Bernards Voices

The first 15 minutes of Slate’s December 8 Cultural Gabfest podcast are devoted to the recent spate of articles on narcissism and the DSM-V restructuring, perhaps, the way it defines personality disorders.  Stephen Metcalf makes the often ignored point, that the obsessive need for validation from others which is characteristic of a narcissist, is rooted in a vacuous sense of one’s self.

Now I have to add another book to my long to-be-read list: Christopher Lasch’s sociological best-seller The Culture of Narcissism.

Caveat: the discussion turns a bit blue in the last minute or so.  

Let’s start with the experts at wikipedia:

Diagnostic criteria (DSM-IV):  The essential feature of Narcissistic Personality Disorder is a pervasive pattern of grandiosity (either in fantasy or actual behavior), need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of situations and environments.
In order for a person to be diagnosed with narcissistic personality disorder (NPD) they must meet five or more of the following symptoms:

Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).

Rarely acknowledges mistakes and/or imperfections

Requires excessive admiration

Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

Lacks empathy: is unwilling or unable to recognize or identify with the feelings and needs of others.

Is often envious of others or believes that others are envious of him or her

Shows arrogant, haughty behaviors or attitude.

Now the greek bit:

He was exceptionally proud, in that he disdained those who loved him.  As divine punishment Narcissus fell in love with his own reflection in a pool, not realizing it was merely an image, and he wasted away to death, not being able to leave the beauty of his own reflection.

I guess it is not at all reassuring to women that “most [narcissists] are men.” Charles Zonor, in the November 29, 2010 New York Times reports that the new, draft DSM-V is eliminating the Narcissistic Personality Disorder. That, then, must be reassuring.

Jonathan Shedler, a psychologist at the University of Colorado Medical School, said: “Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there’s just a huge schism.” He said the committee was stacked “with a lot of academic researchers who really don’t do a lot of clinical work. We’re seeing yet another manifestation of what’s called in psychology the science-practice schism.”

Clinicians know it when they see it.

Today’s letters to the editor in the New York Times on grief are informative.

Gordon Livingston writes:

To set two weeks as the time allocated to mourning the loss of a loved one before receiving a diagnosis of major depression — as proposed in the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — is ridiculous.

This is illustrative of one type of reaction. But it misses the point. Sadness isn’t depression. Loneliness isn’t depression. Mourning and major depression do not mean the same thing. Conflating the 2, by either side of this argument, is a disservice. Depression, that persists two weeks, diagnosed by a psychiatrist or psychologist, a trained professional, should be treated.

In the original op-ed piece, “Good Grief,” Allen Francis (Francis was chairman of the DSM-IV taskforce.) writes:

Grievers with severe and potentially dangerous symptoms–for example, delusional guilt over things done to or not done for the deceased, suicidal desires to join the lost loved one, morbid preoccupation with worthlessness, restless agitation, drastic weight loss or a complete inability to function. But people with such symptoms are rare, and their condition can be diagnosed using the criteria for major depression provided in the current manual, the D.S.M. IV.

I have sympathy with that point of view–just use major depression as the diagnosis–but I don’t support the earlier parts of his op-ed designed to inflame the debate.

Below is also a common argument for inclusion in the DSM–health insurance, then, has a mechanism to help offset the expense. This is valuable. Elena Lister writes:

It is precisely because of my respect for the necessity of the grieving process that I can support its recognition in the diagnostic manual. The only way that many patients can afford therapy is with insurance — which covers only certain mental health diagnoses, and even then in very limited ways.

This debate is being waged by well-meaning people. And if words like “ridiculous” were left out … it might serve an additional useful purpose of raising awareness.

I’ve posted on the DSM5 debate before. You can access these posts by cliking on DSM5 in the right sidebar under Tags. I really like the (yes it lasts 1 hour) This American Life podcast on the DSM referenced towards the end of this post.

From the June 28, The New York Times, Seeking to pre-empt marital strife.

One federally financed study is tracking 217 couples taking part in an annual “marriage checkup” that essentially offers preventive care, like an annual physical or a dental exam.

