Thursday, April 30, 2009

The Great Cham

I finished Peter Martin's well-written biography of Samuel Johnson (1709-1784), who would have to rank as among the most prodigious of literary giants who suffered from melancholia, or what is more tamely termed Major Depression today. The best known English literary critic and general man-of-letters of his century, Johnson earned fame with his essays, his groundbreaking English dictionary, and his work in biography and translation. He was also renowned for his wit and powers of conversation. James Boswell described Johnson's affliction thus:

The 'morbid melancholy,' which was lurking in his constitution and to which we may ascribe those particularities, and that aversion to regular life, which, at a very early period, marked his character, gathered such strength in his twentieth year, as to afflict him in a dreadful manner...he felt himself overwhelmed with an horrible hypochondria, with perpetual irritation, fretfulness, and impatience; and with a dejection, gloom, and despair, which made existence misery. From this dismal malady he never afterwards was perfectly relieved; and all his labours, and all his enjoyments, were but temporary interruptions of its baleful influence.

While Johnson was a highly prolific writer overall, he abhorred what he considered to be his own propensities for sluggish indolence, and indeed, long periods of inactivity punctuated episodes of herculean writing (although I have never encountered any suggestion that he was bipolar). Throughout his life he had a morbid dread of death and of what he perceived as his own sinful nature, although to all appearances he led a largely blameless life. In his last years he noted his conviction that he was "one of those who shall be damned." Asked to clarify, he famously and bluntly replied, "Sent to Hell, Sir, and punished everlastingly."

Johnson' s melancholia infected what was otherwise an iron will, and he fought the black dog indefatigably. He "coped" (to put in anachronistically) by seeking out social contacts, engaging in vigorous exercise, throwing himself into his work, and fortifying his religious faith--pretty much the same methods people use today. However, as was the medical fashion of the era, he was also bled copiously and frequently during his depressive episodes (which would, of course, have produced the opposite of the intended effect).

Johnson was also notorious for ungainly and disconcerting bodily movements that have been speculated to represent Tourette's syndrome, although this is not decided, and he did not exhibit the involuntary profanity that often accompanies that disorder. Martin quotes Boswell's classic description:

...while talking or even musing as he sat in his chair, he commonly held his head to one side towards his right shoulder, and shook it in a tremulous manner, moving his body backwards and forwards, and rubbing his left knee in the same direction, with the palm of his hand. In the intervals of articulating he made various sounds with his mouth, sometimes as if ruminating, or what is called chewing the cud, sometimes giving a half whistle, sometimes making his tongue play backwards from the roof of his mouth, as if clucking like a hen, and sometimes protruding it against his upper gums in front, as if pronouncing quickly under his breath, too, too, too: all this accompanied sometimes with a thoughtful look, but more frequently with a smile. Generally when he had concluded a period, in the course of a dispute, by which time he was a good deal exhausted by violence and vociferation, he used to blow out his breath like a whale...

However, these signs reportedly diminished whenever he was closely engaged in work or conversation, and he could suppress them for limited periods of time, such as in church or while sitting for a portrait.

And here is Martin's remarkable account of an 18th century stroke:

The night after sitting for this last portrait, at about three in the morning, he awakened suddenly with 'a confusion and indistinctness in my head which lasted, I suppose, about half a minute.' To test whether or not it was a stroke and had affected his mind, he immediately composed a prayer to God in Latin, discovering to his infinite relief that 'the lines were not very good, but I knew them not to be very good.' However, he also discovered he could not speak. Calmly, he drank 'two drams' of wine 'to rouse the vocal organs' and 'put myself into violent motion,' but his speech would not come. He could say 'no' but not 'yes.'

One would expect a melancholic, I suppose, to be able to say 'no' but not 'yes' under the circumstances. But throughout his life Johnson was, like Oscar Wilde, supreme master of the one-liner, a few of which follow:
Marriage has many pains, but celibacy has no pleasures.

