Willpower

"During these last decades the interest in professional fasting has markedly diminished. It used to pay very well to stage such great performances under one's own management, but today that is quite impossible. We live in a different world now."

Kafka, "A Hunger Artist"

Of all issues perhaps obesity best embodies the complex, perhaps unfathomable relations between the "willing spirit" and the "weak flesh," as the saying goes; this is all the more true now as obesity, as compared to drug or even alcohol problems, has affected a large fraction of the population. This week's New England Journal of Medicine features a telling large-scale diet study, with an accompanying editorial (the latter is brief and particularly worth reading for general interest).

The study, conducted by Frank M. Sacks, M.D. et al, followed 811 adults over two years and looked at the weight loss resulting from diets containing varying ratios of protein, fat, and carbohydrates. It was an intensive program involving relatively affluent and enthusiastic adults as participants and experienced nutritionists and other weight-loss experts who provided counseling and support.

Unsurprisingly, subjects did not uniformly comply with the dietary ratios and caloric guidelines, but even so the study concluded that the protein/fat/carbohydrate breakdown was not a significant predictor of weight loss (a result that in a rational world would end a thousand fads, but in the real world will have little effect on the weight loss industry). Among the impressive 80% who completed the study, average weight loss at six months was 6 kg (7% of starting body weight), but the weight crept back slightly such that average loss at two years was 4 kg (about 9 pounds of course). The most significant predictor of success? Attendance at counseling and support meetings; in other words, motivation matters.

While 9 pounds is better than nothing, the discouraging overall conclusion (corroborated by many previous weight loss studies) is that on average, diets do not work. Indeed, in the editorial Martijn B. Katan, Ph. D. writes, "Evidently, individual treatment is powerless against an environment that offers so many high-calorie foods and labor-saving devices," and he goes on to emphasize community prevention initiatives that may, barring bariatric surgery, be the only viable intervention. However, "on average" is important, because if one considers that many subjects lost no weight at all, a number of them lost a substantial amount and did keep it off for two years.

As a general philosophical point, it seems reasonable to conclude that those suffering from obesity, somewhat like those in thrall to substances of various kinds, are not (yet) sufficiently motivated to change their behavior. This to me seems like a statement of psychological fact, and is not meant to be remotely disparaging. It is not to say that they are "weak," that they are "happy" about their obesity or that they don't want (at all) to change their dietary and exercise patters; it is merely to say that these motivations are not sufficiently vigorous to change behavior, or they conflict with other motivations. The biochemistry of weight loss is not hard--reduction of caloric intake and increase of caloric expenditure beyond a certain point will result in weight loss, as surely as an apple falls from a tree; it is the psychology of weight loss that is hard.

We increasingly know from evolutionary psychology that the biological hurdles are high for dieters--we are wired to find fats and carbohydrates highly reinforcing, and they are abundantly available in contemporary environments. We are similarly wired to conserve energy and avoid unnecessary exertion. Versus these factors, the disincentives of obesity, except in its most morbid forms, are somewhat abstract and distant; the health effects are often years off, and the social stigma of obesity is often surmountable and may even be decreasing as obesity becomes less uncommon. And while I don't mean to psychopathologize obesity or to make blanket statements, in some cases that problems with self-esteem may curtail the emotional reward of successful weight loss.

Also, we know that diets are much easier in the short term than in the long term. The improvements in physical well-being and appearance that accompany dieting tend to be subtle and incremental. Someone who can stop abusing alcohol or cocaine may feel remarkably better within days, whereas a dieter may not feel or look significantly different for months.

As mentioned, the editorial concludes that once we talk about the treatment of obesity, as opposed to its prevention in the first place, the battle is already mostly lost. At this point that may be true in a general epidemiological sense, but I keep thinking about those few who do get it off and keep it off. The point is not at all that they are "better" or "stronger" than anyone else; rather, in the context of their life narratives their resolve exceeded a critical point because the payoff somehow became worth it to them.

I don't know that there is a simple recipe (so to speak) for getting to that point, although a recent local news story I saw floated the idea of higher insurance premiums for obese state employees (as well as smokers). It would be a bit disheartening if that made the difference, but that's because I'm more of an existentialist than a behaviorist by nature. The means shouldn't matter.

Old Wine, New Bottles

Human nature, essentially changeable, unstable as the dust, can endure no restraint; if it binds itself it soon beings to tear madly at its bonds, until it rends everything asunder, the wall, the bonds and its very self.

