Narcissists, psychopaths, and other bad guys

A patient of mine recently observed that the increasing use of the the term "psychopath" in popular media is really a disguised way of criticizing selfishness.  Dressing up selfishness as an odd and frightening clinical disorder — slapping a diagnostic label on it — makes for catchy news copy, and grants pundits emotional distance between themselves and those monsters who look just like us, but who lack the empathy and remorse that make us human. I immediately thought of how narcissism had its heyday in popular culture very recently as well, and to similar ends.  Narcissists and psychopaths care only about themselves, and have no qualms about hurting and sacrificing others when it suits their purposes.  These are dangerous people lurking among us; all the more reason to publish lightweight magazine and newspaper pieces on how to spot them in the wild.

Both labels sound like psychiatric diagnoses, but actually they're not.  According to Heinz Kohut and other theorists, narcissism is a quality everyone has to a greater or lesser degree.  It normally develops in infancy: the sense all babies have that the world revolves around them.  However, we gradually learn that we are not the center of the world, and that other people, including our primary caregivers, have their own goals and perspectives separate from our own.  Infantile narcissism is thus tempered by the reality of healthy relationships, although its vestiges are present in our self-pride, and perhaps in our proven tendency to overestimate our own efficacy and performance.  Pathological narcissism in this view is infantile normality carried abnormally into adulthood.  It only becomes a psychiatric diagnosis when the condition fulfills certain observable criteria and impairs social and/or occupational functioning.  Likewise, psychopathy is a personality trait, not a diagnosis.  Renowned psychopathy researcher Robert Hare notes that "psychopathy is dimensional (i.e., more or less), not categorical (i.e., either or)."  DSM-IV doesn't include a diagnosis called "psychopathy" or "sociopathy."  Instead, there is antisocial personality disorder, which overlaps with psychopathy but is not the same thing.

These terms, psychopath and narcissist, are loosely applied personality labels when popularized in the media.  What do they add over simply calling someone callous or selfish?  First, they offer an explanation — a pseudo-explanation really — of frightening and/or mystifying behavior.  Our feeling of powerlessness is eased by the label, as though now that the threat is identified, we may be able to do something about it.  Second, such labels imply that misbehavior is a function of one's character, a categorical determination.  Yet categorical psychiatric diagnosis, especially of personality, is controversial in general.  Moreover, we often overestimate personality factors and underestimate situational ones (the "fundamental attribution error") in explaining the behavior of others.  Using a label like psychopath or narcissist to describe another person (whom we've only heard about in the news, and haven't formally evaluated) reaches for a premature conclusion about the cause of that person's behavior.  In a way, we are falsely reassured.

Third, the label adds power to our verbal disapproval.    We have a long history of abusing psychiatric labels in the service of putting others down.  Consider "idiot," "moron," and "imbecile," all originally coined as official categories describing low IQ.  Or "cretin," which originally referred to physical and mental disability due to congenital thyroid deficiency.  Or the casual use of "crazy" and its synonyms.  Some patient advocates argue further that any diagnostic label used as a noun is demeaning, i.e., calling someone a schizophrenic, a neurotic, a borderline, etc.  Instead, it is more respectful to refer to a person (or patient) who has schizophrenia, or a narcissistic personality.  But that's exactly the point of the popular use of terms like psychopath and narcissist: To show disrespect and disdain, to disapprove.  And to underscore the difference between ourselves and the person with the label.

Our earliest social categories are "good guys" and "bad guys," defining one against the other.  From "cops and robbers," to team sports, to bipartisan politics, to our allies and foes on the world stage, we divide self and other at every level, calling the former good and the latter bad.  Callousness and selfishness are in all of us to some degree, and it hurts to admit it; it damages our self-image.  Instead, we psychologically defend against this realization in ourselves by projecting these traits onto others using a broad brush and pejorative terms.  While some people truly are unusually callous or selfish, the popular use of scientific-sounding labels serves our own psychological needs by identifying "bad guys" and making us feel better about ourselves.

