Sex, Drugs, and Twitter

The title is egregiously titillating, yes, although maybe the three may actually encompass human nature pretty well. Time today only for piggy-backing on Psychology Today, which has several interesting posts.

1. After I touched on the ambiguity of marijuana a few days ago, I see that Stanton Peele discusses the prospects of legalizing that drug (at least), in contrast to President Obama's dismissal of the idea. I am not voicing an opinion, just providing a link; and to state the obvious, legalization is no guarantee of benignity (see alcohol, cigarettes).

2. Satoshi Kanazawa presents evidence, furthering the sum total of unfairness in the world, that contrary perhaps to dumb-blonde stereotypes, there is a modest but real positive correlation between attractiveness and intelligence in both men and women. Superficiality as profundity.

3. Moses Ma considers the psychology of Twitter (basically, we evolved over eons in groups of 30 to 70 relatively close peers, and we're continually trying to recreate that in our socially deprived culture, but one can have too much of a good thing and become, if successful, a celebrity, and if unsuccessful, a narcissist). Actually I may give in to Twitter, as part of my slow descent into decadent digital distraction, and as a 140-character pithiness challenge. Blogs encourage prolixity. Bad.

Findings

(Franz Marc, "Tyrol")

Who am I

To stand and wonder, to wait

While the wheels of fate

Slowly grind my life away.

Who am I?

Country Joe and the Fish

(Thanks to Charles Anderson for reference).

I was reading Robert Lowell again this weekend. Overall he is not one of my favorites, but every now and then a few lines of his haunt me--for instance, the final section of "Hawthorne." This for me encapsulates the Romantic's dilemma--where is spiritual significance to be found? Science gives us facts; the universe is awash with truths, but there is truth and then there is Truth. Science cannot ultimately guide us to the latter--we must rely on contingency, consensus, debate, narrative, but without appealing to ghost stories...

Hawthorne

Follow its lazy main street lounging

from the alms house to Gallows Hill

along a flat, unvaried surface

covered with wooden houses

aged by yellow drain

like the unhealthy hair of an old dog.

You'll walk to no purpose

in Hawthorne's Salem.

I cannot resilver the smudged plate.

I drop to Hawthorne, the customs officer,

measuring coal and mostly trying to keep warm--

to the stunted black schooner,

the dismal South-end dock,

the wharf-piles with their fungus of ice.

On state Street

a steeple with a glowing dial-clock

measures the weary hours,

the merciless march of professional feet.

Even this shy distrustful ego

sometimes walked on top of the blazing roof,

and felt those flashes

that char the discharged cells of the brain.

Look at the faces--

Longfellow, Lowell, Holmes and Whittier!

Study the grizzled silver of their beards.

Hawthorne's picture,

however, has a blond mustache

and golden General Custer scalp.

He looks like a Civil War officer.

He shines in the firelight. His hard

survivor's smile is touched with fire.

Leave him alone for a moment ot two,

and you'll see him with his head

bent down, brooding, brooding,

eyes fixed on some chip

some stone, some common plant,

the commonest thing,

as if it were the clue.

The disturbed eyes rise,

furtive, foiled, dissatisfied

from meditation on the true

and insignificant.

Gross Anatomy for Psychiatrists

Alas, poor Yorick. I knew him, Horatio--a fellow of infinite jest, of most excellent fancy. He hath borne me on his back a thousand times; and now, how abhorred my imagination is! My gorge rises at it. Here hung those lips that I have kissed I know not how oft.

Hamlet

It is a psychiatry resident, Christine Montross, M.D., who makes the case in the NYT for cadavers over digital "equivalents" in medical education. As a doctor who nowadays never touches a patient beyond a handshake, I couldn't agree more, even though the experience of real dissection 18 years ago now was intellectually and existentially stressful in the extreme at the time.

Like any experience both transformative and traumatic, medical school leaves a number of indelible memories, but prominent among them was walking into the Gross Anatomy lab for the first time, where in my room there were perhaps a dozen cadavers, each shared by a team of four students. Before the actual dissections began, the entire class was brought in on an evening to be introduced, as it were, as was appropriate to the situation. The bodies bore no identification or information beyond what could be inferred from, well, their anatomy. "Mine" was a thin old man; I wondered endlessly what his life had been like and how he wound up there.

Medical school was plenty anxiogenic overall in an intellectual sense, of course, but Gross Anatomy added a reverential depth to the endeavor. Sure, there were the whisperings and gigglings over body parts, carried out to dispel anxiety most likely, but overall, the experience conveyed the message that the business of medicine was, literally, dead serious, about real people with real bodies that, as all bodies eventually do, failed. Our job was to find out why and to try to prevent it from happening to others in the future insofar as we were able.

The existential encounter was unforgettable; the actual dissection was, to me, a relatively distasteful denouement. It was clear early on that I was more of a theory person than a procedure person, although until I hit a superb VA psychiatry clerkship in my third year, I would have speculated that internal medicine or neurology was where I was headed. But inasmuch as in traditional medical programs, such as mine still was in 1991, the first two years was primarily about mastering massive quantities of abstract information, the experience of read cadavers was a crucial and concrete corrective, a reminder that medicine is about very specific lives and deaths. Gross Anatomy done virtually, in a disembodied fashion, would be very different indeed; like many rites of passage, this one gains in importance with time.

My wife's grandmother died not long ago, at the age of 95, and donated her body to a medical school. I can't imagine a better way to go.

Where is Wisdom to be Found?

A commenter helpfully brought up the question of how to go about finding, one hopes, above average psychiatric care. I don't claim any special expertise here, but as usual I can be induced to give an opinion.

What would constitute above average? I envision a psychiatrist who has both a healthy respect for the claims of biology and an acceptance of the ambiguity and limitations of our understanding and our technology. You don't want someone who is continually touting the newest thing, because in contemporary psychiatry unfortunately, newer is not always better; but neither do you want someone who hasn't heard of the newest thing, because even if newer isn't necessarily better, it may at least be an alternative.

You want someone who is creative with meds and won't give up on them (or other biological treatments) too soon, but who isn't focused on them to the exclusion of all else. He should offer a differential diagnosis that is shorter than DSM-IV, but he should keep the options open. Human nature being what it is, I would have to say you'd be looking for someone with a marked resemblance to yours truly (humble too).

If you see an $80,000 vehicle parked outside the office, that is a bad sign, as is a waiting room festooned with drug company paraphernalia, because that means he isn't thoughtful about appearances if nothing else. If he seems rushed and doesn't make eye contact, you're probably not getting your money's worth. With all due respect to foreign medical graduates, if you can't make out his words easily or he can't make out yours, he should have chosen a specialty less dependent upon verbal exchange. If he guarantees recovery or even improvement, beware, but if he despairs of the efficacy of his own interventions, suggest a career change.