Franz Kafka, "The Great Wall of China" (trans. Edwin and Willa Muir)

"I have a new antidepressant for you...Seroquel XR." These encouraging drug rep's words were directed at a colleague in the office next door (happily I escaped). How did medications initially indicated for schizophrenia successfully migrate to bipolar disorder and now depression? The answer involves both the very porous psychiatric diagnostic system and the slack standards for FDA approval.

Last year, when Abilify was approved for "adjunctive" treatment of depression, patients who saw some commercials started asking for it. The advent of direct-to-consumer advertising on television a few years back allowed pharmaceutical companies to go around physicians at will, and this affected psychiatry more than other specialties due to diagnostic ambiguities. Now that Seroquel XR is indicated for acute treatment of bipolar depression, a number of patients will overlook the bipolar part and will start asking for Seroquel for depression, and a certain fraction of doctors will comply. In fact, Seroquel is widely used "off-label" for both anxiety and insomnia; the maker could probably obtain those indications too if it were worth the company's while.

I think the atypical-antipsychotics-for-bipolar-disorder-and-depression phenomenon represents the confluence of no fewer than five factors. The least interesting is the perennial and understandable drive of pharmaceutical companies to make as much money as possible by accumulating indications. Second, the drug companies are not required to conduct head-to-head trials of prospective drugs with drugs already known to be effective; they need only to demonstrate superiority over placebo. The result is that "new" treatments are not necessarily advances over already available treatments; they are merely different (the "me too" drug).

Third, in recent years the profession has undergone a crisis of confidence in both the safety and the effectiveness of standard antidepressants, particularly for bipolar depression, which is often resistant even to standard mood stabilizers like lithium and valproic acid. Fourth, and related to this, treatment-resistant depression remains a huge problem in general; depression is increasingly recognized as a major source of disability worldwide, and the bad news is that a significant number of patients do not get better even with aggressive treatment.

Why else has a treatment like electroconvulsive therapy, marred as it by stigma and side effects, remained a quite viable treatment for seventy years now? Severe depression can be grim indeed, and ECT still treats it better than anything else. So in the treatment of depression there is very much an effectiveness vacuum; patients urgently want help, and psychiatrists urgently want to help them, so anything at hand that can be shown to be better than sugar pills for depression is likely to be used, even if side effects--such as the high cost, weight gain, and other metabolic issues of atypical antipsychotics--can be alarming. Neither patient nor psychiatrist wants to hear, or to say, "There is nothing more I can do."

Fifth, atypical antipsychotics are both more convenient and, in a purely subjective sense, better tolerated than many alternatives. The standard mood stabilizers--lithium and the anticonvulsants--require monitoring of blood levels other laboratory tests, whereas atypical antipsychotics (unless one counts the lipid profiles that ought to be done to monitor metabolic side effects) do not. This can be an issue of compliance as well as convenience. And while the objective side effects can be dismaying, many patients are subjectively surprisingly tolerant of substantial weight gain (which only adds to the problem of course).

So while I'm thoroughly tired of the phrase "perfect storm," we have one here: a high potential for profit, malleable diagnostic boundaries, and a widespread eagerness to help and be helped with respect to a prevalent illness scourge. Helpful interventions might include ending televised direct-to-consumer drug advertising, requiring higher standards for FDA approval, devising antidepressants that are actually better than the ones we have now (I'm told people are working on that, but breath-holding is not advised), and when it comes to prescribing decisions, knowing when enough is enough.

Great. Just Great.

The Sunday Times had an interesting article by David Orr on the subject of greatness in poetry, or rather, the apparent lack thereof in recent decades. It suggests that Elizabeth Bishop may have been the most recent Great One. Hmm.

As Orr notes, poetry is one genre whose whole reason for being would seem to be to swing for the fences. Sure, there's light verse, limericks, doggerel, etc. but who would care really if these vanished from the earth? What we crave from poetry, if we crave anything, is something that will blow us away, change everything if only for a moment. Yes, this is a highly Romantic conception. But where are the classicists who actually read the likes of John Dryden or Alexander Pope? Poetry is the Romantic genre.

What separates the Great from the Merely Very Good? No more perhaps than separates the Tall from the Of Above Average Height. The Great--in anything--is just a repository of cultural value, beyond a threshold established by social consensus. Of course, look around these days--who's around to assemble a consensus? After all, when I just reflected on the cultural valence of greatness a few moments ago, one of the first things that came to mind was "They're Grrreat!" courtesy of Frosted Flakes. The offspring of advertising and poetry are sterile.