More knowledge may be gained of man's real character, by a short conversation with one of his servants, than from a formal and studied narrative, begun with his pedigree and ended with his funeral. [In psychiatry we call this collateral information].

Sir, we know our will is free, and there's an end on 't.

It is strange that there should be so little reading in the world, and so much writing. People in general do not willingly read, if they can have any thing else to amuse them.

No man but a blockhead ever wrote, except for money.

Wednesday, April 29, 2009


1. I finally got around to seeing a few episodes of HBO's series In Treatment. I'll leave the expert analysis to folks at Shrink Rap and Jung at Heart; but what a lugubrious guy this therapist is (and I think I know whereof I speak)! The show contains a lot that is of serious interest, but the outlandishly ludicrous aspect of it is that nearly all of the guy's patients storm out at the end of the session (if not before), denouncing the process and/or his alleged ineptitude.

If that happens to a therapist on a frequent basis, it's a good sign that he or she has a really tough population, ought to consider career change, or is in fact a fictional character. In fact, I can envision a Kafkaesque cross between The Truman Show and In Treatment in which a therapist gradually comes to realize that he is actually starring in a television series. He ascends through a series of clinical supervisors in a vain attempt to break out of the fictional frame. Therapy as Plato's cave, on two levels. Probably wouldn't appeal to a mass audience.

2. I saw my first case of self-diagnosed swine flu yesterday. I'm sure that's happening millions of times over in doctor's offices all over the world, but at least this guy had the excuse of having schizophrenia.

3. I don't do prison work per se, but a number of folks follow up at the clinic after "discharge" from incarceration. One irony is that they often got more expensive meds in prison than they can afford after release. Also, I can imagine that even in a booming economy it's awfully tough for a felon to get a job; in the current climate it seems to be essentially impossible. That's the sort of thing that might drive a person to...crime.

4. For the matter how long you do this, you'll still encounter something new every now and then. A guy with (subjectively) terrible anxiety comes in and asks to stop his Klonopin in favor of a drug he had in the hospital that had miraculous effects on his nerves. It was Vistaril. My pleasure, at least until he comes back in, having realized he confused it with something else. It's nice to be able to give someone what they want for a change.

Tuesday, April 28, 2009

Vita Contemplativa

Here's a nice one, from the current New Republic (and already available online):

It may already be September. I drank tasteless coffee
in the cafe garden of the Museum-Insel
and thought about Berlin, its dark waters.
Black buildings that have seen so much.
But peace reigns in Europe, diplomats doze,
a pale sun, the summer dies serenely,
spiders weave its shining shroud, the plane trees'
dry leaves write memoirs of their youth.

So this is the vita contemplativa.
The black walls enclosing white sculptures.
The bust of a Greek beauty. So this is it.
An altar before which no one prays.
So this is the vita contemplativa.
Narkissos--A Roman copy of a Greek boy
on prosthetic limbs of bronze (a veteran of which war?).
Then a kuros with his pouch of testes (a vanished phallus).

We seem to occupy a desert island.
Time moves deliberately, without haste.
Helpless rapture, so this is the vita contemplativa.
Bliss. An instant with no hour, as the poet said,
the poet killed in Lublin by a bomb.
But what if, in this or a different city,
the vita activa surged again, what would Artemis,
fourth century B. C. E. do then? Hermes, Narcissus?

Parchment faces stare at me with envy--
I still make mistakes, they can't.
Comparing day and night, so this is it.
Sleep and waking, mind and world, this is it. Joy.
Tranquility, taut attention, the levitating heart.
Lucent thoughts smoulder in black walls.
So this is it. What it is, we do not know.
We dwell in the abyss. In dark waters. In brightness.

Adam Zagajewski, translated from the Polish by Clare Cavanagh

No commentary from me, it just brings to mind that countless times in life, if one is lucky, one experiences "the world in a grain of sand" and "eternity in an hour." But then one looks up, time resumes, and one must do, not merely be.

