On responsibility

I'll leave the "sloppy thinking" series for now, although I expect to return to it in the future.  In this post I'll share some thoughts about personal responsibility, especially as it pertains to the insanity defense.  It's a topic much in the news lately, due to tragic actions by now-household names such as James Eagan Holmes and Jared Loughner.  The matter goes much further though.  We normally assume that adults are responsible for their actions, and that these actions are freely chosen.  The extent to which we treat this as absolute versus a matter of degree determines our fundamental political views, and how we view our neighbors and ourselves. Many facets of everyday life are premised on personal responsibility.  The criminal justice system is the most obvious example.  In a wider sense our willingness to live in community with others depends on each person taking responsibility for his or her behavior.  Nonetheless, we've recognized exceptions to this default assumption for centuries.  Adults who are severely sick or injured may temporarily be unable to assume responsibility for themselves.  Likewise, infants and young children lack the ability to make informed choices and to exercise personal responsibility.  Non-human animals are exempt from personal responsibility and are never considered guilty of a crime — well, not anymore.

English common law recognized that the same lack of responsibility extended to insane adults:

By the 18th century, the British courts had ... developed what became known as the "wild beast" test: If a defendant was so bereft of sanity that he understood the ramifications of his behavior "no more than in an infant, a brute, or a wild beast," he would not be held responsible for his crimes.

The history of the insanity defense then records the trial of Daniel M'Naughten in 1843, where inability to distinguish right from wrong was established as the crucial legal test. This became the standard, both in Britain and the US, for more than 100 years; the "M'Naughten rule" is still the legal standard in many states.  Later modifications tended to liberalize its application, as with the "irresistible impulse" and "diminished capacity" doctrines, until the pendulum swung the other way in the wake of John Hinkley's attempted assassination of President Reagan in 1981.

As a society, we seem to be losing our inclination to forgive the mentally ill, and children, when they commit horrific acts of violence.  Even young teens are now tried as adults when an alleged crime is bad enough.  And although insanity defenses are rare in U.S. courts, and their successful use often results in involuntary hospitalization longer than the prison sentence would otherwise have been, there is nonetheless a popular view that the insane "get away with it."  Jared Loughner recently plea-bargained for life imprisonment despite clear evidence of mental illness and the possibility of an insanity defense.  The court will decide whether James Holmes has severe psychosis, an antisocial personality, or just a very bad attitude.  As in Loughner's case, this determination is unlikely to make a difference in terms of public safety — Holmes won't be freed for decades, if ever.  But the way we handle the question of legal insanity bears on how our society views itself.

Now that we are in a presidential campaign season, we hear rhetoric that cleaves the major parties around the question of personal responsibility.  "You didn't build that," a slightly misspoken point by President Obama about the government's role in promoting business, became a rallying cry for Republicans in defense of the entrepreneur.  Yet both sides have a point:  The government makes and maintains highways (and founded the internet); individuals create trucking companies (and online businesses).  It's really a matter of emphasis, and yet this emphasis is what most of the fighting is about.

Decades ago, social psychologists coined the term "fundamental attribution error" to highlight our tendency to over-apply dispositional or personality explanations to others, in the same circumstances we apply situational explanations to ourselves.  E.g., if others are unemployed we often imagine they are lazy or unqualified (personal factors), whereas if we are unemployed, we often blame a tough economy and a lack of jobs (situational factors).  Of course, some of the unemployed really are lazy or unqualified, just as some killers really have the criminal intent (mens rea) to be convicted of murder.  The question is whether and to what extent we allow for exceptions in cases other than our own.  Denying such exceptions flies in the face of our own legal tradition, our recognition of the fundamental attribution error, and our human kinship — the idea that we humans are more alike than we are different.  We are wise enough not to punish infants or "wild beasts" even if they hurt us; the severity of their behavior and its consequences has no bearing on whether they are personally responsible.  A person who cannot tell right from wrong due to severe psychosis is operating at the same level, and should be treated, not punished.  Personal responsibility is a strong enough concept that it can withstand some nuance and flexibility — especially when that happens to reflect reality.

