Embracing psychiatric uncertainty

coyote

I always get troubled looks from psychiatry residents when I point out that our field is the domain of the uncertain and the not-well-understood — and that it will always remain so.  As soon as the cause of a disease is known, it automatically leaves psychiatry for another specialty. General paresis (advanced syphilis), once identified as an infectious disease, became the domain of internists. Senility (dementia), multiple sclerosis, and many other apparently psychiatric conditions went to the neurologists. Thyroid disorders belong to endocrinology. Brain tumors and hemorrhages are surgical conditions. And so forth. I have little doubt that schizophrenia will someday be understood as due to a slow virus, a complex genetic error, or something else. At that point it will no longer be a psychiatric condition. It will join neurology, internal medicine, or some other specialty.

This makes my residents squirm in their seminar chairs, particularly when I point out that the closest analogy to psychiatry's status in medicine is philosophy's status among the humanities. Philosophy consists of questions in the humanities that we don't yet know how to answer. Once we do, that area is no longer considered philosophy. "Natural philosophy" is what we now call science. It isn't considered philosophy anymore. Logic was one of the classic branches of philosophy; now it is better understood as a branch of mathematics. In the same way, psychiatry consists of questions about human thoughts, feelings, and behavior that we don't yet know how to answer, not down to the level of mechanism anyway. Once we do, that area is no longer considered part of psychiatry.

It's no mystery why the residents are uncomfortable. They want and expect certainty.  Why did they study all that organic chemistry, memorize all the bones and muscles, spend years learning to diagnose and treat, if in the end they can't make definitive statements about their chosen specialty? Many will cling to pseudo-certainties for reassurance.  Simple-minded factoids like "alcoholism is a disease" or "depression is due to a chemical imbalance" give them something to hang onto. Unfortunately, we don't really know what causes depression, and alcoholism is disease-like in some respects, but not in others. Most of our field is complicated, messy, and not well understood. Moreover, this need for certainty in an uncertain field leads many psychiatrists, including and perhaps especially those well out of training, to convey unwarranted confidence regarding diagnosis and treatment recommendations. We can come across as smugly self-assured.

Frankly, this very uncertainty — mystery, if you will — is one of the things I like about psychiatry. It isn't a settled area. It is endlessly debatable, much like an undergraduate philosophy course. Yes, there are concepts and terms to learn, principles to refine and employ, scientific studies to evaluate. There is a body of knowledge, a history, practice guidelines to teach and learn. Most of all, there are real patients to help. Yet as in philosophy, experts in psychiatry can and do disagree. Our diagnostic categories are revised periodically. Treatments come and go. Unscientific fads influence the field, as when American psychiatrists used to diagnose schizophrenia more liberally than our British counterparts, when multiple personality disorder suddenly became common in the 1980s and just as suddenly faded away, and in the way ADHD, PTSD, and bipolar diagnoses are so popular now.

Confident pronouncements of certainty have no place in psychiatry. Humility is the only honest attitude to take to this work. At the same time, the questions we face are fascinating, patients are suffering, and neither can wait for definitive knowledge. We must do the best we can with imperfect knowledge, with limited data and educated guesses, with hunches and subtle impressions. As in life generally, we cannot wait for certainty before acting. As in life generally, this makes psychiatry risky, vibrant... alive.

Should therapists accept holiday gifts?

gift

December brings the annual pleasures and challenges of holiday gifts and how to deal with them in dynamic psychotherapy. Although it is relatively easy to follow a simple rule about this, ideally a good deal of thought goes into a therapist's decision about whether to accept a patient's holiday gift. Below I will give a couple of examples of this from my own practice, and how psychodynamic theory guided my response. All beginning dynamic therapists are taught not to accept gifts from patients. This rule follows from the principle that the therapist should decline all gratifications from the patient aside from the fee paid. A therapist who is swayed by the patient's generosity, physical attractiveness, political connections, or other factors invites a conflict of interest in himself, and thus risks distorting the therapy in pursuit of his own needs and desires. Accepting a gift would be an example of this. Afterwards, the therapist may feel disinclined to challenge the patient, to induce anxiety or point out a contradiction. Conversely, the patient may feel the therapist should reciprocate the generosity, leading to disappointment and possibly anger when the therapist fails to do so.