Monday, April 27, 2009

(Moon) Pie in the Sky

A world of made
is not a world of born--pity poor flesh

and trees, poor stars and stones, but never this
fine specimen of hypermagical

ultraomnipotence. We doctors know

a hopeless case if--listen:there's a hell
of a good universe next door;let's go

E. E. Cummings

After considering human enhancement over the weekend, it seems fitting to reflect on its evil alter ego, cultural degradation, on a Monday. I had long meant to get around to Saul Bellow's Mr. Sammler's Planet, but taking it on the cruise ship was a deliberate exercise in incongruity, sort of like schlepping Madame Bovary to a boxing match, or packing "Notes Toward a Supreme Fiction" for an outing to Chuck E. Cheese's. But its theme of cultural decadence seemed somehow appropriate in the sybaritic surroundings, and Bellow's coruscating prose served as a model in miniature for the blazing Caribbean sun that, ultimately, was its progenitor.

Mr. Sammler's Planet was discussed in a typically trenchant post by D. G. Myers at A Commonplace Blog; it is easily the most entertaining and thought-provoking novel about a basically crotchety character that I have ever read. Published in 1970 and set in New York City, it is the story of the Holocaust survivor and general avatar of Old World culture Artur Sammler and his deep dismay amid a society that seems to have cast aside all cultural, material, sexual and scientific restraint. The very first paragraph frames the book well:

Shortly after dawn, or what would have been dawn in a normal sky, Mr. Artur Sammler with his bushy eye took in the books and papers of his West Side bedroom and suspected strongly that they were the wrong books, the wrong papers. In a way it did not matter much to a man of seventy-plus, and at leisure. You had to be a crank to insist on being right. Being right was largely a matter of explanations. Intellectual man had become an explaining creature. Fathers to children, wives to husbands, lecturers to listeners, experts to laymen, colleagues to colleagues, doctors to patients, man to his own soul, explained. The roots of this, the causes of the other, the source of events, the history, the structure, the reasons why. For the most part, in one ear out the other. The soul wanted what it wanted. It had its own natural knowledge. It sat unhappily on superstructures of explanation, poor bird, not knowing which way to fly.

I love that last part--Freud in a nutshell, no? Or inasmuch as Freud himself aspired to be the ultimate explainer, this is perhaps the narrative and aesthetic riposte to Freud, and the whole modernist and Enlightenment project.

The classically deracinated, alienated man, Sammler finds himself in a world he barely recognizes. Obviously he interacts with what, biologically, are other Homo sapiens, but some kind of cultural speciation seems to have taken place--by means of his transit across the Atlantic Ocean and the 1960's--such that he no longer feels he is among his own kind. There has been a transvaluation of values, embodied in the general kooky flakiness of his own daughter and in the appalling children of his nephew and New World benefactor. Common sense appears to have drained from the world. All of this occurs against the backdrop of the time's fervent enthusiasm about the moon landing and mankind's presumed cosmic destiny. As all eyes turn toward the heavens--and away from the earthly decay all around--the irony, perhaps even the pathos, is rich.

I highly recommend the book--Bellow's best in my opinion except perhaps for The Adventures of Augie March.

Bellow's book came to mind when I was reading Thomas Mallon's article in The Atlantic about prospects for sending (unmanned) spacecraft to other solar systems. Around the same time that Sammler had appeared, when progress of the space program paralleled growing awareness of overpopulation and environmental destruction, the anthropologist Loren Eiseley had published The Invisible Pyramid, which evinced similar ambivalence about human restlessness. As a writer long fascinated both by humanity's mercurial ambition over the eons and by the wider natural world, Eiseley couldn't help being alarmed and saddened by the tremendous environmental threat posed to the latter by the former. As a somewhat bitter metaphor for space exploration he proposed the tendency of some fungi to shoot spores randomly into the air when their own life cycles and locales are exhausted. On this account humanity's perennial sense of Manifest Destiny is not so much heroic as cancerous.