Psychotherapy as generic conversation — Sloppy thinking in psychiatry 4

This fourth installment in my "sloppy thinking" series turns to psychotherapy, or what passes for it in some psychiatric practices.  A very brief history: Sigmund Freud, a neurologist, invented psychoanalysis and its offshoot, psychodynamic psychotherapy, about 120 years ago.  It was, first and foremost, a treatment that involved talking — not merely a conversation that happened to make the patient feel better.  Years later, the object-relations school of psychoanalysis and the humanistic psychology movement of the 1960s partly shifted the focus of dynamic psychotherapy away from technique and toward a healing relationship, a shift prefigured by pastoral counseling and by the ministrations of the nursing profession.  Nonetheless, dynamic psychotherapy remained a treatment: a professional service with clear goals and a coherent rationale, aimed to remedy defined psychological conflicts or deficits.  Meanwhile, over the same century or so, academic psychologists developed the theories and practices of behaviorism via experiments with animals, and later applied behavior modification and various behavioral and cognitive therapies to human suffering.  While such treatments could be offered in a humane and caring manner, the relationship itself was not considered curative. Psychoanalysis and psychodynamic therapy originated in a medical context, and psychiatrists historically have been trained in its theory and practice.  (In contrast, psychologists historically tended to practice the empirically based behavioral and cognitive therapies developed in academia, although this distinction between the disciplines has faded.)  Prior to the advent of psychoanalysis, psychiatry was a medical specialty focused on the management of severe mental illnesses that rendered sufferers incapable of living in mainstream society.  But by the mid-20th century, the field had adopted the new "talking cures" to treat higher functioning patients.  For a few decades, roughly 1950 to 1980, the popular image of the psychiatrist was a psychoanalyst with the trademark couch in the office.

The emphasis in psychiatric training and practice shifted dramatically away from psychotherapy and toward medication treatments in the 1980s as a result of several factors.  Promising classes of medications such as SSRI antidepressants and atypical neuroleptics were developed; federal research funding shifted toward biological psychiatry; psychiatry's new diagnostic manual (DSM-III) encouraged medical-model thinking; managed care tightened the screws on reimbursement; and competition from non-physician mental health professionals heated up.  Psychopharmacology became a defensible niche for psychiatry, unlike psychotherapy which saw increasing competition from psychologists, social workers, marital and family therapists, and others.

Currently, many American psychiatry residencies offer minimal training in psychodynamics, or psychotherapy in general (interesting debate here).  I consider this very unfortunate.  Psychodynamically informed treatment is far richer and more sensitive — ultimately, I have to believe, more effective — even if psychodynamic psychotherapy itself is not offered.  For example, unconscious dynamics can help explain medication non-compliance, and can shed light on difficult psychiatric consultations on medical or surgical inpatients.  It's hard to deny that a mental health professional with a deeper appreciation of human emotions, conflicts, and psychological defenses has an advantage over the same professional without this appreciation.

Where's the sloppy thinking?  It results from the inescapable fact that most psychiatric patients harbor thoughts and/or feelings they want to talk about.  A psychiatrist who avoids all such conversation feels like an "ape with a bone," a medication technician who does his own little piece of work well, but misses the big picture.  So the psychiatrist talks with the patient for 30, 45, or 50 minutes, which makes both the psychiatrist and patient feel better in the moment.  It is billed as psychotherapy, but is it?

That depends on what happens in those 30, 45, or 50 minutes.  Is it well-conducted cognitive-behavioral therapy?  Hardly ever.  Nor is it psychodynamic psychotherapy if it's no more than a conversation that temporarily makes the patient feel better.  Dynamic psychotherapy is a structured treatment that includes a dynamic case formulation, a coherent rationale, strategic interventions, and treatment goals — features uniformly absent in this typical scenario.  Some call these unstructured conversations "supportive psychotherapy," but even that has a technical definition and clear goals.  Supportive psychotherapy is more than letting the patient "vent," or chat as though it were a social visit.  Perhaps all this mislabeling is an unfortunate mistake by well-meaning practitioners who were never trained to perform or recognize actual psychotherapy.  Or maybe it's intellectual laziness.  Or insurance fraud.

An honest profession would call such encounters what they are: Humane medication visits.  Stripped of the pretense of psychotherapy, we might admit that it often takes more than ten or 15 minutes to find out how a patient is doing, and that conversely it doesn't require aimless (yet remunerated) chatting for the better part of an hour either.  By clearly differentiating psychotherapy from generic doctor-patient conversation, we'd regain respect from other mental health professionals who have come to believe that psychiatrists don't take psychotherapy seriously, or that we pompously claim we know what we're doing when we don't.  These criticisms really boil down to irritation at psychiatry's sloppy thinking about psychotherapy, a tragic irony considering the field's long history with this treatment modality.

You guessed it: photo courtesy of Petr Kratochvil.

