Wonder Women

All I have for Christmas Eve are nods to two formidable females, one lowbrow and fictional, the other highbrow and, once, very real.

My favorite post of the week is Providentia's concise review of the strange life and career of William Moulton Marston: psychologist, inventor of the polygraph, creator of Wonder Woman (in 1941), and, it must be said, distinctly unconventional family man. Thank you, Marston, but not for the polygraph, which hasn't stood up very well scientifically.

And today I can't resist this towering Emily Dickinson lyric, in a boreal and reverent mood:


My period had come for Prayer --
No other Art -- would do --
My Tactics missed a rudiment --
Creator -- Was it you?

God grows above -- so those who pray
Horizons -- must ascend --
And so I stepped upon the North
To see this Curious Friend --

His House was not -- no sign had He --
By Chimney -- nor by Door
Could I infer his Residence --
Vast Prairies of Air

Unbroken by a Settler --
Were all that I could see --
Infinitude -- Had'st Thou no Face
That I might look on Thee?

The Silence condescended --
Creation stopped -- for Me --
But awed beyond my errand --
I worshipped -- did not "pray" --

The rest is silence...until the next post.

Happy Holidays.

That is the Question

"There is only one really serious philosophical question, and that is suicide."

Albert Camus

Morbid though it is before the holidays, I feel obliged to finish the thought from last post, about how the ultimate ethical issue of suicide is similar to other grand queries (why be moral? why grow up?) that lack a fully satisfying theoretical answer. And in practical and clinical terms, is it possible, or even advisable to try, to dissuade someone who is seriously suicidal?

But this gives me a chance to touch on "holiday psychiatry" in general. As many hopefully are aware by now, the notion that the suicide rate increases around the holidays is a myth (it actually has a spike in the spring), although some have expressed concern that the dramatic economic downturn may generate more risk this particular year.

While many people complain about the increased stress of the holidays, and certain individuals do indeed fare worse this time of year, in my clinical experience the net effect is positive. In my years of inpatient work the unit census always dipped dramatically the latter half of December. And outpatients--again, on average--seem to coast through holiday time reasonably well.

My hypothesis is that while many may gripe about tedious or irritating family time, the social support of sheer enforced togetherness is usually a good thing (time off from work doesn't hurt either). In this way, family time can be like, well, a very different but well-known kind of social encounter: it may be far from perfect, but it is better than none at all.

At any rate, let's suppose someone is in fact driven to the brink by depression plus the holiday fanfare. As hinted above, philosophers have had a hard time coming up with solid justifications for why suicide is generally an evil. Presumably, the reason is that in order to work, such arguments have to assume too much of what they're trying to prove, that is, the absolute value of life itself.

Any philosophical argument presupposes an adequately rational auditor, and that is the problem--a seriously suicidal person, virtually by definition we say, has lost sight of his or her own vital interests and therefore cannot be considered fully rational. That is why we have involuntary commitment procedures and locked psychiatric hospital wards, because for suicidal individuals reason has broken down.

Fortunately of course, most people make it through life without being constitutionally disposed to seriously suicidal thoughts or behaviors. So native biology is our first and primary protection, but not the only one by far. What are the most common reasons not to commit suicide? The following is not scientific, but based on my clinical observations:

1. Cowardice--Fortunately most people are sufficiently averse to violence, pain, and blood that this in itself will keep many in the land of the living; there is also the associated fear of doing something halfway and winding up brain-damaged. If some absolutely painless and definite means of suicide were widely available, that would make the psychiatrist's job considerably harder. This is a visceral factor that few potential suicides need reminding of.

2. Threat of damnation--Whatever else one might say about religious belief and psychiatry, hell serves--among believers obviously--as a mighty deterrent for many would-be suicides. This consideration is also the basis for one of the most famous passages in English, Hamlet's "To be or not to be" soliloquy. However, most people for whom this rationale has force will have arrived at it long before they talk to a psychiatrist, so I wouldn't usually bring it up (if I know a suicidal someone to be a believer and yet he doesn't volunteer the damnation concern, I will usually ask something like "Have you shared this with your minister, etc.?"). In fact, suicide is such an absolute ethical issue precisely because death is, so far as we know, so final; in the broadly secular context of psychiatry, to emphasize considerations of the afterlife would be positively counterproductive for this reason (again, if someone already has a belief in hell or whatever that protects against suicide, that's great with me).

3. Effects on family--Many potential suicides will already have this preventive concern in place. But sometimes not--depression is, almost by definition, a state of self-absorption such that the ramifications for children, parents, etc. will have been overlooked. For this reason I often try, sensitively and without imputation of a "guilt trip" for their own suffering, to convey the devastation that suicide can wreak in families through the generations.