I wish there were a pat answer for locating this hypothetical sage. Grading doctors and medical facilities on treatment outcomes is the growing if controversial rage, but as always this would always have to be more imprecise in psychiatry (if we can't all agree on the scope of some diagnoses, how could we agree on treatment parameters for those diagnoses?).

Obviously picking someone out of the phone book is the worst option, although it may well be better than nothing. The Internet is somewhat better--there may be a website that reveals the doc's mindset in some way, or a Google search can often reveal a surprisingly detailed trail of even minor publications or conference appearances.

A recommendation from another doctor or therapist is better yet, although keep in mind that they are usually going on inferences based on a psychiatrist's reputation or how he interacts with (referring) colleagues, which may be very different from his bedside manner or clinical acumen. Best of all is word of mouth from folks who have been actual patients--they have the point of view most worth having. But even this isn't foolproof--is he well-liked by patients because he doles out Xanax like candy?

If I had nothing else to go on I would go with an academic center if one with a psychiatry department were less than perhaps an hour away. Even if you get a resident, which is likely, the (relative) enthusiasm, eagerness to please, and exposure to new information may more than compensate for lack of experience, although you would need to confirm that there is supervision by an attending psychiatrist. Academia has all kinds of drawbacks, but in a field as variable and nebulous as psychiatry a large institution usually offers a degree of quality control.

If I were screening a psychiatrist for, say, a family member with severe depression or bipolar disorder, I can think of some questions that might assess clinical flexibility and subtlety. What are side effects of SSRI's? (If sex isn't mentioned, it's already time to move on). What are side effects of mood stabilizers? (If weight gain isn't mentioned, move on). What is your opinion on lithium? Is there an off-label role for drugs like Neurontin and Topamax? Do you feel comfortable prescribing MAOI's and tricyclics? What is the role of ECT? How much do meds usually cost? Are you comfortable with prescribing stimulants or benzodiazepines (the proper answer, essentially, is "It depends").

These are the thoughts that come to mind.

Junkies

Weave a circle round him thrice,
And close your eyes with holy dread,
For he on honey-dew hath fed,
And drunk the milk of Paradise.

"Kubla Khan"


1. Referrals to the clinic in the last few months have suggested an uptick in heroin availability, relatively cheap and "high-quality" stuff, in this area. Hard to resist, apparently, at least when you're young, bored, and have few prospects. It brings to mind Mexican drug violence, which has been in the news more lately and which for me had come appallingly to life in Robert Bolano's fictionalized account in 2666. It makes me wonder, with any given person, what awful things happened so that this guy could get his fix?

Folks in Mexico complain that the real problem is demand north of the border--is this due to our uniquely depraved American culture, or merely disposable income enabling the potential depravity of human nature? As a moral argument this is terrible; a prostitute could similarly say, "Well, the guys want it and will pay for it, so what's a gal to do?" Worse than vice is the inciting of vice in others. Purely as a practical argument, though, it does pay to arrest the Johns too. And the flood of American guns to Mexico sounds like another good reason for gun control to me. But I'm just a Liberal with a crush on Obama.

2. What is one to make of marijuana habits? It's illegal, it's bad for the lungs, and some studies suggest long-term cognitive damage with extended and heavy use. Rarely, it makes someone psychotic. But the problem is that in some areas, such as the ones I've worked in, its occasional use is endemic, and if one focuses on that with everyone who uses it a few times per month, one would never talk about anything else. And the evidence for marijuana as a "gateway drug" or as a cause of other mental disorders is pretty flimsy.

I don't use it and as a physician I don't condone it, but psychiatry doesn't seem to be too worked up about it. My current Textbook of Psychiatry (American Psychiatric Publishing, Inc.) devotes about one and a half out of nearly 1800 pages to cannabis. My Textbook of Substance Abuse Treatment (also APPI) devotes separate chapters to alcohol, nicotine, opioids, cocaine, stimulants, sedatives, and hallucinogens, but not to cannabis. Patients are surprisingly forthcoming about their marijuana, as if they not only don't see it as a problem, but can't imagine that even a stuffy shrink would either.

3. In Psychology Today Stephen Mason, Ph. D. makes a questionable attempt to revive the generally discredited notion of the "addictive personality." But the concept has all kinds of problems, including its tendency to overdefine a person and the splitting of folks into addicts and non-addicts. If one considers behaviors like eating, sex, the Internet, and gambling, I'm not sure there is even a consensus on what qualifies as addiction, much less any coherent construct of an addictive personality.

"Addicts" comprise a surprisingly diverse group and a wide spectrum of severity. Those who really will use any psychotropic substance within reach are rare. It is far more common to see the pure alcoholic, or the opioid abuser with no taste for cocaine, or the cocaine abuser with no taste for opioids. There are, to be sure, people whose impulsivity and whose need for external rewards put them at risk for problematic behaviors--I'm thinking of a former patient who was morbidly obese (largely due to binge eating) and who also had a pathological shopping habit, but she didn't abuse substances. It is hard to see how the notion of "addictive personality" is really helpful, unless it amounts to a global admonition like "If you drink or use drugs you will go to hell." On the contrary, individualize, individualize, individualize...

Sprung

Busy busy, time today only to note that in these latitudes it is March, not April, that is the cruellest month. So, a pair from W. B. Yeats (italics in original):

Her Anxiety

Earth in beauty dressed

Awaits returning spring.

All true love must die,

Alter at the best

Into some lesser thing.

Prove that I lie.

Such body lovers have,

Such exacting breath,

That they touch or sigh.

Every touch they give,

Love is nearer death.

Prove that I lie.

After Long Silence

Speech after long silence; it is right,

All other lovers being estranged or dead,

Unfriendly lamplight hid under its shade,

The curtains drawn upon unfriendly night,

That we descant and yet again descant

Upon the supreme theme of Art and Song:

Bodily decrepitude is wisdom; young

We loved each other and were ignorant.

Squawk

I had seen this local piece not long ago (by J. Peder Zane on the Twitter phenomenon) and then saw it again today on Arts and Letters Daily.

Do I need Twitter? Will it enhance my life? Or is this the tipping point at which my nervous system finally falls a fatal step behind the curve, starting the long stagger into senescence?

Shall I disturb the universe with Tweets? (That always reminds me of Peeps, the appallingly sweet and gooey Easter candy my kids love). More importantly, could I do so with a straight face?

What would Harrison Bergeron say?

What would Emily say?

No bobolink -- reverse His Singing

When the Only Tree

Ever He minded occupying

By the Farmer be --

Clove to the Root --

His Spacious Future --

Best Horizon -- gone --

Whose music be His

Only Anodyne --

Brave Bobolink --

Another

I saw with sadness this morning that Nicholas Hughes, who as a baby slept through perhaps the most infamous scene of 20th century poetry--the suicide of his mother Sylvia Plath in 1962--killed himself last week in Alaska, where he worked as a biologist.

I had wondered before what had become of him and his sister.

Here is Plath's poem "Child:"

Your clear eye is the one absolutely beautiful thing.