Chemical imbalance — Sloppy thinking in psychiatry 1

There's a lot of sloppy thinking in my field.  This troubles me.  While psychiatry inevitably deals with the speculative and poorly understood, this surely cannot excuse faulty logic and intellectual laziness.  Worse yet, this laxity of thought extends across the field, from biological psychiatry to psychotherapy, and from the general to the specific.  My next few posts will address what I see as major areas of psychiatric sloppiness. "Chemical imbalance" is a phrase used by psychiatrists and laypeople alike.  When a mental problem seems to arise from within instead of without, it is said to be due to a chemical imbalance.   In truth, however, no chemical imbalance, nor any structural abnormality in the brain, has ever been found to account for anything we currently consider a psychiatric disorder.  Historically, whenever chemical or structural abnormalities were found to account for abnormal mental functioning, those conditions were no longer considered psychiatric and were adopted by another branch of medicine.  If this trend continues, psychiatry will never include pathophysiology in the usual medical sense.  It certainly does not at present.

Like many paving stones on the road to hell, the phrase "chemical imbalance" was sincere and well-intended at first.  It originally referred to the  biogenic amine model of depression, i.e., the hypothesis that a lack of excitatory neurotransmitters such as norepinephrine and serotonin underlies depression.  While it's a fairly compelling concept, it suffers from a lack of solid evidence.  People who are depressed do not have "decreased serotonin in the brain," and taking an SSRI does not "correct" the serotonin level.  Such drugs may offer benefits as a result of boosting serotonin, but that's not because serotonin levels were low to begin with.  Moreover, the fact that SSRIs increase the amount of serotonin in brain synapses says nothing about the ultimate cause of depression.  A cascade of downstream effects follows from tinkering with serotonin, including receptor down-regulation and probably new protein synthesis.  If there's any inherent chemical imbalance being remedied, we don't know a thing about it.

Population studies show subtle changes on average in the brains of patients with certain psychiatric disorders.  However, the findings in subjects with psychiatric diagnoses overlap so much with those of normal subjects that no blood test or brain study can diagnose mental illness in an individual.  (Dr. Daniel Amen claims otherwise regarding SPECT scanning of the brain, but many critics are skeptical.  Likewise, a putative new blood test for depression raises many questions.)  At best, "chemical imbalance" is shorthand for a presumed brain abnormality that no one has yet proven.  At worst, it is disingenuous hand-waving aimed to add medical legitimacy to the field of psychiatry.

Why is "chemical imbalance" so often advanced as a pseudo-explanation for mental illness?  Many psychiatrists confidently proclaim that psychiatric disorders "are medical conditions just like diabetes and hypertension" to justify chronic ongoing management and the need for medication even when the patient feels subjectively well.  Suffering a "chemical imbalance" implies that proper medication will correct a pre-existing, permanent organic abnormality.   The problem here is that the end (patient cooperation) does not justify the means (lying).  The honest answer is that we psychiatrists believe our medications help relieve psychiatric symptoms and distress — although even that is hotly debated — including maintenance treatment to forestall relapse.  This belief is based on outcomes research and clinical, aka anecdotal, experience, not on knowledge of biological mechanisms.

Psychiatry has long been the red-headed stepchild of medicine.  In medical centers we're often in a separate building across the street from the main hospital.  Other physicians sometimes don't understand what we do and make nervous jokes.  Critics accurately note that psychiatric disorders are never found in standard pathology textbooks, and some claim the field is baseless and harmful.  "Chemical imbalance" gives some psychiatrists the medical bona fides they crave, but at the price of intellectual laziness and sloppy thinking.  This serves no one.  Psychiatry must embrace uncertainty, and not seek false security in empty phrases.  Physicians prescribed aspirin for pain and fever long before we understood the intricacies of these conditions, or the mechanism by which aspirin affected them.  We simply knew it worked — no one claimed that a subtle "aspirin imbalance" was being corrected.  Like it or not, psychiatry is in much the same place now.

I'm hardly the first to critique "chemical imbalance," although some still defend it.  I started with this as the prime example of sloppy thinking in psychiatry.  But as we shall see, there are many others.

Photo courtesy of Petr Kratochvil.

