Friday, December 26, 2008

With Malice Toward None

As a capstone to an extraordinary political year, I'm finishing up Doris Kearns Goodwin's Team of Rivals (I had originally picked it up before Obama's victory and the media's immediate overuse of that phrase). The last Lincoln book I had read was Joshua Shenk's Lincoln's Melancholy, so it was interesting to move from a lugubrious Lincoln to a masterfully crafty one. It is disquieting but necessary to remember that politicians, even when they are ultimately honest and well-intentioned, are by definition manipulators of people. And Lincoln manipulated beyond the best of 'em.

But he manipulated in a way that was neither deceptive nor disingenuous, and that was one of the several things that set him apart. He moved people with carrots far more than with sticks, and always in service of the high purpose of the time. He was extraordinarily ambitious, as anyone who would presume to be President during a Civil War would have to be, but his ambition was yoked to the interests of the nation from the beginning.

I think that psychologically, and apart from his world-historical significance, Lincoln fascinates because his identity was at once extremely complex and incredibly well integrated. His forthright and transparent manner was widely praised during his lifetime even before it became a cliche, and yet he was capable of the most subtle shrewdness when circumstances demanded it. He naturally inclined toward leniency and a somewhat laid-back and laissez-faire approach to life, and yet when he determined to do something he was immovable. He combined high seriousness with a deep appreciation of mundane delights, as countless anecdotes of his earthy humor attest. He could be at once an open book and suggest depths opening upon untold depths.

The point is not that he was a saint or that he made no mistakes; he wasn't and he did. What emerges most strikingly from Goodwin's book is Lincoln's capacity for forbearance, his virtually complete lack of vindictiveness. Lincoln was an intuitive master of, among many other things, human psychology, and as such he had a fine appreciation of human frailty. This was coupled with an absolute self-knowledge and emotional security (his famous bouts of despondency notwithstanding, for he skillfully compensated for them). He was capable of irritability and anger, but he bore no grudge, and few could say so well as he that "nothing human is alien to me." He made tactical mistakes, but he bore no trace of either narcissism or neurosis.

The downside of reading Lincolniana is that one knows how his story ends. Here is the opening stanza of Walt Whitman's great elegy for the fallen President:

When lilacs last in the dooryard bloom'd,
And the great star early droop'd in the western sky in the night,
I mourn'd, and yet shall mourn with ever-returning spring.
Ever-returning spring, trinity sure to me you bring,
Lilac blooming perennial and dropping star in the west,
And thought of him I love.

Ars Psychiatrica needs to recharge--will take a break and return in 2009. Happy New Year and thanks for reading!

Thursday, December 25, 2008

Terra Cognita

The New York Times yesterday ran a nice piece by Oliver Morton of the journal Nature; amid the perennial alarm about the imminent demise of life on Earth, it usefully reminds us of our planet's astonishing antiquity and the indefatigable resilience of life, broadly construed anyway. That may not say much about the longevity of human life, which is very likely to be far more ephemeral, but it is perversely reassuring to know that in the cosmic sense we really can't do much damage (I do rather hope the big cats outlast us by a few million years at least).

I will indulge in another favorite poem, this time by the renegade Victorian Thomas Hardy, dated December 31, 1900 and apparently reflecting on the final day of that nineteenth century. Hardy had a long and well-placed lifespan (1840-1928), reaching from the wane of agrarian Olde England well into the mechanized age. What would he say today, I wonder? His image of defiant avian transcendence is positively Dickinsonian.

"The Darkling Thrush"

I leant upon a coppice gate
When Frost was spectre-gray,
And Winter's dregs made desolate
The weakening eye of day.
The tangled bine-stems scored the sky
Like strings of broken lyres,
And all mankind that haunted nigh
Had sought their household fires.

The land's sharp features seemed to be
The Century's corpse outleant,
His crypt the cloudy canopy,
The wind his death-lament.
The ancient pulse of germ and birth
Was shrunken hard and dry,
And every spirit upon earth
Seemed fervourless as I.

At once a voice arose among
The bleak twigs overhead
In a full-hearted evensong
Of joy illimited;
An aged thrush, frail, gaunt, and small,
In blast-beruffled plume,
Had chosen thus to fling his soul
Upon the growing gloom.

So little cause for carolings
Of such ecstatic sound
Was written on terrestrial things
Afar or night around,
That I could think there trembled through
His happy good-night air
Some blessed Hope, whereof he knew
And I was unaware.

Wednesday, December 24, 2008

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.

Tuesday, December 23, 2008

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.

Monday, December 22, 2008

'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.

Sunday, December 21, 2008

(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.


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.


Friday, December 19, 2008

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.

Thursday, December 18, 2008

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.

Wednesday, December 17, 2008


Macbeth: Canst thou not minister to a mind diseased;
Pluck from the memory of a rooted sorrow;
Raze out the written troubles of the brain;
And with some sweet oblivious antidote
Cleanse the stuff'd bosom of that perilous stuff
Which weighs upon the heart?

Doctor: Therein the patient
Must minister to himself.

Macbeth needed a psychiatric referral and not a brush-off; we know how he turned out (well, psychiatry was a bit green in 1600).

1. Nassir Ghaemi, M.D., a prominent name in academic psychiatry, writes a thoughtful blog at Psychology Today. In his last few posts he has started to explore the issues stemming from the recent well-known scandals of psychiatric research and pharmaceutical companies. As one would expect, the reality is neither one of money undermining everything of value in the profession nor one of open, public-spirited firms working for nothing but the common good. I still need to write my post on this topic (yes, avoidance has its uses).

2. Courtesy of Arts & Letters Daily, I see that Paul McHugh, M.D. has written a useful conceptual and historical review of the concept of hysteria, a famous shapeshifter in both psychiatry and medicine (hysterics are as likely, if not more so, to visit non-psychiatrist physicians as psychiatrists). Basically, hysteria results from the intersection of individual vulnerability and suggestibility with the prevailing winds of groupthink at any time pertaining to what constitutes legitimate illness or illness behavior.

3. Have you nursed a lifelong dream to work in a state psychiatric hospital? If so, it is commendable, because good people are definitely needed. However, before signing up you might want to look at this hair-raising account of life as a social worker in a hospital in a state located somewhere between Virginia and South Carolina. Did you think that snake pit, cuckoo's nest, etc. were safely of the 1950's and 1960's? Think again. If you're going to become seriously mentally ill, be sure to arrange excellent insurance beforehand.