What does it say about us if the essence of human nature is to change its own nature, that is, to have no essence? Doesn't that mean that consciousness is basically destructive, or should we say creative? Is self-enhancement a rejection of the self (death, in effect), or its natural developmental trajectory (greater life)? Is space exploration a rejection of the earth, or the fulfillment of a promise that evolved on earth? We must accept ourselves, yet we must change. Paradox.

Saturday, April 25, 2009

Times A-Changin'

Maybe, or maybe not. Here's Samuel Johnson on "blogging" in 18th-century England (courtesy of Peter Martin's biography). Sound familiar?

(Writing of the proliferation of independent printers) "If we consider chiefly the state of our own country, [it] may be styled with great propriety The Age of Authors...The province of writing was formerly left to those, who by study, or appearance of study, were supposed to have gained knowledge unattainable by the busy part of mankind; but in these enlightened days, every man is qualified to instruct every other man."

(Writing on the pressure of frequent deadlines) "He that condemns himself to compose on a stated day, will often bring to his task an attention dissipated, a memory embarrassed, an imagination overwhelmed, a mind distracted with anxieties, a body languishing with disease: he will labour on a barren topic, sill it is too late to change it; or in the ardour of invention, diffuse his thoughts into wild exuberance, which the pressing hour of publication cannot suffer judgement to examine or reduce."

I have read before that newly prevalent coffee houses in Johnson's era helped to spur the development of literary culture, caffeine promoting attention and perspicacity more effectively than the psychotropics available in taverns and alehouses. Fast forward to contemporary neuroenhancement, whose prime time status is attested to by Margaret Talbot's review of the phenomenon in The New Yorker.

Talbot interestingly profiles college students who, unmedicated, might lapse into indie slackers, but who seem to fire on all cylinders thanks to Adderall, as well as new agey scientific gurus who swear by Provigil. She covers all the usual objections to widespread and off-label use of such agents: the pressure of technocratic conformity, the emphasis upon focused productivity at the expense of serendipitous creativity, and of course known and unknown adverse physiological effects. But she seems to conclude that the practice is roughly analogous to plastic surgery, that is, regrettable perhaps, but likely not illegal or even necessarily unethical.

The enhancement issue occupied my mind a great deal a couple of years ago and yielded a couple of published papers, but here I would say only that neuroenhancement does differ from plastic surgery inasmuch as the former affects not only one's attributes, but also one's capacity or inclination to reflect upon those attributes. If someone without ADHD is in some hyper-focused state due to Adderall or Ritalin, this state may in itself vitiate his ability to consider whether this is a good thing (just as, similarly albeit more dramatically, an actively inebriated person is not well placed to appreciate the virtues of sobriety). It is as if a plastic surgery procedure were to directly (and not just indirectly) make one even more superficial and other-directed than one already was.

For the psychiatrist, it is also somewhat quaint to hear talk of these agents as being fraught with prodigious impact and potentially hazardous effects, when the issue for many folks with real ADHD is less likely to be side effects than limited efficacy.

Thursday, April 23, 2009

Boyle and Beauty

Well, I've heard 'em say there's one for everybody
And I just knew somehow that you'd be the one for me.
'Cause making love to you's not just a hobby
It's the flame the burnt the forest down in me.

Iris DeMent

Shamelessly spongeing as usual off of Arts and Letters Daily, I had noticed a while back a review of Roger Scruton's On Beauty (as yet not tracked down by me), authored by one Sebastian Smee (is it real or is it Dickens?). Smee cites Scruton's contention that beauty serves two crucial functions: it makes us feel at home in the world (a kind of grace unlooked for by the resigned and the gloomy, it is that felicitous and consoling deception without which, as Nietzsche wrote, we would die of the truth); and it serves a rallying point around which we seek to build consensus with our fellows.

