Saturday, December 26, 2009

The Yellow Wallpaper

Thanks for your comment Praymont. I will look for Lenz. As for the The Yellow Wallpaper it is a wonderful nineteenth century instance of madness used for polemical purposes, that I have used in teaching about the history of psychiatry. Charlotte Perkins Gilman said, as I recall, that she wrote this story as a satire of the treatment, known as the 'rest cure' that she received from the illustrious Philadelphia neurologist S. Weir Mitchell. Anyone interested in the history of psychiatry in the late nineteenth century should read this. The link above is to a free online version of the story. For more background on this period you might read my article "Neurology's Influence on American Psychiatry:1865-1915."

Monday, December 21, 2009

Lowboy

I would love to find a history, or even a list, of novels, short stories etc with mentally ill protagonists. Such a history would trace the changing ways the mentally ill have been portrayed and the ways such portrayals reflect the ideas current at the time. One of my favorites was Frank Norris' McTeague, where, as I recall, the protagonist commits senseless violence and is described as an instance of hereditary degeneration. Now we have John Wray's Lowboy, where the protagonist is a sixteen year-old schizophrenic boy know as "Lowboy." Lowboy is a Holden Caulfield type character whose quest to lose his virginity is shown as refracted through his delusions. While the depiction of Lowboy seems true to what one might read in twenty-first century textbooks, it seemed that the author was taking advantage of contemporary fascination with psychotic people "off their meds" and roaming the streets, or in this case haunting the New York subway system. I couldn't help feeling that it was the latest edition to a genre that I might call "madsploitation."

Sunday, December 20, 2009

Joy Luck Club

I haven't read The Joy Luck Club by Amy Tan, but I had the pleasure the other evening of seeing the film version directed by Wayne Wang with a screenplay by Ms. Tan [and someone else]. It is a beautiful film that my wife, who has read the book, says does justice to the book. What struck me was the way it showed relationships changing. As so much of my psychotherapeutic work focuses on people stuck in relationships, often influenced by ghosts from their past, it can seem that such circumstances are diseases like and in need of treatment. In the Joy Luck Club, however, we see four mothers and four daughters knotted up in their relationships with each other [and others] and we also see knots become undone and relationships change. I found it refreshing to see a portrayal of the normal processes in relationships at work. It left me thinking again about what a feeble tool psychotherapy is compared to the good fortune of having relationships that allow for revision. I have included a link to Janet Maslin's review, which will give you a fuller sense of the film.

Saturday, October 31, 2009

AstraZeneca Pays Millions to Settle Seroquel Cases

This Times articles discusses AstraZeneca's settlement over off-label promotions. It got me wondering whether off-label prescribing is greater in psychiatry than in other specialties. Given the extreme flexibility of psychiatry's diagnostic system it would seem that practically all prescribing in psychiatry is "off-label." Yes, we may give people the diagnosis for which the studies on a particular drug were done, but how closely do the symptoms most of the people given these diagnoses match the symptom picture of the people in the study? Of course such prescribing is not truly off-label, but….

Tuesday, October 27, 2009

More on Atpicals and Children

This New York Times article provides the latest on the continuing saga of the misuse of atypical antipsychotics. It will be interesting to track how long it will take until we are thoroughly chastened about the use of atypicals, especially in children. A comparative study of the histories of the rise and fall of various wonder treatments would be of interest-- insulin coma, focal infection etc.

Wednesday, September 16, 2009

Grrr, Sniff, Arf

This book reviewed in the Times gives a neuroscience perspective on the umwelt [life-world] of dogs. Aside from the inherent fascination with what the experience of sniffing reveals to a dog, it also reminded me of how difficult it is to think of people in terms of their differing umwelt's. The act of diagnosing, with its essentially reductive method, runs counter, for me at any rate, to efforts to get into the experience of others. The more remote a person's life-world is from our own, it seems, the easier it is to imagine. Hallucinating people, like dogs, are clearly living in another world. But when people resemble us, it is very difficult not to assume that their world is like our own. Perhaps neuroscience as an alienating way of talking about human experience will actually make this easier. A patient recently said to me that she felt something limbically. Will it be easier to understand human experience when we stop using words that we assume are common to all human experience?

Friday, July 03, 2009

When does realism prevail?

Reading Owsei Temkin's book Galenism, I came upon an interesting paragraph on Vesalius the great 16th century anatomist. In a 1538 publication Vesalius attempted to represent traditional Galenic physiological concepts in visual form. In a drawing of the liver and portal system of veins carrying the caption: "The liver, workshop of sanguification…," the liver is represented with its traditional five lobes. On the other hand, in an illustration of the "organs of generation," where the liver does not play a central role, the liver is sketched incompletely, yet correctly, with two lobes. It was Temkin's conclusion to this observation that caught my attention. It seemed to resonate so well with my experience of practicing psychiatry in a world of distorting theories. "Where realism was of little consequence," he writes, "it could be allowed to prevail." And how are we to know, I thought, when, in our experience, realism does prevail?

