Saturday, May 29, 2010


"Fortunately analysis is not the only way to resolve inner conflicts. Life itself still remains a very effective therapist."

Karen Horney

Alan Schatzberg, M.D., outgoing president of the APA, has presented a solution for what he sees as a major problem besetting the DSM-5 process, that is, excessive coziness with the common folk and their darned opinions:

"One thing we ought to consider is using more technical language. Our cardiology colleagues don't talk about heart attacks but use the term myocardial infarction. Hematologists are not attacked for including leukemia in their nomenclature, and they wouldn't think of giving it up for "way too many white cells disorder" (WTMWCD)! Why shouldn't we follow their lead? To my view, bulimia would be a better term than binge eating disorder. The latter was attacked by a prominent psychiatric critic as suggesting he could be diagnosed with the disorder after a heavy Thanksgiving dinner. Our language should indicate the severity of the possible impairment. Simiarly, temper dysregulation in children sounds too much like temper tantrums. They are not the same, but the use of the language is problematic. We need to be more serious about our terminology. In the end, we will get it right."

Yes, this is what ails contemporary psychiatry, the lack of abstruse terminology that will mystify and impress the hoi polloi (which wouldn't be a bad term for a mental disorder, come to think of it). Time to haul out the Latin and German dictionaries. American psychiatry's cardinal sin has been false modesty, and an unwillingness to stick its fingers into as many pies as possible. We need to be more aggressive in educating the purblind populace about the grave severity of their mental states, crying out for the local psychiatrist. We need to exaggerate the degree of our actual knowledge, for the good of our patients of course.

What is noteworthy about myocardial infarction, though, and countless other terms from other disciplines, is the useful work that the names do in indicating specific and potentially modifiable pathophysiology (in this case, the death of cardiac muscle cells). Unfortunately it's hard to think of a single psychiatric diagnostic term that has that level of specificity. Are neurologists wringing their hands over the term stroke, which seems to enjoy both wide general use and a meaningful clinical designation?

This sounds like the kind of throat-clearing that might lead a psychiatrist to wear a white coat, which is about as useful on a shrink as it is on an accountant. Not really, of course, as perhaps a white coat would helpfully accentuate the placebo effect, as would the casual use of dumbfounding (if insignificant) expressions like amygdalar aberration, or hippocampal ischemia, or limbic encephalopathy. (Unless the patient starts laughing). Yes, melancholia sounds way cooler than depression, but apart from those of us who enjoy cool words, what would the former accomplish beyond self-importance?

Friday, May 28, 2010

The Unnameable

After almost twenty years in my mind, the syllabic cornucopia of psychotropic drug names has made its case for a celebratory post. What has taken so long? And would I want the job of coming up with a moniker for Lilly's next miracle?

I considered a top ten list, but let us consider them by class:

1. Antidepressants: The meat and potatoes of psychiatry, these names are sure to be written with hand-numbing repetition, so it is a good thing that for the most part these drugs are happily named. A linguistic and pharmaceutical titan, Prozac is an arresting amalgam of the soothing, almost soporific Proz- followed by the hard "ack" that provokes comparison with another very popular drug of the 1980's. As the drug itself is meant to do, the name both calms and enlivens.
Zoloft and Paxil, completing the original SSRI trifecta, are also remarkably mellifluous names, although the former's buoyancy wafts dangerously close to corniness. Paxil follows flattery of Latinate pedantry (Latin pax=peace) with the relaxing -il evoking dutiful memories of Elavil, grandaddy of them all.
After these, antidepressant inspiration was spent in both chemistry and name. Celexa, its knock-off Lexapro, and Luvox? Not memorable. Effexor showed a lack of subtlety (Get it, "affects her," the majority of depressed patients being women?), regrettably dubbed "Ineffexor" when failing to work or causing dismaying withdrawal symptoms. Wellbutrin is a name simply rebarbative and without redeeming qualities, and it has been painful to hear a few concretely-minded patients over the years refer to it dismissively as "Badbutrin," which is a crime against both wit and alliteration.

