Finis

"Now my charms are all o'erthrown,
And what strength I have is mine own,
Which is most faint."

Prospero

In the Times Judith Lichtenberg examines altruism, in particular the fact that it seems impossible to isolate pure unselfishness, uncontaminated by all self-interested motives (even if only the often unconscious satisfaction of having done good). But she argues that altruism is no less desirable, individually and socially, for all its imperfections; indeed, a flawed, all-too-human altruism is the best we can hope for in this world, that is, at all.

It seems to me that the wish for unsullied altruism is parallel to the fantasy of an absolute free will, untrammeled by ambivalence, weakness, or material considerations. The totally free and altruistic act would, of course, be the act of God, not of human beings.

That seems like a fine note upon which to end this blog, which has now run for more than two years and 400 posts. A blog has no natural ending apart from the demise or sheer exhaustion of its author. I find that I have said all that I have to say in this format, and nothing would remain here but the recycling of old themes and, of course, gawking at the baubles of the Web as they flash by. I have arrived at that definite point marked not by ambivalence or by frustrated block, but by dispassion--it is time to move on.

If Emerson was right that life consists of what a man (sic) thinks about all day, then this blog has been a reasonable record of the past two years of my life. Many posts have been tossed off, but many have been thoughtful, carefully wrought and even alarmingly personal, especially to any perceptive readers out there. It has been a transitional time, befitting a blog I suppose.

Other projects await. I will need to prepare for a Grand Rounds presentation a few months hence (a late echo of the academic life), and I am getting closer, finally, to starting a private practice, which will take considerable doing. Any additional post here in the future would be a link to a possible different kind of blog, a more professionally discreet and decorous one that might support a practice.

Thanks to readers--be well.

A Score of Scores

"Thus the whirligig of time brings in his revenges."

Twelfth Night

As mundane commemoration of this blog's 400th post, a few points on the infinite Web:

1. After I read this profile of Arvo Pärt, I went back and listened again to the wonderfully haunting "Tabula Rasa." It's spookily spiritual, scarily good, and perfect for Sunday Halloween this year. Music comes in two basic varieties: that which sets you in motion, and that which makes you more still.

2. The Atlantic on the unnerving unreliability of medical research. I have not been to a primary care physician in a dozen years, and barring any new or unusual symptoms, I hope to extend that streak far into the future (do not try this at home).

3. Melvin Konner on the likely primeval advantages of currently unfashionable distractibility and hyperactivity.

4. I happened to see three great local productions of Shakespeare comedies (Twelfth Night, As You Like It, A Midsummer Night's Dream) over the past two weeks. His comedies, entertaining though they are, are ultimately more disturbing than even the depths of Lear or the black hole of Iago because they show us the arbitrariness of erotic attachment. I was wondering why Macbeth wasn't making an appearance in the season of ghouls and goblins, but Viola, Olivia, Orlando, Rosalind, and Demetrius & Co. are finally more frightening than Lady Macbeth. Never look to Shakespeare for consolation--even the funhouse mirror does not flatter in the end.

5. The comedy club last night was uneven. Beyond a certain point, raunchiness is to true humor as bathos is to pathos; both are varieties of sentimentality, and failures of feeling. But okay for Saturday night.

The Haunted Future

"An apple serves as well as any skull

To be the book in which to read a round,

And is as excellent, in that it is composed

Of what, like skulls, comes rotting back to ground."

Wallace Stevens, from "Le Monocle de Mon Oncle"

I've never gone in much for ghosts, but I'm reconsidering this after reading Leon Wieseltier's meditation on the presence of the unseen. He is writing about historical and cultural memory, but to be sure, there are myriad ghosts of the non-supernatural variety if we would just open our eyes and see them. Wieseltier writes, "Ghosts are the natural companions of estrangement; the invisible officers of tradition, of all the valuable things that have been declared obsolete but, in some stubborn hearts, are not obsolete. It is one of the fundamental properties of the human that the absent may be more significant than the present."

Humanity has always been locked in life-and-death struggle with its various ghosts. Monotheism sought to displace the ghosts of sky, sea, and mountain in favor of one great ghost-in-chief (of all absences, perhaps the one most present). The Enlightenment and modernity routed the fairies and ghouls of cave, dell, and stream. Perhaps the third great usurpation has been the perennial presentism of ubiquitous 24/7 Internet media, whose blinding glare renders the pre-millenial past ever more faint.

Memory, both personal and global, comprises legions of ghosts, as does the written word. Perhaps even the spoken word commemorates that which has passed--as Nietzsche wrote (and as the ever elegaic Harold Bloom was fond of quoting), "That for which we find words is something already dead in our hearts. There is always a kind of contempt in the act of speaking." In other words, we never quite catch up even to the present moment, much less the future.