Psychiatry as behavioral neuroscience — Sloppy thinking in psychiatry 3

This third installment in my series on sloppy thinking in psychiatry addresses something a little more subtle than "chemical imbalance" or polypharmacy.  It is the growing vision, well represented by this recent editorial in Current Psychiatry, that the only salvation for the field lies in embracing the language and practice of neuroscience.  With "chemical imbalance" discredited, attention has turned to functional brain imaging and genetics as our last and best hope to retain a shred of dignity as a medical specialty.  Dr. Nasrallah's editorial goes further than most, arguing that we need a new name for psychiatry:  Psyche is an "archaic concept" that "has outlived its usefulness and needs to be shed."  Likewise, our "brilliant future anchored in cutting-edge neuroscience" will be hastened by renaming the major mental illnesses, calling psychotherapy “verbal neurotherapy," and by embracing the language of "brain repair."  But it's not all a matter of terminology: "The disastrously dysfunctional public mental health bureaucracy must be abandoned and transformed into 'brain institutes,' in all states, similar to cancer centers or cardiovascular institutes, where state-of-the-art clinical care, training, and research are integrated." I share the sentiment, really I do.  Wouldn't it be great to see shiny Brain Institutes cropping up all over, replacing those sad, underfunded public mental health clinics?  Wouldn't we hold our heads higher if our business cards promised "verbal neurotherapy" and "brain repair"?  We could call ourselves medical doctors without a hint of doubt or insecurity, sit proudly at the hospital cafeteria table  with the other doctors — you know, the surgeons and cardiologists and such — and charge higher fees as a premier medical specialty instead of our current status as mental health "primary care."  There's a lot to recommend this vision; where do I sign up?

Unfortunately, there is nowhere to sign up.  This is a pipe dream.  Psychiatry isn't clinging to archaic language about the psyche out of nostalgia.  It's the best we have.  "Verbal neurotherapy," while technically a valid description of psychotherapy, is absurd hand-waving.  By the same token, taking a vacation is "locational neurotherapy."  We aren't going to gain anyone's respect by dressing up our current practices in pseudoscientific jargon.

Nor are we withholding "behavioral neuroscience" from our patients now.  In addition to the verbal neurotherapy, i.e., psychotherapy, that forms the mainstay of my practice, I also offer pharmaceutical neurotherapy, advice regarding nutritional and exercise neurotherapies, discussion of various occupational and relational neurotherapies — I even suggest an occasional locational neurotherapy.  I simply lack the hubris, or perhaps it's the marketing genius, to call it that.

When scientists develop safe, effective psychiatric treatments based on neuroplasticity and neuroprotection I'll happily offer them to patients (or refer patients to centers where such treatments are available).  When my Election Day ballot includes a measure to upgrade public mental health facilities to state-of-the-art Brain Institutes, you can count on my vote.  I'm not holding my breath.

Kidding aside, there is nothing sloppy or ill-advised about incorporating neuroscience into psychiatry.  Nor is it a new idea.  From prehistoric trepanning to Freud's 1895 "Project for a Scientific Psychology" (pdf of a 2004 review), from the introduction of neuroleptics in the 1950s (modern commentary here) to the "decade of the brain" in the 1990s, psychiatry has nearly always paid homage to the neural underpinnings of behavior.  The only obvious exception was the heyday of psychoanalysis, from about 1950 to 1980.  Otherwise, we use the best neuroscience we have at the time.  The real problem, of course, is that we ask more of our neuroscience than it can deliver.  Trepanning probably didn't help, Freud abandoned his "project," neuroleptics caused major side-effects and failed to allow patients to return to the community, and the "decade of the brain" turned many psychiatrists into drug-doling technicians.  Science keeps improving, and I'm sure we'll see good things emerge in the coming years.  However, progress will occur at its own pace, and no amount of wishing or envisioning will make it happen any faster.

It is sloppy thinking to imagine that behavioral neuroscience is something new and revolutionary.  The real revolution in psychiatry, if it ever happens, will be the integration of careful neuroscience, psychology, sociology, and other disciplines to elucidate and benefit our lived experience.  This integration will incorporate, not supplant, our higher level understandings of psychology and psychodynamics.  When psychiatry is ripe for the "creative destruction" of polarized thinking and choosing sides, it will be stronger than the sum of its parts, and will have finally reinvented itself  into something we can unequivocally be proud of.

And yet again, photo courtesy of Petr Kratochvil.