I want to fill it with color and ducks,

The zoo of the new

Whose names you meditate--

April snowdrop, Indian pipe,

Little

Stalk without wrinkle,

Pool in which images

Should be grand and classical

Not this troublous

Wringing of hands, this dark

Ceiling without a star.

It's Not You, It's Me

"This is the cultural moment of the narcissist," writes amateur (in the best sense of the word) psychologist Emily Yoffe (her "Dear Prudence" advice column in Slate every Thursday is not to be missed). Problem is, that has been true for at least the past thirty years--Christopher Lasch's acclaimed and acute The Culture of Narcissism appeared in 1979, at the end of the "me decade."

Yoffe's piece is a generally accurate and entertaining popular overview, although I would fault it for suggesting that the narcissist himself usually suffers much less than those around him. To be sure, there are the so-called "oblivious" narcissists who are often high-functioning leaders in politics, business, or other fields, and everyone seems to adduce Bill Clinton as an example although as a psychiatrist I'm not ethically allowed to do that (i.e. diagnose celebrities).

But the central point of narcissism is that the grandiosity and lack of empathy both reflect and attempt to compensate for grievous weaknesses in the self, manifested by painful self-absorption and a gnawing sense of emptiness. These so-called "hypervigilant" narcissists are constantly on the lookout for the validation they desperately crave, and lacking which, they often collapse into despondency or primitive rage.

Limited time today, but my pet theory about many of our current ills, narcissism as much as obesity, is that they are the ironic result of society having achieved levels of average prosperity undreamed of by most people for most of history. And it is the capitalistic prosperity itself--the leisure time, the preoccupation with management and appearance, the endless craving for a new external satisfaction--that is responsible, and not any particular political choices made in recent decades. For most of our history the sheer pressure of work and survival protected us from narcissism. Narcissism is a luxury we seem willing and able to afford, even if it doesn't usually make us happy.

Addendum: Just now I found a most emblematic article, courtesy of good ole Arts and Letters Daily, about the woes of contemporary women who are dissatisfied with their lot no matter how rich, well-wedded, or stocked with cherubic children they may be. I won't say this reflects narcissism per se, only the kind of anomic ennui of contemporary success that I mentioned before. The piece also observes, strangely, that men, in comparison, seem content with their lot. I must not know male psychology like I thought I did...

On Med-Seeking

There cannot be a pinch in death

More sharp than this is.

Imogen (Cymbeline)

I was thinking yesterday about the benzodiazepines (Valium/diazepam, Klonopin/clonazepam, Ativan/lorazepam, Xanax/alprazolam), those somewhat disreputable but often unavoidable therapeutic reinforcements (sort of like a mercenary army, the Blackwater of anxiety treatments). Every doctor seems to have his/her unique philosophy about these drugs, ranging from benzos-as-Tylenol to benzos-as-Four-Horsemen-of-the-Apocalypse. Indeed, the sheer variety of benzo perspectives one encounters pretty much guarantees that ideology more than science or pragmatism is at work. And like much prescribing and diagnosing that goes on in psychiatry, benzos are both overdone and underdone depending on the situation.

My understanding of a substance use disorder is continued use of a substance despite ongoing detrimental effects, whether to health, finances, legal status, work, or relationships. Depending on severity, it may involve involuntary cravings for the substance, desperate attempts to obtain it, and the development of tolerance and potential withdrawal. As is the case for opioids and pain treatment and for stimulants and ADHD, though, the handling of benzos can involve some ambiguous situations.

The central conceptual problem is trying to distinguish recreational euphoria from real relief from ongoing distress, a relief that in itself can seem like a kind of euphoria. After all, a frequent complain among doctors about benzos involves those patients who come in specifically asking for them. To many clinicians this "med-seeking" behavior in itself reflects a likely abuse problem, and surely in some cases it does, but does it necessarily?

It is noteworthy that these three classes of drugs--opioids, stimulants, and benzos--are not only susceptible to abuse but are also among the most reliably effective treatments for pain, ADHD, and anxiety, respectively, especially but not only in the short term. This is no coincidence of course--they clearly have potent and pronounced effects on neurotransmitters that can, depending on the patient, induce therapeutic relief or iatrogenic problems. People in pain may "seek" Percocet, and people with ADHD who have benefited from Adderall in the past may "seek" it again.

To return to benzos, it is worth pointing out that the overall pharmacologic options for anxiety are quite limited. Sure, all the antidepressants, from MAOI's to SSRI's, have effects on anxiety, but they are neither as reliable nor as rapid as those of benzos, and antidepressant side effects are generally worse than benzo side effects (setting aside abuse liability). Beyond antidepressants, one has, for anxiety, such imperfect options as antihistamines, buspirone, atypical antipsychotics, and mood stabilizers, all of which may be plagued with weak efficacy or major side effects. And no, I'm not forgetting psychotherapy, but most of the patients I see have previously or currently tried that. (Primary care and ER docs prescribing benzos may be another matter).

So when someone comes in specifically asking for a benzo, it is at least possible that they do so because benzos have in fact been head-and-shoulders above other drugs in treating their symptoms. Why do patients not come in specifically asking for drugs like Prozac or lithium? (Well, occasionally they do, but not often). Because for depression or bipolar disorder Prozac and lithium are not as clearly superior to competing options.

Another thing doctors tend to hate is patients availing themselves of another person's medication, even if at reasonable doses (this is often from a close friend or family member and therefore more like "in the house" rather than "off the street"). This certainly has its hazards and I don't condone it, but in itself, in the absence of other red flags, could imply a person straightforwardly seeking relief rather than trying to get high. Maybe I'm being psychotically naive here, but I don't think so. Sometimes I think doctors object to such behaviors more because they tend to bypass medical decision-making than because they guarantee a drug abuse problem.

I certainly don't view benzos as panaceas and do not hand them out in a cavalier fashion. And like most psychiatrists I think, I view alprazolam as representing a significantly higher risk of addiction and potentially heinous withdrawal. But unlike some doctors apparently, I don't view patients seeking benzos as prima facie wrong. Innocent until proven guilty.

It occurs to me that just as the prescribing of opioids is somewhat concentrated in specialized pain clinics, which helps to focus attention on potential abuse problems (by random drug screens, the tracking of prescriptions, etc.), clinics devoted to the treatment of anxiety could help to defuse much of the, well, anxiety, related to benzos. Obviously some psychiatrists, particularly in academic settings, specialize in treating anxiety, but the practice is not as widespread as that of pain clinics. Maybe I'll start an anxiety clinic--in my next life.

Odd Couple

If literary correspondence has gone the way of the passenger pigeon, then the newly published epistolary relationship of Robert Lowell and Elizabeth Bishop is a prime specimen, preserved behind metaphorical glass while the contemporary cacophony of Twitter rages outside the museum walls.