“You don’t wait to see the dentist until something hurts — you go for checkups on a regular basis,” said James V. Córdova, an associate professor of psychology at Clark University in Worcester, Mass., who wrote “The Marriage Checkup” (Jason Aronson, 2009). “That’s the model we’re testing. If people were to bring their marriages in for a checkup on an annual basis, would that provide the same sort of benefit that a physical health checkup would provide?”

From the June 29, Wall Street Journal, Worried About a Moody Team?

Warning signs:

Dr. Diamond says sulks or doldrums that persist for two or more weeks could be a sign of depression and should be taken seriously.

Parents should pay attention to how a teen is functioning in school, sports, favorite activities, a job and with friends.

This article recommends consulting first with the teen’s pediatrician, someone who already has a relationship with the family. (Perhaps killing 2 birds with one stone: your insurance provider may require a referral to a psychiatrist anyway.)

From the July 1, USA Today, Of Medical Specialties, demand for Psychiatrist is Highest.

From April 2009 to March 2010, the company Merritt Hawkins received 179 requests for psychiatrists — a 47% increase from the previous year and 121% increase from the 2006-2007 survey.

The firm, which tracked more than 2,800 physician requests, found that psychiatrists were the third-most-requested physician.

Though demand is growing, fewer medical students are entering careers in psychiatry. Health officials say the field garners little interest because psychiatrists earn less than other specialties, even though they spend the same amount of time in medical training.

Thanks to Lauren for finding these articles.

From The Lancet Mental Health Themed Issue, August 22, 2009:

David Kessler and colleagues evaluate the acceptability and clinical effectiveness of an internet-based psychotherapy programme for depression. Nearly two-thirds of those offered the programme completed five or more therapy sessions, a substantially higher rate than we would expect with in-person therapy. Clinical benefits were larger than generally seen with computerised self-help programmes, and similar to those with traditional in-person psychotherapy.

Listen to the podcast (interview starts at 1:20):

The researcher was asked why they didn’t use video/voice in the internet-delivered therapy and relied on text. He posed a very interesting question in response: what about writing made it so effective? Writing requires pausing/reflection/editing which is different than talking. There is also evidence that writing, as a therapy, helps recovery from trauma. And finally, these questions of “eye contact” and “body language / mood congruency” and “anonymity” … have not been adequately tested yet to demonstrate that a therapist and patient, face to face, is necessarily the best setting for all people, for all therapies.

As discussed in other blogs, the DSM-5 is under review and generates a lot of controversy. This American Life does a great job, using the example of homosexuality, to show how and why definitions of mental disorders change over time. Reflecting not just changes in scientific understanding, but also social, political, and personal pressure. That those pressures exist, and have impact, doesn’t invalidate the DSM.

January 18, 2002 podcast of This American Life. Listen here.

In 1973, the American Psychiatric Association (APA) declared that homosexuality was not a disease simply by changing the 81-word definition of sexual deviance in its own reference manual. It was a change that attracted a lot of attention at the time, but the story of what led up to that change is one that we hear today, from reporter Alix Spiegel. Part one of Alix’s story details the activities of a closeted group of gay psychiatrists within the APA who met in secret and called themselves the GAYPA … and another, even more secret group of gay psychiatrists among the political echelons of the APA. Alix’s own grandfather was among these psychiatrists, and the president-elect of the APA at the time of the change. Alix Spiegel’s story continues, with a man dressed in a Nixon mask called Dr. Anonymous, and a pivotal encounter in a Hawaiian bar.

The 1968 definition at the time was a step forward, defining homosexuality as a disease instead of a moral decision.

The new 1973 definition:

302.0 Sexual orientation disturbance (Homosexuality)
This category is for individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation. This diagnostic category is distinguished from homosexuality, which by itself does not constitute a psychiatric disorder. Homosexuality per se is one form of sexual behavior and, like other forms of sexual behavior which are not by themselves psychiatric disorders, is not listed in this nomenclature of mental disorders.

If the patient had subjective distress it was a disorder. If it didn’t bother you, you weren’t sick.

The current DSM deletes the definition; it is not a disorder. It is now ethically wrong for psychiatrists or psychologists to treat it as such.