This account is not typical, fortunately, arising as it does from regrettable adventures in mental health care reform. It is amazing that forty years after the great deinstitutionalization of the 1960's (the effort to move the teeming masses of then-much-larger state psychiatric hospitals into outpatient community programs), we still can't get this right, apparently through lack of funding and organizational mismanagement.

And this occurs in a nation that, before the recent economic plunge at any rate, was apparently the most prosperous in both absolute and relative terms in the history of the world. Mental health care reform appears to be where good intentions go to die. Is the economy booming? Then mental health can spare some funding. Is the economy tanking? Then mental health is going to have to tolerate some cuts. What was that about a society being judged by how it treats the most vulnerable?

Tuesday, December 16, 2008

Strung Out

Heroin be the death of me
Heroin, it's my wife and it's my life
Because a mainer to my vein
Leads to a center in my head
And then I'm better off than dead

The Velvet Underground

"An orgasm is nature's pale imitation of heroin."

Unattributed (if anyone knows source let me know)

Psychology Today blogger Stanton Peele, Ph.D. has a post proposing, according to him, the seven most addictive "substances," from cocaine (least) to, believe it or not, love (most). I won't quibble with his ranking per se, but since many people ask whether one can be addicted to such things as shopping, food, the Internet, and sex, it brought to mind how we go about defining addictions.

The problem is that the very concept of addiction is controversial and philosophically problematic, touching on great questions of free will, emotion, and even spirituality. Most of this is beyond the scope of this post (and, it must be said, beyond the scope of this amateur philosopher), but it seems safe to say that addictions are never entirely chosen nor entirely determined. They always hover somewhere in between, and it's hard to get one's mind around that (sort of like the uncertainty principle of quantum mechanics on a psychological level, perhaps). It is simple-minded to claim that willpower is absolute, but with addictions there is always room for choice ("Do I stop by the liquor store on the way home? Just two won't hurt.").

When we say that someone has a "conventional" addiction to something like nicotine or alcohol, we mean that the direct neurobiological effects of the substance are, if not removing, at least significantly impairing a person's capacity to avoid the substance. If a person stopped smoking three days ago and , feeling intense craving, gives in and takes a smoke, do we say that he was absolutely compelled (against his will) to do this? Well, no, but we think he has diminished volition--because of biological withdrawal effects--as compared to someone, say, who takes a smoke after being abstinent for a year.

We have a great deal of evidence now, from neuroimaging and other sources, that substances of abuse powerfully affect brain pathways. The conundrum is: how do we get form there to inferences about free will? After all, it is pretty likely that, say, flying into a rage is accompanied by certain neurobiological changes as well. If someone looks at me the wrong way and I take him down (I have not, generally, been known to do this), what keeps me from saying that "my brain made me do it?"

There would seem to be two answers to this, one biological and one sociological. Biologically, the question is how specific and how intense the neurochemical changes are as compared to what one might think of as a "normal" pleasurable experience (such as a walk on the beach, an enjoyable concert, or even sex). The more specific and prominent these changes are, the greater reduction in free will we might expect.

The sociological answer would seem to be that society, over time, develops, one hopes, a more refined consensus about what can reasonably be expected from individual behavior. It is reasonable to expect people not to fly into a murderous rage; it is not reasonable to expect all people at all times to be able to stop smoking at will without biological and other cessation strategies that may reduce hindrances to their free will.

Which brings us to the questionable "addictions" to sex, the Internet, and even food. The problem is that these activities just may not override the brain's volitional system in the same way that nicotine, etc. do. After all, just as a thought experiment, suppose that I enjoy reading books; I may even read them, at times, to cope with life's slings and arrows. In fact, I enjoy reading books so much that if I were prevented from reading them for a day or two, I could deal with it, but if it went on for much longer I would start to miss them, would become mentally restless, and would overall feel less happy. Would I be in "withdrawal" from a book "addiction?"

Similarly, if a materialistic person suffers a major financial hit, is he in withdrawal from a money "addiction," or if a "workaholic" is obliged to reduce his hours, does he suffer from "work withdrawal?" We may jokingly say yes, but we shouldn't really mean it.

To return to my example, what if I felt compelled to read so much that I neglected family and work responsibilities? (Note to wife if reading this post: please do not comment here). And after all, inasmuch as reading is pleasurable for me, it is probably associated with release of endorphins and other neurobiological changes at some level. The problem is that these changes are not above and beyond the evolutionary normal pathways that dictate our values and how we choose to attend to them. I would be overindulging in reading not because of an addiction, but because I was repeatedly choosing to do so (as emotional distraction or whatever).

There may be interesting gray areas. One might think sex would be one--after all, sex is arguably, in a purely biological sense if nothing else, one of the most focused, intense, and "rewarding" experiences we are naturally equipped to have. But the operative word here is "naturally," as nothing is evolutionarily normal if not sex. For eons societies have expected individuals to govern their sexual impulses without appeal to anything like a sex addiction clinic.

A true gray area could conceivably be video games and other virtual experiences. As these grow in intensity and engagement, perhaps they could stimulate the brain's reward systems in a way that may be beyond the evolutionary pale, such that cyberdetox would be necessary. Ars Psychiatrica does make for compelling reading, I know, but generally speaking the Internet doesn't appear yet to have reached that point.

None of this is to say that overindulgences in food, sex, or the Internet aren't problems; they certainly can be. But the issue, which may well be amenable to psychotherapy or other means of amelioration, is the individual's basic system of emotional self-regulation, not an "addiction."

Monday, December 15, 2008

Future Shock

"Telephone, n. An invention of the devil which abrogates some of the advantages of making a disagreeable person keep his distance."

Ambrose Bierce

It's interesting to think about the future, but also dismaying, as the futurologist, much like the psychiatrist, is almost certainly destined to be mistaken. But it's irresistible. William Faulkner wrote that not only is the past never dead, it's not even past. The same could be said about the future--in a metaphysical sense perhaps nothing exists except now, this precise moment, but in another sense all past and future are always with us.

The Pew Internet and American Life Project concerns itself with such things and has released results of a survey of technological thought leaders and muckety-mucks regarding what the Internet and wireless communications in general may be like in 2020. The issues explored include the form and extent that these are likely to take, the implications for privacy and security, and the possibility that these technologies may enhance social tolerance and therefore social harmony over time. Also considered is the likely growth in virtual realities (or "reality augmentation") as a part of everyday life. (All those books I've read, and I never realized I was engaging in "reality augmentation").