Bishop (the subject of a post last year) and Lowell (1917-1977) made quite a pair: she retiring, oblique, and lesbian; he irrepressible, oracular, and ambitiously heterosexual. But the two shared not only world-class poetry but also the shifting murk of mental illness. Bishop's mother was institutionalized and she herself struggled with alcoholism; her partner of fifteen years in Brazil suffered from depression and eventually committed suicide some time after the two separated. As for Lowell, while we often hem and haw these days about bipolarity and its nuances, in his case there is no subtlety: he suffered from recurrent, florid, and classically euphoric manic episodes and took lithium for years.

They complemented each other very well as poetic touchstones and as long-distance interlocutors, although Lowell had notions of proposing to her, which likely could have let to a perfectly disastrous relationship. Bishop never alluded to personal matters in her work, but Lowell's opposite inclinations heralded the "confessional" style of poetry. His poetic take on one of his several psychiatric hospitalizations, "Waking in the Blue," is here. Lowell was a mentor and supporter of Anne Sexton as well as she developed her poetic voice.

In what is for him a subdued tone, here is one of Lowell's last poems (he died of a heart attack):

Epilogue

Those blessed structures, plot and rhyme--

why are they no help to me now

I want to make

something imagined, not recalled?

I hear the noise of my own voice:

The painter's vision is not a lens,

it trembles to caress the light.

But sometimes everything I write

with the threadbare art of my eye

seems a snapshot,

lurid, rapid, garish, grouped,

heightened from life,

yet paralyzed by fact.

All's misalliance.

Yet why not say what happened?

Pray for the grace of accuracy

Vermeer gave to the sun's illumination

stealing like the tide across a map

to his girl solid with yearning.

We are poor passing facts,

warned by that to give

each figure in the photograph

his living name.

(Funny, how with every passing year, facts increasingly demand their due--even from poets).

Story and Schizophrenia

This year marks the bicentennial not only of Darwin and Lincoln, and of Edgar Allan Poe, but also of Nikolai Gogol (1809-1853), who will fittingly turn 200 on April Fools Day. In addition to his comic masterpieces "The Nose" and The Inspector General, he is remembered for his short story "The Overcoat" as well as the novels Taras Bulba and Dead Souls. And in "The Diary of a Madman" (1834) he produced an early description of what may be schizophrenia.

Compared to psychoses related to substances or to depression or mania, which are relatively common in historical and fictional accounts over many centuries, schizophrenia is relatively scarcely documented in past records before the 19th century. This has led some historians of psychiatry to argue that schizophrenia could in fact be a relatively novel disease, related perhaps to an as yet undiscovered virus or to modern society itself (a number of studies, although not all, have suggested the urban environment as a risk factor for schizophrenia). Or schizophrenia may just have had a lower profile because its unremitting, less forgiving course has afforded less historical opportunity for articulation in memoirs and literary works.

A summary of "The Diary of a Madman," as well as the historical speculations about schizophrenia, may be found here. The story is notable for being Gogol's only work written in the first person, as the remarkable account of the clerk Poprishchin, who hopelessly admires the daughter of the office director, comes to overhear the conversations of dogs in the street, and ends up convinced he is the King of Spain.

The story is an interesting amalgam, on the one hand a whimsical parody of the hapless functionary oppressed by the system, yet on the other a poignant treatment of a deteriorating mind. It ends as follows (trans. Pevear and Volkhonsky):

No I no longer have the strength to endure. God! what they're doing to me! They pour cold water on my head! They do not heed, do not see, do not listen to me. What have I done to them? Why do they torment me? What do they want from poor me? What can I give them? I have nothing. It's beyond my strength, I cannot endure all their torments, my head is burning, and everything is whirling before me. Save me! take me! give me a troika of steeds swift as the wind! Take the reins, my driver, ring out, my bells, soar aloft, steeds, and carry me out of this world! Farther, farther, so that there's nothing to be seen, nothing. Here is the sky billowing before me; a little star shines in the distance; a forest races by with dark trees and a crescent moon; blue mist spreads under my feet; a string twangs in the mist; on one side the sea, on the other Italy; and there I see some Russian huts. Is that my house blue in the distance? Is that my mother sitting at the window? Dear mother, save your poor son! shed a tear on his sick head! see how they torment him! press the poor orphan to your breast! there's no place for him in the world! they're driving him out! Dear mother! pity your sick child!...And do you know that the Dey of Algiers has a bump just under his nose?

It is telling that Gogol ended this harrowing passage with the grotesquely comic note at the end. It brought to mind the way that well-meaning folks outside of psychiatry, curious about the inscrutable, want to hear about the flamboyant absurdities of the truly around-the-bend, and end up disappointed that these are far outnumbered by sordid banalities. In the interest of understanding stigma, why is craziness so often found to be laughable, in life and in popular culture?

Three possibilities occur to me. One is the theory of humor as incongruity, as the sight of animate persons behaving as things or automata (thus slapstick and, potentially, psychosis; but it's not funny if someone really gets hurt, which is why real schizophrenia is not amusing).

Second is the theory of humor as a way to take down the powerful or pretentious. Oddly, all paranoia can be seen as massively self-centered or grandiose--in a clinical and not a moralistic sense--inasmuch as the target is implied to be sufficiently important as to mobilize intricate schemes of surveillance or hostility. Paranoia is not self-abnegating--quite the opposite. Pathologically this may be unconscious over-compensation for what is in fact the disintegration of the self, but to observers it may appear as self-aggrandizing, which may in turn inspire humor as a way to deflate the paranoia.

Third is the possibility that madness provokes massive anxiety of the there-but-for-the-grace-of-God-go-I variety, and humor is the way we manage this discomfiture.

If Only...

See how the child reaches out instinctively

To feel how fire will feel

See how the man reaches out instinctively

For what he cannot have

The pull and the push of it all

Kate Bush

I won't say much about the Watchmen film except to join many others who have deemed it a curious, but ultimately dully slavish translation of the graphic novel. It is to the book as anatomical illustrations are to erotic drawings; characters and scenes that are charming on the page become cold and absurd on the big screen.

But I thought Dr. Manhattan came off reasonably well, all things considered, and I was thinking lately of the striking scenes in which he "relives" various scenes of his past in the present tense. I scare-quote "relives," of course because Dr. Manhattan, as a being to whom all times are as the present, cannot really be said to redo anything. It's hard to explain why these scenes do not come across as mere flashbacks; perhaps their conjunction with the clock motif emphasizes the inevitability of the past (and of the future, although in the story a gimmicky but necessary "tachyon burst" obscures the future to Dr. Manhattan and restores the temporal suspense that is necessary to human experience).

Those scenes reminded me of something similar, and just today I realized what: the episodes from Eternal Sunshine of the Spotless Mind in which Joel relives his memories of Clementine as they are, almost unbearably, erased. That movie manages to be both poignantly beautiful and metaphysically obscene, combining the fragile contingency of the past with a misguided determination to remake oneself from whole cloth. It brings to mind paradoxes of acceptance and choice.