Naturally, patients often do not know this rule, thus some arrive to a year-end session with a gift in hand. These gifts vary. Some are expensive, some less so. Some are "for the office," others intended more personally for the therapist. Some are homemade, or reflect something personal that had been discussed earlier in the treatment, while others are more generic. Likewise, the nature of the treatment varies from patient to patient, from relatively supportive and concrete, to very "uncovering" transference-based therapy. Given these variables, there is room for some discretion in the no-gifts rule.

A number of years ago I treated a woman who painfully described feeling unvalued by others. Men only appreciated her because she gave them sex; her employer did not value her as a person, but only for her productivity. Our therapy was fairly psychoanalytic in nature. Arriving to a session around the holidays, she handed me a large, beautifully wrapped gift box. It looked store-bought and expensive. I imagined she had taken significant time and trouble to purchase and bring it to me. With some apprehension I told her that we needed to discuss the gift before I could accept it. She was initially hurt by this. However, it soon became clear to both of us that her gift reflected her belief that I, like others in her life, did not value or appreciate her as a person — she hoped I would value the gift and therefore her. On that basis I thanked her but did not accept her gift, a decision she ultimately understood and agreed with.

It turned out very differently with another patient, an older Russian woman who saw me for supportive therapy. Around the holidays she presented me with a bottle of Kahlua, unwrapped if I recall. We had not been working with transference; I did not see how such a gift could damage our work. Also, it is customary in Russia to offer such gifts to one's doctors. I accepted the bottle with thanks, and pleased my patient. No harm done, and perhaps a bit of good in strengthening our working relationship.

Most dynamic therapies lie between these two extremes, somewhere in the midrange of the analytic-supportive continuum (more about that here). I have accepted inexpensive gifts in such cases, except when I sense that the offer is an unhealthy enactment, or that the patient is sidestepping a useful exploration. As is often the case in conducting dynamic psychotherapy, there is a balance between fostering a warm working relationship, versus encouraging reflection and insight. In my view, a blanket rule of refusing all gifts is unnecessarily cold and inhuman for many patients, while accepting all gifts may appear "normal" but does not encourage reflection, and may introduce conflicts of interest. The matter takes case-by-case consideration, neither unthinking acceptance nor unyielding refusal. It should go without saying that I never expect to receive a gift; it's also helpful to note that most patients do not offer them.

Occasionally the opposite issue proves useful to explore: whether the patient expects (or wants) me to give him or her a holiday gift. As we all know at this time of year, both gift-giving and gift-receiving tap deep emotional aspects of our personalities, and sometimes highlight conflicts around themes of self-interest, self-sacrifice, guilt, generosity, reciprocity, and one's value in the eyes of others. I do not offer my patients holiday gifts, but I do wish them, and you, Happy Holidays.

Diagnostic alphabet soup

mossytree

Earlier this year a reader asked me: "I would be very interested to hear your thoughts on patients becoming too focused on diagnoses. [...] While I was in an RTC as a teenager, and recently in the hospital as an adult, I have found that people almost treat their diagnoses as a competition. I was calling it the alphabet olympics. I also have a friend who will rattle off a bunch of abbreviations for his diagnoses. There is always something new popping up too. Sometimes I wonder if over diagnosing is a mistake some psychiatrists make."

I've seen this too. Here's my take on the alphabet soup of diagnosis, and whether it's good for patients to focus on it. First, a little history...

Prior to 1980, before the revolutionary 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry tended to lump disorders into a few broad categories. Schizophrenia covered a wide range of presentations, from relatively minor symptoms to devastatingly severe ones. Depression could be brief, prolonged, triggered by obvious stressors or losses, or appear out of nowhere. Neurosis referred to any presumed unconscious conflicts that interfered with life.

DSM-III changed all that. (An excellent historical review article, in pdf format, is available here.)  This was the first effort by the American Psychiatric Association (APA) to publish an atheoretical, phenomenological psychiatric nosology. What do these $10 words mean?  The idea was to create diagnoses that could be used regardless of one's school of thought or theory. For example, some psychiatrists thought depression was biological, others considered it psychological. Either way, if a patient had a low mood for two weeks, along with poor sleep, appetite, concentration, and libido, he or she had Major Depressive Disorder according to DSM-III. It didn't matter why.