I think that I have always had to work hard to free myself of ghosts. I have often felt like Frodo when the Ring was on his finger: reality dimmed and retreated and he found himself in a parallel or superimposed shadow world. At any given moment or situation, it is difficult to remind myself that "this, here is reality," for I know that "this, here" can only be the most miniscule excerpt of Reality, an atom in the universe. The ghosts vastly outnumber the living, beyond measure.

Internet media is interesting inasmuch as it locks us into a perpetual present, yet also displaces us from an actual present. The hordes of Blackberry and Facebook-checkers are not entirely "there," but they also are not haunted in any meaningful way; they are not afflicted by ghosts, rather, they and their living interlocutors are in a kind of Limbo. All virtualities are not created equal, and I prefer mine to have a history.

And then there are other specters, of alternative selves (and the persons-to-ghosts those selves would have encountered or even conceived) that occupy the paths not taken. There are ghosts of the future, those beings we think we or those we love might become. As James Surowiecki writes, procrastination can be a way of fending off or at least questioning such spirits.

Procrastination can be a manifestation of mere bewilderment or self-doubt, in which case it may help to break down a daunting or nebulous project into smaller, more concrete, and more practical stages. But as Surowiecki notes, procrastination may reflect a more basic instability in motivation, as identity is somewhat fluid and we can never be entirely sure that we will want tomorrow what we want today. He also reports--news flash!--that, believe it or not, human beings are ambivalent creatures beset with inner conflict (apparently economists and behavioral psychologists are just finding this out).

Inasmuch as it represents skepticism about distant, abstract goals in favor of more short-term rewards, procrastination may be a malady peculiar to modernity. Indeed there is a double-whammy here since complex societies demand deferred gratification at the same time that pleasurable and instant distractions grow more abundant. But there is a more fundamental existential issue. We often put things off because we are not yet sure of their value, and hope that the passage of time will clarify it, so that we can decide which among the plethora of "ghosts of the future" may become real.

Slacker Humanity

"I have a kind of alacrity in sinking."

Falstaff


The generally wise Theodore Dalrymple ponders the not-so-heroic motivations of Homo sapiens. His musings imply, to me, a few possibilities:

1. People often make the cardinal mistake of assuming that other people--whether of a different nationality, epoch, or faith--are very much like them. In fact, it pays to approach people as an anthropologist would, assuming nothing.

2. People are motivated by rather short-term factors operating in their local environments, which is why folks are far more worked up about, say, the economy than about such things as climate change or Afghanistan, which at this point represent relatively nebulous and distant threats.

3. Once people reach a certain level of comfort in their lives (and perhaps it isn't a very high level) they are significantly complacent about working harder. That may be why unemployed Americans stand by as undocumented immigrants take low-paying jobs and why the average American is not alarmed about China or India gaining some kind of competitive advantage.

4. As Dostoevsky's Grand Inquisitor claimed, people on average crave comfort and security more than freedom. Or rather, just as the alcoholic, deep down, wants not to stop drinking but to be able to drink without adverse consequences, most people want freedom without responsibility or the possibility of failure.

5. All of this is to say that humans are first and foremost mammals. We are energetic and ambitious except where complacency and the conservation of energy (often wrongly and pejoratively miscast as laziness) prevail, which is frequently.

Real Happiness

"Hope is itself a species of happiness, and perhaps, the chief happiness which this world affords."

Samuel Johnson

Happiness has been a hot and trendy topic in psychology for a while now. Philosopher David Sosa explores the concept by contrasting it with the experience of mere pleasure; using Robert Nozick's famous "brain in a vat" thought-experiment, he argues that happiness must consist in "human flourishing," which, while somewhat question-begging, does imply that human beings finally crave reality as a field of action, and not merely the kind of virtual subjectivity provided by, say, drugs (or of course the Internet, which is now a more plausible instance of virtuality than Nozick's 1974 chemical one). We stand in deep need of a real external world; the solipsist may think he is happy but he is not.

Sosa's argument suggests that happiness may be more objective than subjective, that is, an individual may not be the best judge of his own happiness. And the degree to which we can control our own happiness is forever in question. According to ancient Stoics and Zen Buddhists, we have the capacity to manage our own consciousness to the point of invulnerability to external accident. But skeptics of many stripes have disagreed, claiming that grave losses or hurts may seriously impair happiness.

Perhaps, to paraphrase Shakespeare's Malvolio, some are born happy, some achieve happiness, and some have happiness thrust upon them; happiness is some kind of interaction of temperament and luck. As today's illustration suggests, I happened to be in Washington, DC over the weekend. Surely George Washington led one of the happiest of lives, and not because he was consciously exultant: a middling Virginia planter and mediocre military man, his character coupled with happenstance propelled him to a truly charmed position in an insurgency apparently destined for greatness.