Saturday, June 27, 2009

Practice, Practice

After reading this review, I probably won't read Masters of Sex By Thomas Maier , but the review colored in a little patch of my memory. I felt embarrassed reading it and thinking back to the seriousness and enthusiasm with which I read Masters and Johnson. Liberal self-objectification may not be as vicious as the objectification of others but it is perhaps as pernicious.

Wednesday, May 20, 2009

Moral Treatment and the Personality Disorders

A few comments on one article of particular interest to me, "Moral Treatment and the
Personality Disorders" by Louis Charland in The Philosophy of Psychiatry: A Companion, Jennifer Radden [3d], [Oxford Universit Press, 2004] [pp64-77].
I became interested in Charland because of what he has written about Philippe Pinel, whose work I have been researching for a few years. His thoughts about Personality Disorders are of more general interest. His argument is that Cluster B personality disorders [Anti-social, and Borderline] are not medical kinds but what he calls interactive kinds and should not be within the purview of medicine. His argument is that the treatment of Axis I disorders as well as Cluster A and Cluster C disorders do not require "the sort of moral willingness and effort required by
Cluster B disorders." While "the dependent individual," he notes, "may annoy others … [he/she] does not necessarily intend to annoy them for the sake of it." Charland suggests that people with Cluster B disorders do intend the annoying [harmful] effects they have on others and therefore require a moral treatment, not a medical one, that will help them to intend otherwise. I find his distinction between moral and medical treatments unsatisfactory, to say the least. My own experience with people with Antisocial and Borderline diagnoses is that they like people with any disease, pursue treatment [if we must use that term] to diminish their own personal suffering and not to be be better people [more thoughtful of others feelings]]. The threat of jail is modestly good "treatment" for some people with an Antisocial diagnosis and when Borderlines benefit from treatments [like DBT], it is because help them feel better. It seems to me that the whole
discussion of "kinds" is as misguided when it is pursued by critics of psychiatry like Charland, as it is when it is done by the authors of the DSM.
..........
Charland reveals himself to be a dualist, identifying a realm of
actions that one intends and one that one does not intend. While this
is not the cartesian dualism of substances, it serves the same
function--to distinguish that which we are responsible for--mind,
intention, from that which we are not responsible for--body, cluster A
syndromes. Psychotherapy as inspired by Freud [and Pinel, I would
argue] in contrast is based on a monist principle. Psychoanalytic
discourse does not make a distinction between the intended and the not
intended, or perhaps I should say that the concept of unconscious
motivation is a a concept that joins the intentional and unintentional
in a way that allows one to talk about the intentional in a non
judgmental way. It makes moral therapy as Charland uses it obsolete. I
think that Charland is thinking in pre-Freudian terms and from reading
his work on Pinel, he is also thinking in eighteenth-century dualist
[though obviously not about substances] terms as well.

Friday, May 15, 2009

Waterboarding as Psychotherapy

While we are properly horrified to learn about the use of deliberate near-drowning (waterboarding) as an interrogation technique, it is worth noting that for a period of nearly two hundred years the same procedure was regarded as a form of psychotherapy. The influential seventeenth century physician Jan Baptiste Van Helmont (1580-1644), originated this treatment after observing that a madman, who was revived following an accidental near-drowning, was relieved of his mental symptoms. The most influential eighteenth century physican Hermann Boerhaave. (1668-1738) mentions the use of submersion in the treatment of insanity but recommends it for only the most desperate cases. Boerhaave's student Jerome Gaub also discusses the treatment and attributes its efficacy to anxiety. "The most deeply seated mental defects and the most incurable forms of madness" he writes, "may sometimes be rooted out by anxiety." Perhaps, he speculates, this is "because the tormented and frightened mind is revived by the terrible punishment of her greatly depressed senses…." He cites "men with minds held captive by the violence of love or grief," who recovered their soundness of mind when revived after accidental near-drowning. He insists that the cause of this recovery is the "frightful torment that near loss of life from suffocation inflicts on the mind." Gaub acknowledges that "submersion therapy" is "a terrible remedy" but adds that it is "one hardly to be exceed in efficacy." Gaub took the trouble to attempt a medical explanation of "submersion therapy." He argued that "submersion therapy" worked by provoking anxiety, which he understood as a powerful emotion caused by bodily changes. The most frequent cause of anxiety, he felt, is interference with respiration, which hinders the passage of blood through the lungs and thus places life in jeopardy. These bodily events affect the "common sensorium" [where mind and body meet] so as to excite ideas in the mind that cannot be contemplated without horror and cannot be dispelled. The value of such shock therapy was widely recognized in the eighteenth century. “In mania,” a Montpellier doctor wrote in Diderot and D'Alembert's encyclopédie, “therapy is directed to the body, in which it aims to produce a shock and a deep disturbance .” Such ideas even influenced Philippe Pinel, who cites Van Helmont. Although Pinel did not use "submersion therapy," he did include the role of powerful emotions like fear in dispelling fixed ideas as a component of his moral therapy.