This scheme encouraged multiple diagnoses. A given patient could fulfill criteria for Major Depressive Disorder, an Anxiety Disorder, a Personality Disorder, and other disorders, all at the same time. This reflects a drawback of atheoretical diagnosis. An underlying theory, such as Freudian psychoanalytic theory, or a systematic biological or learning theory, can pull together apparently disparate symptoms into a coherent diagnostic formulation.  Without such a theory to guide diagnosis, each set of symptoms stands on its own. While some DSM diagnoses had exclusion criteria — they could not be listed in the presence of other diagnoses — this still left plenty of opportunity to list multiple disorders in the same person.

Each edition of the DSM grows in size. One reason is that scientists can't stand to leave a good category alone — if it can be turned into two good categories. Thus, anorexia and bulimia, which used to be one disorder, are now divided. Depression is divided into major depression, dysthymia, seasonal affective disorder, adjustment disorder with depressed mood, and so forth. Bipolar disorder comes in Type I and Type II, as well as lesser versions. I am not against making these distinctions when there is good reason to do so, and there often is. But one consequence is diagnostic alphabet soup: a growing set of arcane labels usually shortened to three- or four-letter abbreviations. And the nature of atheoretical diagnosis means that any given patient may qualify for several.

Many psychiatrists feel they "understand" a patient better if they can establish one or more DSM diagnoses — although, being atheoretical, such diagnoses don't actually explain anything. They do, however, point reassuringly to recommended treatments, usually pharmaceutical. Moreover, medications are FDA-approved for each of these indications separately. This has marketing advantages for drug manufacturers. Shyness doesn't sound like a psychiatric problem to be treated with medication, but "Social Anxiety Disorder," essentially a synonym for shyness, does. Dividing anxiety into Generalized Anxiety Disorder, Social Anxiety Disorder, and many other types created markets for various medications. In a parallel fashion, health insurers demanded more specific diagnoses in order to pay for psychiatric treatments. There is money, and therefore politics, behind dividing human misery in these particular ways.

Perhaps the most interesting part of my reader's question is why some patients are attracted to these labels. Her experience with teens and young adults may, in part, reflect embracing these labels in an ironic or mocking way: "Now I have MDD, OCD, and PTSD.  Isn't that a kick?" Probably more relevant is the concrete way a diagnosis seems to account for one's frightening instability. Better to be "ADHD" than merely a scattered teen who can't study. The former confers scientific legitimacy, promises specific treatments, and even justifies entitlements such as extra testing time in school. These labels can also ease personal responsibility and humiliation, as when outrageous social behavior can later be attributed to Bipolar Affective Disorder or some other "chemical imbalance."  Despite the persistent stigma of psychiatric diagnosis, these labels have enough psychological and practical advantages that some patients wear them proudly.

The downside to all of this is that individuals can become known, even to themselves, by impersonal diagnostic labels. Knowing oneself as PTSD, ADHD, and/or OCD can dehumanize. It can prematurely close off inquiry and self-reflection. And DSM diagnoses do not actually explain anything; they are better conceptualized as statistical categories.  Such diagnoses are useful tools, but like all tools they can be misused.

Dollars for Docs

speechmaker

I apologize to my loyal readers for not posting in a long while. Fortunately, I was awakened from my torpor by an eye-opening new database that lists some of the money paid to specific doctors by pharmaceutical companies. The Pulitzer Prize winning investigative journalists at ProPublica tapped the public disclosures of seven companies that have begun posting names and compensation on the internet, some as the result of legal settlements. ProPublica's "Dollars for Docs" provides both an overview of the issue, as well as a handy database search function. It is easy to look up specific doctors, or (as I did) to scan through a whole city or town to see who received money from these seven companies in the past two years. Some caveats are important. First, the seven companies represent just over a third of all pharmaceutical sales in the U.S. The health care reform law, signed in March, mandates that all drug companies report such data to the federal government beginning in 2013. That information will be posted on a government website.  So, this is a preview of the data to come. Research funding is not included here, only speaking, consulting, and related activities. It is also important to keep in mind that listed payments are not automatically unethical or illegitimate. For example, honest consulting relationships between doctors and drug companies reasonably include travel expenses and a consulting fee.

