Wednesday, July 30, 2014

The Weariness of the Self

The Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age
Alain Ehrenberg
(McGill-Queens University Press, 2009)

It appears that we live in the midst of an epidemic of an illness that we call Depression. Looking back to my training as a psychiatrist in the early 1970s, the diagnosis of Depression was usually limited to states that were so disabling that a person could not work, was at risk of suicide, often needed hospitalization and was usually treated with tricyclic antidepressants or ECT. There was a diagnosis of Neurotic Depression that was milder and was always treated with psychotherapy. Our current epidemic is usually explained by two factors: first, the Diagnostic and Statistical Manual of 1980 which eliminated Neurotic Depression and created a vaguely defined category called Major Depression and second, the advent of Prozac, an easy to take medication that was effective for a broad range of symptoms. 
Ehrenberg takes a different tack. He traces the history of depression focusing on two models. The conflict model, initiated by Freud, sees people as whole, but divided by conflict. Transgression and guilt are the forces that drive it, especially in France where Lacan's version of psychoanalysis is dominant and about which Ehrenberg is writing. The key term in the second model is deficiency. Following the social and cultural changes of the 1960s, he argues, transgression and guilt were no longer dominant concerns. She, and Ehrenberg is religious about using that pronoun, can do anything she wants. Now what matters is feeling inadequate, that is to say deficient. Depression is no longer about conflict and guilt, but about feeling inadequate and deficient. Medications like Prozac help with this by allowing people to feel more capable. Ehrenberg seems nostalgic for the old days when conflict reigned and psychoanalysis was popular. He seems to hold the view that feeling better because of a chemical effect is not authentic. Nonetheless, because he sees the changes as cultural, and social he does not make case for going back to the old days. 

What to make of a book like this. It was certainly confusing at times, especially because most of his references are to twentieth century French psychiatry about which I am not very familiar. The broad idealistic/Foucauldian perspective where cultures change without clearly marked material causes is hard to follow. Nonetheless, posing a contrast between a view of human nature centered on the idea of conflict and one centered on a notion of deficiency is quite refreshing. It isn't a matter of a biological/psychological dichotomy. Ehrenberg is clear psychotherapies, going back to Janet, can be based on a deficiency model. Indeed as I think about discussions of psychotherapy in recent years it seems to me that these were often based on the premise that the patient was somehow injured and in need of repair, not that 'she' was in conflict about how to live. The medications and the psychotherapies that we use are consistent with one another in how they view human nature. In this regard it seems to me that Ehrenberg is onto something and that this book was worth reading.

Wednesday, February 19, 2014

The Prisoner of Stress

Having seen Scott Stossel's book My Age of Anxiety” (Knopf) in a bookstore, I was interested in reading Louis Menand's review. Menand, as usual, goes beyond simply giving his opinion about the book under review. In this case he has written an interesting essay on the many meanings of anxiety. Is it an illness? Is it due to unconscious conflicts? Is it an existential condition? Is it due to stressors? None of the above or all of the above. Is it even 'somthing'? In the course of the review he sketches a brief history of our current ideas about and methods for treating anxiety. While he doesn't mention Andrea Tone's book The Age of Anxiety: A History of America's Turbulent Affair with Tranquilizers, I would suggest it as a good place to get a fuller description of this history.  

In the end Menand seems to take an agnostic position about theories of anxiety. His final word leaves room for both biology and psychology. He writes "As a species, we lucked out: natural selection gave us minds, and that freed us from the prison of biological determinism. We can put our genetic assets to positive account if and as we choose, and sometimes we have to try to do the same thing with our genetic deficits. " Not a bad approach to something we may not be able to avoid.