Psychotherapy is all about enacting the Serenity Prayer: grant me the serenity to accept the things I can't change, the courage to change those I can, and the wisdom to know the difference. Like many seemingly simple tasks, this proves to be extremely difficult in practice. Unlike the folks in Spotless Mind, we all know intellectually that we can't change the past. But that doesn't stop many from being consumed with regret and resentment over what they or others did or failed to do "back then."

To my mind many folks both inside and outside the consulting room emphasize either fate or choice more than they ought to. One leads to passivity and enabling, while the other leads to contempt of self or others. We all seek some precarious middle ground that blends acceptance and aspiration.

After long dabbling in philosophy and in life, I've come to see what should have been obvious to me all along: determinism is metaphysically true, while free will is psychologically and pragmatically imperative. Looking backward in time, causation being what it is, events could only have unfolded as they did. Universes that unfolded differently are parallel universes, unattainable by us if not altogether fictitious.

The self that comes to psychotherapy is a compound that is both determined and free, and the intermingling of these two can only be worked out over time. Time will tell--all. The future is metaphysically foreordained, but because we are, thankfully, ignorant of which future this is, we can only act as if we can make a difference--because we do. But not from Dr. Manhattan's perspective; it's a good thing he's just a blue guy in a comic book.

Psychotherapy is a kind of narrative node in which we seek to bore new tunnels through the Moria we're wandering through. But the tunnels were really already there all along, just as our "choice" to come to psychotherapy was fated as well. But what are we to do, just sit here while the mind reels? No, we have no choice (!) but to feel that we are free to change our lives, starting--now. But we must be prepared to forgive ourselves, from the morning-after perspective of fate, if we fall short. Perhaps the art of life is all about proper handicapping.

Uh-Oh

Here's an interesting thing I discovered while glancing over my annual malpractice insurance renewal form (to the tune of $7000). Along with the usual litany of intrusive questions like When did you stop beating your wife? or How many human body parts do you have in your freezer right now? came a new one: Do you have a website?

Fortunately the malpractice slate is clean, although I realize that these days that is as much a matter of luck as anything else. Last year was the first time I had to arrange my own malpractice insurance, having been covered institutionally before that. I don't recall that question last year. Now it appears after Do you communicate with patients by email?

Does hosting a blog make one a higher malpractice risk? If I were "anonymous" it would be easier to lie on the form without being immediately found out, but as there have been instances of anonymous bloggers being unmasked (to put it a tad melodramatically), I could still be risking losing coverage if I answered untruthfully.

As I've suggested before, for many folks blogging is just an extension of other forms of publication. The insurance application does not ask Have you written case reports for academic journals? Is this just because your average patient is much more likely to Google your name than to wander through the university library stacks?

What if I hosted a blog on, say, orchids--would that be somehow more innocuous? Or does the mere fact of a professional's name on a blog--any blog--suggest that he is a loose cannon in some way? Unfiltered by traditional media, he could, any day--in the next ten minutes even--type something so appalling as to invite universal and timeless opprobrium, a great carcass thrown out for the vultures...

Hard Labor

This is prompted by a post by one of my favorite interlocutors. A large part what is lovingly called "the art of medicine" is really just common sense, which has as little to do with art as with medicine (unless it can be said to be the art of life). Doctors are given surprising authority over what should be common-sensical matters, and a good is example is the dreaded "When should I go back to work?" question.

I don't recall a medical school course on determining when people can return to work, although that may have been more helpful (for those without common sense at least) than whatever impractical biochemistry we were memorizing at the time. I'm not talking about the toxic Permanent Disability matter, but the routine but frequent need for folks to have a doctor-sponsored mental health day (or week, or month).

Usually this comes up, of course, when someone is in crisis, and when a patient asks the return-to-work question, my unspoken mental response tends to be a shoulders-shrugging, slightly smart-alecky, "Beats me." That is, he knows the particular cognitive, interpersonal, or physical demands of his work, and the likelihood that he is up to them in his current state, far better than I do. But in reality, he has usually already decided how much time off would be helpful and appropriate, and he is seeking an officially medical imprimatur. The amusing thing is that employers would treat my handwritten note as some kind of solemn injunction. The enforced rest cure, as it were.

But at least I am there when common sense fails, as quality assurance I suppose. Usually the week or so that someone wants off is quite reasonable, but occasionally the inches threaten to extend to miles with respect to someone's hated job. Or more rarely, the workaholic or the dutiful will overlook the obvious need for a break. I am a kind of offsite referee for the peculiar dance of the workplace.

All this falls under the nebulous domain of clinical judgment, at least, when the magic wand and crystal ball are out of order. The wisdom thing. As the systemic and cultural authority of doctors wanes, hedged in by managed care, insufficiently awed patients, etc., one would be inhuman not to relish at least a few quaint areas in which we wield near-absolute power. Thou shalt not work...for three days, or the lightning bolts will fly.

No Grade Inflation Here

NAMI (National Alliance for the Mentally Ill) has released a follow-up report card for states' systems of mental health care. As compared to the 2006 report, unsurprisingly, little has changed overall, and the national average remains a D. No state got an A.

These states got B's: Connecticut, Maine, Maryland, Massachusets, New York, Oklahoma

These states got F's: Arkansas, Kentucky, Mississippi, South Dakota, West Virginia, Wyoming

I do public psychiatry only part-time, and I don't mean to wax sanctimonious, but if you're disadvantaged to start with, and have a mental illness on top of that, but you do happen to be living in, on average, the most prosperous nation in the history of the world, one would hope that you could look beyond the local jail or emergency room to obtain decent help. As a society we obviously have other priorities.

State-by-state grades in 2006 and 2009 are here.

Psychiatry on Life Support

Wait, this was in 1962, in an interesting snippet from Aldous Huxley's Island, his final novel featuring, in compensation perhaps for Brave New World, a utopia. A young nurse from said paradise is complaining about a lecture from a visiting Western psychiatrist (one long paragraph in original; sorry):

"What was it about?"
"About the way they treat people with neurotic symptoms. We just couldn't believe our ears. They never attack on all the fronts; they only attack on about half of one front. So far as they're concerned, the physical fronts don't exist. Except for a mouth and an anus, their patient doesn't have a body. He isn't an organism, he wasn't born with a constitution or a temperament. All he has is the two ends of a digestive tube, a family and a psyche. But what sort of psyche? Obviously not the whole mind, not the mind as it really is. How could it be that when they take no account of a person's anatomy, or biochemistry or physiology? Mind abstracted from body--that's the only front they attack on. And not even on the whole of that front. The man with the cigar kept talking about the unconscious. But the only unconscious they ever pay attention to is the negative unconscious, the garbage that people have tried to get rid of by burying it in the basement. Not a single word about the positive unconscious. No attempt to help the patient to open himself up to the life force or the Buddha Nature. And no attempt even to teach him to be a little more conscious in his everyday life. You know: 'Here and now, boys.' 'Attention.'" She gave an imitation of the mynah birds. "These people just leave the unfortunate neurotic to wallow in his old bad habits of never being all there in present time. The whole thing is just pure idiocy! No, the man with the cigar didn't even have that excuse; he was as clever as clever can be. So it's not idiocy. It must be something voluntary, something self-induced--like getting drunk or talking yourself into believing some piece of foolishness because it happens to be in the Scriptures. And then look at their idea of what's normal. Believe it or not, a normal human being is one who can have an orgasm and is adjusted to his society." Once again the little nurse held her head between her hands. "It's unimaginable! No question about what you do with your orgasms. No question about the quality of your feelings and thoughts and perceptions. And then what about the society you're supposed to be adjusted to? Is it a mad society or a sane one? And even if it's pretty sane, is it right that anybody should be completely adjusted to it?"