2. Anxiolytics: It is a shame that Librium, lifted whole from a pleasing state of balance, did not prevail as a popular benzodiazepine. Similarly, Valium, connoting valiant equanimity, has largely fallen by the wayside. Instead we have Klonopin, which brings to my mind some kind of blunt instrument; Ativan, which seems to me a very gray sort of word, summoning nothing whatsoever; and the always suspect Xanax, whose pernicious influence may draw somewhat from its palindromic potency. A drug used for panic attacks should not end in -ax. But then again, I have heard that the color red, which tends to make people feel agitated and uncomfortable, sells best in grocery stores. Appropriately an afterthought, Buspar is a drug that eminently deserves its lame designation.

3. Mood-stabilizers: With the exception of lithium, which enjoys the elegant purity of being plucked right from the periodic table, the third lightest element in the universe, this group is composed of referential failures. Depakote. Tegretol. Lamictal. Whatever their pharmacological effects (which may be considerable), these names do not inspire confidence, and can be the insult on top of the injury of a diagnosis of bipolar disorder.

4. Antipsychotics: The hoary first generation of "major tranquilizers" could not be topped in dignity. Thorazine summons a compound of Nordic power with neuropsychiatric precision, a hammer brought down with pinpoint accuracy. Haldol conveys both majesty and trustworthiness, as of a respected elder. Navane is a name both implacable and imperious, sounding as if it should have been given by injection only. The contemporary offspring suffer from a failure of ingenuity. While Seroquel suggests a certain sophistication, Risperdal and Geodon are vaguely boorish in tone, while Abilify is simply an embarrassment. The unfortunate progeny of ability and fortify, it is a name that can't be taken seriously, which is a shame, because it isn't at all a bad drug. "Have you ever taken Abilify?" is a bit like asking, "Have you ever drunk Kool-Aid?" Please.

5. Stimulants: Provigil is sort of cool, evoking the steadily tenacious all-nighter, but maybe a bit too ominously. Compared to Ritalin, which is vaguely reassuring but forgettable, Adderall was a triumph of shameless audacity. The name is a naked directive: add this drug to all the patients you can, period. Why simplify or streamline your life when you can, in fact, add more? Add what? Adderall! You can have it all. At this point we are beyond subtlety, the closest possible thing to the drug name "Takethis."

A note on generics: Chemical drug names, with very few outliers, are infelicitous and afford little pleasure, except to the most self-righteous who refuse to pay their respects to brand names. Fluoxetine, carbamazepine, and thiothixene are flashbacks from Organic Chemistry. The only exceptions would be haloperidol and valproic acid, which are stimulatingly, sinisterly(?) decadent, sounding akin to something like absinthe.

In the world of medication management, we take our gratification where we can. (Note: this spoof concerns names and not the medical value of any of the medications mentioned. Ask your doctor).

Wednesday, May 26, 2010

Big Deal

"If you hate violence and don't believe in politics, the only major remedy remaining is education."

George Orwell, "Charles Dickens"

In last month's Atlantic Monthly, Marc Ambinder usefully reminded us of the complex and multifactorial causes of obesity, and therefore the oversimplicity and unhelpfulness of the traditionally stigmatizing, "willpower" approach to weight loss. After all, when we consider the epidemic of fat in this country (and increasingly in prosperous nations generally) in recent decades, it isn't human nature that has changed, it is context that has changed. Our thinner grandparents didn't stay thin by means of virtuous self-renunciation; they had no other choice.

Ambinder documented now well-known social factors--sedentary residential and work environments coupled with high caloric content of foods (especially those hawked to children, the poor, and minorities)--acting in tandem to foster obesity. And he made the important point that it is more and more the case that "going with the flow," that is, eating what the Joneses eat, and doing what comes "naturally" in our highly artificial environment, will in fact make one fat. For most of our evolutionary history, becoming fat required either heroic effort or terrific good luck. In contemporary society, remaining thin requires either remarkable discipline or genetic good fortune. This brings to mind Nietzsche's point that many are virtuous merely through timidity.