Wednesday, January 09, 2013

The Science of Sex Abuse

         This week's issue of the New Yorker has an article by Rachel Aviv on the medicalization of sex abuse crimes. It is well researched, well written and worth reading. She focuses the piece around the story of a man named John, who was drawn to child pornography on the internet, then to a chat room and finally to a rendezvous with undercover police officers. She describes his time in prison and on probation, his relapse, and his re-incarceration. The heart of the article is about the use of civil commitment to keep John "in treatment" after finishing his prison sentence. She describes civil court hearings, psychiatric testimony and life in the treatment facility where John winds up. Aviv is particularly interested in the fact that while John has not harmed anyone [other than indirectly through his support for the child pornography industry], the judicial system seems almost unable to release him for fear that he might assault a child. She discusses the psychological tests and psychotherapy which contribute to the view that John is a risk.  Since the advent of the internet and the emergence of internet child pornography there has been a virtual epidemic of cases like that of John. As yet, however, as I read Aviv, we don't  have a way to distinguish those men who will assault children from those who won't, nor do we have effective means of stopping such men from indulging in pedophile fantasies. As she describes it this creates  a catch 22 situation that leaves men like John to spend years in involuntary treatment. Aviv quotes psychiatrists who deplore the profession being used to medicalize what they regard as a criminal issue. But, of course, there are also those psychiatrists who make a living testifying in civil court and running involuntary treatment programs.
     

Friday, December 28, 2012

Laura's Law

In case you missed it the PBS News Hour had an interesting piece on court ordered outpatient treatment. California has a new law allowing for court ordered outpatient psychiatric treatment for psychiatric patients thought to be dangerous. The law, which is named for a young woman who was killed by a paranoid patient, hasn't been funded. The state, in its wisdom, is leaving this to localities. So far only one county has done so. The piece gives various people an opportunity to speak for and against the law, but doesn't say anything about those few states that have such a law. From my limited experience working in a state that allows for court ordered outpatient treatment I would say that it is neither as helpful nor as harmful as as the two sides quoted in this story suggest. It would be interesting to know whether there is data on how such laws work.

Wednesday, December 26, 2012

A Dark Day for Psychiatry




An article in the Guardian reports that in the first case of its kind in France, Danièle Canarelli, a 58 year old psychiatrist was sentenced to one year's suspended sentence for failing to recognize the grave danger posed by a patient she had been treating for four years.

The union for French state psychiatrists, which backed Canarelli during the trial, said that the landmark verdict was worrying and risked scapegoating the profession over a complex case.

I thought the case raised interesting questions about when or whether negligence should ever be considered as a criminal offense. Beyond that the case highlights psychiatry's sometimes conflicting  responsibilities-- caring for patients and protecting society from the actions of some of those patients.

A more detailed report of the case in Le Monde gives something of the flavor of the case. Here is my attempt at a  summary.

At the opening of the trial the President of the Court, aware of the controversial nature of the trial, spoke directly to the psychiatrists who had come to protest in support for their colleague. "We can understand the legitimate emotion of a profession," he said, "but we are not judging psychiatry or psychiatrists. For us it is a question of knowing if, in a concrete situation, serious misconduct has been committed." Referring to an article in the penal code under which 'unintentional offenses' may be charged, he added that, "There can be no impunity, society does not accept it."

This case began after charges against a murderer were dismissed because he was declared irresponsible as a result of psychiatric troubles. The victim's son opened a civil case against the doctor during which the judged referred the case for criminal prosecution because of a breach of duties of caution and safety. In France such prosecution is allowed if an indirect link between misconduct and damage exposes others to particularly serious risk that "could not be ignored."

In making this ruling the judge relied on the testimony of a psychiatric expert. Over a period of years, the expert pointed out, the murderer had been back and forth between prison and a psychiatric hospital for assault with a knife, arson and attempted murder. During this time he was repeatedly diagnosed as suffering suffering from schizophrenia 'with established dangerousness.'

While other doctors came to this conclusion, Dr. Canarelli did not make this diagnosis, regularly voided his involuntary status in the hospital and granted him furloughs. When asked by the judge why she had done this she replied, "You cannot keep someone involuntarily forever." When the judge asked how else one could treat someone who was unwilling to be treated, the doctor answered, "I was in a trusting relationship with him. He came to all of his appointments, which is rare, and there were no behavioral incidents during his hospitalization."

When confronted with her repeated disagreements with other doctors about this patient's diagnosis, she responded that , "He was a patient who was more complicated than others. I was faced with a conundrum. I was convinced that he had a psychotic condition, but I was puzzled [embarrassée] by the absence of symptoms."