In 2020 my kids will be 21 and 18. I find it a constant struggle to manage what I, for lack of a better term, call their "screen time" (which in our household includes television, computer, or handheld games). At their current ages, at any rate, they can't seem to comprehend why I would want them, every now and then, to spend a little while with a book or playing outside. So it is a kind of neurological "eat your vegetables" sort of thing.

There are of course people who allow their children very little or even no "screen time." That is a bracing sort of philosophy, but I wonder about the implications in a world that will only become more filled with screens. Fast food restaurants increasingly have televisions going, as do doctor's offices and any other public place where waiting is likely. Is keeping kids away from screens anything like keeping them away from germs or allergens?

Will people be happier in the future? If you believe the forecasts, people will only get more and more connected, at least in the virtual and wireless senses, and we know that social support can only be a good thing. However, such a world would also expose us constantly to the sight of others who may be more well-off or happy than we are, which could be bad (we know that relative goods--compared to what others enjoy--are more significant for happiness than their absolute number).

Neuronarrative today has an interesting post, an interview with brain and aging expert Gary Small, M.D. about neurological implications of some of these technologies.

Sunday, December 14, 2008


Ay, in the very temple of Delight

Veil'd Melancholy has her sovran shrine,

Though seen of none save him whose strenuous tongue

Can burst Joy's grape against his palate fine;

His soul shall taste the sadness of her might,

And be among her cloudy trophies hung.


I don't use the term "mind-blowing" very often; or if I do, this time I really mean it. As I touched down on page 893 of Roberto Bolano's astonishing and sprawling 2666, I couldn't remember the last time I was so far into a book before realizing that it was a great one. That may sound like faint praise, as if it were merely slow to warm up, or it grew on me, or whatever; the actual literary impact is prodigious, as if one stretched Ravel's circling crescendo Bolero to a tome nearly the size of War and Peace.

Bolano (I still can't manage the tilda in his name, which is lame of me), the Chilean expatriate who lived in Mexico and later in Spain, died in 2003 at only fifty, the victim apparently of hepatitis C contracted from earlier heroin use. Since then he has become a posthumous literary superstar in the English-speaking world as his last novels are being translated. This book was included among the 10 most notable works of 2008 by the New York Times (Jonathan Lethem's review is here), and here is a useful post on it by Chekhov's Mistress.

A poet who reportedly turned to novels in his last years to support his family, Bolano was writing against time in this crowning work, and it shows, not at all in any sloppiness, but in the propulsive force of its sentences. I had the sense that Bolano was racing ahead, turning around now and then to urge haste, as I rushed to catch up to him before he got out of sight. The work contains everything expected of epic--family, love, sex, crime, war, politics, history--but in the most surprising contexts and contortions.

The framing device of the book, comprising five large, semi-autonomous and linked sections, is the fictional, extremely reclusive, and floridly pseudonymous German novelist Benno von Archimboldi. The appallingly dark heart of the book is the horrific epidemic of "femicides" occuring in Santa Teresa, Mexico, supposedly a fictionalized version of Ciudad Juarez (the real-life, drug culture-related mayhem of which is chronicled here). For three hundred pages Bolano provides a harrowing litany of women, many of them prostitutes but many factory workers or waitresses, who turn up raped and mutilated, dumped in ravines and beside desert roads. Many of them go unclaimed, and the police, whether inept or corrupt, can't make any progress in solving the crimes.

The intertwined themes of the book are beauty--the sheer indulgent delight of story--and horror--the reign of apathy in the face of absolute evil. Like all great literature, it aims to find redemption amid desolation and loss. Bolano's style strikes me as an improbable cross between Hemingway and Proust; individually, his sentences are flat, dispassionate and often wry, but their cumulative effect is noble, sweeping and reflexive, like a bird circling above a great expanse. The result is at once gritty and, at times, grandiloquent. Here is Bolano, grimly, on men and women:

Ingeborg laughed too. Then she began to talk about the way some women were attracted to men who killed women. About the high regard in which woman-killers were held by whores, for example, or by women who chose to love without reservations. In Reiter's opinion these women were hysterics. But Ingeborg, who claimed to know women of the sort, believed they were just gamblers, like cardplayers, more or less, who end up killing themselves late at night, or like the habitues of racetracks who commit suicide in cheap rented rooms or hotels tucked away on back-streets frequented by gangsters or Chinamen.

Here he is, using the very wide-angle lens, on nature:

"All this light is dead," said Ingeborg. "All this light was emitted thousands and millions of years ago. It's the past, do you see? When these stars cast their light, we didn't exist, life on Earth didn't exist, even Earth didn't exist. This light was cast a long time ago. It's the past, we're surrounded by the past, everything that no longer exists or exists only in memory or guesswork is there now, above us, shining on the mountains and the snow and we can't do anything to stop it."

Here he is describing Archimboldi's style, which captures his own as well:

The style was strange. The writing was clear and sometimes even transparent, but the way the stories followed one after another didn't lead anywhere: all that was left were the children, their parents, the animals, some neighbors, and in the end, all that was really left was nature, a nature that dissolved little by little in a boiling cauldron until it vanished completely.

Bolano's way is narrative abandon, but crucially tempered by the constraints of mortality and human frailty. The book's first section recounts the quest of four European literature professors for the elusive Archimboldi whom they both love and specialize in. The academic life is depicted in all of its alternating profundity and vacuity. The long middle of the book, set in arid Mexico, is also a narrative desert; like a plant that struggles vainly to sprout despite lack of rain, the story can't seem to escape the squalid nightmare of Santa Teresa's murderous culture. But the last section, a chronicle of Archimboldi's amazing, bewildering life, erupts in narrative ingenuity, with one story found to be encased within another in a way that put me in mind of The Arabian Nights. The best word for this book is narrative plenitude, without superfluity.

That last section brings all of the book's disparate characters together, but not in a physical sense or even in a thematic one, unless one counts the detached contingency with which people, across continents and decades, come together--for a book, for love, or for murder--and then drift away into the murk of time or forgetfulness. The story comes to an end, like life, with finality but without resolution.

Read it; no review can give a sense of it. I am encouraged to find a contemporary novel this good. The holidays may not require great literature, but January definitely will. The solstice is less than a week away.

Friday, December 12, 2008

Noises in the Attic

Alas, how is't with you,
That you do bend your eye on vacancy,
And with th'incorporeal air do hold discourse?


(Illustration by Adolf Wolfli, hospitalized for psychosis in Berne, Switzerland from 1895 until his death in 1930).