The perennial critique of psychiatry is all there: the narrow reductionism (psychoanalytic at that time), the inattention to questions of value as pertaining to the well-lived life or the good society.


How will psychiatrists retrain when the utopia comes?

Serenity Now

O reason not the need! Our basest beggars

Are in the poorest thing superfluous.

Allow not nature more than nature needs,

Man's life is cheap as beast's.

King Lear

Reading Judith Warner's latest column brought to mind Chekhov's haunting novella "Ward Six" (the ultimate there-but-for-the-grace-of-God story for psychiatrists). Warner muses on the (around these parts) contemporary craze for mindfulness, which has seeped into a good deal of the psychotherapy literature by now.

Warner frets, with a telling lack of complete mindfulness, that implacable attention to "the moment," and the remorseless casting aside of any concern that could be viewed as petty or as a potential distraction from the pursuit of Mindfulness, could have the effect of making one somewhat inhuman, or what would be worse, boring. And to the truly mindful, having to tolerate (relatively mindless) family members and (ex?)friends could be like the recovering alcoholic having to sit through beer commercials. She postulates that being human may involve being a bit "ragged" from time to time.

As a non-Buddhist but one long fascinated by that mindset, these wry concerns ring true. If I understand Buddhism correctly, the source of all suffering is desire; one follows surely from the other--extinguish desire and, one, hopes, relieve suffering. But given that, as Buddhist monks ably demonstrate, all we absolutely need is a cell, a robe, water, and bread, what justification can there be for maintaining further desires at all? If thy eye offend thee...Of course, desire (and I'm not talking (just) about a new Lexus here, but desire for family closeness, world peace, whatever) is also arguably one's reason for living. That offensive eye provides vision; if it doesn't, maybe it should indeed go, as should desire if it no longer justifies life.

The Buddhist move is much like the colloquial philosophical move of "the grand scheme of things." We do this all the time to maintain perspective in life. A guy cuts me off in traffic--is it ultimately, in the grand scheme of things, worth it to me to murder him? "Don't sweat the small stuff," we say. The problem with this as a general move is that from the standpoint of the universe, nothing we do or care about matters. In the grandest scheme possible, the earth vanishes in five minutes--doesn't matter.

No, things matter at all only in a contingent way and according to how we happen to be constituted as conscious animals with a long evolutionary history. For our own individual and social well-being we somehow manage, singularly and consensually, to work out what "really" matters. But it may be unwise to say that this happens primarily as the work of the solitary, determined, and mindful self. It is a spiritual project, and one that culture ought to refine and not coarsen.

All this reminded me of Stoicism, Chekhov and "Ward Six." The doctor is trying to convince a skeptical patient of that Greek wisdom:

"There is no real difference between a warm, snug study and this ward," said Andrey Yefimitch. "A man's peace and contentment do not lie outside a man, but in himself."

"What do you mean?"

"The ordinary man looks for good and evil in external things--that is, in carriages, in studies--but a thinking man looks for it in himself."

"You should go and preach that philosophy in Greece, where it's warm and fragrant with the scent of pomegranates, but here it is not suited to the climate. With whom was it I was talking of Diogenes? Was it with you?"

"Yes, with me yesterday."

"Diogenes did not need a study or a warm habitation; it's hot there without. You can lie in your tub and eat oranges and olives. But bring him to Russia to live: he'd be begging to be let indoors in May, let along December. He'd be doubled up with the cold."

Let the storms of life rage! The mind cares not, nestled as it is in its dark, moist womb of bone. Ah, high-maintenance humanity, both cursed and blessed with a limbic system and a midbrain, not to mention everything from the neck down...I would say that as a society we show little sign yet of becoming morbidly mindful.

DFW Revisited

Fear the hearts of men are failing
These our latter days we know
The great depression now is spreading
God's word declared it would be so.

Uncle Tupelo


D. T. Max's review of the life and work of David Foster Wallace in the current New Yorker comes six months after the writer's death by hanging--another victim of the wretched "black dog." Lately I was rereading some of Wallace's essays--on tennis, on television, on David Lynch--and I was most struck by their coruscating intelligence, their fierce intensity. If I knew nothing about him apart from his writings and the fact of his suicide, I would have inferred that he had bipolar disorder, but apparently, from what little I have picked up from the press, he was never classically manic (in the Robert Lowell sense anyway).

But the sheer urgency and obsession with detail of his prose make one wonder, although not because it veers out of control--indeed, it is fascinating because it seems always on the verge of shivering to pieces, but pulls back just in time. And his incredible humor is evident in every line: very dry, yet unself-conscious, ingenious, yet never supercilious. His exuberant brilliance doesn't overwhelm, because he is constantly reminding the reader how much he himself, the author, doesn't know.

Wallace's illness began in adolescence, it seems, with anxiety and panic symptoms, and it sounds like the depression that followed for nearly three decades rarely abated altogether, although the symptoms were more or less controlled at times. He had ECT twice, once as a young man (when it was somewhat helpful) and again in the year before his death (when it wasn't).

Interestingly he did relatively well on Nardil for years, just as some rare individuals seem to do better on MAO inhibitors than on newer and supposedly "cleaner" antidepressants. But sometime in the year or two before his death he may have had a tyramine reaction after eating at a Persian restaurant (MAO inhibitors and exotic cuisine don't mix well), and as he struggled for years to crank out a third novel he developed the classic concern that the antidepressant was dulling his creativity. So he stopped the Nardil. It sounds like it was pretty much downhill after that, although obviously we don't know if staying on it would have made a difference.

Wallace seemed always to struggle from a conviction that something was seriously wrong not only with himself, but with his era. And while he did serious student work in philosophy, he always came back to literature as a possible way out; it's hard to think of another author who so urgently looked to fiction as a "writing cure." According to Max's review:

His goal had been to show readers how to live a fulfilled, meaningful life. "Fiction's about what it is to be a [freaking] human being," he once said. Good writing should help readers to "become less alone inside."...The central issue for Wallace remained, as he told McCaffery, how to give "CPR to those elements of what's human and magic that still live and glow despite the times' darkness."