4. This too shall pass--This is the consideration that seriously suicidal people are least likely to have perceived, and therefore one that I most emphasize. In most cases depression is an episodic illness; when it flares it can be awful, but relief is likely to come (even without treatment, although treatment obviously hastens recovery). And yet the deeply depressed person, by the nature of the illness, cannot imagine this--all they can see is darkness (that's what true hopelessness is). So the way I usually think of it is that suicide is a permanent solution for a temporary problem, and I remind people that their own values and their attachment to life will recover if they will only give it time.

Okay, I've had my say on that, and will come up with something appropriately rosier tomorrow.

'Tis the Season

Hamlet: Denmark is a prison.

Rosencrantz: Then is the world one.

Hamlet: A goodly one, in which there are many confines, wards, and dungeons, Denmark being one o' the worst.

Rosencrantz: We think not so, my lord.

Hamlet: Why, then 'tis none to you, for there is nothing either good or bad, but thinking makes it so. To me it is a prison.

Over the weekend I finished reading philosopher Susan Neiman's Moral Clarity: A Guide for Grown-up Idealists. If you're looking for a last-minute gift for the amateur ethicist or preoccupied moralist on your list, and I'm sure you are, I recommend it. It has me feeling all Christmasy (?).

In an era of divisive political polarization it is difficult to convey the sense of an ethics that stems neither from self-interested identity nor from might-makes-right "realism," and Neiman makes as a good a case for Enlightenment values as one could for the general reader, I think. This is not meant to be a review (Simon Blackburn's for the New York Times is here), but the following notions stood out for me (what is the written equivalent of a sound bite?). In Neiman's view:

1. The Left, resigned to identity politics and the postmodern view of ethics as mere "discourse of power," has ceded useful distinctions of value and morality to the Right.

2. The problem is that the Bush administration, while draped in the garb of Enlightenment values, instead pursued policies based on naked self-interest, whether personal or national (often rationalized as "realism").

3. In other words, the Left has risked being amoral and relativist, while the Right has risked hypocrisy. Both tendencies support the complacent status quo.

4. In the recent political climate idealism in general and the Enlightenment in particular have gained reputations of being naive, imperialistic, and simplistic, when they needn't be any of these things. There is a fruitful middle ground between being grimly, resignedly realistic and being pie-in-the-sky naive.

5. The growing influence of evolutionary psychology, while it can shed light on why we have moral impulses at all, cannot be allowed to determine the limits of ethical possibility. After all, the whole point of ethics is not (or at least not merely) description, but rather prescription; we can, even if only with great difficulty and in minute increments, decide to be other than what we, contingently through natural selection, are.

6. Religious believers have no monopoly on ethics; it cannot be the case that "If God is dead, then anything is possible." A valid ethical system must be universalizable, not depending on what any one individual, clan, or nation feels to be a divine command.

7. One of the hardest questions in philosophy is "Why be ethical?" That is, why be ethical in the really reflective sense, rather than just comporting oneself based on self-interest and fear of punishment? After all, a fair number of people (and probably only a relatively small number of them psychopaths) more or less behave themselves in life not because of any deep ethical commitments that they could justify or even articulate, but simply because they don't want to step on any toes or stir up any trouble.

In philosophy (or maybe just in philosophy graduate departments and amateur philosophers like myself) there is the perennial dream of some ethical justification that will open the eyes of the immoralist to the error of his ways. But Neiman, seemingly granting that if such universal and theoretical justification were possible it probably would have been found by now, likens being moral to growing up. I like this metaphor a lot. The egoist who asks why be moral (at all) is much like the teenager (implicitly) asking why one should, in fact, grow up (in the sense, I suppose, of being generally responsible for oneself).

Being moral has several things in common with growing up. Human beings are probably evolutionarily constituted to do both, although with sufficient discretion it is quite possible to get by in life, and at times even to be externally very successful, without doing so. Both are exceedingly difficult to define, but we feel we know them when we see them. Both states are reached not through simplistic or black-and-white theoretical roadmaps, but by complex practices comprising both individual will and social consensus.

They are also alike in that they are never all-or-nothing; everyone struggles against lapses of self-interest or immaturity. Neither sainthood nor purity is reasonable or even desirable. The ethical person and the grown-up can remember and understand well the egoist and the teenager, but not vice versa--the latter cannot really comprehend what they are missing. If you seriously ask for a theoretical justification for being an ethical or a grown-up person, then you're not one (yet).