Both of these ring true for me. With respect to the first point, real beauty, whether derived from nature or artifice, entails a spiritual sense of surprised wonder. It is uncanny, bearing the imprint of the beyond, even if one believes in no beyond. Second, when we are convinced that we are in the presence of beauty, we cannot help universalizing it; our minds seek out reasons why others ought to degree that this, indeed, is beauty. This would accord with one evolutionary psychological explanation for aesthetic response, that the arts tended to bind groups together in remote time.

In his review Smee also refers to a John Updike comment to the effect that no man is likely to see anything more beautiful than a naked woman. This seems to be very characteristic of Updike, and exemplifies why his work often grates on my nerves, because this seems to me to be exactly wrong. Erotic attraction differs from beauty precisely because the former does not involve any stipulation of universality. If I find a book or piece of music particularly compelling, I cannot help but think that a friend not only may find it so too, but that he ought to. But if I find a woman attractive, I couldn't care less about whether others agree; she is "beautiful" to me, period. Eros is primarily visceral, whereas beauty, while it obviously has sensuous components, is ultimately rational.

However, in a pursuit as sensuous as music, which Schopenhauer deemed the greatest of the arts because it somehow penetrated to the essence of things, and toward the condition of which Walter Pater said the rest of the arts continually aspire, there may be more overlap between the visceral and the rational. We may be more "rationally" drawn to vocal beauty if the singer is attractive. Thus the global brouhaha over Susan Boyle--can 34,000,000 Youtube hits be wrong? The serendipity of beauty in unexpected places embodies the quasi-grace of aesthetic wonder, while the worldwide hysteria reflects a drive for consensus, probably all the more desperate because we struggle so much more these days to agree about anything, even music (the fuss over Boyle is a kind of transient microcosm of what living through Elvis or the Beatles must have been like).

Cynics argue that Boyle, far from being an actual gem in the rough, may well be a highly artificial reality-TV product, and the truly jaded claim that there is really no such thing as authenticity. Certainly, beauty can be achieved by highly contrived means (think of Ulysses as compared to, say, The Odyssey), but I think there is a particular attraction for beauty in its less self-conscious manifestations, which represent the reassuring hope that beauty is ultimately beyond our busybodying influences. We may shape it and refract it, but it was here before we were and will remain when we're gone.

Recently I've fallen in love with another rough-hewn beauty with a weirdly transcendent voice: Iris DeMent, three of whose great Youtube clips (with regrettably rather fewer than 34,000,000 hits) can be found here, here, and here.

Wednesday, April 22, 2009

The Sage

I'm starting to think that being an advice columnist would be a cool hobby--you get to read all kinds of fascinating, intimate letters from strangers, generate pithy observations on life and proper conduct, and you don't have to worry about after-hours calls or malpractice insurance. Advice-peddling is to psychotherapy what, say, homeopathy is to mainstream medicine. Both respond to the same basic needs.

For a while I've followed "Dear Prudence" (Emily Yoffe) at Slate, and only recently did I start Cary Tennis's column at Salon. Their differences are striking; advice columnists have their own styles, I suppose, as therapists do. Prudence is blunt, wry, and worldly; she does not tolerate fools and the self-indulgent gladly. Her replies are succinct and no-nonsense. Tennis is more reflective, tentative, and speculative, engaging in poetic flights of fancy to get a point across. I wish I could be more like Prudence, but by nature I'm more like Tennis.

A frequent admonition heard (and inevitably, parroted) during my training was that psychotherapy does not involve giving advice. I guess there are two reasons for this: the latter may undermine agency and personal responsibility, and it very likely oversimplifies irreducibly complex situations. But advice columnists perform valuable functions, acting as moral arbiters and as amateur psychologists. Many of the dilemmas prompting advice-seeking involve uncertainty about what is appropriate in myriad life situations, usually involving relationships or personal ethics. If psychotherapy is ultimately about self-understanding, advice-giving emphasizes propriety and practical wisdom.