Auditory hallucinations are the darndest thing. We all have our moments in life obviously, and I think that my own experiences plus a willing imagination can provide at least a vague idea of what it might be like to undergo a good number of the clinical syndromes I see. Can I know exactly? Of course not, as some patients like to point out, but that is always the case between two people (can they know exactly what it is like to be me?). Like any decent doctor or therapist, I make the effort and continually check in with the person in question to see how my imagined approximation is holding up.

Voices are tough though, as I have never experienced anything like them. The ominous creak upstairs, the pillow in the dark mistaken for something else, yes, but voices are something else entirely. I doubt that dreams provide any semblance of waking hallucinations. I can only imagine that they are disturbing at the least and potentially terrifying. My lack of experience makes me all the more curious about what it might be like to have them, so I hope that imagination gives empathy a needed boost.

Voices are most commonly associated with schizophrenia, but they constitute psychotic symptoms that may occur in various other conditions: severe depression or mania, substance abuse or withdrawal, and various neurological disorders such as dementia and delirium. Visual hallucinations can occur along with voices, but the former are more commonly seen in "organic" conditions such as substance withdrawal and delirium. Atypical voices can occur with borderline personality disorder or post-traumatic stress disorder. Not long ago I saw someone with voices that, she volunteered, had names. This is unusual, and given her history of severe abuse, it may suggest dissociative identity disorder (the same as "multiple personality disorder").

If someone hears the voice of a loved one who has died, this is considered normal. Similarly, hearing the voice of God is normal if such is culturally appropriate for the person and not accompanied by psychopathology. It is also possible, although perhaps rare and certainly not well understood, for some people to have random and isolated auditory hallucinations without having a psychiatric or neurologic condition.

Like much in psychiatry, the heterogeneity of auditory hallucinations is impressive. Most commonly they are strange (i.e. not sounding like anyone known to the patient) and derogatory. That is, they utter insults, often using profanity. Somewhat less commonly, they issue commands, sometimes bizarre and sometimes threatening.

But auditory hallucinations can be quite subtle, and in those cases it is hard to know how aggressively to go after them (particularly when they aren't obviously distressing to the patient). Someone may hear faint voices but be unable to make out what they are saying (this is often described as hearing a barely audible conversation in an adjoining room). They may hear noises that don't seem "real" (i.e. generated by the physical environment) but that aren't voices. Some people hear music; this seems to occur with the elderly more often. Some of this may be more likely with the relative sensory deprivation of hearing loss.

When it comes to true schizophrenia, there is nothing quite like seeing someone in the grip of a first psychotic break, or in the months thereafter. There is a distinct air of dismay, bewilderment, and consternation. The patient appears at once puzzled, confused, and afraid. I am often surprised that patients and their families are not particularly focused on the diagnosis--it is as if they know already at some level. I give it to them anyway as gently as I can (or remind them as the case may be) and emphasize manageability of symptoms with treatment.

The psychotherapy of psychosis involves education and intentional self-distraction among other things. People in the grip of voices sometimes wander long distances away from home, as if they are being hounded. It takes them a while to learn and to believe that they don't have to listen to the voices, that the voices, despite their threats, are actually powerless to hurt them or anyone else. People who have lived with schizophrenia for years become relatively accustomed to voices, although they can obviously still be upset and agitated by an exacerbation.

While recent studies have suggested that older antipsychotic drugs (like haloperidol (Haldol)) are every bit as good as newer ones, in my experience the newer ones are better tolerated in a subjective sense. Patients are more willing to take them. The metabolic side effects (weight gain and diabetes) can be a major problem.

In the ten years since residency I have never accepted drug company gifts or support of any kind. So my drug preferences are based on what I read in the literature and my experience with patients. Risperidone (Risperdal) is my favorite antipsychotic to start with; it seems to balance solid effectiveness with good tolerability. I found out the other day that 30 doses of generic risperidone 3 mg was only $46; I was surprised, that almost approaches affordability.

Olanzapine (Zyprexa) has the worst metabolic side effects on average, but its efficacy is impressive; it is often a reasonable option for those having major insomnia and who are thin (to start with). Unfortunately it is exorbitantly pricy. Quetiapine (Seroquel) is well-tolerated, but as it too can cause weight gain (and is very expensive too), so is often prescribed too loosely for insomnia and anxiety (in the absence of psychosis). Aripiprazole (Abilify) is a decent alternative because it produces less drowsiness and weight gain, but not uncommonly it generates unpleasant akathisia (a restless feeling).

The other day at our small clinic 37 patients received their monthly or bimonthly antipsychotic injections (they are for people who cannot or will not keep up with taking pills daily, but these kinds of shots are voluntary). I heard that Risperdal Consta now comes with a smaller needle for deltoid rather than gluteal use; I suppose that is an improvement. I imagine it must hurt though.

Thursday, December 11, 2008

Grand Inquisitor

The heart asks pleasure first
And then, excuse from pain --
And then, those little anodynes
That deaden suffering;

And then, to go to sleep
And then, if it should be
The will of its Inquisitor
The liberty to die.

Emily Dickinson

Several items caught my eye today. It is dark and stormy here, with the potential for sudden catastrophic death looming over the landscape (okay, there's a tornado watch); so forgive the theme of menace.

1. On the brightest note, I was alerted to a comprehensive listing of psych-related blogs at "101 Fascinating Brain Blogs" at Online Education Database. It includes all the well-known ones but also many I wasn't aware of (oh, and it commendably includes Ars Psychiatrica).

2. Art Blog by Bob yesterday featured "The Scream" and several other works of the evidently dysphoric painter Edward Munch (painter of today's illustration here as well). Check it out.

3. For any readers in Kentucky I happened upon a Scientific American article about the United States Narcotic Farm (or Narco) near Lexington. From 1935 until 1975 the huge facility housed many of the nation's criminal addicts, which included some prominent names over the years. It was the setting for a great deal of addictions research involving the prisoners, although toward the end the C.I.A. and others apparently developed concerns that research involving both L.S.D. and less than fully informed consent may have been going on. The article includes a slide show and alludes to a documentary about Narco that would be very interesting.
4. Also in Scientific American is an article on schizophrenia and its relation to language. Schizophrenia is an enormously complex illness and we are far from understanding it, but given the prevalence of auditory hallucinations in the disorder, links to language function have long been a focus. Apparently genes related to language are increasingly suspected in schizophrenia, which may be a casualty of our species' very rapid brain growth over the past million years or so. It is odd to think of such a devastating illness deriving from the same developmental pathway leading to, among many other things, the great poets.