Polypharmacy — Sloppy thinking in psychiatry 2

My second post in this series on sloppy thinking in psychiatry is devoted to polypharmacy, the medical term for prescribing multiple medications at once, especially for the same problem.  Polypharmacy is at best a risk thoughtfully taken because nothing simpler and safer will do.  At worst it's a dangerous error, exposing patients to unnecessary hazards purely as a result of laziness and sloppy thinking by their doctors.  Unfortunately, the latter is all too common in psychiatry.  Let's look at why. It has been said that the less we know about an illness, the more treatments we have for it.  Instead of one definitive cure that attacks the root of the problem, various remedies ease symptoms — not the cause — often via different mechanisms.  A good example of a definitive cure is a specific antibiotic to treat a bladder infection.  We know how bacterial infections work, and we have antibiotics to attack the root of the problem.  Ancillary treatments for fever or pain are sometimes used, but they are clearly secondary, and often optional.  In contrast, the pathogenesis of psychiatric disorders is not known, thus we have no treatments to attack the roots of these problems.  For example, antidepressants affect neurotransmitters that appear implicated in depression, but the exact way these neurotransmitters relate to the syndrome of depression is unknown.  Thanks to our ignorance, we have medications that affect serotonin, and others that affect norepinephrine and/or dopamine.  In recent years atypical neuroleptics (antipsychotics) have been approved as add-ons for treating depression, a worrisome development given their risks.

Since we don't have a definitive cure for depression, many patients report partial (or minimal) improvement from any one medication.  The prescriber may then add another on the theory that it may help via a different chemical mechanism — a theory that is difficult to confirm or refute, as we don't know the mechanism in the first place.  The original medication is not stopped: If the patient improves, why disrupt a winning combination?  And if the patient doesn't improve, we wouldn't want to withhold an antidepressant from a depressed person, would we?  Sloppy thinking all around, yet sadly common.

Similar arguments can be made for the treatment of bipolar disorder and schizophrenia.  Lacking a true understanding of pathogenesis, we treat empirically.  And empiric treatment, while often compassionate and necessary and helpful, invites the shaky logic of adding more medications hoping for more empiric benefit.

Compounding and worsening this situation is psychiatry's abandonment of parsimony in diagnosis and clinical assessment over the past 30 years.  Prior to the publication of DSM-III in 1980, psychiatric evaluation was an attempt to explain a patient's seemingly unrelated complaints using a single theory (often psychoanalytic, but possibly biological or even behavioral).  The introduction of phenomenological diagnosis in DSM-III encouraged multiple diagnoses in the same patient, say Major Depression and PTSD on Axis I, and a personality disorder on Axis II.  There was no longer any attempt to tie it all together.  This has encouraged a piecemeal approach to treatment: a medication for depression, a different one for PTSD, maybe something for sleep, and something else again for agitation due to the personality disorder.  That's four different psychiatric medications already, and we've hardly even started.  Patients with personality disorders often complain of "mood swings," so let's add a mood stabilizer like lithium or Depakote.  And they're anxious, so we could add a benzodiazepine tranquilizer like Ativan, or a beta-blocker like propranolol, or an atypical neuroleptic.  Or what the hell, all three!  We're up to seven or eight medications now, and we haven't even considered a stimulant for their ADHD — because, after all, the patient is having trouble concentrating... funny how it was never diagnosed before.  And we haven't augmented the antidepressant with thyroid supplementation, nor have we added a second antidepressant...

While 10+ psychiatric medications is clearly over top, I've evaluated a number of patients who arrive on six, often an (1) antidepressant, (2) mood stabilizer, (3) tranquilizer, (4) sleep aid, (5) stimulant, and (6) another antidepressant or mood stabilizer.  Almost without exception, I've been able to cut this list in half, and in some cases down to zero, or more often, one medication.  It's less a matter of expert medication choice, and more an aversion to sloppy thinking.  According to one study, antipsychotic polypharmacy can be simplified without harm 2/3 of the time.

Psychiatric polypharmacy is often intellectually lazy.  Needless to say, there are far more drug combinations than there are studies assessing the risks and benefits of these combinations.  Polypharmacy is nearly always an educated guess, not "evidence based medicine."  It's not even good single-case research, where one would ideally change a single variable at a time.  All too often, medications are added to treat the side-effects of other medications, as with "ADHD" in the case above, a tail-chasing exercise that only gets worse over time.  With every added medication there are added side-effects, and sometimes adverse interactions that can be more harmful than the original problem.  In my experience, generic side-effects such as weight gain and cloudy thinking are more the rule than the exception in patients taking multiple psychiatric medications.  It should happen a lot less than it does.

Once again, photo courtesy of Petr Kratochvil.

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.