At any rate, here's a poem that I found to be striking, if not Great (it's already publicly available at http://www.tnr.com/):

Hardy's Sky

A sky out of Thomas Hardy: bleak, cloud-broken, swollen with

wind-shiver, grey-gold with touches of crucifixion and apocalypse,

everything a flight, a fugue, so the small voices of these slate juncos

make music a huddle of refugees might make--bedraggled, bent

under tattered loads, feeling the weather change, the air harden,

the taste of things grow harsh and crude on their forced march

towards haggard light, towards some poor haven, this endless trek

against weather, firest blossoming from the sky ceiling, the ferocious

thump of air waves pushing them, staggering ear drums, pure dread

bursting in scatterflash and stuttercrack, these terminal fireworks

at odds with all past knowledge. So the beat goes on, no end to it,

and in this Thomas Hardy sky you'd see, had you eyes for it, words

like numb and wasting inscribed, and sad or dim, drearisome, wan,

and everything tucked in like a heart in its beating chest of bone

so the whole body thrums with it, beaten through and through by it.

Eamon Grennan

(Thomas Hardy--he was great; I didn't know junco--it is apparently a kind of finch).

Odds and Ends

I've been busy looking over page proofs for an epically wrangled-over article ("Evolution, Human Enhancement, and the Narrative Self," available by email request) for Literature and Medicine. Blog posting takes two minutes; academic print publishing can take two years (maybe if a blog is wine by the box, the academic journal is something more sophisticated). But there is something to the knowledge that one's work is occupying physical space in libraries (I take my pleasures where I can get them).

At any rate, this blog reflects my liking for quotes, which are like grains of sand that get lodged in my oyster of a brain until, one hopes, they are transmuted into something else. So as I was looking over that manuscript I came across a few quotes that, to switch metaphors, serve as the survey stakes for what I was trying to get across. To reverse metaphors, I should allow the possibility that these great quotes are themselves pearls that I merely manage to grind back down into my sandy prose.

But philosophy has no direct influence on the great mass of mankind; it is of interest to only a small number even of the top layer of intellectuals and is scarcely intelligible to anyone else. On the other hand, religion is an immense power which has the strongest emotions of human beings at its service. (Freud, "The Question of a Weltanschauung").

Perhaps the tragedy of classical psychoanalysis was its inability to accept that what most human beings most need is not insight, but something else entirely (which is only partially supplied by religion). Freud hoped that the treatment would change the allegedly neurotic need. But would we still recognize Homo sapiens without this need?

This is Socrates' legacy, and it is precisely this challenge that Freud takes up: to figure out a form of conversation in which one can succeed in genuinely taking oneself into account. (Jonathan Lear, Freud).

By bringing psychology into philosophy, Freud was trying to make the latter more philosophical. But his psychology wasn't yet psychological enough.

If I were having a philosophical talk with a man I was going to have hanged (or electrocuted) I should say, "I don't doubt that your act was inevitable for you, but to make it more avoidable by others we propose to sacrifice you to the common good. You may regard yourself as a soldier dying for your country if you like. But the law must keep its promises. (Oliver Wendell Holmes, quoted by Steven Pinker).

This is a spot-on summary of the necessary compatibility of free will and determinism. All is determined, but human society (and specific persons) can only function by presupposing that individuals can modify their behavior.

Yes, we were natural for eons before we were cultural--before we were human, even--but so what? We are cultural now. (Robert Scholes, quoted by Harold Fromm).

In a way this mind-bender, conjoined with evolutionary psychology, motivated my whole paper. How much does our escalating knowledge of our own contingent human nature grant us real freedom to alter our own individual and species identity?

One of the good things psychotherapy can do, like the arts, is show us the limits of what science can do for our welfare. The scientific method alone is never going to be enough, especially when we are working out how to live and who we can be. (Adam Phillips).

Amen.

Mood-Stabilizers All Around

I was much further out than you thought
And not waving but drowning.

Stevie Smith


Who could object to a "mood-stabilizer?" It sounds as gentle and as appealing as a spring rain. Indeed, when I mention it to patients they often seem to like the sound of it (if not quite so much as "nerve pill," which is really hard to turn down). "Antidepressant," by contrast, has sort of a grim ring to it, perhaps because "anti-" sounds, well, oppositional, and "-depressant" like, well, a downer. Names matter.

Ah, that vexed bipolar subject again. When DSM-V finally emerges (or to paraphrase David Hume, falls stillborn from the printing press) in the next few years, probably the single greatest impact upon everyday clinical practice will involve the evolving classification of bipolar disorder (the classification of Axis II/personality disorders may run a close second).