Happiness is not only not congruent with pleasure--it may be compatible with considerable suffering. Did Abraham Lincoln have a happy life? While he was a jovial sort at times, and an ambitious man who surely knew his own magnitude, he also suffered grim depressions, presided over national mayhem, and died grievously. And yet the scale of his moral achievement, as well as his lasting status as the most beloved of presidents, confers an indisputable happiness upon his life, just as the verdict of history renders Mao Tse-Tung's an unhappy life even if the tyrant died serenely at peace.

Is depression consistent with happiness? I think it depends on severity in a way that is comparable to the experience of pain. Many with chronic, low-grade distress, whether emotional or somatic, may achieve a certain detachment from their affliction that affords scope for happiness. Similarly, episodes of severe melancholy or pain, when transient, may be "happily" endured. But depression is unique among maladies in that a sense of hopelessness is itself a cardinal symptom, making it one of the chief obstacles to happiness.

Yellow Bile

Guildenstern: The king, sir --

Hamlet: Ay, sir, what of him?

Guildenstern: Is in his retirement marvelous distempered.

Hamlet: With drink, sir?

Guildenstern: No, sir, rather with choler.

After an email I sent about a mutual patient complaining of irritability, her wise therapist commented to me on how many more patients she had seen with anger issues in recent years. She wrote, "My belief is that we are witnessing a 'cultural disorder,' with skewed attachments, a sense of entitlement, a lack of accountability, and a crisis of conscience." I too have been surprised by how many patients present with not only dysphoria, but with barely contained annoyance over the conditions of their lives.

Considering how many patients present with symptomatic behaviors of rage episodes and "going off on people," anger per se is surprisingly uncommon as a cardinal diagnostic symptom in psychiatry. As always, it all depends on context. General irritability may characterize depression, mania, or ADHD. Men in particular seem to react with defensive rage when threatened by anxiety. Borderline, narcissistic, and antisocial personality disorders often involve an inability to modulate indignation and temper.

A Times article discusses the occurrence of bullying at ever early ages (think Kindergarten), attributed speculatively to controlling, snarky parents as well as a general media culture valorizing materialism and mean-spiritedness. After several decades of sociologists decrying the disconnectedness, narcissism and entitlement of up-and-coming generations, are we seeing the fruits in an increasingly thin-skinned populace, in both clinical and political terms? Is resentment mutually amplified by the man on the street, virtual and media alter egos, and the much vilified political establishment? Indignation and claims of victimization are everywhere and are thereby cheapened.

Is It Depression?

"When I use a word," Humpty Dumpty said in a rather scornful tone, "It means just what I choose it to mean--neither more nor less."

Lewis Carroll

I took the title of this post from a drug ad I saw today, a question that, contrary to its originator's intent, yields no clear answers. What kinds of answers does someone seeing a psychiatrist seek, and will she get them? (For complex and controversial reasons, it is epidemiologically more likely to be a she, although that leaves plenty of he's too).

Someone seeing a doctor for chest pain wants to know two main things: one, is this a potentially mortal threat, and two, what can be done for it? The cardiologist can resort to a number of physical exam findings and (more likely these days) tests to answer these questions. What is at issue is: what underlying biological process does the pain reflect?

The psychiatrist's function is not much like this. If presented with someone with depressive symptoms, it is true that there are occult medical syndromes (such as, say, hypothyroidism, vitamin B-12 deficiency, or pancreatic cancer) that could be responsible, but these etiologies are vastly outnumbered by idiopathic depressions. The patient may want to know: is this caused by a "chemical imbalance," or by relationship problems, or by a history of abuse? One may speculate or construct a narrative around this, but is impossible to know for sure.

So if a psychiatrist is usually unable to identify underlying pathophysiology, what can he/she provide? Context. A large part of psychiatry is the proper use of the sick role--people present with ambiguous symptoms that are often the target of stigma in the community at large, and the question is: am I merely weak, or am I losing my mind, or is something else going on? While the psychiatrist has limited appeal to diagnostic tests, he can call upon wide experience with persons exhibiting similar symptoms (for this reason, it is extraordinarily scary to be a neophyte in psychiatry, because one has neither firm science nor experience as backing, only clinical supervision).

The granting of the sick role and the understanding and compassion involved can be quite powerful. The psychiatrist "mans" the gateway of mental disorder, conveying seemingly contradictory messages: you are merely human and therefore vulnerable like the rest of us, and so not beyond the pale, yet to a greater or a lesser degree you are more impaired than the average person. Beyond this, there is really only management of symptoms, as I have written before, in the way that a pain specialist manages symptoms. This may take the form of dynamic understanding, or cognitive reframing, or medications, but none of these is directly treating a clear-cut disease process.