For some of us the holiday season is not primarily about God or even family time, but rather, if we're lucky, about idealism, both global and personal ("Peace on Earth" and--New Years resolutions). Christmas, appropriately for its ancient pagan origin around the winter solstice, is based on the conviction that no matter how things are now (good or bad), they can get (even) better.

The comparison between ethics and maturity brought to mind, perversely I guess if not for my line or work, another question for which philosophy has long struggled to find adequate answer: Why is suicide a bad idea? Almost everyone agrees that it is, but why? That cheery topic prompted the Hamlet quote above, but my thoughts on it will have to wait until next post.

(Not) Just Another Day at the Office (continued)

How pregnant his replies are! A happiness
That often madness hits on, which reason and sanity
Could not so prosperously be delivered of.

Polonius


A young fellow comes in, for a routine check-in after hospital discharge. He has been diagnosed with schizophrenia, although he disputes that (surprise). But he protests that what he really needs is not "pills," but rather housing and a job. "All you all ever talk about is pills...always more pills...what am I supposed to leave my kids, a bunch of pills?"

Good question. Fortunately his community support worker is sitting in with us; hopefully she has all kinds of great ideas for him. His last job was $7 an hour at Biscuitville, and with gas prices being what they were then, what was the point, really? The Obama campaign/transition team keeps sending me emails--what are they going to do for him?

Another guy, middle-aged this time. It sounds like he was quite successful, with a high-paying sales job and a family until he developed a severe psychotic disorder several years ago. Since then it has been steeply downhill, with several hospitalizations, disability, and divorce.

I had first met him a few weeks ago, when his family brought him in in a floridly psychotic state. At that time he was disheveled, paranoid, and exhibited thought-blocking. This time it is after his discharge and I barely recognize him. To be sure, his appearance is subtly off: a few hairs out of place, and a jacket that is a bit too long and too bright. But he is making an effort, and arrives early for his appointment.

He has been put on prodigious amounts of haloperidol, both oral and by long-acting injection, but he tolerates it without complaint. His chief concern seems to be a compound of loneliness and futility. He is heartbroken over not having seen his kids for months, and his ex-wife seems to have been able to deny him access. He wants to look into working and being productive again, like he used to be. Yet he sheepishly allows glimpses of persisting delusional systems. I don't think he could or should hold a regular job at this point. He lives alone, but does attend a church, and has some support from his family of origin. He has lost almost everything.

Why?

Married With Children

Okay, a little bit of comic relief for the weekend, based on an exchange my wife told me about.

We had a "computer guy" come over and "clean up" our computer because it appeared to have some viruses. The rather detached and deadpan fellow arrived and sat down in front of the device. Not long after he asked, "Do you have any alcohol?"

This seemed a little bit unusual, so my wife asked, half-jokingly, "Do you need a drink?" Maybe our computer viruses were more serious than we thought, or maybe this was a different kind of "computer guy" than we were used to.

"Rubbing alcohol," he corrected. It was duly obtained, and he went to work with it, removing, of course, some old peanut butter and assorted bits of "sticky stuff" adorning the mouse and keyboard (hadn't even noticed). So we got computer maintenance and detailing as well. He charged extra to detail the children though, so that will have to wait. (We're not dirty people, really, I think he must have been on the fastidious side--not that there's anything wrong with that).

Note to self: no more late-night PB & J while blogging.

Blog in a Bottle

This little post is purely for the sake of symbolic #100, spanning the first five months of this personal experiment, and an excuse perhaps to take the weekend off. It also affords a chance to think about the weirdness of blogging.

Perhaps the first question the blogger has to ask is: Am I writing for myself or for others? However much one might claim the former ("I don't really care if anyone reads it"), we know it's bogus. If it were for oneself it would be in a journal stashed in the closet and not on the Internet. Even the radically reticent Emily Dickinson (at least where actual publication was concerned), did not after all burn her poems, and presumably died hoping against hope that someone would discover them--and her.

Of course, writing within view of others, so to speak, is not at all the same as writing for others. Most bloggers, I think, have the attitude of "I'm pretty much writing for myself over here, but if you want to come look no one's going to stop you."

Even in relatively formal blogs comprising amateur reportage, commentary, or professional insights there is embodied an aspiration to be found of interest--not to six billion obviously, and indeed six might suffice. Don't all human beings secretly fantasize that their deepest speculations might be widely found to be somehow remarkable? Don't we all wish at some level to be the writer, thinker, or even celebrity whose hidden journals, once found, are a source of endless intrigue? Well, maybe it's just my own narcissism ("Physician, heal thyself").

