternally calling, never ceasing throughout one's life. They are ordained to accomplish a great earthly pursuit: as a dark image, or as a bright apparition sweeping by, gladdening the world -- it makes no difference, both are equally called forth for the good unknown to man. And it may be that in this same Chichikov the passion that drives him comes not from him, and that his cold existence contains that which will later throw man down in the dust and make him kneel before the wisdom of the heavens.

Doesn't this capture the human predicament perfectly, that we are driven by passions that we do not choose, and yet are blessed (or cursed) with consciousness of the fact? Our passions endow us with the only agency we can have and yet in the end return us to that place whence we, involuntarily, came into being.

Brevity = Wit?

"More matter, with less art."

Gertrude/Shakespeare


This Humble Blogger has been feeling more prosaic than profound of late, so I was interested yesterday to read a defense of the often overlooked genre of the short story, by Steven Millhauser. He makes the (fittingly concise) case that the short story, in avoiding the bloated overreaching so often characteristic of the novel, is more capable of perfection.

I confess that while I naturally go for the underdog, I have never found the short story easy to love. Many of the virtues that Millhauser points out--the modesty, precision, and focus of smallness itself--are to be found in poetry even more than in short fiction. If I'm in the mood for an intense and potent reading experience, I'll go for the former. All too many short stories manage to be both brief and superficial. Maybe they have to be--if the characters and situations introduced were truly worthy of significant interest, they might warrant more than the ten or thirty pages devoted to them.

Short stories, while often pleasant enough and worth the limited time they require, usually leave me wanting more (much like an appetizer or snack). I don't need In Search of Lost Time necessarily--longer is obviously not always better when it comes to novels, but arguably a good eighty or one hundred pages at least are needed to deliver a decently round character profile or a compelling narrative arc. In fact, as I've written here before, the novella/short novel genre may be the best of all worlds, balancing depth and breadth.

In my Sisyphean years of trying to interest psychiatry residents in literature, we usually resorted to short stories as a way of making a virtue of necessity. (It is worth pointing out, though, that when people say they "don't have time" for something they usually mean they "don't have interest," because people manage to make time for what they really find to be a priority; it's rather more polite and face-saving however to talk about time). I found myself coming back to several canonical authors who, against the literary odds I've mentioned, manage to make supreme art out of the short story. My personal top five would be:

1. Anton Chekhov--The master of the diffident Russian soul (as Dostoevsky had the labile, impulsive Russian soul well covered) who subtly chronicled an astonishing array of psychopathology in dozens of stories.

2. James Joyce--In Dubliners he perfected the short story so completely that he saw nothing else to do but progressively dismantle his creation in future works.

3. Flannery O'Connor--She relentlessly (and with wickedly bone-dry humor) disclosed and lacerated human perversity in a way that almost makes an agnostic believe in sin.

4. Alice Munro--Chekhov reborn, she manages with her limpid, clinical detachment to endow the short story with novelistic sweep.

5. Jorge Luis Borges--He realized that literature, like philosophy, is a necessary means of clearing away deadness, of making the world unexpected and therefore interesting.

Honorable mention: Ernest Hemingway--In his early stories it is painful to see the eventual suicide view the world as fiercely but lovably beautiful.

The preceding is highly opinionated and likely depends a great deal on temperament. I enjoy beachwalking a great deal more than spelunking too, but I can't pretend to erect any aesthetic philosophy upon the fact. (Then again, most people enjoy looking at the ocean rather than into a dark, dank cave: ah, I scent a theory of human nature).

So, short story champions unite, let me know what I ought to be reading, until I have "time" for novels again at any rate...

Physician, Govern Thyself

Everywhere there's lots of piggies

Living piggy lives

You can see them out for dinner

With their piggy wives

Clutching forks and knives to eat their bacon.

George Harrison

This Humble Blogger is traveling this weekend (a brief jaunt to the far side of Appalachia), but a story worth noting, which will doubtless generate much buzz within academic and general psychiatry, is reported here by The New York Times. Dr. Charles Nemeroff, one of the biggest names in biological psychiatry and psychopharmacology (in psychotherapy, as one might expect, not so much), has been added to the list of psychiatric luminaries who have been caught underreporting the income (in some cases in the seven figure range) provided by pharmaceutical companies for "research" and "education" (both of which activities, while sometimes legitimate, have often served primarily to extend the market share of certain products).