In the current American Journal of Psychiatry Christopher D. Schneck, M.D. joins the growing chorus supporting a broader bipolar definition, one that includes so-called "mixed depression," or depression associated with "subsyndromal" manic symptoms (which may include mood lability, irritability, agitation, or "racing thoughts" that fall short of a manic episode). In the current classification the only possible "mixed episode" is the simultaneous occurrence of a full major depressive episode and a full-blown manic episode for one week (these states can be clinically impressive and personally appalling, but are uncommon).

What is driving this reconsideration is the disappointingly poor performance of antidepressants not only in general, but particularly in bipolar depression. Run-of-the-mill antidepressants haven't had a good few years, frankly. First came concerns about medication-induced suicidality, then scandals involving research publication bias, and now this, the possibility that wide swaths of the clinical territory previously thought suited for antidepressants will at some point shift to bipolar states calling for mood-stabilizers. Is anyone "just" depressed any more? And I won't even get into the potential overlap with borderline personality and other characterologic and cultural issues.

A diagnostic shift may well be called for, but the potential problem is bipolarity as "the night in which all cows are black," that is, the bipolar concept is so elastic as to include a large segment of the psychiatric population. For instance, it is very rare for me to see a depressed or anxious patient who does not, when specifically asked, endorse "mood swings." Depression and anxiety in themselves make people more sensitive to everyday stressors, which can generate mood instability. Similarly, insomnia is nearly ubiquitous in depressed and anxious states. When people lie awake at night they tend to focus on their (inevitably fretful) thoughts more, which--again, when specifically asked--is highly likely to be confirmed as "racing thoughts."

Another problem is the treatment implications of sending a patient down the bipolar diagnostic road. Clinical inertia being what it is, there is often no turning back, at least for a long time. Antidepressants, while not without their problems, tend on average now to be relatively cheap, well-tolerated, and straightforward to take. Mood-stabilizers, by contrast, are often very expensive, can cause weight gain and other troubling side effects, and may require periodic blood tests for monitoring. Easier-to-take mood-stabilizers have been sought in Neurontin and Topamax, but these haven't turned out to be effective for this indication. Many clinicians now--granted, somewhat lazily--reach for atypical antipsychotics for bipolar disorder, but those are fraught with risk and expense as well.

I don't recommend a reactionary, strictly by-the-DSM-IV, approach to bipolar disorder, and I've treated plenty of ambiguous cases with mood-stabilizers, but it is never a straightforward process. Often folks in this gray area end up taking several antidepressants and mood-stabilizers from different doctors over multiple years, and one has to try to figure out what seemed to work best; the name for what is going on is often quite conjectural. In this business we ultimately have only one tool in the box: pragmatism.

Pleistocene Pleasures

"My business is to sing."

Emily Dickinson

I recommend Denis Dutton's The Art Instinct, a concise, accessible, and compelling overview of evolutionary psychology as it applies to the origins of the arts (the NYT review is here). The basic argument is that artistic interests and pursuits are universal to human experience (although with obvious temporal and geographic diversity) and are grounded in dispositions formed over a million years of hominid evolution.

Dutton's approach is nuanced and respectful of the gaps in our knowledge (theories of evolutionary psychology are far harder to demonstrate than are general evolutionary theories because, for one thing, brains don't fossilize). We do not, obviously, explicitly approach the arts in evolutionary ways any more than we consciously seek out a high-fat diet because it protected our ancestors from famine; the motivations in each case are quite literally unconscious.

In addition to general theories he handles the major arts individually. He maintains that all else being equal, people prefer depictions of landscapes that have basic features--a slightly elevated view of juxtapositions of open space and vegetation, signs of water, and small groups of animals and figures--of the African savanna in which humanity evolved. Narratives of all kinds (from Shakespeare to soap operas), Dutton claims, are natural ways of navigating the extreme complexities of human social life in a way that doesn't risk real-life consequences. Linguistic aptitude also can attract potential mates, although less so perhaps than impressive upper body strength (not all of us were blessed with both).

Music is clearly important to Dutton personally, and he acknowledges that it poses the greatest challenge to evolutionary theory inasmuch as such an abstract art does not, compared to other arts, seem as relevant to past survival advantage over evolutionary time. He ends up concluding that even more than the other arts, music is much like the peacock's tail, that is, a very contingent concoction designed to woo potential mates (witness the predominance of love as a perennial musical theme).