In decrying the still popular tendency to demonize the obese, Ambinder made the point that in the end, stigmatization just doesn't seem to work very well. Would obesity be even more prevalent if there were no stigma whatsoever, or if fatness were actively celebrated? Well, probably, but at least when it comes to eating behaviors, the extraordinary rise of obesity in recent decades despite active stigmatization suggests that the latter stops working at a certain point. One wonders if such a point might be somewhere around the point at which the majority of people are overweight--it is simply hard to stigmatize the majority, it seems to me.

One can push individual responsibility only so far, to the point where the general outlines of mysterious "free will" can be said to lie. Beyond this point, why even speak of some kind of nebulous "free will" that is supposedly going unexercised in some malfeasance of bad faith? If people endure discomfort, ill health, shame, and stigmatization and still do not lose weight, why pretend that they could if they only tried harder?

Ah, this is where it gets tricky. Ambinder acknowledged that in experiments or other settings where people have (voluntarily of course) been put into extraordinary low-calorie and high-exercise environments for extended periods of time, they lose weight of course. Similarly, if one could pay people $1 million per pound lost, the obesity rate would shrink rapidly. Holding a gun to someone's head will help them to make wiser dietary choices. In this sense, obesity is not like cancer, which does not respond to similar incentives.

But unfortunately perhaps for human nature, numerous studies have shown that even most people who do succeed in losing large amounts of weight only rarely keep it off. That is because in our society of abundant calories and minimal necessity of exercise, and in the absence of genetic luck, it requires heroic effort to lose weight and keep it off. That's where human nature comes in; for the most part discipline and consistency are, by definition, average and not heroic.

This brings me back to the Orwell essay, in which he argued that Dickens perpetually urged a revolution in individual moral behavior rather than a reconsideration of social systems and incentives. Orwell suggested that while such urging has a radical aspect (a reimagining of human moral capacity), it also can be a deeply conservative, implicit embrace of the status quo, for when has human nature ever changed from the ground up and in a spontaneous fashion?

But consider Orwell's three-part approach of education, politics, and violence for social change. Inasmuch as childhood obesity is a significant root of the epidemic, then education about nutrition and exercise, a la Michelle Obama's campaign, can play a major role. Politics could reduce the influence of food advertising, influence consumption via taxation, and increase options for safe and convenient exercise in residential and urban locations.

By violence Orwell meant of course social unrest (assassination as the ultimate force for cultural change), but it occurs to me that violence could also refer to, say, bariatric surgery, of which Marc Ambinder openly proclaimed himself a successful beneficiary. If fat is the enemy, then by all means pressure people to fend it off themselves, and create the conditions in which they can best be motivated and educated, but beyond a certain point, stop waiting for mythical humans of superior willpower. Just cut out the fat, figuratively speaking. Kill it, and thereby begin to transform human nature itself. In that sense all technology is violence, altering the material context of human experience.

Monday, May 24, 2010

Happy Birthday Bob

I'm told that Dylan is 69 today. If Obama deserved the Peace Prize, how much longer does Bob have to wait for his literature Nobel?

Just Like a Woman

Nobody feels any pain
Tonight as I stand inside the rain
Everybody knows
That Baby's got new clothes
But lately I see her ribbons and her bows
Have fallen from her curls.
She takes just like a woman, yes, she does
She makes love just like a woman, yes, she does
And she aches just like a woman
But she breaks just like a little girl.

Queen Mary, she's my friend
Yes, I believe I'll go see her again
Nobody has to guess
That Baby can't be blessed
Till she sees finally that she's like all the rest
With her fog, her amphetamine and her pearls.
She takes just like a woman, yes, she does
She makes love just like a woman, yes, she does
And she aches just like a woman
But she breaks just like a little girl.

It was raining from the first
And I was dying there of thirst
So I came in here
And your long-time curse hurts
But what's worse
Is this pain in here
I can't stay in here
Ain't it clear that--

I just can't fit
Yes, I believe it's time for us to quit
When we meet again
Introduced as friends
Please don't let on that you knew me when
I was hungry and it was your world.
Ah, you fake just like a woman, yes, you do
You make love just like a woman, yes, you do
Then you ache just like a woman
But you break just like a little girl.