5. The New England Journal of Medicine has an editorial on the current status of physician-assisted suicide in the United States, now legal in both Oregon and Washington state after the latter recently approved it by a decisive 58-42 margin. With 6.7 million people, Washington is twice the size of Oregon and will be an interesting test of the law.

As the article documents, the procedure in Oregon has not drawn the multitudes that were originally feared. From 1998 through 2007 only an average of 34 patients per year carried out the procedure. The law requires two physicians to independently confirm that a patient is both terminally ill and competent to make the decision. As one would expect, the most common diagnosis was terminal cancer. The "physician assistance" usually involves prescription of barbiturates, which the patient apparently must administer himself.

No psychiatrist is required to be involved, although consultation with one is encouraged if there is any suspicion of depression or questionable competence. However, the article notes that no psychiatry consultations were made in 2007, and only 12% of cases involved consultations in the nine previous years.

I have pretty firm opinions on most issues, but this is one I struggle with. We know that suicidal ideation in general is much, much more likely to be related to a mental disorder (most commonly depression, substance abuse, or schizophrenia) than not, and we are familiar with concerns arising from end-of-life suicidality that may stem from inadequate palliative care or fears of being a burden on family members.

A philosophical question in psychiatry is whether suicidal ideation can be anything but a manifestation of disorder. The arguments pro and con are complex and beyond the scope of a blog post (Courtney S. Campbell wrote a heftier review of the issues in The New Atlantis), but I personally believe that it is possible for a terminally ill person, afflicted perhaps with irreversible physical or mental decline, to desire death without being considered clinically depressed.

However, considering the finality of suicide, and the issues of subtle or not-so-subtle suggestion or coercion that can arise, I wonder sometimes if we're making it too easy, too comfortable to make such an existentially stark decision. It may be hard for a psychiatrist to say, but it is a conscious being's inherent right to commit suicide. If someone tells me he's going to, then I will commit him to a hospital or otherwise take steps to prevent him. But if he doesn't tell me or anyone else, then no one is going to stop him.

The question is: why does he think he has a right to get someone else to help him? Some decisions are meant to be excruciatingly difficult and painful; that often means they shouldn't be made at all, or if they are made, certainly not with nonchalance. I think there is some risk to any society of allowing people to go too "gently into that good night." To me this seems the wisest and most conservative approach.

Wednesday, December 10, 2008

Where Liberals Lurk

And if you gaze for long into the abyss, the abyss gazes also into you.


I got to thinking about political dispositions in the mental health professions when I read a recent post by D. G. Myers in A Commonplace Blog. He tries to account for the great preponderance of political liberals in academia, particularly in humanities and social science departments, which is well-documented and has apparently been the case for a long time. I'm not sure I quite agree with his claims, but they are worth reading here (plus a couple of comments from yours truly).

Another group that is predominantly liberal-leaning is mental health professionals. I have remarked about this before and am quite sure that I have seen surveys supporting it, but with limited time and database access I am unable at the moment to summon citations (I welcome suggestions by anyone who knows of any, even if they don't support my supposition). I am not saying that this professional political bias is obviously either good or bad (and certainly not that a liberal therapist is better than a conservative one), but I'm curious as to why it may be. I am not aware of this kind of trend in health care professionals in general (if anything, physicians are popularly associated with more conservate viewpoints on average, although I don't have data for that either--after all, this is a hobby, not a job).

In thinking about this I was reminded for some reason of Jonathan Haidt's work on morality and political worldviews (links to which can be found here). Haidt, a psychologist who has also written extensively on happiness, has argued that both liberals and conservatives place high value on moral and ethical considerations, but that they tend to appeal to different sources of moral significance.

Briefly, Haidt maintains that moral considerations can be divided into five domains, which he describes as: harm/care, fairness/reciprocity, ingroup/loyalty, authority/respect, and purity/sanctity (and he postulates evolutionary roots for each of these). In general meaning these terms are fairly self-explanatory. His central point is that modern ethical thought in the West (which has been the foundation of liberal politics) has focused, disproportionately perhaps, on the first two domains, which pertain to issues of individual autonomy, the well-being of the self, and particularly justice.

According to Haidt, conservative thought does not disregard the domains of harm/care and fairness/reciprocity, but it tends to give equal weight to the other three domains, which relate to the need for collective restraint and clear boundaries of appropriate behavior. For example, political dissent even in tense wartime conditions, which is a basic value of liberalism, is suspect from a conservative point of view due to appeals to loyalty and respect. Liberals and conservatives often cannot agree on a particular issue not because one group is more ethical or even more clear-thinking than the other, but because their moral foundations are different. As a psychologist Haidt is just trying to explain, not to justify; I don't know if he is right, but the categories make intuitive sense to me.

So why would mental health professionals lean toward the harm/care and fairness/reciprocity domains? A possibility that comes to mind is that we tend, on average, to work with people who have been socially marginalized as a result not only of direct illness effects but also of often very powerful social stigma. Autonomy and self-determination are precisely what they struggle with; too little self and not too much (in the true sense of the term) is the issue.

We keep seeing the David half of countless David and Goliath confrontations, so perhaps it is natural for us to be critical of prevailing trends and to stick up for the little guy. Somewhere I read once that the mad are the absolute poor, for they have lost even their minds. And as Myers points out with respect to academia, once a political slant gains ground in a subculture, it often grows more marked with time as members tend to recruit more of their own into the discipline.

Of course, most liberal therapist-types are liberal well before they become therapists. And with respect to the five moral domains, we still have a lot to learn about how people, through whatever vagaries of biology and culture, develop the "courage of their convictions." And these five factors presumably interact with five other factors, those commonly used for psychological profiles (OCEAN: opennness (vs. conventionality); conscientiousness (vs. laxity); extraversion (vs. introversion); agreeability (vs. contentiousness); neuroticism (vs. lack thereof)).

For instance, I have always had a strong aversion to violence, whether toward animals or human beings. What seemed squeamish or even weak to a 13-year-old has become an attribute that I do not apologize for (although I would be a really pathetic Marine). And I have long had a regard for authority that is not, so to speak, excessive. So presumably both psychological and moral factors account for what I do for a living.

Tuesday, December 9, 2008

Happy Happy, Joy Joy

"Most people are about as happy as they make up their minds to be."