The addition of yet another big name to a number of other big names who have been investigated shows that these potential conflicts of interest infect the profession from top to bottom. I do not know these people personally, and one should not rush to judgment. But some of these individuals are making very large amounts of money, which is their right in a capitalist society, but it frustrates me, to put it mildly, to think of all the patients who can't afford their medications. How much of those inflated prices go toward providing stipends, junkets, lunches, etc. to doctors? The situation seems a bit analogous to the (recently even more notorious) sky high reimbursements for CEO's--there may be nothing illegal about it, but it is mighty unseemly. And while medicine inevitably has, and must have, business aspects, it can be no conventional business inasmuch as it deals in human need and suffering.

Psychiatry has recently shown itself to be particularly susceptible to this sort of thing. And yet this is not only or even primarily about greed, for no medical student in his or her right mind would choose psychiatry for the money (it is among the lowest paying of specialties). Perhaps a competing explanation is the fact that psychotropic medications, despite the absurdly optimistic impressions conveyed by pharmaceutical marketing, remain of very limited effectiveness and tolerability for many people. After more than fifty years now of drug development, there is almost a desperate hope for a wonder drug that will make more drastic inroads into schizophrenia and depression. Maybe there is the wish that if enough money flies back and forth, we will end up with something worth buying. A few people out there know that I've been railing against this sort of thing for years, and these stories only deepen my disappointment in what ought to be, and of course in many cases remains, an honorable profession.

Mind-forged Manacles

"The child's toys and the old man's reasons
Are the fruits of the two seasons.
The questioner who sits so sly
Shall never know how to reply."

Auguries of Innocence



Two fundamental facts distinguish psychiatry from the rest of medicine: the frustrating ambiguity of diagnosis (only partially resolvable by scientific advance because a good part of the ambiguity is philosophical in nature), and the possibility of compulsion that is always implicit in the endeavor. The two difficulties are related of course, for it is one thing to compel an allegedly incompetent person to undergo treatment for unambiguous disease (e.g. appendicitis), and quite another to force treatment for contestable syndromes. While other physicians may occasionally encounter incompetent patients (for whom they usually end up calling in a psychiatry consult), only in psychiatry is the distasteful potential for involuntary treatment always lurking in the background.

Some antipsychiatry fanatics seem to think that psychiatrists delight in forcing treatment on unsuspecting multitudes, but such individuals usually haven't spent much time around psychiatrists. Obviously there are dysfunctional outliers as there always are, but of all the factors that may lead someone to pursue psychiatry or clinical psychology, a joy in foisting treatment on those who don't want it is usually not among them. Arguably, due to the cultural craze for psychotropic medications, stoked not least by direct-to-consumer advertising, the pool of patients who need treatment but won't accept it is dwarfed by "patients" who seek treatment inappropriately or in the wrong places.

Since returning to a public system I have begun seeing the hard cases, of this variety at least, that is, those who are significantly, often grievously impaired by psychotic symptoms but who refuse treatment and do not warrant involuntary hospitalization. Families of such individuals often cannot comprehend how "the system" can allow people to refuse treatment and remain so evidently ill (and as one hapless mother I saw yesterday found out, everything changes in this respect when a patient turns 18). But personal freedom is the default setting here, to be overridden only in the most life-threatening of circumstances. Sure, there is the argument that the psychotic person is not really free, that it is the illness and not the person talking, but society does not have much confidence in psychiatrists' ability to make that sometimes subtle philosophical judgment in the absence of clear and present danger.

So the delusional fellow I saw yesterday who refused to take anything but trazodone seemed somewhat surprised when I didn't threaten him with meds or with commitment. I offered my clear recommendations and said I would see him back next week if he changes his mind (he probably won't, until he gets sick enough that someone does petition him back into the hospital). It doesn't make as good a story as One Flew Over the Cuckoo's Nest, but then again one shouldn't infer much about psychiatry from the big (or small) screen.