In other words, when someone presents saying "my chest hurts," the appropriate next questions are, "What is really wrong with me and how can it be fixed?" When someone presents with "I am depressed," she has usually diagnosed herself. There is a sense in which one cannot be mistaken about one's own depression any more than one may be mistaken about being in pain (subjectivity prevails here). The questions that follow are: "How does my experience compare with others you have encountered; is there hope for me; and how can this be managed?"

Identity Crisis

Christine O'Donnell has a new ad in which she not only distances herself from witchcraft, but also boldly (and baldly) asserts, "I am you." Really? So politicians are now inserting themselves not only into my living room but into my very psyche? Obviously she meant that she is like me or shares my values (which she doesn't), but the difference between simile and metaphor is significant here. I'm spending the morning repairing my boundaries.

Mad Scientists at Work

"I have neither the scholar's melancholy, which is emulation; nor the musician's, which is fantastical; nor the courtier's, which is proud; nor the soldier's, which is ambitious; nor the lawyer's, which is politic; nor the lady's, which is nice; nor the lover's, which is all these: but it is a melancholy of mine own, compounded of many simples, extracted from many objects, and indeed the sundry contemplation of my travels, in which my often rumination wraps me in a most humorous sadness."

Jacques, As You Like It

Most psychiatrists can't go a week without hearing the "guinea pig" comment from a patient alarmed by the all-too apparent imprecision of the enterprise. Problem is, it would be bad enough if treatment were up in the air; the reality is that diagnosis itself is often in flux. Two links--Mitchell Newmark, M.D. at Shrink Rap and Joe Westermeyer, M.D. in the green journal--illustrate nicely the yawning gulf between theory and practice when it comes to the art of the shrink.

Patients (and insurance companies) often crave DSM-type diagnosis for the sake of clarity, but such categories often do not usefully guide treatment. Both psychotherapeutic and biological interventions, strangely, can be both more general and more idiosyncratic than by-the-book diagnoses would suggest. After all, many of the most basic psychotherapeutic stances--Rogerian acceptance and cognitive reframing just to name two--apply across numerous diagnoses. The same may be true of medications--"antidepressants" are used to treat not only depression, but multiple anxiety disorders as well as eating disorders.

In this sense, two seemingly contradictory propositions may be said to be true: every case of depression is alike, and no two cases of depression are alike. The former may as well be the case when it comes to biological treatment, or rather, it is merely the case that depression exists on a spectrum of severity which dictates the aggressiveness (but not the basic type) of intervention. But it is just as true that when it comes to the fine-tuned approach to the patient (including, but not limited to, formal psychotherapy), myriad developmental and personal variables guide treatment far more than DSM diagnosis. Another way of putting this is that despite decades of attempts to make the DSM more specific, individuals within a category (whether schizophrenia or borderline personality disorder) are still more different than they are similar.

I think of evaluation and treatment as situated among three axes: severity, symptoms, and idiosyncratic history. The most basic question is: how impaired is the individual, and what extremity of intervention is called for? The first issue, whether evaluation or treatment is required at all, has already been answered, by the patient or someone close to him/her, by the time the clinician is on the scene. The second issue is whether biological intervention is likely to be helpful. In select cases, the third issue is whether inpatient or residential treatment is indicated.

Individuals are driven to treatment by symptoms, and once it is decided, if it is decided, that biological intervention is appropriate, it is shaped by symptoms more than by diagnoses. Yes, there are a few major categories helpfully kept in mind--primary psychotic disorder, depression/anxiety, bipolarity, substance abuse, and ADHD (or other cognitive impairments)--but those suffice for general formulation so far as biological treatment is concerned. When it comes to general and psychotherapeutic approaches, the unique idiosyncrasy of the patient is the chief guide of treatment.

As Dr. Newmark points out in his post, psychiatry remains profoundly different from the rest of medicine, where diagnosis is everything, in this respect. If a patient presents with chest pain, it is supremely important to know whether it is due to a heart attack, aortic dissection, bronchitis, pulmonary embolus, gastroesophageal reflux, or costochondritis, because each of these calls for clearly distinct treatments. Psychiatry is not like that. Deciding whether a person's diagnosis is depression, bipolar disorder, or schizophrenia will suggest moderate differences in treatment, but the latter will derive more from specific symptoms and personal background. This goes to show that psychiatry remains far more art (or "art") than science. The research-powers that be have yet to persuade the practitioner otherwise.