Saturday, May 22, 2010

Recommended Reading

A post at Shrink Rap invites suggestions for recommended reading on psychiatric topics, prompting me to chime in with my top ten. These are not "recommended" per se; these are the books, some read before I became a psychiatrist and some read after, that struck or influenced me most deeply. This sort of list can only relate to the sort of person I was to begin with; other people might read these ten and be disappointedly unfazed, but I can't help believing they are noteworthy in their own ways. In no particular order:

1. "Civilization and its Discontents," encountered in undergrad, was my first experience of Freud, and still the most memorable. He unforgettably explained how the basic human dilemma is not so much intrapsychic as social and interpersonal. As Sartre infamously put it, "Hell is other people," although fortunately it's not so simple.

2. The Birth of Neurosis, by George Frederick Drinka, impressed me with the cultural contingency of hysteria and psychological symptoms in general.

3. The Savage God: A Study of Suicide, by A. Alvarez, used the case study of Sylvia Plath as a springboard to an existential and phenomenological consideration of the suicidal mindset.

4. Listening to Prozac, by Peter Kramer, raised fascinating and vexing questions about the relation of diagnosis to medication.

5. The Myth of Mental Illness, by Thomas Szasz: any serious psychiatrist must know, and come to grips with, the argument that the whole enterprise is fundamentally misguided.

6. Darkness Visible, by William Styron, may be forever the best account of the experience of depression. No sentimentality or silver linings here (although he did recover).

7. "Ward Six," by Anton Chekhov: There but for the grace of God...

8. "Miss Lonelyhearts," by Nathanael West, is a deeply quirky examination of the emotional hazards of the therapy project, broadly considered (in this case, pertaining to an advice columnist).

9. The Perspectives of Psychiatry, by Paul McHugh and Philip Slavney, convincingly argues for the irreducible complexity of psychiatric understanding.

10. With all due respect to Irvin Yalom, I would pick Kafka's brief, gnomic parable "Before the Law" as the ultimate existentialist text: in the end, it's unavoidably up to you.

11. (Honorable Mention): Hamlet, by William Shakespeare: the unfathomably neurotic young psychiatrist as doomed Danish tragic hero.

Thursday, May 20, 2010

Heart of Darkness

"The old doctor felt my pulse, evidently thinking of something else the while. 'Good! Good for there,' he mumbled, and then with a certain eagerness asked me whether I would let him measure my head. Rather surprised, I said Yes, when he produced a thing like callipers and got the dimensions back and front and every way, taking notes carefully. He was an unshaven little man in a thread-bare coat like a gaberdine with his feet in slippers, and I thought him a harmless fool. 'I always ask leave, in the interests of science, to measure the crania of those going out there,' he said. 'And when they come back too?' I asked. 'Oh, I never see them,' he remarked, 'and, moreover the changes take place inside, you know.' He smiled as if at some quiet joke. 'So you are going out there. Famous. Interesting too.' He gave me a searching glance and made another note. 'Ever any madness in your family?' he asked in a matter-of-fact tone. I felt very annoyed. 'Is that question in the interests of science too?' 'It would be,' he said without taking notice of my irritation, 'interesting for science to watch the mental changes of individuals on the spot, but...' 'Are you an alienist?' I interrupted. 'Every doctor should be--a little,' answered that original imperturbably. 'I have a little theory which you Messieurs who go out there must help me to prove. This is my share in the advantages my country shall reap from the possession of such a magnificent dependency. The mere wealth I leave to others. Pardon my questions, but you are the first Englishman coming under my observation...' I hastened to assure him I was not in the least typical. 'If I were,' said I, 'I wouldn't be talking like this with you.' What you say is rather profound and probably erroneous,' he said with a laugh. 'Avoid irritation more than exposure to the sun. Adieu. How do you English say, eh? Good-bye. Adieu. In the tropics one must before everything keep calm.' ...He lifted a warning forefinger...'Du calme, du calme. Adieu.'"

Joseph Conrad

Tuesday, May 18, 2010

Talk About Cherry-Picking

This is it, a double-take headline on NPR that is the unholy spawn of social Internet and medical marketing pressures: speed-dating at the Doc Shop.