Literature as moral and existential CPR--that is a tall order. Indeed, in contrast to his non-fiction works, which Wallace seems to have tossed of fairly easily, he agonized over his fiction. After his second novel and magnum opus Infinite Jest in 1996 twelve years had passed when, after struggling for years with an uncompleted third book, he took his own life. One wonders if, despite his general genius, he was asking too much of his own fiction.

Max quotes from Wallace's first novel The Broom of the System:

Apparently she was some sort of phenomenon in college and won a place in graduate study at Cambridge...but in any event there she studied...under a mad crackpot...who believed that everything was words. Really. If you car would not start, it was apparently to be understood as a language problem. If you were unable to love, you were lost in language. Being constipated equaled being clogged with linguistic sediment.

Without being reductive, I wonder if Wallace sought in words a cure for a depression that ultimately was not about words, but about the way his brain was wired. But if you're looking at a nail and don't have a hammer, you might use a heavy book instead. And some get by with that, if the wires aren't too tangled, or the nail isn't too big (metaphors mixing here). But as Wallace wryly put it in an interview, "I had kind of midlife crisis at twenty, which probably doesn't augur well for my longevity." He died at 46, and his story suggests that he braved much to get that far.

Wallace never wrote directly about his own depression, but Max quotes the following from the story "The Planet Trillaphon:"

I'm not incredibly glib, but I'll tell what I think the Bad Thing is like...Imagine that every single atom in every single cell in your body is sick...intolerably sick. And every proton and neutron in every atom...swollen and throbbing, off-color, sick, with just no chance of throwing up to relieve the feeling. Every electron is sick, here twirling off-balance, and all erratic in these funhouse orbitals that are just thick and swirling with mottled yellow and purple poison gases, everything off balance and woozy. Quarks and neutrinos out of their minds and bouncing sick all over the place.

Malaise that penetrates to the sub-atomic fundamentals of being: it's hard to think of a better metaphor for severe depression. And yet Wallace's writings show his capacity to be more delightfully alive to the wonder of living than most of us ever manage. Sometimes our current treatments are no anodyne: but I can't help wishing he hadn't stopped the Nardil. Maybe the third novel never would have been, but perhaps he would have survived; as it is we have neither. There is depression and then there is depression; his was not the kind to toy with.

Female Scribblers

Elaine Showalter's A Jury of Her Peers, according to one review, points out that 19th century Great Britain produced several literary titans with two X chromosomes--Jane Austen, the Brontes, George Eliot, and then Virginia Woolf later on--while the United States during the same period produced, well, Harriet Beecher Stowe. Why? Apparently Showalter suggests that even poor British women had servants, while their American counterparts kept house. But it would seem that children above all may have barred the way to literary greatness.

The Library of America series may serve as a rough guide to canonical status, and only seven women have volumes devoted to them: Stowe, Sarah Orne Jewett, Willa Cather, Edith Wharton, Gertrude Stein, Flannery O'Connor (who is the subject of a new and reportedly excellent biography), and Katherine Anne Porter. With the exception of Stowe, who amazingly bore seven children, none of these women ever answered to "Mommy." (Emily Dickinson, who obviously warrants a volume but doesn't have one yet--some copyright issue I guess--obviously wasn't a mother either).

Uncle Tom's Cabin is among my sheepishly as yet unread classics. Stein I have never yet been able to stomach (the emperor's clothes problem for me). Cather, Wharton, and Porter I find very good indeed, but probably only O'Connor would I consider absolutely essential, if only because she is sui generis.

Jewett (1849-1909) I had never read until recently, and given her general obscurity since her death a century ago one wonders whether her Library of America status may be owing to a bit of feminist affirmative action. The daughter of a successful country doctor, and granted independence by family wealth, she was much acclaimed in her lifetime and traveled widely in literary circles. In an interesting parallel with O'Connor's lupus, she struggled with rheumatoid arthritis for much of her life.

The text of Jewett's striking story "A White Heron" is here, and I also read her short novel The Country of the Pointed Firs, a local color affair based on the Maine coast and featuring eccentric but tough farm women and old salt-of-the-earth sailors. Not much happens, but the characters, relationships, and above all the sense of place are conveyed quietly but powerfully--perhaps a kind of premodern Virginia Woolf.

Watching the Watchmen

(Courtesy DC Comics and Titan Books)

Quis custodiet ipsos custodes?

Juvenal

The film version of Watchmen comes out in a couple of days, and based on early and, as they say, "mixed" reviews, it sounds like they may have managed to screw up another comic book adaptation. I was surprised to see the R rating, which means gratuitous sex and violence rather than egregious silliness. It's hard to know which is worse; but I defer judgment.

The original 12-issue Watchmen limited series by Alan Moore and Dave Gibbons came out in 1986-1987. By that time I had moved on to other things than comics, and I caught up with it only a couple of years ago after coming across high praise of the work, now compiled into graphic novel format.

The comics genre widely construed has been surprisingly celebrated in recent years, blessed with the quasi-respectability of Art Spiegelman, Chris Ware, and many others. But Watchmen may be the preeminent work that employs not only graphic methods, but in the service of a sophisticated superhero theme, and without resorting to stock favorites (the book involves a slightly alternative 1980's United States in which there have been costumed--and controversial--superheroes, but no recognizable figures such as Superman, Wonder Woman, etc.).

Watchmen has widely been hailed as having "deconstructed" (how musty that term already seems) the superhero genre. It takes seriously the reality of actual adult folks wanting to dress up and fight bad guys, and it dissects the motivations, ambiguity, and consequences involved (by implication, it refuses to patronize those with a legitimate interest in reading about costumed superheroes). Its characterization, construction, and artistic skill are first-rate; it is a compelling read that assumes no prior knowledge of comics.

Comics will never be seriously respectable, and the superhero genre may be the lowest brow of all. Yet masquerade and concealment (I'm talking to you, Anonymous) are powerful human motivations, affording empowerment and experimentation with identity. Think Halloween. Masquerade, particularly of the androgynous variety, was a central theme in Shakespeare's comedies.

Of course the superhero is about not only anonymity, but also vigilantism, and as such I suppose the genre sprang from particularly urban frustrations and anxieties (Spider-Man doesn't spend much time in Iowa). Some have criticized the superhero concept as being ultimately fascist, promising extreme and concentrated power, even if purportedly for the good, outside of the usual channels of the law. It's the great question of social theory: how is real authority found or legitimized?

One can see this as being about adolescent wish-fulfillment (much as Freud arguably saw all artistic pursuit). But as I am wont to do, I also see a kind of religious aspect to the superhero, and to the supervillain as well. The former often comes by his or her powers through a miraculous "accident," and the force for good could be seen as plenitudinous grace of a kind, unlooked for. And yet evil must have its due, its Doctor Doom, its Adversary.