Abraham Lincoln

Abe was typically pithy when he supposedly said or wrote this, but even he may have nodded in this instance, for it reflects a simplistic and misleading conception of what happiness might be. It came to mind after the media buzz generated by a study about happiness and social networks. The study suggested that those individuals rated highest in happiness (by a "standard measure" of the same) were most likely to have broad social networks of similarly happy people.

The first thing that is apparent is the stunning obviousness of this "finding," like so much of social science research. I mean, who could have guessed that happy people are not usually recluses, or surrounded by miserably negative folks? It is much like another shocking recent study suggesting that television watching is usually inversely proportional to happiness. It also confirms what every disaffected teenager has suspected: the popular "in" folks really are different.

Well, I suppose the study may show that schadenfreude, by means of close-up exposure to the unhappy, is not the best route to happiness. To be sure, when I ask people what (if anything!) they have found helpful about a recent psychiatric hospitalization, I am surprised that the response often involves their apparently gratified awareness of others who are even worse off than they are. But this may suggest that it is primarily the distressed who may be helped by acquaintance with the even more distressed; happiness may enjoy a magnanimity that unhappiness cannot afford.

Of course, people have debated what happiness means for thousands of years. I guess the contemporary question is whether one can be seriously, lastingly unhappy without also meeting criteria for depression. We have decided that bereavement, as well as other various disappointments in life's natural course, is distinct from depression, but is unhappiness that occurs for no particular reason anything other than depression?

In this business we talk about someone being "euthymic," or free of significant depressive or manic symptoms. But this is a fairly sterile term, and it seems like happiness ought to be something more, perhaps a spiritual sense (secular or not) that one's life is headed in a meaningful trajectory. Yet happiness is not inconsistent with pain and suffering; indeed, we might say that unhappiness is suffering exacerbated by a sense of meaninglessness. So can one be happy and depressed at the same time? How about happy and dysthymic? I'm not sure.

I hope this blog has already established that medications are not my chief personal or professional interest, although in light of escalating psychiatry/pharma scandals, I think I may list a separate disclaimer indicating my near-total lack of interaction with drug companies over the years. And clearly there are things one can do on one's own or in psychotherapy to improve one's mood and likelihood of happiness.

One of those things is increasing one's proximity to other people, preferably happy people. One of the cruel vicious circles of depression, however, is that people, particularly happy people, do not generally relish the company of seriously unhappy people (that may be one way they stay so happy). At the risk of sounding excessively wry here, I suppose that unhappy people ought to seek out the company, at least, of those somewhat less unhappy than they are, thus ratcheting up their own happiness potential ever so slightly. Thereby one might progressively advance closer to the shangri-la of the truly happy.

A significant hitch can occur when the most negative people in one's life, the ones potentially most detrimental to happiness, also happen to be one's family, friends, or associates. There is always the possibility that, like a substance abuser needing to avoid triggers, one could need to break free of a toxic influence. Problematically, this study suggests that if you want to become or remain happy, you ought to avoid the unhappy like the plague. I guess the naturalistic fallacy, the notion that what (contingently) is the case ought in fact to be the case, is the basic hazard of science.

But there is also the risk that unhappiness, like depression, can come to be seen as primarily a lifestyle choice and not what it is, an extremely complex interaction of biology and behavior. The risk of Lance Armstrong stories is the notion that anyone ought to be able to overcome cancer if they only try hard enough; the parallel risk with this kind of study is the notion that we can safely blame the depressed because they "choose" their unhappiness. In this business, if it's simple, it's almost always wrong.

Sunday, December 7, 2008

The Year in Music

The man that hath no music in himself,
Nor is not moved with concord of sweet sounds,
Is fit for treasons, stratagems, and spoils.
The motions of his spirit are dull as night,
And his affections dark as Erebus.
Let no such man be trusted. Mark the music.

Lorenzo, The Merchant of Venice.

I am no musician, but I am an avid listener and I know what I like. If you couldn't care less, please feel free to stop reading now. What follows is outrageously opinionated, and for all I know could potentially offend many.

Overall I didn't find 2008 to be as remarkable a musical year as 2007, but maybe that was just me. Listed below are some records that I found to be notable, for better or worse; it is by no means comprehensive, as between work, family, blogging, and reading, I have time to sample only a fraction of even well-known releases. I may have overlooked some great ones and would like to hear about them if so.

To get relative disappointments (for me) out of the way, I found several of the year's heralded albums to fall a bit flat. R.E.M.'s Accelerate was competent and featured their signature sound in an ununusually focused and lively package, but overall they seem like a band that, ever since the prodigious Automatic for the People, just hasn't had that much more to say.

Two new and ballyhooed acts, Fleet Foxes and Vampire Weekend, seemed striking at first, but after a couple of listens they started to sound a bit twee and contrived. This was particularly the case with Vampire Weekend's quasi-African rhythms--this sort of thing was done a long time ago, and much better, by the likes of Peter Gabriel and Paul Simon.

Two interesting middling successes (I can't bring myself to call them failures) were My Morning Jacket's Evil Urges and The Raconteurs' Consolers of the Lonely. Evil Urges is one of those works that is highly proficient and eclectic but ultimately leaves me indifferent, and without a clear understanding of what the band is about. Perhaps it is possible to be too proficient and eclectic, when one goes out of one's way to leave one's showily ingenious mark on as many musical styles as possible within one album (is it really a good idea to try to impersonate both Prince and Wilco on the same record?). As for The Raconteurs, their album was vigorous and contains some tremendous riffs (with Jack White it could hardly be otherwise), but I found it to lack the endearing whimsicality of the White Stripes.

For me the most overlooked record of the year was Kathleen Edwards's Asking for Flowers. She combines a hauntingly wistful voice and a softer, more feminine Neil Young sound. Musically the record is a huge advance over her more work(wo)manlike first two efforts. There isn't a weak song on it, and she is one to watch.

January saw Cat Power's second album of covers, Jukebox. What is it with her and covers? Maybe she just prefers performing to songwriting. Well, with her voice it doesn't matter--she can sing nursery rhymes if she wants to. It is one of the great natural voices for both indie and blues, and owing to her well-documented history of emotional vicissitudes, I'd like to think that my profession may have played at least a miniscule part in keeping the voice singing. The one new tune, the Dylan homage "Song to Bobby," is spectacular, as is her remake of her own prior song "Metal Heart."

Portishead's Third was another tour de force for the somewhat lugubrious group. Plenty of bands are dark--last year's Boxer by The National, which everyone seemed to find stupendous, was dark, but in a droning sort of way that I found, even after multiple listenings, to be about as interesting as a cold drizzle. But Third is dark in a way that sounds variously magisterial and slightly deranged, if that possible; it is at once anxiogenic and uplifting. For me "The Rip" was one of the sublime songs of the year.