The case against the doctor was strengthened when she was questioned about the patient's exit from her clinic three weeks prior to the murder. At that time, the patient's sister warned the doctor that her brother was making death threats. In addition he failed an appointment with the doctor because of a wound received during an altercation. At Dr. Canarelli's request the patient was sent to her office after treatment of his wound. However, he refused her offer of hospitalization and abruptly left her office. She said that she was alone with a nurse and felt she couldn't detain him, but she didn't  call for help. She waited three hours to call the police.

In response to this testimony the judge commented that the doctor's failure to call the police for three hours meant that the patient was "in the city, while you told us that he was sick and could do harm." This comment sparked indignation among the psychiatrists in the courtroom. "Judges should do internships in psychiatric hospitals," one audience member commented to another.

The prosecutor argued successfully that "there is a moment when social defense must come before the patient."

On December 18 Dr. Canarelli was sentenced to one year's suspended sentence for manslaughter [homicide involontaire]. The court concluded that 'shortcomings identified in monitoring the patient' were 'at the origin' of the behavior leading to the murder. These shortcomings, court concluded, constituted serious misconduct and warranted the criminal liability of the psychiatrist. Recalling the multiple incidents that should have alerted the doctor to the patient's dangerousness, the judge said that Dr. Canelli's attitude "bordered on blindness."

Above all, the judge noted, this doctor had time to see her patient evolve. The judge was careful avoid including all errors made by doctors in his judgement noting that, "contrary to other doctors …who must act and react in emergencies, she was able to register clinical observations over time."

The president of the Union syndical de la psychiatrie responded to the court proceedings by answering several questions. Here are two questions and answers.

1. Why do you support Dr. Canarelli?
"What bothers us in this process, is the impression that we must find a scapegoat. We consider unacceptable and will make this the main responsible psychiatrist, because here this was a complex situation where the responsibility of the physician is practically zero. What exactly is she being criticized for. … failing to ensure public safety, as if  that was her role and not that of the police. In spite of her reporting his flight, he was not arrested. We are not police officers. Between the patient and the psychiatrist, everything must be based on trust and therapeutic care, not security.
2. What impact would the conviction of Dr. Canarelli have?
This would surely lead to there being a sword of Damocles over every practitioner. This pressure transform psychiatrists into guardians of public order. The risk that  patients would then remain confined to the hospital longer -while you reducing the number of beds ! Fortunately, this kind of case is rare, because the police normally intervene in reported cases, and, it is always useful to remember, because psychiatric patients are not more dangerous than the rest of the population. .






Tuesday, December 18, 2012

I am Adam Lanza's mother

My daughter sent me this article following the Newtown masacre. What struck me was the mother's view that the choices for her son were between prison and shuttered hospitals. I had thought that the twentieth century had created comprehensive community programs  for difficult cases such as hers. Reading her impassioned plea I felt that I had returned to the nineteenth century.  Are community programs also shuttered in her area or is access to them so difficult that it amounts to the same thing.  It does seem to me that the question of access to such programs should be an important part of the 'conversation' that we are having in the wake of this most recent tragedy. Certainly in the area where I practiced psychiatry, funding for comprehensive public  programs are being cut. Such programs are necessary because the incentives in the private sector do not favor providing adequate treatment for difficult people such this woman's son.

Friday, August 24, 2012

More on Breivik




The Washington Post reports that a Norwegian court sentenced Anders Behring Breivik to prison on Friday, denying prosecutors the insanity ruling they hoped would show that his massacre of 77 people was the work of a madman, not part of an anti-Muslim crusade. In a reversal of my expectations the prosecution continued to argue that he was insane while the defense argued that he was an anti-Muslim terrorist. Importantly Breivik wanted to be considered a terrorist. As I said in my earlier post this seems significant in showing that insanity is two edged in that it can be used both as an exculpating defense and a delegitimizing accusation. 
I recently learned David Mark Chapman,  who was convicted for murdering John Lennon in 1980 also refused an opportunity to plead insanity and insisted on pleading guilty.