I have been mulling over the prospect of a new practice; this is exactly the start-up idea I was looking for.

Let us dispense with the longueurs of the 15-minute visit. Even allowing for the luxury of a 5-minute bathroom break, I can envision 11 accelerated diagnostic evaluations per hour. The Adderall scripts will by flying fast and furious.

(Note to DEA: this is a satirical post).

Friday, May 14, 2010

Auf Wiedersehen to Academia

A few days ago a friend and former colleague sent me news that a paper that we had begun at least three years ago (what is that in "blog years?") had finally appeared in the print world. He wrote it, I merely advised and proofread. But while I've been physically removed from the university for two years now, it occurred to me that only now, with the paper trail complete, was the academic experience complete, with closure as the cliche goes. As my first peer-reviewed article appeared in 2000, this nicely rounded the experiment up at a decade.

When I was a senior resident in the late 90's, the department chairman at the time, Allen Frances, M.D. (he of DSM-IV notoriety) rounded a few of us up to discuss our career prospects. At that point I had developed a strong interest in the history and sociology of psychiatry, and told him so. He nodded vaguely, as I recall, and said something about that being a worthwhile "hobby" (his word) to pursue alongside my real career of clinical work and, perhaps, more respectable (and funded) research.

At the time I privately took some offense, for the philosophical dimensions of psychiatry were a primary passion of mine; all of the mainstream trappings of the profession were necessary evils. The clinical experience has always been crucial, but its props (the diagnostic categories, the meds, etc.) I have always taken with some grains of salt. When I entered an academic position at a different institution, it was understood that the "props" (to include inpatient work and ECT) would earn my keep and justify my salary, but the deeper motivation for me was the intense and hard to define strangeness of the psychiatric endeavor itself.

So began a rather parallel career. On a theoretical (not, I hope, a personal) level I fumbled my way toward hysteria as the route to the pervasive but often acknowledged role of narrative and value(s) in clinical work, and I found, in poetry and short fiction, promising windows upon this state of things. In my mainstream work I tried to do good, broadly speaking, for people (ranging from administrators to patients) who want what they contingently want and upon whom thoughtfulness, unfortunately, is all too often wasted. But as I never really felt at home in the psychoanalytic community--it has always seemed a bit hieratic, a bit hothouse to me--a niche wasn't easy to find. I always felt that literature had more to teach psychiatry than vice versa.

Unless one counts a few paid trips to conferences (granted, Emily Dickinson in Hawaii is hard to beat), I was never funded a cent for publications or presentations over those years. My clinical work paid the way, so in that sense Allen Frances was right, my humanistic leanings were a kind of professional hobby in a way. I was an amateur, although hopefully in the best sense of the term. This was probably as it should be; why should taxpayers pay for an academic physician to indulge in esoteric speculations perhaps of no use to anyone (and surely not of measurable use) when he could be doing the "real work" of seeing patients?

I confess I never greatly enjoyed teaching medical students or psychiatric residents, at least not in the classroom setting and not the kind of mainstream stuff (the "descriptions and prescriptions") that they most wanted to know (I don't fault them, as they were responding to a professional and economic system with its own incentives). I mention this somewhat sheepishly, because teaching is one of those things--perhaps like growing your own vegetables or volunteering in soup kitchens--that is considered universally praiseworthy. But I most enjoy those activities that are done for their own sake, and for that reason the best learning takes place outside of a classroom. There were the occasional exceptions, the thoughtful ones; good teachers speak to a group of 30 for the sake of the 5 or so who truly care, or in the hope of increasing that 5 to 10. I'm just not wired that way; an autodidact by nature, I have found my best teachers in libraries, bookstores, and the "book of nature" for the most part.

The reason I finally left academia was the realization that, in medicine at least, tenure means nothing in the absence of separate funding. I was awarded tenure and...nothing changed; I still had to maintain a busy clinical practice to earn a few precious hours per week that I might devote to thinking and writing. But the kind of topics I care about are to medicine what, say, poetry is to the publishing world--it doesn't make any money for anyone. So it occurred to me that I didn't really need the academy; I could do clinical work anywhere to finance my parallel interests in literature and psychiatry. Clinical work--the fact of suffering--is the existential engine, but the narrative mode is the way I prefer to steer.