The problem with advice-giving is that one is almost always going on painfully limited information. Whenever I read a letter the therapist in me instantly has a thousand questions about how some pathetically dysfunctional family or relationship got to be that way. If depth psychology is about reveling in (potentially infinite) complication, time-limited and cognitive-behavioral therapies aim to simplify, as advice-giving does. What I would love to know is whether the letter-writers ever derive any benefit from the replies they receive--it would be nice to have later updates on particularly juicy or precarious situations.

Tuesday, April 21, 2009

Category Mistakes

I am but mad north-north-west. When the wind is southerly, I know a hawk from a handsaw.


I think I've identified the source of the nagging cognitive dissonance I've felt at times while writing this blog. The quasi-professional imprimatur implied by the title and by my medical status implies a content for the most part that I am not interested in delivering much of the time. I'm interested in two main things: worthwhile writing in general on whatever topic strikes me, and a constellation of topics--narrative, beauty, and puzzles of identity and existence chief among them--that might be considered the vast penumbra of psychiatry.

I suspect a number of folks arrive at the blog (although often not the ones leaving comments) looking for insight into the nuts and bolts of psychiatry: the meds, the diagnoses, what it's like to be a shrink. And I write on these at times of course, but for the most part I'm content to leave these matters in the office. Most of the things I ever had to say about psychiatry as an entity and a profession I've already expressed in obscure academic contexts.

My natural inclination is to examine the narrow phenomenon of the psychiatric with the much more venerable and flexible tools of the arts, of general moral understanding, and of common sense. So when folks at a social gathering inevitably wonder aloud if I'm examining them, my tacit response (in addition to "Not unless I'm getting reimbursed") is that I need them to help me to better understand the weird undertaking of psychiatry, not the other way around.

So I'm doing a blog because I enjoy writing, and I enjoy it outside of the traditional strictures and pressures of publication (I sacrificed my 20's to the inferno and purgatory of medical school and residency, respectively, partly so that I would not be desperate for funds at this stage of my life). I do not do it to purvey some priceless wisdom that anyone could associate with psychiatry.

What I consider a good post is a kind of micro-personal essay, which doesn't imply that it is primarily about me, obviously, but that it conveys an apprehension of some experience--whether an idea, a cultural entity, or a book--that is refracted through a particular sensibility (mine). If you couldn't care less about the sensibility or the writing, then the wonderful thing about the Internet and blogging is that you have wasted "only" a few seconds of your life. Or not wasted, at least not entirely.

Two questions arise. If this is not primarily a vehicle for professional expression, why not leave it in a private journal, and why include the psychiatric title and implication at all? Well, as I've written before, few are less interested in or expectant of a mass audience than me, yet as I share a basic human message-in-the-bottle kind of aspiration to being known--even if only by a handful among six billion--it seems worth doing for a while. And the psychiatric handle may be somewhat arbitrary--I can think of any number of personal and biographical aspects more indicative of my worldview than happening to be a psychiatrist--but it will have to do, for now.

Monday, April 20, 2009


Beauty is momentary in the mind--
The fitful tracing of a portal;
But in the flesh it is immortal.

Wallace Stevens

Few experiences of childhood anticipation rival the first sight of a roller coaster's bending rails rising above the trees. It is summer, or promises to be so soon, and one has traveled an hour, or two, or three, to see and ride just this. The crowds--competing suitors for this prize--are already streaming from the vast parking lot. There isn't a moment to lose.

More spectacular ones are continually being built, and I enjoy the steel singularities too, but it's hard to beat the classic wooden coaster. The struts ascend rank upon rank--antique, delicate, and seemingly incongruent with the mass, velocity, and torque they must support. The wood has a disconcertingly weathered and derelict look, and one wouldn't be surprised to see high weeds growing beneath. There is a ritualistic feel to the wooden ride: the deliberate ratchet skyward, the ecstatic drop, and--what the newer coasters lack--the long hilly straightaways that mimic a high-speed race down country roads. As one hurtles through the high turnaround, it feels even on the hundredth ride as if one will careen into empty space.