I can't make up my mind about Jenny Lewis's Acid Tongue. Like Evil Urges, it seems to suffer from a scattered eclecticism, but since it is her voice, it doesn't seem to bother me as much. The title song is Lewis at her absolute best, while "The Next Messiah" is ambitious if nothing else. Some of her songs are so sweet and direct (like some on Rilo Kiley's first record) that it can be hard to decide whether they are merely saccharine schlock, or whether they are so much so as to be actually subversive (in which case one can relish the beauty without guilt; as I think Nietzsche wrote somewhere, it is possible to be superficial out of profundity). She does make one think (among other things), and that is more than many pop musicians manage.

I'm not sure if I can get used to the "new" Lucinda Williams on Little Honey, which virtually all reviewers saw as a much sunnier work, for better or worse, than her usual. The voice and spunk are still there, but some of the pathos is missing ("My Little Honeybee," for all its energy, seems finally crass, although perhaps that is ageism on my part since I might give the ditty a pass in a performer two or three decades younger). Of course, there's no matching the successive heights of Car Wheels on a Gravel Road and Essence, where she had a kind of anguished gravitas.

Well, I could go on, but I am opined out. Please let me know what I overlooked, or which of my judgments is most egregiously mistaken.

Saturday, December 6, 2008

Spicy Southern Gothic

(No, not that spicy; this is a wholesome blog).

Is there a way to find the cure for this implanted in a pill

It's just the name upon the bottle, which determines if it will

Is the problem you're allergic to a well familiar name?

Do you have a problem with this one if the results are the same?

The White Stripes, "Girl, You Have no Faith in Medicine"

What care the Dead for Winter?
Themselves as easy freeze --
June Noon -- as January night --
As soon the South -- her Breeze --

Of Sycamore -- or Cinnamon --
Deposit in a Stone
And put a Stone to keep it Warm --
Give Spices -- unto Men --

Emily Dickinson (excerpt)

1. A psychiatrist close to me met a new patient to the clinic, a young man with a documented history of schizoaffective disorder, one day after his discharge from the hospital. Faxed hospital records describe the admission, but the patient was asked what, in his view, led to the hospitalization. "Too many spices," was the mumbled reply. Further questioning failed, alas, to illuminate this response ("spices" did not mean drugs, which, atypically, were not involved in the case).
Hearkening to a libertarian streak, the doctor's spontaneous response was, "Well, if the man prefers a bland diet, who am I to object? Are we as a society going to compel him to consume spicy food?" Perhaps the patient's figurative implication was that "the world is too much with us," and that we confront too much, too fast in this, perhaps literally, maddening culture. Perhaps this man was sane in an insane place.
Perhaps, but the hospital record suggested that this cute academic formulation wasn't the whole story, so prescriptions were duly written and the fellow shuffled back out into the extravagantly seasoned world of ours. Another reminder that psychiatry, warts and all (more every day if you watch the news), seems to be a necessary evil.

2. My commute goes between barren tobacco fields and crumbling barns, that rural part of old Dixie in which seeing the Stars and Bars openly blazoned is by no means beyond the pale (interestingly though, not only this state, but this county went for Obama, albeit very narrowly). I moved here from a slave-owning but Civil War border state, and it intrigues me to speculate on the subtle cultural differences between the two states, both a hundred and fifty years ago and now. I've been reading Doris Kearns Goodwin's Team of Rivals, which title has suffered overuse in recent weeks; the Lincoln bicentennial is just two months away.
At any rate, the other morning I saw an old black hearse sitting off in a field, with a small American flagpost affixed to the driver's side window. I wasn't sure whether this was some kind of political commentary, or someone's idea of a joke, or what. Maybe I should bring my camera next time; then again, maybe I should just keep on driving by.

Thursday, December 4, 2008

Feline Farce

There have been myriad queries (okay, one or two) about the lamentable cat situation (chronicled here November 23). Pictured at right is an actual Novalis cat at risk of villainous entrapment (did I mention...? ha ha). (Due to a technical glitch, illustration later removed).

One additional cat was trapped, although it actually wasn't one of ours, but rather a stray (we think) we had seen lurking around the neighborhood for a while. My wife pleaded for its release, as it would have faced sure euthanasia at the animal shelter. The neighbors relented, and the stray was pardoned (although I haven't seen it since, so I wonder).

It turns out that the neighbor wife's cat phobia (stemming from a past "bad experience") is the issue, as well as the teenaged son's fear of having a cat scratch up his pristine new car. My first car was a 1975 Dodge Dart--I was more worried about making it across intersections without stalling than about domestic cat defacements. But I did not bring up that "bad experience."

Water guns were proferred and declined. Neighbors agreed to withdraw traps so long as steps are taken to limit feline prowling. As a gesture of good will (and a kind of neighborly placebo), we agreed to erect a privacy fence in the back that will at least keep that neighbor out of sight, out of mind (with pleasure), both for the cats and for us.

I point out that we were actually, without knowing it, offering the neighbor wife free therapy, in the form of graduated exposure, for her cat phobia. In a better world, our friendly felines would gradually have infiltrated their yard, stamping out their rodents and gently marking their territory, and, no catastrophe ensuing, neighbor wife would have been won over to their charms: cure effected. But as usual, psychiatry's efforts go unappreciated.

I tried to think of a proper cat-trapping poem to dignify the occasion; the corpus in that category being limited, I could only choose Rilke's great and terrible "The Panther" (translated by Robert Bly):

From seeing the bars, his seeing is so exhausted
that it no longer holds anything anymore
To him the world is bars, a hundred thousand
bars, and behind the bars, nothing.

The lithe swinging of that rhythmical easy stride
which circles down to the tiniest hub
is like a dance of energy around a point
in which a great will stands stunned and dumb.

Only at times the curtain of the pupil rises
without a sound...then a shape enters,
Slips through the tightened silence of the shoulders,
reaches the heart, and dies.

Wednesday, December 3, 2008

On Psychiatric Overdiagnosis

Consternation and derision greeted the recent Archives of General Psychiatry study that suggested that large numbers of American college students have mental disorders. Every once in a while psychiatrists like to assert that a large proportion of the population needs nothing so urgently as, well, to see a psychiatrist as soon as possible, and it gets everyone in an uproar. Psychoanalysts used to be good at this, but it works just as well for the DSM system. Rather than quibble over numbers, I have a few general comments.