I am a devotee of the wide angle lens, of the aerial shot showing the interconnectedness of things, and of the ephemeral that is all the more valued for being so. It is in my nature to take things in in a glance as it were and move on. I don't say it's the best, indeed it likely is not, but it's the way I think and see.

Blogging can obviously be time-consuming. A major decision is whether to write only when one really feels some compelling pressure to express something (um, in a literary way I mean), or whether one ought to get something down every day even if it means a pedestrian post or two (or more). Some days one looks at the screen and thinks, "I got nothin' here."

So as a metaphor I'm sure others have probably used countless times already, a blog seems to me the cyber version of the message in the a bottle, sent out in a second rather than over a few years, but still providing one with the fantasy of achieving an unexpected connection. Human beings have a way of needing to project themselves across space and time.

So if anyone has any comments about what is useful or interesting in this or any blog I'd be happy to see them. Remarks such as "More interesting posts please" or "Okay, you can stop now," while understandable, might be best directed to my email. If you made it this far--thanks for reading!

Who's Afraid of the DSM?

An unhappy people in a happy world --

Read, rabbi, the phases of this difference

An unhappy people in an unhappy world

Here are too many mirrors for misery

A happy people in an unhappy world --

It cannot be. There's nothing there to roll

On the expressive tongue, the finding fang.

A happy people in a happy world --

Buffo! A ball, an opera, a bar.

Wallace Stevens

I'm sure we'll be hearing a lot about psychiatry's Diagnostic and Statistical Manual in coming years, with the fifth edition due out around 2011. For some of us, diagnostic issues, like politics did around 2006, is about to get a lot more interesting. The New York Times has an article today on how things are coming along (without a single bone of contention, rest assured).

There are some misunderstandings about the infamous tome. As is widely noted, the number of official "mental disorders" has increased significantly with every edition of the book, to nearly 300 today. But many of these are minute variations of the same basic problems. For instance, Alcohol Abuse is a distinct diagnosis from Alcohol Dependence, but both are just degrees of severity of the same addiction.

As I've written here recently, the DSM often does not directly dictate a great deal about how a psychiatrist goes about treating a specific patient, whether with medication or psychotherapy. This is true because the treatments we have are geared to very broad symptom domains that often span several (technically) distinct diagnoses. This is why psychiatrists tend to think very holistically; this can look like sloppiness, and it can progress that far, but in itself this approach is often merely realistic.

For instance, in terms of the general clinical approach it is far more important to figure out whether a patient has, basically, an anxiety problem or a substance abuse problem (or if both, which is the driving process) than to decide which of several anxiety disorders is present or which substance is being abused. The latter details are not meaningless, but they matter less for treatment than does the broader paradigm for the purposes of available treatments.

A good example of this is Binge-eating Disorder (involving gorging on food without the compensatory purging characteristic of bulimia), which has not previously been an official diagnosis but is being considered for the next DSM. If a psychiatrist under the current system learns that this behavioral symptom is present, then he will attend to it and use customary medications and/or psychotherapy to work on it, regardless of whether it is in itself an official diagnosis. After all, the majority of patients with Binge-eating Disorder will have accompanying anxiety or mood syndromes that are "coded" diagnoses; this kind of "comorbidity" is what makes diagnosis so slippery to begin with.

But psychiatrists are very much affected indirectly by the way in which the DSM drives insurance reimbursement, future psychiatric research, and general cultural understandings of mental illness. Like any massive institution, psychiatry is like a great ship that can be steered in a new direction only a little bit at a time and with massive effort; a new DSM is a significant nudge on the wheel. In the short term, a new edition likely won't change much about what transpires in psychiatrists' offices, but the long term differences will matter. As the NYT article notes, the elimination of homosexuality as a diagnosis decades ago certainly did matter.

The linked article states that the most recent DSM edition was in 2000, but this was a relatively trivial edit of the last major revision in 1994. In the latter year I was a third-year medical student making up my mind what area of medicine to pursue; I now realize that the buzz over that new edition was, while not a deciding factor obviously, nonetheless part of my interest in a field that never fails to be strange, surprising, and contested.

While psychiatry will always have a political element--in the widest sense of negotiated human values and the idea of the good life--there are in fact real human brains amid all the cultural buzz. Brains have real attributes, which one hopes we are getting slightly better at identifying and modifying. So one hopes the next DSM will represent at least a modicum of progress and not just another turn of the wheel...for the sake of a turn of the wheel.