Children must be provided opportunities for wonder, for some early joys must have the inertia of a lifetime. The best come from sun, water, sky, and from storied fantasy, but there is an innocent joy of technology too, which is easy to forget these days (I don't know for sure, but I doubt that amusement parks are particularly "green"). On a roller coaster, of course, once you get on you are compelled and not free; you're getting exactly the same ride everyone else is (well, the back may be a little faster), every ride is physically identical. And yet the lack of freedom is freely, exhilaratingly undertaken, and there is a fine art of delectable repetition. Lots of things in life are like that I guess, the best things anyway. There is nothing new under the sun--and that's okay. One can easily imagine a world without roller coasters, but as it is, plenitude is something to be grateful for. Elemental delights are best.

Roller coasters, like skyscrapers and rockets, are great oddities of nature, testaments to our kind's hunger for height and speed. It has only been in the past few years that I have realized how punishing wooden coasters are. As a teenager at King's Island, when the hordes dissipated near closing time, I would ride the Racer or the howling Beast a dozen times or more. Now my body feels and retains the violence--as it does the violence of sub-tropical sun.

Young 'un number two just reached 48 inches this year and so has been able to ride a few coasters. I wasn't sure how he'd react, as he's unpredictable, liable to playing in traffic or on precipices if not watched, yet sometimes disturbed by darkness or noise. After the first one, a vintage wooden one that had us bouncing up and down and from side to side, he had a kind of stunned expression. When asked how he liked it, he took a moment before declaring, somewhat solemnly, "Yes!" Then: "I want to go on it again!" and off he ran.

Monday, April 6, 2009

Spring Hiatus

"Is it a world to hide virtues in?"

Twelfth Night

In a few days we'll take the young 'uns by car, plane, ship, and roller-coaster on the tragically American quest for the perfect vacation. Off the grid for the most part, so this site will be idle for a couple of weeks.

Eight months and 185 posts in, I'm growing a little restless with the format here. I guess that's what drives one to blog in the first place, restlessness that is. I'm not done yet, but it may be time for a reboot of some kind. You know, get back to first principles, whatever those might be.

Saturday, April 4, 2009

Men Failing to Thrive

In The New Republic Sherwin Nuland reviews Mark S. Micale's new book on the history of hysteria in men. Yes, it exists, but seems to have been hiding in plain sight over the millenia.

As yet another horrific mass shooting occurs (New York state this time), it occurs to me that this is a uniquely male breaking point. Other appallingly violent behaviors, such as serial killing and suicide attacks, are carried out by females in a minority of cases. I'm sure there must be one somewhere, but I cannot spontaneously remember an example of a female walking into a public place and starting to shoot. Why is this? And it brings up the classic mad vs. bad conundrum. Is a "random" mass shooting like a tornado--a force of nature very difficult to predict precisely--or is it an act of the purest evil? Can it be both at once?

Unemployment is soaring here (fourth in the country as of February 2009). How do you make a man depressed, particularly in a rural area? Take away his manufacturing or construction job, leaving him with lots of time on his hands, to do either nothing or to mind the kids while his wife ekes out a secretarial position. In a couple of months, repossess his car (and no mass transportation out here). In a few more months, foreclose on his house so that his family has to move in with his in-laws. By now he'll be unable to afford the pain clinic where he has been treated for back injuries sustained in those manufacturing or construction jobs. Oh, and he has a 9th grade education, so if he's going to retrain it's going to take a long time, and where will the money come for that, exactly?

I'm not sure that SSRI's have been studied in this population. SSRI's--did I mention, take away his sexual function?

Strange the places human misery washes up in the wake of a distant explosion of greed and fiscal ineptitude...