Psychiatrists seem to have the idea that they are the ultimate arbiters of diagnosis. They aren't; the society in which they practice is. Now, psychiatrists do have more expertise than the average person on the street when it comes to mental functioning, but some wisdom is not the same as omniscience. The psychiatric profession--explicitly via the DSM, implicitly via aggregrated clinical habits--submits proposals as to what should constitute mental disorder. However, it is the society at large, contingent upon public attitudes and financial resources, that ultimately decides what the purview of psychiatry will be.

The analogy that comes to mind is the distinction between military tactics and defense policy. As the famous quote goes, war is too important to trust to the generals. In the case of democracy at least, a society decides (by virtue of the government it elects) the general kind of defense policy it will pursue. The military is entrusted with the mission of carrying out those military goals. But the military does not set defense policy--in a democracy at least. To be sure, military personnel have opinions about defense matters that, due to their expertise, should be given particular attention, but they do not have the final say.

To stretch the metaphor to a breaking point, the problem is that the "war on mental illness" (would that be like the "war on drugs" or the "war on terror?") is not a coordinated campaign, but rather comprises endlessly complicated guerrilla tactics carried on in many thousands of consulting rooms. Psychiatrists have their "marching orders," a plan of what is to be accomplished and what is or is not appropriate in carrying out that plan, in the form of, say, FDA recommendations, the DSM, and the nebulous concept of "standard of care," but due to professional privilege it is easy for psychiatrists to become vigilantes. They become so sure of their power and, granted, so honestly aggressive toward "the enemy" (mental disorder, recall, not the patient), that they exceed appropriate bounds. When psychiatrists try to be Batman, things go awry.

When a soldier or even a general becomes insubordinate or even undermines the mission in subtler ways, he can be removed. When individual psychiatrists commit malpractice, of course, they can be removed in a way too. But there is no easy feedback system for influencing the profession as a whole when it has strayed too far. Economics can accomplish this, and did so when society essentially decided that it could not pay for long-term psychoanalysis for anyone who wanted it.

Psychiatry, like the Republican Party, may be venturing farther into the wilderness. Criticism of diagnostic and prescribing trends, along with high-profile pharma cases rocking academic psychiatry, has put the profession out of step with "mainstream America." Psychiatry needs to understand that while people at all ages have varying degrees of mood instability and impulse control, not everyone wants to classify these differences along a diagnostic spectrum. People want to have the freedom to be odd or even imprudent even if it may do them harm; they want the freedom to screw up without having to see a psychiatrist. Lack of "awareness" and "access" can be real issues, but when psychiatrists focus on them excessively they can lose sight of the fact that some people just do not desire their services. Psychiatry seems to think, "If only they knew us better, they would like us--what's not to like?" Hmm.

For the foreseeable future there will be enough truly unambiguous psychopathology to keep the profession plenty busy without having to go stir up diagnoses. None of what I've written is meant to romanticize very real depression, bipolar disorder, schizophrenia, and yes, personality disorder and substance abuse, for which psychiatry is alas, quite necessary. But overall mainstream psychiatry is looking a lot like the party of Delay, Bush, McCain, and Palin. Let's see, whom else can I offend?

Tuesday, December 2, 2008

Lugubrious Lucubrations

If you're down he'll pick you up, Doctor Robert

Take a drink from his special cup, Doctor Robert

Doctor Robert, he's a man you must believe,

Helping everyone in need

No one can succeed like Doctor Robert.


Psychiatry is mostly unlike the rest of medicine, for better and worse, but it seems to me it has some things in common with my (admittedly distant) understanding of what a pain specialist does. If any of the latter happen to read this, set me straight.

1. Mental disorders, like pain syndromes, are often correlated with objective factors, but they are nonetheless fundamentally subjective and therefore frequently misunderstood and vulnerable to stigma. Diagnosis is therefore ambiguous and liable to being contested.

2. Both mental disorders and pain syndromes may get better with the mere passage of time. Watchful waiting is always an option.

3. Conservative treatment methods (psychotherapy/physical therapy) should be considered first.

4. Both mental and pain disorders are at risk of settling into chronic pernicious syndromes (often in a mutually reinforcing way).

5. Medication treatments in both carry the risk of addiction, sometimes iatrogenic. This can create tension in the clinical relationship.

6. In both psychiatry and pain medicine, simple cases are rare because primary care physicians have already taken care of most of those.

7. Both mental and physical distress are sensitive to suggestion and placebo (or nocebo) effect, both cultural and medical.

8. The treatments are broad in their effects and not specifically pegged to diagnosis; therapy is therefore more empirical and pragmatic than theoretical.

9. The aim is not cure, but rather symptomatic management either indefinitely or until the episode gets better on its own.

10. Both physical pain and emotional distress, beyond a certain point, threaten to become all-encompassing and to monopolize consciousness.

11. Both physical and emotional pain are necessary and at times even advantageous, but one can have too much of a good thing.

12. People may be growing less stoic, more sensitive to both physical and emotional distress in contemporary culture. There is a straight line between aspirin and Prozac.

Cool (or at least cooler than we thought)

We are stardust
We are golden
And we've got to get ourselves
Back to the garden

Joni Mitchell

And yet, except for us,
The total past felt nothing when destroyed.

Wallace Stevens, from "Esthetique du Mal"

The New York Times has a mind-bending article today about new theories of the early Earth. Some geologists are thinking that our planet cooled down rather faster than was previously thought, meaning that life may have gotten started, not as soon as conditions allowed, but perhaps only after a few hundred million years beyond that point.

Based on apparently abstruse calculations, it is also thought that soon after the Earth coalesced 4.5 billions years ago it was struck by a Mars-sized object (not Mars, but something roughly the size of Mars)--much of the extruded vaporized material came together as...the moon. In the several hundred million years after that cataclysm, the Earth is thought to have been struck, perhaps on four different occasions, by objects more than 200 miles in diameter; the energy released by each collision would have evaporated the oceans. How cool is that? What a show that would have been. It's probably a guy thing.

This morning I came upon a line in the book I'm reading (2666): "The scarred moon still shone in the sky." It is easy to forget that the Earth's surface has been ravaged even more than the moon's, but we have had the benefit of the extreme makeovers of plate tectonics. Planetary plastic surgery; the moon is a crone, the Earth remains a debutante.

Oh, there was also an article about doctors behaving badly (mostly surgeons of course). It took 4.5 billion years to produce...what?