Nonetheless, most of the listed activity is pretty suspect. I first learned about "Dollars for Docs" from Dan Carlat's blog. As Carlat points out: "The vast majority of payments are for doctors who give 'educational' talks to other doctors, presumably focusing on one of the drugs made by the funding company." And as he notes, the sheer enormity of the database is probably its most striking aspect — published surveys show that well over 100,000 doctors receive cash from drug companies. Most of the amounts in the database are small, up to a few thousand dollars, not much compared to the income of most doctors. But some are considerably higher. My eye-opening experience was to scan the list of San Francisco doctors, where I found a few colleagues I know who added tens of thousands to their income in 2009 and 2010 speaking for drug companies. It makes me think differently about those doctors — which is the point, right?

Supporters of the status quo argue that there are many other potential conflicts of interest, and that not all recipients of industry money are necessarily biased. Both of these points are true, but irrelevant. Money is universally recognized as motivating; that's why people are paid to work. A universally recognized motivation, voluntarily chosen and standing here in plausible conflict with unbiased patient care, should be unacceptable from the perspective of medical ethics. Medical ethics does not stop with financial conflicts of interest. Physicians are prohibited from sexual relations with patients for similar reasons: A sexual motivation is very likely (although not absolutely guaranteed) to conflict with clinical care. Other systematic sources of bias will be addressed when they can be identified and controlled. The fact that we can't minimize all sources of bias is not a compelling reason to ignore obvious financial ones.

When comprehensive numbers are available online in 2013, we will finally have meaningful disclosure about this potential conflict of interest. What we as a profession, or as the public, do with these disclosures is another matter. As I've noted before, the public seems more concerned than the medical profession itself about industry-fueled bias. To that end, patients may begin to use such public databases as a means to choose doctors.  The website of the newly formed Association for Medical Ethics features a searchable database similar to "Dollars for Docs" but with a more explicit message: that accepting industry support is unethical in clinical practice. If this idea catches on — and I suspect it will, at least in some areas — speaking and consulting fees will not be the only financial motivation at play here.

If I accused you of being a Martian...

spiderhand

Cross-posted from "Sacramento Street Psychiatry". In dynamic psychotherapy, patients often say how hurt and victimized they feel as a result of unkind judgments or criticisms by others:

"My coworker called me a hypocrite!"

"My mother told me I neglect her by not visiting enough."

"My husband complains I'm too self-centered."

Although sharing such complaints with a caring listener is basic human nature, in therapy it is also recognized as a defense mechanism called externalization. A fundamental tenet of psychotherapy is that change comes from within. The hurtful coworker, mother, or husband is not present in the room, and cannot be influenced directly by the discussion. It is the patient's reaction that can be examined and perhaps modified.

I tend gently to move things along in therapy, as opposed to letting them unfold at their own pace. I often question this in myself, sometimes wondering if I am too results-oriented. On balance, though, I believe it saves time, money, and tedium for both of us if I focus on issues that can actually make a difference. With this in mind, I don't let externalizations just sit there. I playfully illustrate how harsh judgments only sting if the patient accepts or endorses them at some level: the hurt is really self-criticism, and the solution is really a new self-appraisal.

If I accuse you of being a dirty rotten Martian, it isn't apt to have much impact. You may question my sanity, but you are not put on the defensive or moved to offer a spirited rebuttal. Nor do you engage in sober soul-searching to assure yourself I'm mistaken. You already know you are not a Martian, so the putdown rolls off your back.

In contrast, what if I accuse you of being selfish? This charge is harder to dismiss. We are all selfish to some degree; it's a judgment call where to draw the line between self-interest on the one hand and self-sacrifice on the other. Moreover, as Sigmund Freud describes in Civilization and its Discontents, humans are able to live together in society because we repress many self-gratifying urges into the unconscious. We are, in other words, more selfish (and narcissistic, and greedy, and hypocritical, and childish...) than we like to think.

The criticisms that sting are the ones that stir up our own self-doubts. Maybe we are hypocritical, neglectful, self-centered. Perhaps our shameful defect has been exposed. This is what calls up anxiety, reactive anger, and defensiveness.

Such self-criticism is unpleasant when made conscious in therapy. Yet this is the path toward change. For the problem is not in the external world after all. It resides in the mind of the person in the therapy room, a person who now more clearly sees where his or her troubling feelings originate.

I really do use the Martian example all the time in my work with patients. It's a thing of joy to watch how something so apparently frivolous can shift the focus from unhelpful externalization to honest insight.