Carmine Deo and Susan Visser, from Community Hope and members of the Healthy Outcomes Partnership, provided this presentation late this morning. It is entitled The Broad Spectrum of Mental Illness and Its Treatment.  We were in the intimate setting of the Blue House and had a quite energetic discussion.

We talked about frequency of mental illness in society. One statistic is a useful starting point for the discussion. 1 in 4 people annually will have a mental health “problem.” 14% of those with a “problem” will be diagnosed, by doctors and therapists (professionals, credentialed, certified) in accordance with the DSM methodology, as having a moderate to severe mental illness.

We in HOP want to raise community awareness and reduce stigma. We want to make that first call for help as easy as possible.

And it is an interesting question whether having more people labelled mentally ill increases the stigma or having more people labelled that way reduces the stigma. The argument for the former is that with narrow, clear definitions of illnesses adjudicated by doctors and therapists, the stigma is reduced because the public at large is reassured that not every case of sadness or loneliness or rage is an illness. But the flip side is that the more common the illness, and the more likely each 1 of us, individually, will have a need during our lifetime to see a therapist, the less scary and more normal the illness becomes.

This is a question of semantics. And a lot of it has to do with these words “illness” and “disease.” The presentation starts by defining those terms and others, starting with “health.”

We didn’t come to a resolution.  But I would like to say that these definitions are not near as cavalier as they are often portrayed in the public by the media.  And this stuff is very, very complicated stuff.  Our brains complex.  Not well understood.  The definitions evolve, and science improves.  But this is not casual stuff.

What services does Community Hope provide?

The support services provided by our professionally trained and dedicated staff are essential for continued recovery and a successful reintegration to family and community life.

Their programs “offer as much or as little support as an individual requires.”

Daily Living Assistance — Counselors teach the daily living and social skills essential to living with a home and a community.

Case Management — Linkage to behavioral health and medical care and community based services ensures a continuum of care and quality support.

Medication Monitoring — For most of our residents, medication is crucial to recovery and daily functioning.  Staff monitor medications, educate residents about the need for prescribed drugs and coordinate medical appointments.

Crisis Intervention — In the event of a relapse, our crisis intervention team helps the individual minimize or avert hospitalization

This is a very good podcast from January of Brian Lehrer interviewing Dr. Jonathan Metzl, associate professor of psychiatry and women’s studies and director of the Culture, Health, and Medicine Program at University of Michigan. They talk about his new book, The Protest Psychosis: How Schizophrenia Became a Black Disease which provides a cautionary tale of how anxieties about race continue to influence doctor-patient interactions.

I shy away from the whole topic of schizophrenia. I don’t know why, except that it has to do with all the noise and alarmist information on the disease, but also, to be blunt, how that noise has created a stigma about it in my own eyes.

In this cautionary tale, the cultural biases that not only invaded an individual therapist’s diagnosis, but also underpinned the “scientific” conventional wisdom of the mental health industry, was staggering. I wonder what biases exist, and we live with, today.

As a practicing psychiatrist, Metzl points out all the work he must do when a patient walks into his office to overcome the resistance or antagonism the patient may have with the field of psychiatry, and create for the patient an environment of trust and respect.

I finally got around to reading Louis Menand’s article on psychiatry in the March 1, 2010, The New Yorker. The article covers the same ground, though much more comprehensibly, that many of my recent posts (also Jan. 13, Jan. 6 ) have–kicking off with a review of Gary Greenberg’s Manufacturing Depression (2010).  It is a worthwhile read.  Menand asks all the questions we’ve been asking, and if he leaves us with any point of view it is that “science will never answer them.”

Do not read the psychiatric literature. Everything in it, from the science (do the meds really work?) to the metaphysics (is depression really a disease?), will confuse you. There is little agreement about what causes depression and no consensus about what cures it. Virtually no scientist subscribes to the man-in-the-waiting-room theory, which is that depression is caused by a lack of serotonin, but many people report that they feel better when they take drugs that affect serotonin and other brain chemicals.