So the Ars Psychiatrica blog was the unfinished business of my academic career, the things left over that needed saying that I hadn't gotten around to sending to refereed journals. It was nice to publish in three seconds rather than three years, although many, many posts could have benefited from stringent peer review. I have always admired writers who, instead of whining about people not buying their stuff, arrange to have a day job that will earn them a living (T. S. Eliot at the bank, Wallace Stevens at the insurance company). I do get tired of contemporary journalists and writers complaining about the Internet threatening their livelihood. Why don't they do what the rest of us have to do, learn a trade that they can get paid for? I'd love to get paid for keeping a blog, but it isn't going to happen.

Saturday, May 8, 2010

Escape Artists

"But my mama never warned me about my own destructive appetites."

Jenny Lewis

Let us mark Mother's Day with a nod to one of the least praiseworthy of fictional mothers, Emma Bovary. Forever foisting her daughter--who was an unacceptable intrusion upon her own self-absorption and self-indulgence--upon the maid, Madame Bovary was one upon whom motherhood was truly wasted. Fortunately she had only one offspring to neglect and not several.

Indifferent mother, unloving wife, adulteress twice over, disastrous spendthrift, melodramatic and self-pitying hysteric, and ultimately miserable suicide, Madame would be utterly despicable if it weren't so tempting to identify with her. Her basic problem was an appetite that could not be satisfied by the milieu in which she found herself. The first step toward forgiving her is, of course, the basic feminist recognition that like all women, she was born into a world designed to frustrate female motivations at many turns.

Madame Bovary was a hapless Romantic, an escapist, a fantasist forever pining for some vaguely imagined realm of glamour. She happened to be paired up with the worst possible mate for her, the profoundly unimaginative Charles. Devoted and reliable, he would have proven a serviceable husband for a number of women, but for Emma he was poison.

Charles and Emma ended in calamity and not mere unhappiness because both of them were impractical dreamers. There was no check on the development of parallel marital fictions. Charles achieved his fantasy of domestic bliss through total denial of what was going on in front of his eyes; his only claim of diminished responsibility derives from his low intelligence.

Emma, after all, wants to be able to accept reality as it presents itself to her senses, but she is unable to. She endeavors to love her husband, but the love will not come. She prays for virtue; she fitfully and impulsively tries to summon maternal instincts. The spirit on some level is willing, but the flesh craves more than her straitened bourgeois existence can provide. And that is part of the problem, that she wants it both ways, that is, the respectability and stability of a doctor's wife as well as total freedom and exotic adventure.

One can imagine her as a writer or an actress, pursuits that were open to women even in that pre-feminist era. But she either lacked the courage of her convictions, or she did not understand herself well enough to recognize where she might find what she needed. Perhaps she was a failed artist, or one endowed with an artistic temperament without accompanying discipline or skill. The problem is not really escapism itself, for the pharmacist Homais, who smugly and pedantically revelled in every grubby aspect of "the given," comes off as an odious figure. For it is human nature to be impatient with reality, to be bored, to need perpetual stimulation of one kind of other. Thus religion, thus the arts, thus games and sports (Homo ludens indeed), thus war, drugs, and sexual intrigue. Some are arguably born more bored than others, and inasmuch as relief of boredom is one of the central tasks of life, Madame Bovary made a particular mess of things. Consciousness is restive by nature; the trick is to afford this restlessness its due scope without hurting others or oneself unduly along the way.

Wednesday, May 5, 2010

It Depends

"To generalize is to be an idiot; to particularize is alone distinction of merit."

William Blake

A New York Times article reminds us of the distinction between complicated and complex, and our tendency to mistake the latter for the former. Complicated is a list of 10,000 instructions that must be followed to the letter; complex is a system so intricate that one can only hope to guide and shape its overall outline, not master or control its every detail.

David Barash shows how science neglects individuality in favor of generalizations.

Consciousness and its myriad maladies are instances of complex particularity. Psychiatry is therefore hubristic and diagnosis is stupid, but human beings have a need for these things.