Thursday, April 2, 2009

Uneasy Lies the Head

Picking up from a Shrink Rap post, I was thinking more about the often asked question of whether we could deal with someone in high office (let's say President, Vice-President, Cabinet Secretary, Senator, or Governor) with a significant history of an Axis I mental disorder. The most likely examples would probably be panic disorder, obsessive-compulsive disorder, depression, or bipolar disorder. As much as I detest stigmatization of mental disorders, I would have to say no, for two reasons: the art of prognosis in psychiatry remains shaky, and psychiatric impairment is often subtle and difficult to demonstrate objectively.

Even if such a candidate for high office had gone years without an episode, or had been stable on medications for a very long time, these kinds of mental disorders are apt to recur without warning. Obviously we know something about psychiatric prognosis: someone who has been hospitalized six times for depression can be expected to have a tougher time of it than someone who has been stable on Prozac for five years. But of the latter person, could I say with any confidence that he or she will likely go the next four or eight years without a major episode (even, of course, considering the major additional stress that elected office would bring)? No.

Most other chronic or recurring disorders are not like this. Hypertension, diabetes, or even heart disease tend to be more predictable over time based on fairly objective criteria. It is the very randomness of mental disorders, at least at our current level of understanding, that makes them so hard to deal with. A medication that has worked for a person for years could stop working tomorrow, and we often don't know why.

The second major concern is that while medical disability from a heart attack or (a la Chief Justice Roberts) a seizure is pretty much evident for all to see, impairment from mental disorders is often open to contentious interpretation. If anxiety, depression, or mania were affecting an elected official's performance, it would likely be subtle, gradual and subjected to partisan debate. This would be very much complicated if the official in question had little insight into the impairment, and chaotic impeachment proceedings might be necessary.

All this could change eventually of course. If or when our understanding of mental disorders progresses to the point where we can more reliably predict and modify their course, then a major mood or anxiety disorder might survive the vetting process. But unfortunately my guess is that we'll see the first female president, and probably even the first gay president, long before we see the first bipolar president.

Wednesday, April 1, 2009

Why Reproduce Anyway?

At Salon "kryptogal" articulates a woman's mystification by the fact that the great majority of human beings choose to have children since it is questionable whether doing so reliably increases happiness (for the parents involved, that is). The title, "Does having children ruin your life?" suggests the point of view.

The psychology of parenting is intriguing for the same reason that the psychology of religion is: both phenomena must reflect something very basic about human nature, since most people who have ever lived have pursued them. Or should we say have been pursued by them? Are there many choices, except for things like survival or food, that are more determined by unconscious and instinctual factors than the "choice" to believe or to have babies? And then of course there is that galling minority who opt out of one or both (I'm in the minority on religion and in the majority on parenting).

Of course, throughout most of human history having babies may have reflected nothing more profound than sexual instinct plus the absence of good birth control. But the availability of the latter in the developed world for forty-odd years hasn't brought parenting to halt. Yet...reproductive rates have been trending downward for a while in this country, and particularly in Europe. Could it be that an inertial effect of eons-long tradition is beginning to wane? That would suggest that parenting will in fact be more of a conscious, and an idiosyncratic, decision in the future. Or is there something deeply psychological about the parenting path beyond sexual inertia and social tradition?

Biological infertility aside, have studies been done to compare psychological profiles of married folks who choose to have kids and those who choose not to? I mean baseline profiles, not the depressive troughs that parents are well-known to endure during the toddler and teenage years. I would be interested also in long-term studies comparing both the childless and the "childed" over decades in terms of their respective gratitude or regret over their decisions.

I think it may have been the Greek Solon who said "Call no man happy before he is dead." I take that to mean not that death is good, but that happiness is not a momentary feeling, but rather the overall contour of a life. The only answer to a question of whether any ongoing life is a happy one is, therefore, "Time will tell." Am I glad I had kids? I can't say yes or no, only "Ask me in thirty years." But maybe other major life decisions--marriages, careers--are like that too...