Saturday, June 23, 2012

Prosecutors in Norway Seek Hospital for Gunman


The New York Times has reported that in a remarkable turn of events prosecutors in Norway asked that  Anders Behring Breivik   be committed to a hospital rather than sent to prison. What seemed particularly significant was their reasoning: “In our opinion, they said, it is worse that a psychotic person is sentenced to preventative detention than a nonpsychotic person is sentenced to compulsory mental health care.” The following day the Times reported that Breivik's defense lawyers were arguing that he was of sound mind when he committed the crimes. Understanding why these arguments are the reverse from what I would ordinarily expect is certainly a puzzle. Later I learned that Members of the defense team evoked Mr. Breivik’s human rights in their conclusion that he should be held accountable for his crimes. Mr. Breivik has said that the killings were committed in self-defense to combat what he has called the “Islamic colonization” of Europe. He has argued that an insanity judgment would detract from his cause. "The defendant has a radical political project, said Geir Lippestad, onf of his lawyers. "To make his acts something pathological and sick deprives him of his right to take responsibility for his own actions."I am curious about other cases where the defense and prosecution have made similar arguments. 

Tuesday, June 05, 2012

Lovesickness

The Archives of General Psychiatry has published another of James Harris' wonderful discussions of art and psychiatry. This month Harris discusses the American painter Benjamin West's (1738-1820) painting of Erasistratus Discovering the Cause of Antichochus' Disease. He uses the painting as an opportunity to provide brief, incisive  discussion of Lovesickness. I have had a longstanding interest in lovesickness. As Stanley Jackson pointed out many years ago Lovesickness provided one of the earliest circumstances where doctors diagnosed and treated pathogenic secrets as the cause of illness.   Thanks to Harris for expanding my appreciation of this interesting disorder. 

Thursday, May 31, 2012

How I Became a Historian of Psychiatry: Gerald Grob

Gerald Grob, one of the great historians of psychiatry, has submitted his statement to the blog h-madness' series on "How I Became a Historian of Psychiatry." Having read much of Grob's work many years ago and been much impressed by his intelligence and good judgment, I was quite moved by this piece. I pass it along for those who don't regularly read h-madness.

Friday, May 18, 2012

Spitzer Apologizes

Psychiatry seems endlessly political. Having read Ronald Bayer's excellent chronicle of the story of homosexuality being read out of psychiatry's Diagnostic and Statistical Manual I was puzzled when I read the New York Times headline " Leading Psychiatrist apologizes for Study Supporting Gay 'Cure'." I was completely unfamiliar with the story it relates of Robert Spitzer's sponsoring and publishing a study on treating homosexuality in 2001.  The author of the article, Benedict Cary, suggests that it was Spitzer's anti-establishment impulses manifesting themselves again that led him to conduct the study. I found myself wondering if the study didn't express some  reservations that Spitzer still had about his advocacy for the de-medicalization of homosexuality. At the end of the article Spitzer, clearly thinking about his legacy in the history of psychiatry says of his apology: " You know, it's the only regret I have; the only professional one, … And I  think, in the history of psychiatry, I don't know that I've ever seen a scientist write a letter saying that the data were all there but were totally misinterpreted. Who admitted that and who apologized to his readers."  He might have added that it would be hard to find a psychiatrist turning 180 degrees from one politically controversial position to another -- not to mention in the wrong direction.

Wednesday, May 16, 2012

Diagnosing the DSM

Allen Frances' May 11, 2012 op-ed piece in the New York Times "Diagnosing the DSM" is a wonderful piece of common sense. He argues that we don't need to insist that psychiatrists are in cahoots with drug companies to see that conflicts of interests render the American Psychiatric Association incapable of developing a diagnostic manual that does not overreach and medicalize much of everyday life. His suggestion that some presumably neutral arbiter such as the National Institutes of Health should take on this task is worth discussion.
As it happens I was just rereading a wonderful essay by Peter Sedgwick in his 1982 book Psychopolitics, titled "Illness--Mental and Otherwise." While it is aimed at the anti-psychiatry theorists of the day, its central point is that all diagnosis, whether of mental or of physical disorders, involves value judgments. The great success of the DSM as well as its scientific pretentions make it clear that we must take Sedgwick's arguments seriously if we are going to have an honest debate over the reasonable limits of psychiatric diagnosis.