The commodification of psychiatry

Several recent articles, blogs, and even my participation in HealthTap (discussed in my last two posts) have led me to think about how psychiatry, and mental health treatment generally, are increasingly viewed as commodities.  In the language of economics, a commodity is a physical good, such as food, grain, or metal, which is interchangeable with any other product of the same type.  Commodities are carefully specified, e.g., "Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico," but the supplier is immaterial.  Everything one needs to know about a commodity is in the specification.  Based on that alone, a smart buyer seeks the lowest price. Much has been written lately about the psychiatric "med check," a 10 to 20 minute encounter every few months for patients who take psychiatric medications.  A New York Times profile of one such high-volume practice generated notoriety for this approach, well deserved in my view.  Even the profiled doctor had reservations, but succumbed to the lure of higher income as compared to the traditional model of one patient per hour.

Although psychiatric medication management can be done well, the "med check" is often critiqued as an assembly-line approach that treats collections of symptoms, not people.  The assembly-line metaphor highlights the commodification of both parties.  On an assembly-line, each "part" moving down the line can be treated as any other. Likewise, each worker is interchangeable with any other having the same qualifications.  In commodity psychiatry, any fully specified "Major depression, single episode, moderate severity" can be treated as any other.  Mental health workers of a given specification (psychiatrist, nurse, counselor) are interchangeable as well.  The only thing left is to let the marketplace (or government) set the price of this commodity transaction.

While commodity treatment is easiest to recognize in the stereotypical "med check," it is rampant in the rest of the field as well.  Suicidal patients should immediately be sent to the ER, yes?  Because all patients who declare themselves suicidal are the same, just like "Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico."  Well, no.  In supervising residents and talking with colleagues, I'm amazed how often patients cool their heels, and spend thousands of dollars, in three-day inpatient stays triggered by a threat of suicide.  I claim no magical gift for curing depression or suicidal urges, and I've had my share of patients who scream, "I'm heading for the Golden Gate Bridge right now!"  Nonetheless, I can't recall the last time I hospitalized anyone for suicide risk, and I've never had a patient die by suicide.  Why?  Because it means something when someone threatens suicide, and that meaning varies from person to person.  "Suicidality" isn't a commodity specification, and it should not be treated as such.

Nor is psychotherapy immune from commodification.  "You have social anxiety?  We offer a 16 session cognitive-behavioral treatment for that." As though people who are anxious in social situations are interchangeable — and as though any practitioner who conducts a brand-name 16 session intervention is the same as any other who offers that brand.  The specification is all that matters, the supplier is immaterial.  Perhaps the ultimate example of therapy as commodity is when there is no therapist at all, as in this recent article about a smartphone app designed to decrease social anxiety.  Here, however, the app really is a commodity: Every copy of the app works the same, and it treats all users exactly the same as well.

With an ever-expanding diagnostic manual, and with a pharmaceutical, electronic, or scripted cure for every ill, psychiatry speeds toward a future where it no longer matters who has symptoms, it only matters what the symptoms are.  Likewise, practitioners are interchangeable and thus should be chosen for the lowest cost, just as a buyer spends the least possible on a certain grade of wheat.  It makes no sense to pay for an expensive psychiatrist or psychologist to perform psychotherapy, when psychotherapy is a commodity that can be supplied by people who charge less, or perhaps by a computer program, website, or smartphone app.

To be sure, there are areas of medicine well-served by rote protocol.  Thankfully, no one stops to "customize" CPR during a cardiac arrest.  But in most health care scenarios, treating patients as commodities is dubious.  And in the subtle realm of emotional health it's tragic.  As I wrote in my post about nomothetic versus idiographic thinking in psychiatry, western medicine derives its considerable power from lumping patients into a disease category, and then applying statistically proven treatment to members of that category.  For example, in psychiatry we are not forced to approach a new case of bipolar disorder in complete ignorance; among other things, we know lithium is apt to relieve the signs and symptoms.  But if we stop there, at the nomothetic level of knowledge, we are treating the bipolar disorder, not the patient.  The "supplier," the person suffering the disorder, is immaterial.  We are doing commodity psychiatry.

The alternative is not to abandon the hard-won knowledge of western medicine and nomothetic research.  It is to acknowledge that every person sharing a diagnostic category is unique — that no individual experiences major depression or bipolar disorder in quite the same way as anyone else.  Understanding and enhancing each patient's unique experiential reality is the essence of psychiatric practice, and mental health care generally.  Since these nuanced goals cannot be accomplished without considering the "supplier" — the person with the disorder, as well as the person offering care — the commodity model will forever shortchange psychiatrists and their patients.