Comics are fundamentally a miniature genre, packing a world not into a grain of sand, but into a scrap of paper as it were. Their soaring--and frequently absurd--intensities derive whatever pathos they can from the contrast with their lowly corporeal manifestation. Transmutation onto the big screen upsets this tension, and usually bypasses grand in favor of grandiose. A few superhero films are worth watching--Superman, Spider-Man 2, Batman Begins, Iron Man--but their tie to the humble comic is tenuous at best.

The Course of Life

They warn you about killers and thieves in the night

I worry about cancer and living right

But my mama never warned me about my own

Destructive appetite.

Jenny Lewis

Suppose as thought experiment that I were to look for a new job. Crazy in this economy, right? Poor choice of words perhaps, as the demand for psychiatric services seems perennially high. Will diagnose, prescribe and counsel, for cash destined for the mattress (hold the 401(k)--please).

So the question is: does a blog like this improve or imperil one's job chances, even if it's left off of the CV? (It is currently on). I've never been an employer, but does anyone make a hire these days without running the hapless chap through Google first? Plenty of folks have been embarrassed by drunken and other shenanigans bumblingly posted on Facebook (okay there), but what about the hybrid personal/professional blog?

I would hope the humble site here would reflect some creativity and independence of spirit, but some employer might grumble, "As if that's a good thing?" But if so, why would I want to work for him/her? Um, because the mattress might get low on cash.

What about private practice, with multiple individual "employers" as it were? Would the blog usefully advertise my clinical and philosophical views without Too Much Information, or has the latter threshold already been crossed? As I compile posts it is easy to forget how much could be inferred from a careful reading of the entire series (do not try at home). I don't like the idea--or the effort--of painstakingly editing past posts in detail, but it might be necessary to jettison a few of the more casual or jejune efforts (like this one) that might not measure up to Professional Dignity.

Blogging topics to be deferred:

My High School Prom

Domestic Pet Peeves

Back to the Dentist

Annals of Toilet-Training

My Vintage Bottle-cap Collection

(Just kidding, prospective boss; a sense of humor is important to me in a boss, unless the economy gets any worse, in which case I can play it straight with the best of 'em).

What would Freud do?

Material Objections

"You don't believe in me," observed the Ghost.

"I don't," said Scrooge.

"What evidence would you have of my reality beyond that of your senses?"

"I don't know," said Scrooge.

"Why do you doubt your senses?"

"Because," said Scrooge, "a little thing affects them. A slight disorder of the stomach makes them cheats. You may be an undigested bit of beef, a blot of mustard, a crumb of cheese, a fragment of an underdone potato. There's more of gravy than of grave about you, whatever you are!"

"A Christmas Carol"


Two links on freedom and belief:


1. Courtesy of Arts & Letters Daily, an intriguing article on the brain's reward system describes the case of a woman who suddenly developed pathological gambling after taking dopamine for Parkinson's disease. This sort of story punctures our more overblown conceptions of free will (as did the obesity post a few days back), even if we can't do without some form of it, albeit perhaps in shrunken form.


The article also argues that gambling, including that heretofore respectable form of the stock market, deprives the dopamine system of its rationale by disconnecting effort from emotional reward. Throughout evolutionary history effort did not always pay off, obviously, but effort and skill were proportional to success--spearing the prey or winning the girl or guy--often enough to make dopamine's rewards meaningful. Both gambling--by making the payoff random--and drugs such as nicotine and cocaine--by making the payoff guaranteed--short-circuit the meaning-making function of the dopamine system.


2. At A Commonplace Blog D. G. Myers mounts a worthy defense of theism and tolerates my agnostic remonstrations. As usual, I argue that the quandary is not belief in God in the abstract, but rather the extreme multiplicity of religious conceptions across geography and history; absent the accidents of disposition and upbringing, there is no compelling justification for specifying God beyond the ultimately absent and inscrutable place-holder of value. That is, we cannot justifiably specify God in sufficient detail for belief in "Him" to make specific moral or metaphysical differences in our lives. We are left with mere wonder.

How Much Time Do I Have?

But at my back I always hear

Time's winged chariot hurrying near;

And yonder all before us lie

Deserts of vast eternity.

Andrew Marvell

A couple of weeks ago I dragged myself to the dentist, to the same office I used to go to when I lived around here before, ten years ago. (This is not, granted, an auspicious beginning for a blog post, or for any writing except perhaps a letter to one's grandmother, but bear with me). Once there I was asked whether I had seen any other dentists in the decade-long interim. I thought they were joking; they weren't (and lest you suspect the obvious, they hadn't even looked at my teeth at that point). I assured them that I never go more than nine years between visits. But the fact that they had to ask that question is a good reminder of why, for me, dentistry was safely off the list of life possibilities from very early on. But that's rather uppity of me I know--like I'm too good to be gazing into other people's oral cavities?

Deciding the frequency of medication management visits is no exact science, obviously, so except with folks that I'm particularly concerned about and who need to return soon, I usually just throw out a number, and I guess my mind usually lands on one, three, or six months depending on the person. These are arbitrary, but just have a tidy sound to them. Occasionally I may split the difference and do two or four months, but never five. There is no clinical reason why someone couldn't come every five months, it just isn't a factor of twelve. In my view even the most stable medication patient ought to check in (in person) at least twice per year, but again, I can't say this is scientific, it just feels right to me.

Psychiatrists are well known to keep patients waiting much less than do other physicians, and presumably this is the legacy of the precisely regulated 50-minute visit. But even with medication visits, I can't imagine keeping folks waiting an hour as they undoubtedly do in other doctors' offices. To some degree this is common courtesy, but it is also the case that some might find the psychiatric visit to be more stressful than a routine appointment; in other words, there may be some folks one wouldn't want to be hanging out in the waiting room for an hour or two, for their own good and that of others as well.

Many psychiatrists schedule medication visits every fifteen minutes, but I haven't been able to bring myself to do that yet. In my opinion, unless there are a significant number of no-shows or cancellations, it is hard to manage meaningful visits, even with stable folks on medications only, on that kind of schedule. The single most common complaint I hear from patients about other psychiatrists (which have included both private and community types) is that they didn't take the time. That is, they had the prescription pad poised to write from the moment the patient stepped into the room, and the patient felt rushed and not remotely listened to. In a high-functioning population with some cancellations, scheduling three per hour may be reasonable, as I did in a student counseling center I worked at. (The most common complaint I hear about other psychotherapists is that they brought up their own problems and issues too often in session; who are these people?).

Of course, if there is anything that shouldn't be one size fits all, it is psychiatry. Some patients really do only need five to ten minutes, after which we find ourselves discussing weather or sports (and I don't keep them sitting there a half hour for that). But a good number of medication patients need a full thirty minutes, and if that's not factored into the schedule, one will either have to cut people off or get behind and keep people waiting. Medication management, though, is more nebulous in this regard than the classic "50-minute hour."

Not really ambitious this rainy Sunday--the drops fall and the minutes tick by...