He also points out that compared to other arts, we tolerate and even invite an astonishing amount of repetition (albeit with variation), both of tonal ideas within musical works and of musical works themselves (over a period of years one might listen to a favorite album a hundred times, which we're not likely to do even with a poem). Let's see, what other human behavior involves the appreciation of extreme repetition with variation? Well, nothing comes to mind here, I'll think of it later.

Dutton takes clear aim at modernism in the arts (particularly atonal music and some avant-garde follies of the visual arts) as a misguided notion that taste can be culturally contorted to an infinite degree; rather, evolution suggests that our interests, while quite manifold, are finally finite. Indeed, avant-gardism over the past century has arguably been a massive expression of cultural hipsterism, in which mere exclusivity (manifested in the sheer cost of works of art as well as the smug satisfaction of being counted among the cognoscenti) has carried some sectors of the arts well into the realm of sophisticated kitsch.

The most hilarious example of this is best captured in Dutton's words:

The imitations reached rock bottom in 1961 with Merda d'artista, a series of works produced, in every sense of the word, by the Italian conceptual artist Piero Manzoni. In fact, in 2002 the Tate Gallery paid $61,000 to add to its collection Can 004 from Manzoni's series of ninety cans of his own feces...In Manzoni's case the only humor to be found is in the messy fate of many who acquired works in the Merda d'artista series: quietly, but knowing exactly what he was up to, Manzoni had improperly autoclaved the cans. At least half of those bought by museums and collectors eventually exploded.

In the closing pages of his book Dutton argues that great art relies on authentic individuality against a cultural background of stable values and the sense that some things do ultimately matter. This may be why the ironic age has found contemporary masterpieces to be hard to come by.

I find these kinds of evolutionary accounts to be fascinating and, really, deeply spiritual inasmuch as the fact of consciousness (and the necessary supposition of free will that comes with it) shields us from reductionism. Sure, one can say that Beethoven manipulates merely primitive urges just as one can say that tones are merely compression waves conveyed through air, but to do so is to miss the point. So much is both given and contingent, but the question in the arts, as in life, is: where do we go from here?

Full Partners

What is it men in women do require?

The lineaments of Gratified desire.

What is it women in men do require?

The lineaments of Gratified desire.

William Blake

Psychotherapy is, famously, not about giving advice. So it's interesting to browse the blog posts at Psychology Today which are, of course, stuffed with advice, much of it pretty good. What else are they supposed to do? One can manage only so many posts on empathic listening. Maybe opining spontaneously and at length into the Internet vacuum makes it easier to stay mum and receptive in session.

For obvious reasons, though, particularly as none of their therapist bloggers is anonymous, the approach is fairly general even when not theory-driven. So I was curious to find two well-written posts that offer diametrically opposed marital advice.

Michael J. Formica advocates authenticity in relationships by cautioning against general enabling. Usually I think of an enabler as someone who looks the other way or otherwise tacitly approves of a partner's substance abuse, but he uses it for anyone who, to the detriment of his or her own vital interests, enables a partner's own personal script, whatever it may be. Of course, we immediately recognize this as the submissive, self-abnegating type who, Formica warns, risks giving him/herself away in a relationship.

As if in rebuttal, John R. Buri marvels at how many people, having married "for love," at some point stop being even minimally engaging, civil, and affectionate toward a partner. In his view "authenticity" is taken by many as license to be callous and indifferent in a relationship if that seems to "come naturally." His recommendation is to let go of the self, at least enough to express a certain level of affection even if it doesn't feel "natural."

Of course, these two needn't be seen as disagreeing at all; indeed, we can envision them working with the two partners in the same dominant-submissive relationship. The joke goes that dermatology therapeutics consists of: drying it out if it's moist and moistening it if it's dry. I suppose the corresponding couples counseling approach is: if it's rigid and unyielding, soften it up, and if it's passive and squishy, firm it up.

But there are all kinds of judgment calls here. How do we decide which "interests" are vital enough to qualify for "authenticity?" That is, what do we merely want from a relationship as opposed to truly need? And selfless affection for the partner sounds wonderful--until it crosses into inauthenticity. No answers here--I guess that's why therapy pays the bills and blogging doesn't.

The glorious early stages in a relationship are like being in a fine sailboat with the wind at your backs; everything trends in one direction. Over time, the wind shifts to the side and then eventually to the front. Unable to sail directly into the wind, you tack between self/authenticity on the right and other/affection on the left. Nobody manages it well enough to actually reach a destination--the goal is merely to stay afloat, even if going in wide circles.

And then there are the beachcombers...