Efficacy of dynamic psychotherapy

The following post is an adaptation of an argument I presented on Sacramento Street Psychiatry, my blog on the Psychology Today website.  As usual, I welcome your comments. Western medicine's great strides are largely due to understanding etiology (the biological basis of disease), defining a nosology (a system of categorizing diseases), and testing treatments aimed at these nosological entities, not at individual patients. Take 100 healthy volunteers, swab their throats with Streptococcus, and perhaps 88 will soon develop strep throat. Both our knowledge of bacterial infections (etiology) as well as repeated empirical observation of similar cases leads us to conclude that Streptococcus causes a recognizable condition called strep throat (nosology). Once patients are diagnosed with strep throat — once their conditions become exemplars of this disease category — experiments can be done to show which treatments relieve the condition. Western medicine is the accretion of such knowledge.

Hypotheses about disease categories, and about treatments aimed at these categories, can be tested using randomized controlled trials (RCTs), our most powerful statistical method to assess the effect of independent variables. As in the rest of medicine, evidence supporting the efficacy of psychopharmacology, as well as manualized psychotherapies such as CBT, depends on sorting patients into nosological categories such as "major depression," applying different treatments to comparison groups, and finding statistically significant group mean differences.  In psychology such a research approach is called nomothetic; the goal is to identify general laws of behavior.

However, another kind of knowledge is important too. Why didn't the other 12 subjects get strep throat? Is it the same reason for all 12, or is the answer different for each of them? Looking at what makes people unique, as opposed to members of a category, is called idiographic research in psychology. This is the nature of psychodynamic theory and treatment, and why it resists the usual RCT approach to research. Patients who present for such treatment rarely fit neatly into a category such as "depressed." They vaguely say their lives aren't working well for them, or that their relationships are unsatisfying in a particular way. They lack meaning and purpose in life.  They get a "funny feeling" when dealing with competition. Their boss triggers authority issues.  They can't trust their spouse's fidelity. And on and on.  Such complaints are not exemplars of a nosological category. We may not know what causes schizophrenia or bipolar disorder — we have no etiological understanding of any psychiatric disorder, one reason they are called "disorders" and not "diseases" — but at least these labels reflect a coherent nosology.  Not so with the presenting complaints of most psychotherapy patients.

Psychodynamic therapists and psychoanalysts find little of value in the nomothetic approach. DSM-IV and similar nosology sheds no light on the particular patient in the office, with his unique history, dreams, fears, hopes, etc. The psychoanalytic/dynamic perspective is to understand the uniqueness of that specific patient, and to promote unique helpful changes that may have no relevance to any other patient seen in the practice.

This is not to discount the importance of the nomothetic approach where it applies. If a patient's condition is exemplary of a nosological category, it should be treated that way.  Doing so allows us to use powerful research tools to separate bias and wishful thinking from real treatment effects.  If a patient presents with major depression, bipolar disorder, or schizophrenia, nomothetic research can and should guide treatment. In such cases, psychodynamic therapy must stand or fall on the same RCT basis as other treatments.  The evidence base for manualized psychotherapies such as CBT, IPT, and a few others is stronger than for dynamic psychotherapy. If someone is seeking relief of major depression, pure and simple, I am happy to refer them to a CBT therapist, and have done so on a number of occasions.  It would be nice to be able to claim strong evidence for the efficacy of prescription antidepressants as well, but unfortunately this is less clear.

CBT and other manualized therapies for specific conditions are much easier to study than dynamic therapy for ill-defined complaints. So it's really no surprise there are more such studies.  Idiographic research methods, e.g., pre and post measures in single-case designs, have been used to study dynamic psychotherapy, both whether it works and how. But nomothetic researchers consider this "weak science": There are no control groups — no groups at all, actually.

The bottom line is that dynamic psychotherapy has different goals than CBT or medication.  It doesn't aim to treat a nosological category such as major depression.  Since it isn't based on a nomothetic treatment model, RCTs are the wrong assessment tools to use.  Idiographic research methods may be statistically weaker than their nomothetic counterparts, but they are the best that this domain of inquiry allows.  (Seligman argues that naturalistic surveys have their place too.)  Dynamic psychotherapy is based on a rich theoretical foundation that has been scrutinized and refined for the past century. But ultimately it comes down to the individual and the unique mix of discomforting feelings and troubling thoughts that led him or her to reach out for help.