Other books covered in the article:

• Irving Kirsch’s The Emperor’s New Drugs (2010)
• Christopher Lane’s Shyness (2007)
• David Healy’s The Antidepressant Era (1997)
• Andrea Tone’s The Age of Anxiety (2009)
• David Herzberg’s Happy Pills in America (2008)
• Jerome Wakefiled and Allan Horwitz’s The Loss of Sadness (2007)
• Peter Kramer’s Against Depression (2005) and Listening to Prozac (1994)
• and older books from the 50s and 60s.

As I read my way through the article, I found myself often agreeing with the skeptical point of view, but I had to kick myself back awake.  Mental illness is real.  Bad things can happen.  People’s lives get destroyed.  The fact that there is energetic debate within and outside the industry shouldn’t lead people to the conclusion that these diseases are not real and shouldn’t be treated with the best tools available.

As a branch of medicine, depression seems to be a mess. Business, however, is extremely good. Between 1988, the year after Prozac was approved by the F.D.A., and 2000, adult use of antidepressants almost tripled. By 2005, one out of every ten Americans had a prescription for an antidepressant. IMS Health, a company that gathers data on health care, reports that in the United States in 2008 a hundred and sixty-four million prescriptions were written for antidepressants, and sales totalled $9.6 billion.

What a successful [drug trial] typically shows is a small but statistically significant superiority (that is, greater than could be due to chance) of the drug to the placebo.  So how can Kirsch [in The Emperor's New Drugs] that the drugs have zero medicinal value?

His answer is that the statistical edge, when it turns up, is a placebo effect.  Drug trials are double-blind: neither the patients (paid volunteers) nor the doctors (also paid) are told which group is getting the drug and which is getting the placebo.  But antidepressants have side effects, and sugar pills don’t.  Commonly, side effects of antidepressants are tolerable things like nausea, restlessness, dry mouth, and so on.  (Uncommonly, there is, for example, hepatitis; but patients who develop hepatitis don’t complete the trial.)  This means that a patient who experiences minor side effects can conclude that he is taking the drug, and start to feel better, and a patient who doesn’t experience side effects can conclude that she’s taking the placebo, and feel worse.  On Kirsch’s calculation, the placebo effect—you believe that you are taking a pill that will make you feel better; therefore, you feel better—wipes out the statistical difference.

One objection to Kirsch’s argument is that response to antidepressants is extremely variable. It can take several different prescriptions to find a medication that works. Measuring a single antidepressant against a placebo is not a test of the effectiveness of antidepressants as a category. And there is a well-known study, called the Sequenced Treatment Alternatives to Relieve Depression, or STAR*D trial, in which patients were given a series of different antidepressants. Though only thirty-seven per cent recovered on the first drug, another nineteen per cent recovered on the second drug, six per cent on the third, and five per cent after the fourth—a sixty-seven-per-cent effectiveness rate for antidepressant medication, far better than the rate achieved by a placebo.

Kirsch suggests that the result in STAR*D may be one big placebo effect. He cites a 1957 study at the University of Oklahoma in which subjects were given a drug that induced nausea and vomiting, and then another drug, which they were told prevents nausea and vomiting. After the first anti-nausea drug, the subjects were switched to a different anti-nausea drug, then a third, and so on. By the sixth switch, a hundred per cent of the subjects reported that they no longer felt nauseous—even though every one of the anti-nausea drugs was a placebo.

Later studies have shown that patients suffering from depression and anxiety do equally well when treated by psychoanalysts and by behavioral therapists; that there is no difference in effectiveness between C.B.T., which focusses on the way patients reason, and interpersonal therapy, which focusses on their relations with other people; and that patients who are treated by psychotherapists do no better than patients who meet with sympathetic professors with no psychiatric training. Depressed patients in psychotherapy do no better or worse than depressed patients on medication. There is little evidence to support the assumption that supplementing antidepressant medication with talk therapy improves outcomes. What a load of evidence does seem to suggest is that care works for some of the people some of the time, and it doesn’t much matter what sort of care it is. Patients believe that they are being cared for by someone who will make them feel better; therefore, they feel better.