Wednesday, May 13, 2009

Military Mental Health

The complexities of providing mental health services to soldiers was suggested by the recent case of the soldier who shot and killed five of his fellow soldiers at a military mental health center in Iraq. Although he managed to find a gun to use, it seems that his commanding officer was alert to his problems. He had the soldier turn in his gun and referred him for counseling. But that apparently isn't the way the soldier experienced it. In an interview, the soldier''s father said that his his son had recently angered a commanding officer, who had "threatened"  him. When the officer ordered the soldier to undergo counseling and relinquish his weapon--a major rebuke in the military-- he became nervous that the Army was "setting him" up to be discharged. Having recently built a new home, he was deeply anxious that he could loose not only his steady paycheck but also his military pension, his father said.“If a guy actually goes to the clinic and asks for help, they think of him as a wimp and he’s got something wrong with him and try to get rid of him,” Mr. Russell said. “Well, he didn’t go and ask voluntarily for help. They scheduled him in, and they set him up. They drove him out. They wanted to put as much pressure on him as they could to drum him out.”

He added: “I think they broke him.”

A General in charge of the soldier's unit, however, said that, “The tools were all being used. They thought that he needed a higher level of care than the unit could provide, so they sent him to the clinic. I mean, you see, all the kind of things that we’re taught to do were in place.”



Monday, May 11, 2009

Psychiatry without Psychotherapy

An article in the August 2008 issue of the Archives of General Psychiatry noted not only a significant decrease in the number of psychiatrists practicing psychotherapy, but a lack of interest in learning psychotherapy among psychiatric residents in the United States. A letter in the April 2009 issue of the same journal notes that a survey among Canadian residents showed that 84% "anticipated practicing psychotherapy and viewed it as an important component to their work and identities." For those who are inclined to see the rise of biological psychiatry as portending the inevitable decline of psychotherapy, this survey strongly suggests that economic and cultural factors are at work as well. 

Friday, March 13, 2009

Looking for the Pineal

Under the rubric of saving a good theory from the data, I read that in 1637 Descartes went to the anatomical theater in Leiden to observe a dissection performed by Adriaan van Valkenburt (1581-1650) hoping to see the pineal gland in man. It must have been a great disappointment to him that the professor could not show him the gland and even had to confess that he had never found it in a human subject. Descartes saved his theory by using the fact that the skull was opened some days after the beginning of the dissection. [Lindeboom, Descartes and Medicine, p.37]

Wednesday, January 14, 2009

More poison in the well

It seems about weekly that one can read about another scandal involving the manufacturers of psychotropic medications. It does not surprise me that companies will market their drugs in whatever way they can. It does sadden me that doctors in general, and psychiatrists in particular, seem to have been complicit in poisoning the well. I have prescribed zyprexa for schizopherneic patients for years and sadly watched some of them get fat. I have switched as many as I have been able to switch back to first generation medications, usually without difficulty or apparent harm. given how little trouble I have had over the years with tardive dyskinesia due to first generation medications and the amount of metabolic side effects I have observed with second generation medications, I would say that the profession has allow a great harm to occur. Why was this? It seems to me ironic that one of the reasons is the critique of psychiatry for neglecting the epidemic of tardive dyskinesia produced by first generation medications. That I believe made us quite uncritical of the marketing of second generation drugs like Zyprexa.

Tuesday, January 13, 2009

Reanimating Nature

As I was reading Steven Shapin's wonderful little book 'The Scientific Revolution,' and thinking about psychotherapy I came upon the following paragraph [p37]: "It must, however, be pointed out that there is nothing, so to speak, 'in the nature' of machines to prevent them from being regarded as mysterious, and a strand of thought going back to the Hellenistic period accounted machines something more than the sum of their material parts. Boyle, for example, wrote about the cultural variability of the appreciations of machinery. He related a --probably apocryphal-- story about the Jesuits "that are said to have presented the first watch to the king of China, who took it to be a living creature." Boyle himself accepted the adequacy of an account wholly in terms of "shape, size, motion &c. of the spring-wheels, balance and other parts of the watch," while recognizing that he "could not have brought an argument to convince the Chinese monarchs, that it was not endowed with life." A mechanical metaphor for nature meant, as all metaphors accepted as legitimate do, that our understanding of both terms changes their juxtaposition. The rightness of a metaphor is not subject to proof."
As someone who sees psychotherapy as fundamentally about trying to persuade people that they are not machines, but living creatures, this little story had great resonance. I realized that psychotherapy aims to reanimate nature, through whatever metaphors are at hand.

Sunday, January 11, 2009

The lingering presence of psychoanalysis

As I was reading C.U.M. Smith's "Brain and Mind in the 'Long' Eighteenth Century" I was thinking about psychoanalysis' lingering presence in the 21th century. Smith writes that "one important reason for the lingering of the old neurophysiology [ie. the one based on animal spirits] was the difficulty of knowing with what to replace it. The traditional understanding of the human being was at least a consistent system. Alexandre Koyré," Smith goes on to point out, said] "… the same of Aristotelian physics. … [Koyré] remarks that it '…forms an admirable and perfectly coherent theory which, to tell the truth, has only one flaw (besides that of being false)… that it is contradicted by the everyday practice of throwing.'"