Psychiatric anosognosia

This post was inspired by an article in the May 30th issue of The New Yorker, "God Knows Where I Am" by Rachel Aviv.  Full-text online is only available by subscription, but a free abstract is available here.  In the process of telling a riveting and ultimately very sad story, the author discusses psychiatric insight. Insight is a curious concept as used in psychiatry.  In common parlance insight is unquantifiable, something like charm or wisdom.  We feel we know it when we see it.  But most of us hesitate to make finer distinctions.  We may allow that someone strikes us as a little insightful or very wise.  Beyond that, it seems ludicrous to attach a scale to it, or to refer to insight as though it could be measured precisely.

Nonetheless, in psychiatry an assessment of insight is part of the "mental status examination"  (MSE), the psychiatrist's version of the physical exam in general medicine.  Along with assessments of mood, affect (expressed emotion), paranoia, suicidal feelings, and other issues, the psychiatrist also evaluates the patient's insight.

Psychiatry has no standardized way to assess this.  We may ask our patient: "What is your understanding of the problem that brought you here today?"  It's a great question — the problem is what to do with the answer.  Critics note that if the patient's response accords with the psychiatrist's own belief, the patient is judged to have good insight.  Thus, in an earlier era when psychoanalysis was predominant, a patient with schizophrenia exhibited good insight by agreeing that his "schizophrenogenic" mother caused the problem.  Nowadays, this would be evidence of clear impairment; the insightful patient would instead agree with his psychiatrist that he has a "chemical imbalance."

For better or worse, many such judgments in psychiatry — perhaps most of what we do — cannot be divorced from social context.  Exuberance in one crowd may look like hypomania in another.  "Inappropriate" affect begs the question, what is appropriate?  And likewise, an understanding of one's own mental health status (or psychiatric label) is meaningful only within one's social group and culture.

Anosognosia is a term from neurology.  As defined in Mosby's Medical Dictionary, 8th edition:

[an′əsog·nō′zhə]

Etymology: Gk, a + nosos, not disease, gnosis, knowing

a lack of awareness or a denial of a neurologic defect or illness in general, especially paralysis on one side of the body. It may be attributable to a lesion in the right parietal lobe.

Certain patients with brain disease or injury appear not to know they are paralyzed (or blind, etc).  Presumably, parts of the brain involved with self-awareness are damaged.  This lack of knowing then becomes one of the signs of the disease itself, and may help with diagnosis.  For example, the cause of a paralysis may be localized to the parietal lobe if it is accompanied by anosognosia.

The term has lately appeared in psychiatry (and is discussed briefly in the New Yorker piece).  This is a worrisome error in my opinion.  Its use seems intended to make psychiatry sound better understood, and more biological/neurological, than it really is.  A person who denies having a psychiatric disorder may delusionally attribute his or her difficulties to space aliens.  This makes a good case for extending anosognosia into psychiatry.  But a denial could equally be an honest difference of opinion, as when a patient discounts a diagnosis of Social Anxiety Disorder because shyness is a family trait.  Here, denial of an anxiety disorder is certainly not a sign of having such a disorder.  And of course social stigma leads many patients to deny having a psychiatric disorder; this denial likewise bears no relationship to having the disorder itself.

The reasons patients may deny having a psychiatric disorder are far too varied to reify such denial with a neurological term.  It creates a suspicious "Catch-22," where disagreeing with one's doctor is itself a diagnosable condition with a fancy medical name, and the implication of brain-structure underpinnings.  This is sophistry, and the mark of a profession whose false certainty belies insecurity.

Many years ago I wrote a short essay arguing that social judgments in psychiatry  (e.g., inappropriate affect) are both inevitable and essential to our work.  I was not a psychiatrist yet, but nothing I have seen since has changed my view.  Despite great advances in biological psychiatry, we still cannot ascribe specific attitudes or viewpoints to neurological damage.  Insight is still subjective.  And if we ever do identify the seat of "psychiatric anosognosia," our understanding will no longer be psychiatry, but neurology.