In 1980, the F.D.A. required that anxiety medications carry a warning stating that “anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic.” The anxiety era was over. This is one of the reasons that when the SSRIs, such as Prozac, came on the market they were promoted as antidepressants—even though they are commonly prescribed for anxiety. Anxiety drugs had acquired a bad name.

The position behind much of the skepticism about the state of psychiatry is that it’s not really science. “Cultural, political, and economic factors, not scientific progress, underlie the triumph of diagnostic psychiatry and the current ‘scientific’ classification of mental illness entities,” Horwitz complained in an earlier book, Creating Mental Illness (2002), and many people echo his charge. But is this in fact the problem? The critics who say that psychiatry is not really science are not anti-science themselves. On the contrary: they hold an exaggerated view of what science, certainly medical science, and especially the science of mental health, can be.

Progress in medical science is made by lurching around. The best that can be hoped is that we are lurching in an over-all good direction.

The DSM lists only disorders—clusters of symptoms, drawn from clinical experience—not diseases. Since people manifest symptoms in an enormous variety of combinations, we get a large number of disorders for what may be a single disease.

Depression is a good example of the problem this makes.  A fever is not a disease; it’s a symptom of disease, and the disease, not the symptom, is what medicine seeks to cure.  Is depression—insomnia, irritability, lack of energy, loss of libido, and so on—like a fever or like a disease?  Do patients complain of these symptoms because they have contracted the neurological equivalent of an infection?  Or do the accompanying mental states (thoughts that my existence is pointless, nobody loves me, etc.) have real meaning?  If people feel depressed because they have a disease in their brains, then there is no reason to pay much attention to their tales of woe, and medication is the most sensible way to cure them.  Peter Kramer, in Against Depression (2005), describes a patient who, after she recovered from depression, accused him of taking what she had said in therapy too seriously.  It was the depression talking, she told him, not her.

Depression often remits spontaneously, perhaps in as many as fifty per cent of cases; but that doesn’t mean that there isn’t something wrong in the brain of depressed people.

Depression is episodic. It starts and stops. Then starts again. Kramer argues that is progressive, and episodes worsen (deepen) over time.

In the case of mood disorders, it is difficult to find a test to distinguish mental illness from normal mood changes. The brains of people who are suffering from mild depression look the same on a scan as the brains of people whose football team has just lost the Super Bowl.

Given the current scanning technology, and where and how we choose to look.

Science, particularly medical science, is not a skyscraper made of Lucite. It is a field strewn with black boxes. There have been many medical treatments that worked even though, for a long time, we didn’t know why they worked—aspirin, for example. And drugs have often been used to carve out diseases. Malaria was “discovered” when it was learned that it responded to quinine. Someone was listening to quinine. As Nicholas Christakis, a medical sociologist, has pointed out, many commonly used remedies, such as Viagra, work less than half the time, and there are conditions, such as cardiovascular disease, that respond to placebos for which we would never contemplate not using medication, even though it proves only marginally more effective in trials. Some patients with Parkinson’s respond to sham surgery. The ostensibly shaky track record of antidepressants does not place them outside the pharmacological pale.

At the bottom of column 15, in a 18 column article, we have arrived at the most important part of the article for me. I hope everyone reads this far.

Many people today are infatuated with the biological determinants of things. They find compelling the idea that moods, tastes, preferences, and behaviors can be explained by genes, or by natural selection, or by brain amines (even though these explanations are almost always circular: if we do x, it must be because we have been selected to do x). People like to be able to say, I’m just an organism, and my depression is just a chemical thing, so, of the three ways of considering my condition, I choose the biological. People do say this. The question to ask them is, Who is the “I” that is making this choice? Is that your biology talking, too?

Yes, your biology, and your psychology, and your philosophy talking.

The decision to handle mental conditions biologically is as moral a decision as any other.

The recommendation from people who have written about their own depression is, overwhelmingly, Take the meds! It’s the position of Andrew Solomon, in The Noonday Demon (2001), a wise and humane book. It’s the position of many of the contributors to Unholy Ghost (2001) and Poets on Prozac (2008), anthologies of essays by writers about depression. The ones who took medication say that they write much better than they did when they were depressed. William Styron, in his widely read memoir Darkness Visible (1990), says that his experience in talk therapy was a damaging waste of time, and that he wishes he had gone straight to the hospital when his depression became severe.

Don’t hesitate to ask someone for help.

Jane Brody reports today on body dysmorphic disorder.

A pioneering researcher, Dr. Jamie D. Feusner, and his colleagues at the David Geffen School of Medicine at the University of California, Los Angeles, recently found patterns of brain activity in people with B.D.D. that appeared to differ from those of others. The differences showed up in areas involved in visual processing. The more severe the symptoms, the more the person’s brain activity on imaging scans differed, on average, from normal levels, the researchers reported in the February issue of The Archives of General Psychiatry.

Winona Ryder, in Girl Interrupted, says “Crazy isn’t about being broken, or swallowing a dark secret. It’s you, or me, amplified…”  This is one of the difficult things about mental illness.  Symptoms range across of a broad continuum from mild to extreme, and it is easy to read an article like this and dismiss it by thinking everyone does that, or everyone feels this way.

In an interview, Dr. Phillips described how crippling the disorder can become for those who spend hours in front of a mirror trying to “fix” their “ugly hair” or disguise a facial blemish only they can see.

But when you re-check and re-lock your front door ten times on your way out of your house, or when your depression persists for two weeks, or when, as in this example, you spend hours in front of a mirror looking at your face, then the behavior is impacting your day to to day life and you should consider asking for help.  Crazy is about more … compulsion, rumination, obsession … “it’s you, or  me, amplified.”

Also today, Dr. Richard Friedman, muses on self-defeating behavior.

What was striking about this intelligent and articulate young man was his view that he was a hapless victim of bad luck, in the guise of unfaithful women and a capricious boss; there was no sense that he might have had a hand in his own misfortune.

I decided to push him. “Do you ever wonder why so many disappointing things happen to you?” I asked. “Is it just chance, or might you have something to do with it?”

His reply was a resentful question: “You think it’s all my fault, don’t you?”

Now I got it. He was about to turn our first meeting into yet another encounter in which he was mistreated. It seemed he rarely missed an opportunity to feel wronged.

Perhaps there is a hidden psychological reward.

The American Psychiatric Association found itself in this position when it included a category for self-defeating patients in an earlier version of its Diagnostic and Statistical Manual of Mental Disorders.

Partly in response to social and political pressure, the notion of masochistic character has disappeared from the manual altogether, even though the behavior is a source of considerable suffering and a legitimate target for treatment.

Stanton Peele, psychologist, addiction expert, and blogger for Psychology Today, discusses the proposed changes to The Diagnostic and Statistical Manual of Mental Disorders.

It was unfortunate that Jami Floyd, substituting for Brian Lehrer, started the conversation with a Tiger Woods sex addiction comment. But if you listen until the end, there is some good, but scattered, discussion on dimensional assessment–a scale of severity–being added in DSM-5.   For example, in the past alcohol abuse was a yes/no diagnosis: either you were an alcoholic or not.  With a graduated scale, the doctor can better characterize how alcohol abuse disrupts a patient’s life without being diagnosed as an alcoholic.

Dr. Peele concludes by emphasizing the point that disorders are only disorders if they disorder your life. And then he calls Floyd on her trivializing the word “addiction” during her wrap-up. That was probably lost on many listeners.

On February 10, 2010, Benedict Carey wrote in The New York Times, that the news DSM-5 has been posted on DSM5.org, and is open for public review and comment.

The DSM-5, or the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders, is due out May 2013.  It will be published by the American Psychiatric Association.

There is a lot of “inside baseball” noise in the DSM-5 debate–between experts in the fields of psychiatry, psychology and neurology.  I’m wary, though, of how the popular press reports on it.  It is important, extremely important, but could be often misunderstood.

Important things to focus on when following this debate:

• is there rigorous scientific evidence underpinning the classification?
• does the revised classification reduce or increase the stigma associated with mental illness?
• are patients, currently treated, spared the confusion of a changed diagnosis
• and ultimately, does the DSM-5 become a useful tool in diagnosing, treating, and thus reducing patient’s suffering